the exact nature of the erectile dysfunction to try and determine aetiology and whether psychological assessment would be appropriate. Generally though, a chronic history of worsening erectile dysfunction not associated with excess alcohol suggests an organic diagnosis. Obesity, cigarette smoking and excess alcohol consumption are all likely to contribute to erectile dysfunction of whatever cause.

Suggested practice is to assess serum prolactin, thyroid stimulating hormone and crea-tinine, as well as routine biochemistry for lipid profile, liver function tests, electrolytes, a full blood count and glycosylated haemoglobin. If a hormonal aetiology is identified, it should be specifically addressed.

Otherwise, an oral PDE-5 inhibitor would be first-line therapy if there were no contraindications. Lower doses may be less effective in men with diabetes and the patient should be encouraged to persevere and try higher doses of the initial agent. If the first agent is unsuccessful, an alternative PDE-5 inhibitor can be tried but is not usually successful. Second-line treatments, such as transurethral/intracavernosal alprostadil, sublingual apomorphine or use of vacuum tumescence devices, can then be tried—usually deter-

A full history and examination must be taken to identify comorbidities—particularly cardiac status—and current treatments. This should be coupled with a frank discussion of mined by patient preference. Consulting experience suggests second-line treatments are often disappointing and it is important not to raise expectations falsely .

If treatment for erectile dysfunction is not satisfactory, it is important to broach emotional and psychological well-being in the consultation. Permanent erectile dysfunction can be devastating for some men—and for some relationships.

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