A systematic search of the medical literature was performed on
March 14, 2007. The search, limited to human subjects and journals
in English language, included the National Guideline Clearinghouse,
the Cochrane database, MEDLINE, and International Pharmaceutical
Erectile dysfunction (ED) is defined as the inability to achieve
an erection sufficient for satisfactory sexual intercourse.1 It
is estimated that approximately 52% of men in the United
States who are 40 years and older suffer from some degree of ED.2 The
etiology can be due to psychological, vascular, endocrine, neurologic,
urologic, or pharmacologic causes, and may often be multifactorial.
The development of effective oral therapies has revolutionized the
treatment of ED. More men are seeking treatment and most are seeking
it through primary care providers.
ED typically occurs in men older than 40 years and the risk increases
with age and comorbidities. Men may present to their primary care
provider with a complaint of ED, but a full workup may reveal more
serious underlying causes such as depression or cardiovascular disease.
In fact, many patients with ED may have subclinical atherosclerosis
and those without a clear etiology should be evaluated for vascular
disease, as ED appears to be an independent predictor of cardiovascular disease.3,4 Severity
of ED varies from patient to patient but usually increases with
age. Men suffering from ED may also complain of problems with libido
and/or ejaculation, depending on the cause of their ED.
All patients with ED should be evaluated for abnormalities in
the size and consistency of the prostate, testicles, and penis.
The physical examination should also include blood pressure measurement
and femoral and pedal pulse evaluations to further identify cardiovascular-related
ED. Endocrine evaluation should include inspection for thyroid gland
abnormalities, breasts for gynecomastia, and hair distribution or
general masculine development. Perineal sensation and bulbocavernous
reflex are part of an appropriate neurologic evaluation. Patients
with abnormalities in the systems above should be further evaluated
and may require referral to an appropriate specialist (e.g., urologist,
To aid successful treatment, an accurate diagnosis of ED must
be made through a thorough history and physical findings including
ED screening; sexual, medical, social, and medication histories;
a physical examination; laboratory tests; and possibly additional
cardiovascular testing. Screening patients for ED can be easily
accomplished by using a patient-focused questionnaire. The Sexual Health
Inventory for Men is a standard clinical tool that aids in diagnosing
ED (Fig. 30-1).5 It includes five questions from the ED
portion of the International Index of Erectile Function related
to confidence, penetration, maintenance, and satisfaction; a score
of 21 or less indicates the patient is likely to have ED. In addition
to screening male patients for ED, primary care providers should
discuss sexual history as a means to improve and clarify diagnoses.
Some sexual changes may be related to aging rather than to ED. As
men age they sometimes require increased sexual stimulation, ...