LH and FSH are measured if testosterone is low. Prolactin is measured if testosterone is low or if there is loss of libido. If testosterone treatment is contemplated PSA and a rectal examination should be performed as a baseline. Testosterone should not be used in eugonadal men as it may promote the growth of occult prostatic cancer. Patients who should be referred on for specialist opinion include young patients who have always had difficulty, patients with a history of trauma or patients with genital abnormalities.
Appropriate advice is given about the correction of underlying risk factors.
As sexual activity carries a degree of cardiovascular risk it is advisable to assess cardiovascular status before initiating treatment. Patients with a sizeable psychogenic component should be referred for psychosexual counselling. If this serviee is readily available patients with purely psychogenic ED should not initially be offered alternative treatments. However, the short term use of pharmacological agents may be a useful adjunct. Young men with androgen deficiency should be referred.