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8 Animal studies have demonstrated both smooth-muscle disruption and decreased production of neural nitric oxide synthase in cigarette-exposed animals.

Some evidence exists to suggest that chronic inflammation associated with metabolic syndrome also plays a role in endothelial dysfunction and erectile function, possibly due to oxidative stress. Examples of common neurologic conditions that can lead to ED include cerebral vascular accident, multiple sclerosis, Parkinson’s disease, and spinal cord injury. Microvascular disease associated with diabetes is thought to compound the endothelial and neural injuries associated with this disease.

Pelvic surgery may disrupt both neural and vascular pathways, resulting in ED. Hormone deficiency or hypogonadism, whether primary or secondary, has been thought to impact erectile function.

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11 Hormone deficiency, however, is less frequently the cause of ED than diabetes or vascular disease. Many entities with a strong relationship to ED also diminish bioavailable testosterone, including obesity, diabetes, and opioid use.

Other hormones involved in testosterone metabolism or availability, like thyroid stimulating hormone and gonadotropins, also may impact erectile quality, presumably through regulating bioavailable testosterone. Understanding the relationship between testosterone and ED has been impaired by a lack of standardized measurement of this hormone and the cyclic nature of its release and consumption. Some self-administered measures may be useful in the primary care setting to screen for and evaluate the degree of ED. 12 The most commonly used instrument is the International Index of Erectile Function, a 15-item questionnaire that has been validated in many populations and is considered the gold standard to evaluate price of sildenafil at walmart patients for ED.

13 The Sexual Health Inventory for Men is a short-form, 5-item questionnaire developed to monitor treatment progress.

12 It is important to recognize that short-form questionnaire does not evaluate specific areas of the sexual cycle, such as sexual desire, ejaculation, and orgasm; however, it may be useful in discussing ED with patients and evaluating treatment results over time. If it cvs price for sildenafil is determined that ED is a problem, the patient evaluation should include a detailed sexual and medical history and a physical exam.

In particular, it is important to evaluate the ED within the context of ejaculatory problems.

There is a strong interplay between premature ejaculation (PE) and ED, with about a third of ED patients reporting PE.

The relationship between the PE and ED is bidirectional and successful treatment of one often requires treatment of the other. A number of specific questions relating to sexual function can help the clinician evaluate the complaint of ED.

Questions should focus on the following: How long has ED been a problem, and did it start gradually or suddenly? How frequently do you have intercourse currently, and how frequent was it in the past? Do you have difficulty with penetration and/or loss of the erection during intercourse in the absence of premature ejaculation? How firm are your erections (use a scale of 1 to 10)?

Do your erections vary under different circumstances, such as with different partners, oral stimulation, or masturbation?

Do you have morning or evening erections and, if so, what is the quality of these erections?

Is there any new curve or bend to your penis to suggest Peyronie’s disease?

What are the location and severity of the curvature? Are you having any difficulties with sexual desire, arousal, ejaculation, or orgasm?

If so, did these difficulties occur with the onset of the erectile dysfunction or are they separate issues? Once questions related to the specific erectile complaint have been reviewed, additional questions relating to medical history and psychosocial factors need to be evaluated. In particular, these include the following: symptoms suggesting the presence of diabetes, peripheral vascular disease, neurologic disease, or chronic liver or kidney disease; a complete list of medications and recreational drugs, including over the counter “prostate supplements” which may have anti-androgen effects and questions

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Careful peripheral vascular examination that includes palpation of the lower extremity pulses as well as auscultation for bruits in the abdominal and femoral regions.

Detailed neurologic examination to include gait and postural instability, with blood pressure changes, distal extremity and saddle sensation, and reflexes, including cremasterics and bulbocavernosus.

Careful genital examination, noting testicular size (to screen for hypogonadism) and palpating the penis for Peyronie’s plaques. Rectal examination to assess sphincter tone and evaluate the prostate. Careful abdominal examination looking for organomegaly masses or other signs of liver or kidney disease.