Family medicine
Erectile Dysfunction
Erectile dysfunction is the persistent inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Vasculogenic ED (atherosclerosis, HTN, DM) [1][2] | Gradual onset, absent morning erections, vascular RF present | 「你有冇糖尿、高血壓、高膽固醇？朝早有冇自然硬起嚟？」 |
| Psychogenic ED (performance anxiety, stress) | Sudden onset, situational, preserved morning erections | 「係咪某啲情況先有困難？自慰嗰陣OK唔OK？」 | |
| Serious Not To Miss | Pituitary tumour / prolactinoma | Headache, visual field defect, ↓libido, galactorrhoea | 「有冇頭痛、睇嘢矇咗、或者胸部流嘢出嚟？」 |
| Leriche syndrome (aortoiliac occlusion) [4] | Buttock claudication + absent femoral pulses + ED | 「行路嗰陣臀部有冇痛？」; check femoral pulses | |
| Prostate/pelvic malignancy (post-treatment) | Hx of surgery/radiation, LUTS, weight loss | 「有冇前列腺嘅問題或者做過手術？」 | |
| Pitfalls | Drug-induced ED | Temporal link with starting medication | 「你幾時開始食呢隻藥？同ED開始嘅時間夾唔夾？」 |
| Hypogonadism (primary or secondary) | ↓Libido, fatigue, ↓body hair, small/soft testes | 「有冇覺得成日攰、冇精神？鬚有冇少咗？」; examine testes | |
| Peyronie's disease | Penile curvature, palpable plaque, pain on erection | 「硬起嚟嗰陣有冇彎曲或者痛？」 | |
| Masquerades | Depression | Low mood, anhedonia, sleep disturbance, ↓libido | 「你最近有冇覺得做咩都冇興趣？瞓得好唔好？」 |
| Diabetes mellitus [2][7] | Polyuria, polydipsia, weight loss, known DM | 「有冇成日口渴、去廁所多咗、體重輕咗？」 | |
| Hypothyroidism | Fatigue, weight gain, cold intolerance, constipation | 「有冇覺得特別怕凍、體重重咗、便秘？」 | |
| Trying to Tell Me Something? | Marital/relationship crisis | Partner pressure, affair, loss of intimacy | 「你同伴侶嘅關係最近有冇變化？」 |
| Non-compliance with meds to preserve erections [3] | Stops antihypertensives intermittently | 「你有冇因為擔心影響性功能而停過藥？」 | |
| Fear of cancer / serious disease | Health anxiety | 「你有冇擔心呢個問題係因為嚴重嘅病？」 |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, build rapport, set agenda | 「你好，我係X醫生。今日有咩可以幫到你呀？」「多謝你嚟睇醫生，我哋傾下先。」 | Warm greeting + open question scores interpersonal marks; establishes trust for sensitive topic |
| 0:30–1:00 | Elicit chief complaint; let patient tell their story | 「你可唔可以講多少少，大概係咩情況呀？」「幾耐之前開始㗎？」 | Open-ended → patient leads; avoid jumping to assumptions |
| 1:00–2:30 | Symptom analysis & key history | 「你朝早瞓醒嗰陣有冇自然勃起呀？」(morning erections) 「係所有情況都有困難，定係某啲情況先有？」(generalised vs situational) 「有冇食緊咩藥呀？例如血壓藥、糖尿藥、情緒藥？」 | Discriminates organic vs psychogenic [1][2]; drug history is high-yield |
| 2:30–3:30 | Red flags, PMH, risk factors | 「有冇糖尿病、高血壓、高膽固醇呀？」「有冇心臟病或者做過手術？」「你有冇覺得心情差、壓力大呀？」「有冇飲酒或者食煙嘅習慣？」 | Screens vascular RF, depression masquerade, lifestyle factors |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得呢個情況係咩原因呢？」(Ideas) 「你最擔心嘅係咩呀？」(Concerns) 「你今日嚟睇醫生，最希望我可以點樣幫你呀？」(Expectations) 「點解揀咗今日嚟呢？」(Why today → hidden agenda) | ICE is directly tested on case report; "why today" uncovers hidden agenda (e.g. marital tension, fear of serious disease, partner pressure) |
| 4:30–5:15 | Social/functional impact, sexual/relationship Hx | 「呢個問題有冇影響你同太太/伴侶嘅關係？」「工作方面有冇受影響？壓力大唔大？」 | Biopsychosocial assessment; relationship impact is a key social problem |
| 5:15–5:45 | Summarise back, check understanding | 「等我總結一下⋯你嘅情況大概係⋯我有冇漏咗啲咩？」 | Shows active listening; corrects misunderstandings |
| 5:45–6:00 | Safety net & close | 「如果你突然覺得胸口痛或者心情好差，記得即刻嚟睇醫生。我哋之後會安排抽血檢查，下次覆診再傾。」 | Safe closure; addresses CV risk screening |
