IMPOTENCE -- Taking A History and Physical Exam WellnessWeb The Patient's Network Dr. Chris Steidle - Northeast Indiana Urology ERECTILE DYSFUNCTION (Impotence) Taking a History and the Physical Exam The single most important part of the evaluation of male sexual dysfunction is the history. A sexual history is often difficult for the inexperienced practitioner, but again is extremely important. All areas should be explored in the history of a patient with sexual dysfunction, and these would include a history of prior genitourinary disease or surgery, such as testicular damage, prior testicular torsion, penile surgery, scrotal surgery such as hydroceles or spermatoceles. Symptoms of vascular disease such as intermittent claudication or blood vessel disease to the legs and specifically, diseases such as Lerich syndrome should be elucidated. This is a triad of buttocks claudication in young men who lose their erections and this is a common cause of erectile dysfunction in men with arterial insufficiency. It is also important to document things such as endocrine problems. Again, the most important and largest cause of erectile dysfunction is diabetes mellitus. Other causes from the endocrine system would include hyperprolactinemia , which is an elevated prolactin in the serum. This could come from pituitary adenomas and has a very specific type of erectile dysfunction, that being a loss of desire, but a good functioning of the erectile mechanism. A history of stomach debilitating diseases such as cancer should be elicited; or treatment for cancer, such as chemotherapy or radiation. Neurologic diseases, such as multiple sclerosis, strokes, cord damage or problems should also be discussed. Vascular surgeries, neurologic spine or inguinal surgery should be explored for evidence of damaged blood vessels, damaged innervation, loss of the sympathetic control. Sleep disorders such as sleep apnea syndromes should be discussed. History of psychologic problems and even specifically the drugs to treat psychologic problems also have a role in this. A marital history is important. The frequency of intercourse, the frequency of ejaculation. Attention should be paid to mental status changes. History of nocturnal erections, whether a patient wakes up in the morning with an erection, how are the erections when not having intercourse. How are the erections during oral sex or masturbation, and how do these compare and is this type of sexual history or sexual functioning apparent? All medications should be reviewed, including over the counter should be discussed. Tobacco use, should document the amount of tobacco use and the length of time that the patient has smoked. Alcohol use, recreational drug use, especially marijuana should be documented. The interest of the patient's partner should be documented. Specific sexual dysfunction questions include a discussion of important personal problems that may arise, such as stressful job situation, impending divorce, separation, sex with other partners, all should be documented. Also, include has the patient seen other physicians. It is important that the prior treatment and workup be documented and discussed. In our clinic we typically rate an erection on a ten scale with ten being rock hard and we consider five adequate for penentration or "stuffable." We also discuss how long intercourse lasts. Does it usually end with an ejaculation? What is the character, frequency, 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 your partner provide you with enough stimulation to allow adequate sexual relationship? We also discuss alternative sexual measures. Physical examination should focus on not only overall body habitus, whether the patient's have obesity. Secondary sexual characteristics, breast swelling and enlargement such as gynecomastia, which would indicate a hormonal or drug cause of the erectile dysfunction. Examination of the genitalia should include the presence or absence of plaque-like formations in the corporal bodies that would indicate Peyronie's disease. The anatomy of the meatus and the urethra. Examination of the testicles should include the size, locations, presence or absence of masses, the presence or absence of hernias as well. Neurologic examination should focus on the penile sensation as well as a bubble cavernosus reflex. Finally, the pulses should be palpated for evidence of vascular dysfunction. Send mail to Dr. Steidle Impotence Home Page