What happens after the history, physical examination, and laboratory tests have been carried out?

In most cases, once possible causes have been identified and evaluated, your doctor may discuss lifestyle changes and possible therapies with you. This goal-oriented approach centers around the doctor and patient discussing possible origins of the problem and then making a decision about therapy (Figure 31). In select cases, when

Approach to the evaluation and treatment of erectile dysfunction.

Figure 31. Approach to the evaluation and treatment of erectile dysfunction.

Adapted with permission from N Engl J Med 2000;342:1807. Copyright © 2000, The Massachusetts Medical Society.

the patient wants to know more about the cause of the ED—is it really an artery problem or a vein problem?— then further investigation is required. Young men with no identifiable medical conditions or risk factors should undergo further evaluation because these individuals are the best candidates for penile vascular surgery.

If there appears to be a significant psychological component to the ED then it may be appropriate to seek consultation with a psychiatrist, psychologist, or sex therapist. Although organic problems account for 80 to 90% of the cases of ED, realistically, in many men there is some psychological overlay. Treating the ED may resolve psychological problems related to ED, but if there are significant psychological stressors, then psychological counseling at the same time as medical therapy may be more beneficial than medical therapy alone.

It is important to identify possible causes of your ED so that you and your doctor can find the best method of treating it. The success rates of many therapies have been subdivided based on the causes and the degree of ED. Knowing where your problem comes from will allow you to determine the likelihood of success of a given therapy and to avoid falsely elevated expectations.

It is often very helpful if your partner can participate in the evaluation and treatment process. Realistically, an intervention is unlikely to succeed if your partner is not interested in resuming sexual relations. For example, if your partner is a postmenopausal woman, she might suffer from atrophic vaginitis, which stems from lower estrogen levels that cause the vaginal mucosa to become thin, dry, and prone to irritation. If this is the case, she may find intercourse uncomfortable—and you may not

It is often very helpful if your partner can participate in the evaluation and treatment process.

have a supportive partner to help you through the therapy for your ED. This might be an opportunity to address both problems; discomfort from atrophic vaginitis can be improved by using lubricants during intercourse. In addition, the use of topical estrogen cream helps restore the vaginal mucosa in women for whom such agents are appropriate, so your partner may want to discuss with her primary care provider or gynecologist the risks and benefits of topical estrogen therapy for atrophic vaginitis.

What laboratory tests are performed?

The laboratory evaluation of ED is limited in most cases. If you are treated by a primary care provider on a regular basis, such information as a fasting blood sugar test, kidney function tests, liver function tests, and lipid profile are often available. If you have experienced unexplainable weight gain or loss and/or other signs or symptoms of abnormal thyroid function, then thyroid function tests may be performed. All men with ED should have a serum testosterone level checked. Because the testosterone level varies throughout the day and tends to be highest in the morning, it is best to have the testosterone level checked in the morning. In some men, such as obese men and those with liver disease, the total testosterone level may be low, but the free testosterone level (the active form of testosterone) is normal. If the testosterone level is low, then a prolactin level should be checked to rule out a pituitary adenoma (a benign brain tumor).

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