What questions might the doctor ask me during my initial visit?

Questions such as the following will help evaluate the cause and the magnitude of the erectile dysfunction:

• How long have you been experiencing ED?

• Was the onset abrupt or a slow, progressive deterioration in function?

• Can you identify a precipitating event?

• Is the problem constant or intermittent?

• Does it occur with only one partner or with all partners if there are multiple partners?

• Do you achieve any erection with stimulation, and do you notice nocturnal or evening erections?

• Do you get an erection that is rigid enough for penetration?

• Does your erection last long enough for completion of sexual performance?

• Is there any penile pain or curvature associated with erections?

• What medical conditions do you have?

• Have you had any prior surgery?

• Do you take any medications?

• Do you smoke?

• Do you drink alcohol, and if so, how much?

• Do you use any recreational drugs?

• Do you feel stressed or depressed?

• Is the ED causing you to feel stressed or depressed?

• Is your partner interested in restoring your sexual relationship?

Often, your physician may ask you to complete a questionnaire: the International Index of Erectile Function, or IIEF (see Appendix A), an abbreviated questionnaire called the Brief Sexual Function Inventory (BSFI), or the Sexual Health Inventory for Men (SHIM), an abbreviated IIEF that contains five questions (see Appendix A). These questionnaires are helpful in assessing your problem and also may help assess your response to therapies.

What is the doctor looking for during the physical examination?

The physical examination looks for clinical signs of several disorders including hypertension, cardiovascular disease, renal or liver disease, peripheral vascular disease, thyroid problems, and neurologic problems that may be causing your ED. It is a head-to-toe examination in which your doctor will look at:

• Your heart rate and blood pressure to determine whether there might be a vascular problem.

• Your head and neck to rule out yellow sclera (liver failure) and to check for thyroid enlargement and swollen lymph nodes.

• Your chest to see how well your lungs and heart are working and to look for gynecomastia (tender or enlarged breasts in males, which can be a sign of a pituitary problem).

• Your abdomen, which will be examined by palpation (feeling with the hand or fingers, by applying light pressure), to rule out enlarged liver or kidneys, abdominal masses, or tenderness.

• Your genitalia (external sexual organs) to make sure that there are no plaques or abnormalities of the penis; the doctor will also check the testes to make sure that both are present, of normal size, and have no tumors and will check secondary sex characteristics, such as pubic hair.

• Your femoral pulse, located in your thigh, and pulses in your feet to rule out peripheral vascular disease.

• Your penile sensation, reflexes, and rectal tone. This may be uncomfortable: the doctor will check the bulbocavernosus reflex by inserting a finger in your rectum, squeezing the tip of penis, and noting a contraction of the anus at time of squeezing penis.

Why is my doctor checking my testosterone level?

There are several reasons why your doctor will check a testosterone level during your initial evaluation. First, rare benign pituitary tumors can lower testosterone production and cause decreased libido and ED. These tumors are treatable, and the sexual side effects are potentially reversible. Second, if you have decreased libido, the doctor is attempting to determine whether supplemental testosterone can improve poor libido. There is no other way of assessing your testosterone level besides the blood test because neither libido nor testis size is a good gauge of testosterone levels. Clearly, if you have a decrease in your libido and your testosterone level is low, then supplemental testosterone will enhance your libido. However, in some patients with ED, who fail oral therapy and have a low normal serum testosterone, the use of supplemental testosterone may enhance the response to oral therapy, despite having normal libido.