What is the recommended workup for a 32-year-old male with sexual performance issues?

Comprehensive Workup for Sexual Performance Issues in a Young Male

A 32-year-old male with sexual performance issues should undergo a thorough medical, sexual, and psychosocial history, physical examination, and selective laboratory testing including morning serum total testosterone levels to identify the underlying cause and guide appropriate treatment. 1

Initial Assessment

Medical and Sexual History

• Detailed description of the sexual performance problem:
  • Onset (sudden vs. gradual)
  • Severity and degree of bother
  • Whether problem involves attaining and/or maintaining an erection
  • Presence of nocturnal/morning erections (suggests psychogenic component)
  • Presence of masturbatory erections
  • Situational factors (specific contexts or partners)
  • Prior use of erectogenic therapy 1

Psychosocial History

• Screen for psychological factors:
  • Anxiety, depression, relationship issues
  • Major life events or stressors
  • Substance use (alcohol, recreational drugs)
  • Performance anxiety 1

Medical History Review

• Comorbid conditions: cardiovascular disease, diabetes, hypertension, hyperlipidemia
• Medications that may affect sexual function
• Family history of vascular disease
• Lifestyle factors: smoking, alcohol consumption, physical activity 1

Physical Examination

General Examination

• Vital signs including blood pressure and pulse
• Body habitus and secondary sex characteristics 1

Genital Examination

• Penis: skin lesions, urethral meatus placement/configuration
• Stretched penile examination to check for occult deformities or plaque lesions (Peyronie's disease)
• Testicular size and consistency
• Presence and consistency of vasa and epididymides
• Check for varicocele 1

Laboratory Testing

Essential Tests

• Morning serum total testosterone level (mandatory) 1
• Fasting glucose or HbA1c
• Lipid profile 1, 2

Additional Tests (Based on Initial Findings)

• If testosterone is low: luteinizing hormone (LH), follicle-stimulating hormone (FSH)
• If cardiovascular risk factors present: additional cardiac workup
• If ejaculatory issues present: post-ejaculatory urinalysis (for retrograde ejaculation) 1

Specialized Testing (If Indicated)

• Validated questionnaires: Sexual Health Inventory for Men (SHIM), Erection Hardness Score 1
• For suspected vascular issues: penile Doppler ultrasound
• For suspected anatomical issues: scrotal ultrasound 1

Important Considerations

Cardiovascular Risk Assessment

• ED is a risk marker for underlying cardiovascular disease
• Assess exercise capacity (ability to walk 1 mile in 20 minutes or climb 2 flights of stairs in 20 seconds)
• Consider cardiology referral if unable to perform these activities 1

Psychological Component

• Even with organic causes, psychological factors often contribute
• Consider referral to mental health professional to address performance anxiety and relationship issues 1

Common Pitfalls to Avoid

• Failing to measure testosterone levels, which should be done for all men with ED 1
• Overlooking psychological factors, which frequently coexist with organic causes 1
• Neglecting to assess cardiovascular risk, as ED may be an early marker of cardiovascular disease 1
• Not using validated questionnaires to objectively assess severity and track treatment response 1
• Focusing only on erectile function while ignoring other aspects of sexual health (desire, ejaculation, satisfaction) 3

This structured approach ensures comprehensive evaluation of the young male with sexual performance issues, addressing both physical and psychological factors that may contribute to the condition, and providing a foundation for effective treatment planning.