The physical examination specifically looks for signs of vascular insufficiency. Those individuals with a primarily psychological cause to their erectile dysfunction will usually be quick to say they still have early morning erections most of the time.

Those individuals with physical contributory factors to their erectile dysfunction usually will have a diminished, if not absent, early morning erection. Questions regarding the early morning erections, that are present in all potent men, are helpful also in distinguishing psychological and physical problems. Ejaculation dysfunction along with erectile dysfunction often is seen in patients with primarily a psychological etiology. Patients with significantly depressed libido will need examination of their blood testosterone level. Decreased libido may be either primary, due to a decrease in the level of testosterone, or secondary to the erectile dysfunction itself, with the patient preferring to avoid the "fear of failure."

Most patients who come into a urologist's office with erectile dysfunction complaints are over the age of 40 and are stable individuals with the same sexual partner for over 20 years, with good support from their wife or sexual partner. Regardless of how successfully we as urologists or primary care physicians can restore a male patient's erection, if the relationship with his partner is in terrible shape, the couple will still have a very unsatisfactory sex life. Now that Viagra is available as a safe, oral agent that works in a broad spectrum of patients with various physical causes, our main purpose in the psychosexual history is to identify those individuals whose erectile dysfunction has a primarily psychological cause. The psychosexual history is by far the most important part of the history in determining the course of therapy. A history of curvature of the penis, suggestive of Peyronie's disease, a history of alcohol or drug abuse, or a history of significant vascular disease involving coronary arteries or arteries to the lower extremities or carotid arteries helps establish a systemic problem with vascular-occlusive disease. A history of risk factors for vascular disease and risk factors for impotence, such as cigarette smoking or a history of elevated blood cholesterol levels, also helps in determining that the patient's problem is primarily physical rather than primarily psychological. Meanwhile, in those individuals with a normal libido, the blood testosterone level would be of little value.