"Doctor, I have a sexual problem"
Objectives
- Identify which component of the sexual response is altered before assuming a diagnosis.
- Recognize the clinical elements that point to an organic cause of erectile dysfunction.
- Relate erectile dysfunction to cardiovascular and metabolic risk factors.
- Understand that erectile dysfunction does not automatically equal testosterone deficiency.
- Outline a stepwise treatment strategy, including what to do if first-line therapy fails.
Defining the problem
Chief complaint: "For a few months now I haven't been performing the same sexually".
He is married, in a stable relationship, and reports that the problem began approximately 8 months ago. He finds it hard to talk about it and cannot clearly define which aspect of his sexuality is altered.
What is the best initial approach?
What should we ask?
The term "sexual dysfunction" is very broad. We need to determine whether the patient mainly has:
- decreased sexual desire;
- difficulty achieving an erection;
- difficulty maintaining it;
- ejaculatory disorders;
- orgasm-related problems;
- penile pain or deformity;
- emotional or relationship difficulties.
More information emerges
He maintains sexual desire and can reach orgasm. He reports no significant ejaculatory disorders. At first the problem occurred occasionally; over the last few months it has become more frequent and now occurs in most sexual encounters.
What is now the most likely syndromic diagnosis?
Organic or psychogenic?
- he occasionally has morning erections, although less often than before;
- the problem also occurs during masturbation;
- he does not identify any major conflict with his partner;
- it did not begin after a traumatic sexual episode;
- the decline has been gradual.
Which interpretation is most appropriate?
Important concept
The old rigid distinction between "organic" and "psychological" erectile dysfunction may be too simplistic. Many patients have mixed components. Gradual onset, the problem occurring in different sexual situations, and decreased spontaneous erections justify investigating organic factors.
The medical history emerges
- has had hypertension for 7 years;
- is overweight;
- gets little physical activity;
- smokes approximately 10 cigarettes a day;
- had elevated blood glucose at a previous check-up;
- has no history of pelvic surgery;
- reports no neurological disease.
Why is this history important?
The case takes on a new dimension
What should the physician explain to him?
Erectile dysfunction shares numerous risk factors with cardiovascular disease. For this reason, especially when it appears in a man with risk factors, the visit is an opportunity to assess his cardiovascular and metabolic health.
Initial evaluation
In addition to the medical and sexual history, the following should be considered:
- blood pressure;
- weight and BMI;
- genital examination;
- cardiovascular assessment;
- blood glucose or HbA1c;
- lipid profile;
- morning total testosterone when appropriate;
- other tests according to history and findings.
The IIEF-5 questionnaire can be used to quantify erectile function.
Clinical pearl
A visit for erectile dysfunction can be the gateway to detecting previously unknown cardiovascular risk factors.
Testosterone
What is the correct answer?
Treatment
What would be a reasonable initial strategy?
Treat the patient
- smoking cessation;
- physical activity;
- weight loss when appropriate;
- blood pressure control;
- metabolic control;
- treatment of diabetes and dyslipidemia if present.
Treat the erection
PDE5 inhibitors are usually the first-line pharmacological option:
- sildenafil;
- tadalafil;
- vardenafil;
- avanafil.
⚠️ Alert
PDE5 inhibitors are contraindicated with nitrates because of the risk of severe hypotension.
What if he does not respond?
Does this mean there are no more alternatives?
Before declaring a PDE5 inhibitor a failure, you must confirm that it was used correctly.
Final result
What should you take away from this case?
- "I have a sexual problem" is not a diagnosis: first identify which function is altered — desire, erection, ejaculation, orgasm, or pain/deformity.
- Preserved desire + persistent difficulty maintaining the erection → erectile dysfunction.
- A rigid separation between organic and psychogenic causes is simplistic; many patients have mixed components.
- Hypertension + smoking + overweight + metabolic abnormality → think of vascular factors and cardiovascular risk.
- Erectile dysfunction can be the gateway to detecting undiagnosed cardiovascular risk.
- Erectile dysfunction does not automatically equal testosterone deficiency; testosterone should not be prescribed without prior evaluation.
- Treat the erection + evaluate and treat the patient comprehensively, with second- and third-line options available if first-line therapy fails.