Erectile Dysfunction

Erectile dysfunction (ED), or impotence, is defined as the persistent inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance. The typical patient is at least 50 years old, is usually married or in a long-term monogamous relationship, and has had a year or more of gradually progressive ED. Often he is otherwise in good mental and physical health. Because penile erection is a neurovascular phenomenon, however, there are a number of neurologic and vascular conditions that can lead to ED. Vascular disease such as atherosclerotic stenosis or occlusion of the cavernosal arteries, or vascular problems secondary to smoking, can cause ED. Antihypertensives, antidepressants, antiandrogens, histamine type 2 (H2) receptor blockers, and recreational drugs are commonly associated with ED. Diabetes, hypertension, hyperlipidemia, and alcohol use are risk factors in ED. ED frequently provides insight into the patient's emotional problems.

A delicate approach must be taken. It is necessary to use tact and appropriate language that will be understood by the patient. Explaining that ED is a common problem often sets the tone. Deep-seated problems necessitate careful questioning. The interviewer may discover latent homosexuality;guilt and taboos experienced early in life may have left a lasting impression, affecting sexual performance. It is most important to classify the origin of the ED, because there are specific therapies for different causes.

Start by asking some of the following questions:

''If you were to spend the rest of your life with your sexual function just the way it is now, how would you feel about that?''

''Are you satisfied with your sexual function?'' If not, ' 'What are the reasons?''

What is your relationship status? Is it a happy one?''

''Is your partner satisfied with your sexual function?'' If not, ' 'What are the reasons?''

When was the last time you had a satisfactory erection?''

''Over the last 4 weeks, how would you rate your confidence that you could get and keep an erection?''

When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?''

During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?''

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?''

A careful history is the most essential component in the evaluation of ED. Key and direct questions are important:

' 'How much do/did you enjoy sexual intercourse?''

''When you have sexual stimulation or intercourse, how often do you ejaculate?'' How easily can you reach an orgasm (climax)?'' How strong is your sex drive?'' ''How easily are you sexually aroused?'' ''Are your orgasms satisfying?''

Some other questions may help determine the cause of ED. Psychogenic causes for ED should be suspected in men who have a history of unusual anxiety, stress, or sexual abuse or in those with ethnic, cultural, sexual, or religious inhibitions. ED is often psychogenic in men younger than 40 years. Ask the following questions:

' 'Do you have early morning erections or nighttime emissions?'' ''Do any individuals other than your partner arouse you?'' ''Are you able to masturbate to an erection or climax?''

An affirmative answer to any of these questions reassures the interviewer that the ED is probably psychologic in origin. Letting the patient discuss his problems may allow him to vent some of his anxieties, but the patient's confidence must first be secured by guaranteeing confidentiality. The interviewer must also resolve his or her own sexual anxieties in order to have a confident and straightforward discussion. An open dialogue about the anxieties surrounding sexual intercourse may be productive. The interviewer must be careful not to impose his or her own moral standards on the patient, however. Improving communication between partners is also helpful.

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