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++

Probability diagnosis

++

Ageing

++

Drugs esp. excess alcohol

++

Diabetes (autonomic dysfunction)

++

Stress/anxiety/depression

++

Serious disorders not to be missed

++

Vascular:

++

  • Generalised arteriopathy esp. lower limbs

++

Infection:

++

  • Generalised: viral, bacterial

++

Tumours:

++

  • Pituitary fossa

++

Other:

++

  • Systemic illness

  • Chronic kidney disease

++

Pitfalls (often missed)

++

Pelvic trauma

++

Excessive cigarette smoking

++

Iatrogenic e.g. prostate surgery, drugs

++

Thrombosis corpus callosum

++

Rarities:

++

  • Neurological e.g. MS

  • Hypogonadism e.g. Klinefelter’s

  • Anatomical e.g. tight frenulum, Peyroine’s disease

++

Masquerades checklist

++

Depression including drugs

++

Diabetes

++

Drugs: various

++

Thyroid/other endocrine: several (see history)

++

Spinal dysfunction e.g. spinal cord pathology, cauda equina lesion

++

Is the patient trying to tell me something?

++

Consider psychosexual dysfunction incl. marital disharmony, performance anxiety

++

Key history

++

  • Nature of onset including nature of sexual relationship

  • Ask about nocturnal and early morning erections

  • Drug history incl. alcohol, nicotine (4 times risk), street drugs (cocaine, cannabis), pharmaceutical agents esp. antihypertensives (beta blockers, diuretics), hypolipidaemic agents, antiandrogens (prostate cancer treatment), antidepressants, antipsychotics, H2-receptor antagonists

++

Key examination

++

Genitourinary, cardiovascular and neurogenic examinations are important. This should include a rectal examination; examination of the vascular and neurological status of the lower limbs; and genitalia esp. the testicles and penis. Check the cremasteric and bulbocavernosus reflexes.

++

Key investigations

++

First line:

++

  • glucose

  • FBE

  • free testosterone (androgen deficiency)

  • thyroxine (hypothyroidism)

  • prolactin

  • LH

  • FSH

  • Urinalysis

++

Consider:

++

  • LFTs esp. GGT (alcohol effect) and KFTs

  • nocturnal penile tumescence

  • Doppler flow studies

++

Diagnostic tips

++

Endocrine causes to consider include androgen/testosterone deficiency, hyperprolactinaemia and hypothyroidism. Consider pituitary fossa tumour.

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