Uncovering the hidden agenda: The presenting symptom is ED, but the real reason for consultation may be: marital/relationship crisis, fear of prostate cancer, partner's pressure to conceive, non-compliance with antihypertensives to preserve erections [3], depression, or anxiety about masculinity. Always ask 「點解揀咗今日嚟呢？」 and 「有冇其他嘢想同我傾？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & duration | When did ED start? Gradual or sudden? | 「幾時開始有呢個問題？係慢慢嚟定突然間㗎？」 | Gradual → organic; sudden → psychogenic [1][2] | Organic vs psychogenic |
| Morning erections | Do you still get morning erections? | 「朝早瞓醒嗰陣有冇自然硬起嚟？」 | Preserved morning erections suggest psychogenic cause; absent suggests organic [2] | Psychogenic (preserved) vs organic (absent) |
| Situational vs generalised | Does it happen with all partners/situations or only certain ones? | 「係所有情況都有困難，定係某啲情況先有呢？例如自慰嗰陣OK唔OK？」 | Situational → psychogenic; generalised → organic [1] | Psychogenic if situational |
| Libido | Has your sex drive changed? | 「你對性方面嘅興趣有冇減少？」 | ↓Libido → hypogonadism, depression, hyperprolactinaemia | Endocrine cause, depression |
| Ejaculation | Any problems with ejaculation? | 「射精方面有冇問題？例如太快、太遲、或者射唔到？」 | Retrograde ejaculation (DM), premature ejaculation (anxiety) | DM autonomic neuropathy, anxiety |
| Relationship | How is your relationship with your partner? | 「你同太太/伴侶嘅關係點呀？」 | Relationship conflict is a major psychogenic cause | Psychogenic ED, hidden agenda |
| Mood/stress | Are you feeling low, stressed, or anxious? | 「你最近心情點呀？有冇覺得好大壓力或者唔開心？」 | Depression is a masquerade [2]; performance anxiety common | Depression, anxiety disorder |
| PMH – vascular RF | DM, HTN, hyperlipidaemia, IHD? | 「你有冇糖尿、高血壓、高膽固醇、心臟病？」 | Vascular disease is the commonest organic cause [1][2] | Vasculogenic ED |
| Drug history | What medications are you taking? | 「你而家食緊咩藥？有冇食血壓藥、情緒藥、胃藥？」 | Thiazides, β-blockers, SSRIs, antiandrogens can cause ED [2] | Drug-induced ED |
| Smoking & alcohol | Do you smoke or drink? | 「你有冇食煙飲酒嘅習慣？」 | Smoking → vasculogenic; alcohol → hypogonadism, neuropathy [5] | Vasculogenic, alcoholic neuropathy |
| Neurological Sx | Any numbness/tingling in hands/feet? Bladder problems? | 「手腳有冇痺或者冇感覺？小便有冇困難？」 | Peripheral/autonomic neuropathy (DM), spinal cord pathology | Neurogenic ED |
| Endocrine Sx | Visual changes? Headaches? Galactorrhoea? | 「有冇頭痛、睇嘢矇咗、或者胸部有液體流出？」 | Hyperprolactinaemia from pituitary tumour [6] | Prolactinoma |
| Claudication | Pain in buttocks/legs when walking? | 「行路嗰陣臀部或者腳有冇痛？」 | Leriche syndrome: buttock claudication + absent femoral pulses + ED [4] | Aortoiliac disease |
| Surgical Hx | Any pelvic/prostate surgery or radiation? | 「有冇做過前列腺手術或者盆腔手術？」 | Nerve damage → neurogenic ED | Iatrogenic neurogenic ED |
| Family Hx | Family history of DM, heart disease? | 「屋企人有冇糖尿病或者心臟病？」 | Identifies CV risk | Vascular RF |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Safety; mandatory for case report | — |
Case Report Form Answer Builder
- CC: Erectile dysfunction × [duration]
- HPI must include: onset (gradual/sudden), duration, severity (unable to achieve vs unable to maintain), presence/absence of morning erections, situational vs generalised, libido, ejaculation function, relationship context, vascular RF (DM/HTN/hyperlipidaemia/smoking), medications, mood, functional impact
- Examples: "Patient wants to know why he has difficulty achieving erection and seeks treatment" / "Patient came because wife is unhappy with sexual life" / "Patient worried ED is a sign of serious disease"
- Tip: Frame it as the patient's agenda, not the medical problem. Use "Why today?" to identify the best single answer.
