What is the initial workup for erectile dysfunction?

Initial Workup for Erectile Dysfunction

The initial workup for erectile dysfunction should include a comprehensive sexual, medical, and psychosocial history, focused physical examination, and laboratory testing including morning serum total testosterone levels. 1

History Taking Components

• Sexual history: Identify onset of symptoms (sudden vs. gradual), symptom severity, degree of bother, difficulty with attaining and/or maintaining erections, situational factors, presence of nocturnal/morning erections, and prior treatments 1
• Medical history: Assess age, comorbid conditions (cardiovascular disease, diabetes, hypertension), prior surgeries, medications, family history of vascular disease, and substance use 1
• Psychosocial factors: Evaluate relationship status, quality of relationship with partner, psychological conditions (depression, anxiety), and major life events 1
• Medication review: Identify medications associated with ED, particularly antihypertensives, tranquilizers, antidepressants, and recreational drugs 1

Physical Examination

• Vital signs: Blood pressure and pulse 1
• Genital examination: Assess for penile skin lesions, urethral meatus placement, occult deformities or plaque lesions (Peyronie's disease), and testicular size 1
• Secondary sexual characteristics: Evaluate for signs of hypogonadism 1
• Cardiovascular assessment: Check lower extremity pulses 1

Laboratory Testing

• Essential laboratory tests:

  • Morning serum total testosterone level (recommended for all men with ED) 1
  • Fasting glucose or hemoglobin A1c 1, 2
  • Lipid profile 1, 2

• Additional testing (when indicated based on history and examination):

  • Thyroid-stimulating hormone 2
  • Prostate-specific antigen (particularly if considering testosterone therapy) 1
  • Free testosterone or androgen index (if hypogonadism is suspected) 1

Special Considerations

• Cardiovascular risk assessment: ED is a risk marker for underlying cardiovascular disease and should prompt evaluation of cardiovascular risk factors 1, 2
• Psychological evaluation: Consider referral to mental health professional for psychological factors that may be contributing to ED or to promote treatment adherence 1, 3
• Specialized testing: For select patients who don't respond to initial therapy, additional testing may include vascular assessment, neurological testing, or nocturnal penile tumescence evaluation 1, 4

Clinical Pearls and Pitfalls

• Sudden onset of ED often suggests psychogenic causes, while gradual onset typically indicates organic etiology 1, 4
• The presence of morning or nocturnal erections suggests (but does not confirm) psychogenic ED 1, 5
• Digital rectal examination is not required for ED evaluation but may be indicated in men over 50 years for prostate cancer screening 1
• Validated questionnaires like the International Index of Erectile Function or Sexual Health Inventory for Men can help initiate discussion and objectively assess severity 1
• ED often precedes symptoms of coronary artery disease by approximately three years, making it an important early warning sign 2, 6