The Initial Consultation if you have erectile dysfunction
It is important to feel comfortable talking to your doctor about erectile dysfunction. Get an idea about what your doctor may ask you here.
When preparing to go to a physician’s office for the initial consultation, it is important to consider many things before the visit. The physician’s office may or may not send you a questionnaire beforehand to help you put things into perspective. I currently use a questionnaire that generates a score and rates the severity of the erectile dysfunction.
The International Index of Erectile Function Questionnaire is an instrument for measuring male sexual dysfunction in a clinical setting.
There are several questionnaires available, and many practices use a general questionnaire that reviews salient points on sexual drive, erections, and ejaculation, as well as the perception of sexual problems and overall satisfaction. The scoring system provides a means of measuring how severe the problem is and helps to put patients at ease. Then the physician and the patient can be on the same track when discussing erectile dysfunction. The questionnaire allows me to grade the erectile dysfunction from severe dysfunction to no dysfunction at all.
On the day of the consultation, it is also important to have the sexual partner present, if possible. This may not be practical if there are several partners and the sexual partner is uncomfortable talking about sexual problems outside the relationship.
It is also important to review other general medical problems that may have an effect on erections, including medications and prior surgical procedures.
Another thing to think of when preparing for the initial consultation includes smoking history. Oftentimes I ask, “Do you smoke?” Patients will then tell me, “Oh, no, I quit.” At this point I always ask when they quit and how long and how much they smoked. It is not surprising to find people replying, “Well, I quit last week.” I still consider these patients smokers.
It is essential to bring a complete list of medications including the dosage that you are taking to the first office visit. Remember to mention all medicines including vitamins and herbal supplements. Many herbal supplements can have direct effects on genital tissues and can be associated with sexual dysfunction. Patients often do not realize the potency of these herbal compounds.
Discovering causes of erectile dysfunction
A patient’s age is a key factor. Erectile dysfunction increases with age as revealed by the Massachusetts Male Aging Study.
I then discuss and characterize the quality of the patient’s erections using a scale that rates erections from 0 to 10. A 10 is a perfect erection: rigid, the best erection ever. An erection that is barely able to penetrate is approximately a 5. When there is no swelling, or tumescence, of the penis whatsoever, this is a 0. Before the penis can become rigid, it becomes tumescent.
M.F. was a forty-five-year-old man who presented the office with difficulty achieving and maintaining an erection. He came in at the urging of his wife. He had no risk factors and was otherwise a healthy vigorous male. He did indicate, however, that he had no difficulty with erectile dysfunction at all when he was with his girlfriend. This, of course, was given in a confidential nature, but it pointed to substantial marital distress and discord. This is not an uncommon scenario, so I always inquire how the patient’s erections are with other partners.
Problems with libido
Libido is another component of the male sexual response. Problems with libido are usually related to depression, stress, partner dissatisfaction, and even hormonal imbalances. When asked about desire, men with erectile dysfunction will often respond by saying that they have no desire.
What they really mean is that they are afraid to initiate sexual activity because of fear of failure. This is not a true loss of desire, but it is a good indicator of organic erectile dysfunction.
The man who has lost all interest in sexual activity has a true loss of desire. He may get an erection, but he is not interested in pursuing sexual intercourse. This is an uncommon situation, and immediately indicates an unusual cause of erectile dysfunction called prolactinoma. This is a prolactin-secreting.
During a patient history, I also focus on the things that can affect erections including the timing of intercourse, masturbation, and the patient’s work schedule.
Z.F. was a forty-five-year-old man who presented the office with an inability to maintain his erection. He had an extremely physically intensive job, but his examination was entirely normal. He also had excellent desire and a supportive partner present. I performed a penile injection on the patient, and while the medication worked to produce what was a rock-hard erection, he actually fell asleep on the table. It became readily apparent after a careful history, that the man worked sixteen hours a day at heavy physical labor and was exhausted at the time of anticipated sexual relations. After we dealt with this problem, he was able to restore his erectile functioning and found he performed much better after he had a good night’s sleep. Reworking his schedule produced dramatic results.
Erection problems during sexual Intercourse
At this point I always inquire when was the last time he had intercourse and how hard the penis was during intercourse. If the erection wasn’t as hard as it could have been, I ask when was the last time it was rock-hard, an erection characterized as a 10. At this point, many men will have trouble characterizing their erections.
A simple, helpful tool to characterize an erection is to ask, “Could you hang a towel on it?” Although this sounds somewhat ridiculous, many men can relate to this.
When describing a rock-hard erection, I often ask, “Could you hang a wet towel on it?”
This to me denotes a sufficient erection for penetration. I also try to determine the presence of morning erections and characterize their quality, again using the same 0 to 10 scale. Finally, I discuss whether the erection was the same with masturbation as with intercourse.
This question can be somewhat uncomfortable for some men, but if asked in a professional manner, it is rarely a problem. It is not uncommon to find a situation where an erection will be very good with a partner’s girlfriend and poor with the patient’s wife. You’ll never find this out if you don’t ask.
One of the key things to ask in the medical history is, “Can you ejaculate with a soft penis?” This can be one of the most important indicators of an organic problem. I try to use the history to give me a feeling as to whether this is organic or has an underlying psychological problem.
I also use the history to help guide me as to how aggressive a laboratory investigation and other subsequent tests need to be.
When a problem is organic, medication or a concurrent medical condition can be an obvious cause. Years ago, the majority of erectile dysfunction cases were diagnosed as psychological. More recently, however, with more sensitive tools and measurements of erections, we now know that this is not true, and in fact, the vast majority of erections are organic in nature.
How soon you get ejaculation?
I then discuss ejaculation — when it happens, how long the patient is able to maintain penetration before the ejaculation happens, how much ejaculate is produced, and whether it is a whitish color, which is considered normal, or more rarely, stained with blood. Some men will say they don’t know, but I tell them that the only way to know is to look.
Many men, however, will know the volume of ejaculate because they have a feeling for how much comes out at the time of masturbation.
Blood in the ejaculate is usually the result of a simple infection. This condition, termed hematospermia, is easily treated, and reassurance is the most important prescription in this situation.