Around 10% of men and up to 50% of women experience sexual difficulties at some point, and although some will need specialist advice, the GP should be able to help with most problems. When dealing with any sexual problem, bear in mind the following:

• Some sexual problems have a physical origin and some a psychological origin, but many are a mix of both.
  
• Sex is usually a two-way activity; consider the couple (and don’t make assumptions about sexuality).
  
• Don’t forget that sexual problems can be a sign of serious organic disease.
  
• Explore the patient’s ideas (e.g. what the patient thinks the problem is, and what they think is ‘normal’), concerns (e.g. something seriously wrong, effects on relationship) and expectations (e.g. likely outcome or treatments).
  
• GPs can make a big difference to patients using quite basic techniques – for example, providing information, reassurance or the chance to talk to someone with non-directive counselling skills.

Erectile Dysfunction (Impotence)

Erectile dysfunction (ED) is the inability to get or maintain an erection that is sufficient for satisfactory sexual intercourse. Sustained ED affects about 8% of 20- to 40-year-olds and half of men over 70. Causes include organic (e.g. atherosclerosis, neurological disease, diabetes, hypertension, medications) and psychological (e.g. depression or anxiety, or relationship problems). ED is mostly psychological in nature in one-third of patients, mostly physical in one-third and a mix of both in the remaining third.

History

Take a full history, especially:

• Medications (e.g. antihypertensives such as beta-blockers, antidepressants, anticonvulsants)
  
• Alcohol and smoking
  
• Sudden onset, morning erections maintained and reduced sex drive suggest psychological causes
  
• Gradual onset, absence of morning erections and normal sex drive suggest physical cause.

Examination

Examination should include: full cardiovascular examination including BP, peripheral pulses (ED shares many risk factors with cardiovascular disease [CVD]), genital exam for hypogonadism or anatomical problems, neurological exam (e.g. for spinal cord lesions or peripheral neuropathy).

Investigations

C

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