The single most important part of the evaluation of male sexual dysfunction is the patient's history. A sexual history is often difficult for the inexperienced practitioner, but, again, is extremely important in determining the cause of the problem. Many subject areas should be explored while taking the history of a patient with sexual dysfunction. Specific topics should include genitourinary disease or surgery, testicular damage, prior testicular torsion, penile surgery, or scrotal surgery such as for hydrocele or spermatocele.
The physician should ask the patient about any symptoms of vascular disease such as intermittent claudication or blood vessel disease to the legs, and specifically, about any diseases such as Lerich syndrome. This last condition is a pattern of buttocks claudication in young men who lose their erections, which is a common cause of erectile dysfunction in men with arterial insufficiency.
It is also important to document any known endocrine problems. The most common cause of erectile dysfunction is diabetes mellitus but there are other endocrine-based causes including hyperprolactinemia, which is an elevated prolactin in the serum. This condition can be caused by pituitary adenomas and creates a very specific type of erectile dysfunction where a man loses desire for sex, but maintains good function of the erectile mechanism.
Any history of debilitating diseases such as cancer should be noted, along with treatments such as chemotherapy or radiation. Neurologic diseases, including multiple sclerosis, strokes, cord damage or other cord problems should also be discussed. Vascular surgeries, neurologic spine or inguinal surgery should also be explored for evidence of damaged blood vessels, damaged innervation, or loss of the sympathetic nerve control.
The physician should ask about sleep disorders, such as sleep apnea syndromes, and about psychologic problems, along with the names of any drugs used to treat them. A marital history is important and should include the frequency of intercourse and the frequency of ejaculation. Attention should be paid to any changes in mental status. Other questions should focus on the frequency of nocturnal erections, whether a patient wakes up in the morning with an erection, and whether the erections are different when not having intercourse, during oral sex or masturbation, and how they compare to one another.
All medications should be reviewed, including any over the counter products. Tobacco use, including the amount and length of time that the patient has smoked, are important to note. Any alcohol or recreational drug use, especially marijuana, should also be documented. The physician should also attempt to ascertain and note the level of interest of the patient's partner in solving the erectile dysfunction problem.
Sexual dysfunction questions should also cover significant personal problems that may exist, such as a stressful job situation, impending divorce, separation, or sex with multiple partners. Also, If the patient has seen other physicians about impotence, it is important that the prior treatment and workup be documented and discussed.
In our clinic, we rate an erection on a scale of one to ten, with ten being rock hard and five being adequate for penetration or "stuffable." We also ask how long intercourse lasts and does it usually end with an ejaculation? What is the character and frequency and what is the force of ejaculation? Is there an odor to the ejaculate? Is there blood in the ejaculate? How often does the patient have intercourse? What is the level of interest in sexual relations or how often does this happen? Does the patient's partner provide enough stimulation to allow an adequate sexual relationship to occur? We also discuss alternative sexual measures.
The physical examination should focus on overall body habits, whether the patient is obese, for example, and on such secondary sexual characteristics as breast swelling and enlargement (called gynecomastia), which indicates a hormonal or drug cause of the erectile dysfunction. An examination of the genitalia should include determining the presence or absence of plaque-like formations in the corporal bodies indicative of Peyronie's disease as well as the anatomy of the meatus and the urethra. Examination of the testicles should include the size, location, presence or absence of masses and the presence or absence of hernias. The neurologic examination should focus on penile sensation as well as obtaining a bulbocavernosus reflex. Finally, the pulses should be palpated for evidence of vascular dysfunction.