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Introduction

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Erectile dysfunction (ED) is defined as 'the inability to achieve and maintain an erection sufficient to permit satisfactory sexual intercourse' (NIH Consensus Development Panel on Impotence, 1993), and was believed to have affected over 150 million men in 1995 worldwide, accounting for at least 1 in 10 men in Western countries. Despite the introduction of novel treatments for this condition, this figure is still expected to rise to over 320 million by the end of 2025 (Ayta et al., 1999). It is therefore essential that the clinician performs an appropriate, thorough and directed investigation of a patient presenting with ED to ensure the maximum chance of success in subsequent treatment (Table 9.1).

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Table 9.1Clinical assessment of erectile dysfunction
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Each consultation should commence with a full clinical history, including sexual, psychosocial and medical, a physical examination, and routine laboratory tests. Following this, confirmation or further evaluation can be pursued with additional diagnostic approaches. Throughout all the following investigations described, it is essential that the physician creates an atmosphere of calm, empathy and responsiveness, so that the patient can cooperate openly and fully. It must be emphasized that there is no standard approach to investigating ED, and so it is essential to appreciate and understand the tests available to gain a successful outcome. The extent of investigation needs to be tailored to the individual's wishes. The following is a concise approach to initially managing the patient in the clinic setting, followed by a description of diagnostic studies currently available.

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Patient assessment

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Clinical history

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The clinical history is the most important part of the diagnostic evaluation of the patient with ED. ED may represent an early marker of cardiovascular disease and even depression, which can then be addressed appropriately (Montorsi et al., 2003a). The initial focus should address whether the patient does have ED, and not a dysfunction of libido, ejaculation or orgasm. Various questionnaires have been formulated to aid the physician in this manner, as well as determining its severity. The most commonly used is the International Index of Erectile Function (IIEF; Table 9.2).

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Table 9.2IIEF-5 scoring system (abridged version)

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