A 42-year-old man comes to the office with concerns about his sexual function. The patient reports an abrupt inability to participate in sexual intercourse for the past 2 months. He is variably able to achieve an erection during foreplay but is unable to maintain an erection sufficient to engage in intercourse. The patient reports normal sexual desire. He has been married for 4 years and says, "I am ready to start a family, but my wife is focused on her job right now and is not as excited as I am." Medical history is notable for hypertension, migraine headaches, and irritable bowel syndrome. Current medications include lisinopril and as-needed polyethylene glycol and ibuprofen. The patient does not use tobacco or illicit drugs and drinks 1 or 2 cans of beer on weekends. He exercises several times per week. Family history is notable for hypertension in his parents. Blood pressure is 124/68 mm Hg, pulse is 70/min, and BMI is 23 kg/m². Physical examination shows normal heart sounds. Extremities are warm and peripheral pulses are normal. The patient's genitalia and body hair distribution are normal. Visual fields are intact. Blood cell counts and serum chemistry are within normal limits. Which of the following is the best response and next step concerning this patient's symptoms?

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Explanation: 11ec2b69_bfd2_3ec7_8f63_3be61da3c685_MD0005_00 Normal male erectile function requires interplay between psychological and physical stimulation, and vascular, neurological, and hormonal systems. Causes of erectile dysfunction (ED) can be categorized as organic (eg, hypogonadism, arterial insufficiency, neurological impairment) or psychogenic. Psychogenic ED is typically due to interpersonal conflict, performance anxiety, or an underlying emotional disorder. Clinical factors suggesting a psychogenic etiology include sudden onset, situational ED (eg, ED with a certain partner but normal erectile function during masturbation), and persistence of nonsexual nocturnal erections. This patient's abrupt onset and underlying interpersonal conflict with his wife suggest a psychogenic cause, which should be pursued with a more detailed psychological assessment. (Choice A) Organic ED is often initially intermittent or slowly progressive and is more common with advancing age. Phosphodiesterase-5 inhibitors (eg, sildenafil) are first-line treatment for organic ED and are effective in most patients. However, this patient's symptoms are more consistent with a psychogenic cause, and a more detailed psychological assessment should be performed first. (Choice B) ED due to hypogonadism typically has a gradual rather than an abrupt onset. Libido is usually suppressed, and additional features (eg, testicular atrophy, loss of body hair) may also be present. (Choice C) Spinal MRI is useful for evaluating ED due to lumbosacral nerve root compression (eg, cauda equina syndrome, spinal stenosis). However, these patients typically have additional symptoms, such as back pain, leg weakness, or bowel and bladder dysfunction. (Choice D) Vascular imaging with duplex ultrasound or penile angiography is occasionally useful for evaluating organic ED due to impaired blood flow. However, this would be unlikely in a young nonsmoker with a normal vascular examination. Educational objective: Psychogenic erectile dysfunction is typically due to interpersonal conflict, performance anxiety, or an underlying emotional disorder. Clinical factors suggesting a psychogenic etiology include abrupt onset, situational symptoms, and persistence of nonsexual nocturnal erections. References: Erectile dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/27929275)

A 42-Year-Old Man Comes to the Office with Concerns About