Initial Diagnostic Workup for Erectile Dysfunction
The initial diagnostic workup for erectile dysfunction should include a thorough medical, sexual, and psychosocial history, a focused physical examination, and selective laboratory testing including serum total testosterone measurement. 1
Comprehensive History Taking
- Obtain a detailed medical history focusing on cardiovascular disease (hypertension, atherosclerosis, hyperlipidemia), diabetes mellitus, depression, and alcoholism 1
- Assess for risk factors including smoking, pelvic/perineal/penile trauma or surgery, neurologic disease, endocrinopathy, obesity, pelvic radiation therapy, Peyronie's disease, and medication use 1
- Document sexual history including onset of symptoms (gradual vs. sudden), symptom severity, degree of bother, and ability to attain and/or maintain erections 1, 2
- Distinguish ED from other sexual dysfunctions such as premature ejaculation or orgasm issues 1
- Evaluate for presence of nocturnal/morning erections and masturbatory erections, which may suggest psychogenic etiology if present 1
- Assess lifestyle factors including sexual orientation, relationship status, and quality of relationship with partner 1
- Consider using validated questionnaires such as the Sexual Health Inventory for Men to assess severity and guide treatment 1, 3
Focused Physical Examination
- Measure vital signs including pulse and resting blood pressure 1, 3
- Perform genital examination to assess for penile skin lesions, urethral meatus placement/configuration, and occult deformities 1
- Examine the penis for Peyronie's disease by stretching the penis and palpating from pubic bone to coronal sulcus 1
- Evaluate secondary sexual characteristics and lower extremity pulses 1
- Digital rectal examination is not required specifically for ED evaluation but may be appropriate for men over 50 with life expectancy >10 years for prostate cancer screening 1
Laboratory Testing
- Measure morning serum total testosterone levels in all men with ED 1, 3
- Consider fasting glucose/hemoglobin A1c and serum lipids to identify cardiovascular risk factors 1, 3
- Thyroid-stimulating hormone testing may be appropriate in selected cases 3, 4
- Additional specialized testing is generally not required for initial evaluation 1, 5
Special Considerations
- Counsel patients that ED may be a risk marker for underlying cardiovascular disease and other health conditions 1, 6
- Consider cardiovascular risk assessment before initiating treatment, especially in sedentary men with multiple risk factors 1, 6
- For men with predominantly psychogenic ED, consider referral to a mental health professional 1
- Specialized testing (vascular and/or neurological assessment, monitoring of nocturnal erections) may be indicated in select patients who don't respond to initial therapy 1
Common Pitfalls to Avoid
- Failing to recognize ED as a potential early marker of cardiovascular disease 6, 3
- Not reviewing current medications that may contribute to ED, particularly antihypertensives like beta blockers and diuretics 6
- Overlooking psychosexual factors that may contribute to or exacerbate ED 1, 2
- Performing unnecessary extensive laboratory testing when a focused approach is sufficient 3, 7