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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 Abstracts.

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, endocrinologist).

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, ...

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