What is the initial workup and lab evaluation for a patient presenting with erectile dysfunction?

Initial Workup and Lab Evaluation for Erectile Dysfunction

For patients presenting with erectile dysfunction, the initial workup should include a thorough medical, sexual, and psychosocial history, a targeted physical examination, and selective laboratory testing including morning serum total testosterone, fasting blood glucose, HbA1c, and lipid profile. 1, 2

Comprehensive History

• Obtain detailed medical history focusing on age, comorbid conditions (cardiovascular disease, diabetes, depression), prior surgeries, medications, family history of vascular disease, and substance use 1
• Assess sexual history including onset of symptoms (gradual vs. sudden), symptom severity, degree of bother, ability to attain and/or maintain erections, situational factors, presence of nocturnal/morning erections, and prior treatments 1
• Evaluate psychosocial factors including relationship status, partner's sexual function, and quality of relationship 1
• Use validated questionnaires such as the International Index of Erectile Function or Sexual Health Inventory for Men to objectively assess ED severity 1, 2

Physical Examination

• Measure vital signs including pulse and blood pressure 1
• Perform genital examination to assess for penile skin lesions, urethral meatus placement, and occult deformities or plaque lesions 1
• Examine for secondary sexual characteristics and signs of hypogonadism 1, 2
• Evaluate lower extremity pulses to assess vascular status 1

Essential Laboratory Testing

• Morning serum total testosterone (measure before 10 AM due to diurnal variation) 1, 2
• Fasting blood glucose and HbA1c to screen for diabetes 1, 2
• Lipid profile (total cholesterol, HDL, LDL, triglycerides) to assess cardiovascular risk 1, 2

Additional Testing Based on Clinical Presentation

• Consider free or bioavailable testosterone if hypogonadism is suspected based on history or examination 2
• Prostate-specific antigen (PSA) and digital rectal examination should be considered in men over 50 with estimated life expectancy >10 years, and are essential if testosterone replacement therapy is being considered 1, 2

Specialized Testing for Select Patients

• For patients who do not respond to first-line therapies, additional specialized testing may be necessary 1, 2
• These tests may include penile Doppler ultrasound, bulbo-cavernosus reflex testing, dorsal sensory nerve conduction studies, and nocturnal penile tumescence and rigidity assessment 1, 2

Clinical Considerations and Potential Pitfalls

• Counsel patients that ED is a risk marker for underlying cardiovascular disease and other health conditions that warrant evaluation 1
• Recognize that ED may be the first presenting symptom of diabetes or cardiovascular disease 2, 3
• Consider referral to a mental health professional to address psychological factors, reduce performance anxiety, and improve treatment integration into relationships 1, 4
• Remember that testosterone levels should be measured in the morning due to diurnal variation 2
• Laboratory results should always be interpreted in conjunction with the patient's comprehensive history and physical examination findings 2, 5