Physical examination is often of great importance in clarifying suspected etiologies. Start with a general examination, and keep in mind some of the vascular, endocrinological, and neurological causes of ED. Assess the degree of androgen-ization checking for body hair and any evidence of gynecomastia. Examine the genitalia carefully for any abnormalities. Check whether the foreskin can be retracted, and look for conditions such as phimosis or balanitis. Deep palpation of the penis can reveal fibrotic thickening (Peyronie's plaques) in a proportion of men presenting to sexual dysfunction clinics. Cremasteric and bulbocavernous reflexes should be elicited as well as saddle sensation and deep tendon reflexes of the legs. The size and consistency of the testicles should be assessed. If urinary symptoms are present, rectal sphincter tone and prostatic examination are necessary. Cardiovascular risk assessment should be undertaken [see Appendix and Jackson et al. (17)].
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