1. In patients, specifically pregnant women, adolescents, and perimenopausal women:

    1. Inquire about sexuality (e.g., normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction).

    2. Counsel the patient on sexuality (e.g., normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction).

  2. Screen high-risk patients (e.g., post-myocardial infarction patients, diabetic patients, patients with chronic disease) for sexual dysfunction, and screen other patients when appropriate (e.g., during the periodic health examination).

  3. In patients presenting with sexual dysfunction, identify features that suggest organic and non-organic causes.

  4. In patients who have sexual dysfunction with an identified probable cause, manage the dysfunction appropriately.

  5. In patients with identified sexual dysfunction, inquire about partner relationship issues.

Men - Erectile Dysfunction

  • Definition:

    • Persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3 months


    • Consider validated assessment tools:

      • Erection Hardness Scale (EHS)

      • Sexual Health Inventory of Men (SHIM)

      • International Inventory of Erectile Function (IIEF)

    • Sexual history

      • Partner/preferences/contraception

      • Desire/libido

      • Opportunity

      • Obtaining/maintaining erections

      • Orgasm, Ejaculation, Pain

    • Cardiac risk factors (smoking, diabetes, hypertension, obesity, hyperlipidemia)

      • PVD: Claudication during activity or decreased thigh muscle strength or size

    • Drugs (alcohol, cocaine)

    • Medication (antidepressants, antihypertensives)

    • Psychogenic

      • Nocturnal/morning erections

      • Erections during masturbation or with alternate partners

      • Situational variability (eg. improved while on vacation)

      • Psychosocial stressors, partner relationship

      • Concern about poor sexual function (performance anxiety)

      • Previous traumatic sexual experience

      • Depression

    • Ejaculatory disorders (premature ejaculation and other abnormalities)

    • Hypogonadism, disorders of orgasm

    • Peyronie’s disease

    • Spinal cord injuries, pelvic and prostate surgery/trauma/radiation

Physical Exam

    • Vitals (blood pressure), ABI

    • Gynecomastia

    • Genital exam

      • Decreased male hair distribution

      • Peyronie's disease

      • Small testes

    • Peripheral vascular exam

      • Abdominal, femoral bruits

      • Peripheral pulses

    • Neurologic

      • Pelvic sensation

      • Anal sphincter tone

      • Prostate Exam


  • HbA1c, Lipids

  • Consider morning Testosterone in hypogonadism, young age, or suspect libido/ejaculatory disorder

    • If low, confirm with free or bioavailable testosterone and sex hormone binding globulin (SHBG) levels

      • If low testosterone, do prolactin (pituitary) and LH (testicular failure)

        • Prolactin high, consider pituitary imaging and referral

        • LH and FSH high (testicular failure), consider testosterone replacement therapy if no prostate cancer (consider DRE and PSA in age >45yo)

  • Consider CBC, electrolytes (glucose, renal), LFT, TSH

  • Urinalysis


  • Treat underlying medication condition (medication adherence)

  • Lifestyle modification (stop smoking, weight loss if overweight)

  • Medication review

  • If psychogenic cause suspected consider sex therapy/psychiatric referral AND/OR trial of medical therapy

  • If neurogenic or vasculogenic causes suspected consider trial of medical therapy


  • Education, discuss risks/benefits of treatments

  • Contraindicated if using nitrates (eg. nitroglycerin), severe CHF, unstable angina, hypotension, recent stroke/MI

  • Phosphodiesterase type-5 inhibitors (PDE5-inhibitors)

    • Sildenafil (Viagra) 25, 50, 100 mg once daily 1 hour before sexual activity PRN

    • Tadalafil (Cialis) 5, 10, 20mg PO PRN or daily

      • Half life 18h, may also improve voiding symptoms

    • Vardenafil (Levitra)

  • Refer for the following:

    • Failed medical therapy

      • Second-line: Intraurethralalprostadil, intracavernosal vasodilator injection, vacuum erection pump device

      • Third-line: Penile prosthesis

    • Significant penile anatomic disease

    • A younger patient with a history of pelvic or perineal trauma

    • Cases requiring vascular or neurological assessment

    • Complicated endocrinopathies

    • Complicated psychiatric or psychosocial problems

    • Patient or physician desire for further evaluation

    • Follow-up with patients after treatment is initiated to evaluate progress and monitor therapy (e.g., testosterone as above)

      • Monitoring on testosterone

        • Surveillance for prostate cancer (yearly rectal examinations and PSA)

        • Detection of polycythemia (measuring hematocrit every six to 12 months)

          • Decrease testosterone dose if hematocrit rises above the normal range



  • Sexual history as above (Partners/preferences/contraception)

  • Sexual health concerns

    • Desire/interest

    • Ability to become or stay sexually aroused?

    • Ability to experience/reach the desired intensity of an orgasm?

  • Genital pain

    • Vaginal dryness or burning (genitourinary syndrome of menopause)

    • Dyspareunia (vaginismus, vulvodynia, vulvar vestibulitis)

      • Where is the pain located?

      • Pain before genital touch (vulvodynia, anxiety)

      • Pain during deep thrusting (pelvic floor muscle dysfunction, PID, endometriosis)

      • Pain after sex (vestibulodynia, vulvar fissures, dermatoses)

      • Pain during non-sexual times (vulvodynia, pelvic flood dysfunction, pudendal neuralgia)

  • Relationships

  • History of sexual abuse

  • Menopause

  • Depression/anxiety

  • Medications (antidepressants)

Physical Exam

  • Confirm normal pelvic anatomy

  • Evaluate for tenderness, legions, prolapse, vulvovaginal atrophy, discharge/bleeding


  • Depending on history/physical exam, consider

    • Pelvic ultrasound

    • STI screen

    • CBC, TSH, prolactin

  • Testosterone, and other hormones no utility


  • Sex therapist or psychotherapist

    • CBT, mindfulness-based interventions

  • Vaginal lubricants, moisturizers, estrogen therapy, ospemifene

  • Directed masturbation for lifelong anorgasmia


  • Female genital sexual pain disorders (vaginismus, dyspareunia)

    • Pelvic physical therapists

    • Multidisciplinary approach

  • Sexual dysfunction secondary to antidepressant

    • Consider Buproprion or Sildenafil (Viagra) as adjunct

  • Menopause

    • Local vaginal estrogen for genitourinary syndrome of menopause

    • Transdermal testosterone +/- HRT has been effective for short-term low sexual desire

Age of Consent (CMPA)

  • 18 years for exploitative (prostitution, pornography or relationship of trust, authority or dependency)

  • 16 years for non-exploitative

  • 14 years up to 5 years older

  • 12 years up to 2 years older