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Probability diagnosis

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Ageing

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Drugs esp. excess alcohol

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Diabetes (autonomic dysfunction)

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Stress/anxiety/depression

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Serious disorders not to be missed

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Vascular:

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  • Generalised arteriopathy esp. lower limbs

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Infection:

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  • Generalised: viral, bacterial

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Tumours:

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  • Pituitary fossa

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Other:

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  • Systemic illness

  • Chronic kidney disease

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Pitfalls (often missed)

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Pelvic trauma

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Excessive cigarette smoking

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Iatrogenic e.g. prostate surgery, drugs

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Thrombosis corpus callosum

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Rarities:

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  • Neurological e.g. MS

  • Hypogonadism e.g. Klinefelter’s

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

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Masquerades checklist

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Depression including drugs

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Diabetes

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Drugs: various

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Thyroid/other endocrine: several (see history)

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

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Is the patient trying to tell me something?

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Consider psychosexual dysfunction incl. marital disharmony, performance anxiety

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Key history

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  • 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

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Key examination

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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.

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Key investigations

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First line:

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  • glucose

  • FBE

  • free testosterone (androgen deficiency)

  • thyroxine (hypothyroidism)

  • prolactin

  • LH

  • FSH

  • Urinalysis

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Consider:

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  • LFTs esp. GGT (alcohol effect) and KFTs

  • nocturnal penile tumescence

  • Doppler flow studies

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Diagnostic tips

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

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