| Likely Examples | Exact Wording | |
|---|---|---|
| Ideas | "I think it might be because of my diabetes/medication/age/stress" | "Patient thinks ED is due to his diabetes medications" |
| Concerns | "I'm worried it means I have a serious disease / my marriage is affected / I'm not a real man" | "Patient is worried that ED will ruin his marriage" |
| Expectations | "I want Viagra / I want blood tests / I want a referral" | "Patient hopes to receive medication (e.g. PDE5 inhibitor) to improve erections" |
- In primary care: Vasculogenic ED secondary to atherosclerotic risk factors (DM, HTN, hyperlipidaemia, smoking) [1][2]
- Minimum supporting evidence: gradual onset, absent morning erections, presence of vascular risk factors, no situational variation
- If history suggests sudden onset + preserved morning erections + situational → Psychogenic ED
| DDx | Key Discriminator |
|---|---|
| 1. Psychogenic ED | Sudden onset, situational, preserved morning erections, identifiable stressor |
| 2. Drug-induced ED | Temporal correlation with medication (β-blocker, thiazide, SSRI) [2] |
| 3. Hypogonadism (primary/secondary) | ↓Libido, fatigue, ↓body hair, small/soft testes; check testosterone |
| Domain | Problem |
|---|---|
| Biological | Underlying vascular risk factors (DM/HTN/hyperlipidaemia) inadequately controlled |
| Psychological | Performance anxiety / depression / low self-esteem secondary to ED |
| Social | Marital/relationship strain; possible medication non-compliance affecting BP control [3] |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Vasculogenic ED (most likely) | Absent/diminished peripheral pulses (dorsalis pedis, posterior tibial, femoral) | Palpate bilateral femoral, popliteal, dorsalis pedis, posterior tibial arteries | Indicates atherosclerotic peripheral arterial disease → same process affects penile arteries |
| Leriche syndrome | Absent bilateral femoral pulses [4] | Palpate femoral arteries at inguinal crease | Triad: buttock claudication + absent femoral pulses + ED |
| Hypogonadism | Small, soft testes | Palpate testes for size and consistency | Testicular atrophy suggests ↓testosterone production [6] |
| Psychogenic ED | No reliable physical sign in brief FM station | Normal cardiovascular and genital exam; diagnosis by history (preserved morning erection, situational) | Diagnosis of exclusion supported by normal examination |
| Drug-induced ED | No specific physical sign | Review medication chart; temporal link | Diagnosed by history and medication review, not examination |
| Hyperprolactinaemia | Bitemporal hemianopia (if macroadenoma) | Confrontation visual field testing | Pituitary macroadenoma compressing optic chiasm [6] |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to ask about morning erections — this is THE key discriminator between organic and psychogenic ED [2]
- Not asking about medications — β-blockers, thiazides, SSRIs, antiandrogens are common culprits [2]
- Missing the hidden agenda — patient may be non-compliant with antihypertensives to preserve erections [3]; partner may have pushed them to come
- Not exploring ICE — ICE is directly scored; always ask all three
- Labelling as "just psychological" — 50% of ED is organic; most patients need blood glucose, lipid profile, hormones, ECG [2]
- Forgetting depression screen — depression is both a cause and a consequence of ED
- Not checking vascular risk factors — ED is an early marker of cardiovascular disease; miss this = miss serious diagnosis
- Sudden onset ED + perineal/saddle anaesthesia + urinary retention → Cauda equina syndrome → Emergency referral
- ED + bitemporal hemianopia + headache → Pituitary tumour → Urgent MRI + endocrine referral
- ED + buttock claudication + absent femoral pulses → Leriche syndrome → Vascular surgery referral [4]
- ED + chest pain on exertion → IHD → Cardiology workup (note: do NOT prescribe PDE5 inhibitors with nitrates — absolute contraindication)
「我哋會安排抽血檢查糖尿、膽固醇、荷爾蒙，同埋做心電圖。如果你有胸口痛或者情緒好差，記得即刻返嚟。我哋下次覆診會同你商量治療方案。」
High Yield Summary
What to ASK: Morning erections (organic vs psychogenic), onset pattern, medications (β-blockers/thiazides/SSRIs), vascular RF (DM/HTN/HLD/smoking), mood, relationship, ICE, "why today?"
What to WRITE: CC with duration; gradual vs sudden onset; morning erections present/absent; vascular RF; medication list; ICE verbatim; most likely diagnosis = vasculogenic ED (or psychogenic if history fits); DDx = psychogenic / drug-induced / hypogonadism; biopsychosocial = uncontrolled vascular RF / performance anxiety or depression / marital strain; physical sign = absent peripheral pulses
What NOT to MISS: Morning erection question, medication-induced ED, depression masquerade, Leriche syndrome, non-compliance with antihypertensives [3], PDE5i-nitrate contraindication, cauda equina red flags
Active Recall - Family Medicine Clinical Test
[1] GC 184. Erection and erectile dysfunction.pdf (Classification of ED: organic vs psychogenic) [2] MBBS4 Sexual function t Dysf140824.pdf (Organic causes, psychogenic causes, morning erections as discriminator, investigations needed) [3] MBBS4 t Sexual problems in GP160925.pdf (Non-compliance with antihypertensives to protect erections, sex in HTN and DM) [4] MBBS Final MB (Surgery) (Felix PY Lai).pdf p932 (Leriche syndrome triad) [5] Ryan Ho GI.pdf p304, p312 (Alcohol-related hypogonadism/ED, cirrhosis endocrine changes) [6] Ryan Ho Endocrine.pdf p110 (Hyperprolactinaemia causing ED, hypogonadism) [7] Maksim Medicine Notes.pdf p89 (Diabetic autonomic neuropathy causing ED)
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