Erectile Dysfunction:
A guide to diagnosis and management

Discussion of the situations in which ED occurs and the presence or absence of early morning erections can help elucidate the cause. Symptoms of vascular disease and diabetes should be sought, along with a medication history, cigarette and alcohol use.

The routine examination should exclude comorbid diseases:

• examination of genitalia is important to exclude plaques in the shaft of the penis (Peyronie disease), however, patients will usually present to complain about a curvature in the erect or semi-erect penis which may/may not be painful and may/may not interfere with satisfactory sexual intercourse

• scrotal examination may reveal small testicular volume, suggesting hypogonadism.

Table 1. Common causes of erectile dysfunction

Because the neurological supply to the corpus cavernosum travel around the outer capsule of the prostate, only significant damage to these would lead to ED. Under these circumstances, digitalrectal examination (DRE) would theoretically reveal significant prostate disease such as hardness and irregularity of the prostate consistent with advanced cancer of the prostate. This is uncommon but needs to be excluded. In the absence of significant prostate abnormality upon DRE, the issue of prostate specific antigen (PSA) should be dealt with separately, i.e. only after obtaining informed consent. Usual investigations are shown in Table 2.

Table 2. Investigation for ED

Addressing psychological issues
The patient's age is important in that it reflects the individual's 'overriding concern' or 'gaze'. For example, a man in his early 20s is primarily consumed with his emerging identity. Contradictions
he may be facing include:
• strong-weak
• mature-immature
• independent-dependent
• stoic-emotional
• sexual predator-sexually vulnerable.

In addition, he may also be wrestling with the issue of sexual identity, and clearly the issue of body image is central to his being.

For a man in his mid 20s onward, his 'gaze' is predominantly that of 'engagement', referring to the external environment, namely work, and internal engagement at a personal, intimate level with
another person or people in general. Confusion and uncertainty about any of the above are common, and the possible resultant anxiety may present as ED.

Similarly, middle aged men may have significant anxiety in dealing with loss of youth and emerging old age. Despair rather than acceptance may result, leading to, or at least contributing to ED. This group is also preoccupied with 'disengagement' from the workforce. While this stage may lead to a higher quality of life, it may also bring with it anxieties for him and or his partner who may not be used to having him home all day. Consideration of these issues often leads to an appreciation by the patient that his concerns have been validated (regardless of whether or not his dysfunction is resolved).