If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination in a systematic way, moving from less sensitive to more sensitive matters. Begin with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What’s the age and health status of his sexual partner? Find out about past marriages, if any, and ask him why he thinks they ended. If you can do so discreetly, ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?

Focus your medical history on the causes of erectile dysfunction. Does the patient have type 2 diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient’s impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about intake of alcohol, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.

Next, ask the patient when his impotence began. How did it progress? What’s its current status? Make your questions specific, but remember that many patients have difficulty discussing sexual problems, and many don’t understand the physiology involved.

The following sample questions may yield helpful data: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?

Ask the patient to rate the quality of a typical erection on a scale of 0 to 10, with 0 being completely flaccid and 10 being completely erect. Using the same scale, also ask him to rate his ability to ejaculate during sexual activity, with 0 being never and 10 being always.

Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient’s sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient’s vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.

♦ Central nervous system disorders. Spinal cord lesions from trauma produce sudden impotence. A complete lesion above S₂ (upper-motor-neuron lesion) disrupts descending motor tracts to the genital area, causing loss of voluntary erectile control but not of reflex erection and reflex ejaculation. However, a complete lesion in the lumbosacral spinal cord (lower-motor-neuron lesion) causes loss of reflex ejaculation and reflex erection. Spinal cord tumors and degenerative diseases of the brain and spinal cord (such as multiple sclerosis and amyotrophic lateral sclerosis) cause progressive impotence.

♦ Endocrine disorders. Hypogonadism from testicular or pituitary dysfunction may lead to impotence from deficient secretion of androgens (primarily testosterone). Adrenocortical and thyroid dysfunction and chronic hepatic disease may also cause impotence because these organs play a role (although minor) in sex hormone regulation.

♦ Penile disorders. With Peyronie’s disease, the penis is bent, making erection painful and penetration difficult and eventually impossible. Phimosis prevents erection until circumcision releases constricted foreskin. Other inflammatory, infectious, or destructive diseases of the penis may also cause impotence.

♦ Peripheral neuropathy. Systemic diseases, such as chronic renal failure and diabetes mellitus, can cause progressive impotence if the patient develops peripheral neuropathy. This condition affects about 60% of males with diabetes. Associated signs and symptoms of diabetic neuropathy include bladder distention with overflow incontinence, orthostatic hypotension, syncope, paresthesia and other sensory disturbances, muscle weakness, and leg atrophy.

♦ Psychological distress. Impotence can result from diverse psychological causes, including depression, performance anxiety, memories of previous traumatic sexual experiences, moral or religious conflicts, and troubled emotional or sexual relationships.

♦ Trauma. Traumatic injury involving the penis, urethra, prostate, perineum, or pelvis may cause sudden impotence due to structural alteration, nerve damage, or interrupted blood supply.

♦ Vascular disorders. Various vascular disorders can cause impotence. These include advanced arteriosclerosis affecting both major and peripheral blood vessels, Leriche’s syndrome (slowly developing occlusion of the terminal abdominal aorta), and arteriosclerosis, thrombosis, or embolization of smaller vessels supplying the penis.

♦ Alcohol and drugs. Alcoholism and drug abuse are associated with impotence, as are many prescription drugs, especially antihypertensives. (See Drugs that may cause impotence.)

♦ Surgery. Surgical injury to the penis, bladder neck, prostate, urinary sphincter, rectum, or perineum can cause impotence, as can injury to local nerves or blood vessels.

Care begins by ensuring privacy, confirming confidentiality, and establishing a rapport with the patient. No other medical condition affecting males is as potentially frustrating, humiliating, and devastating to self-esteem and significant relationships as impotence. Help the patient feel comfortable about discussing his sexuality. This begins with feeling comfortable about your own sexuality and adopting an accepting attitude about the sexual experiences and preferences of others.

Prepare the patient for screening tests for hormonal irregularities and for Doppler studies of penile blood pressure to rule out vascular insufficiency. Other tests include voiding studies, nerve conduction tests, evaluation of nocturnal penile tumescence, and psychological screening.

Treatment of psychogenic impotence may involve counseling for the patient and his sexual partner; treatment of organic impotence focuses on reversing the cause, if possible. Other forms of treatment include surgical revascularization, drug-induced erection, surgical repair of a venous leak, and penile prostheses. Encourage the patient to maintain follow-up appointments and therapy for underlying medical disorders.

Most people erroneously believe that sexual performance normally declines with age. Many also believe (erroneously) that elderly people are incapable of or aren’t interested in sex or that they can’t find elderly partners who are interested in sex. Organic disease must be ruled out in elderly people who suffer from sexual dysfunction before counseling to improve sexual performance can start.

Encourage your patient to talk openly about his needs and desires, fears and anxieties, or misconceptions. Urge him to discuss these issues with his partner as well as what role both of them want sexual activity to play in their lives.