What is the initial diagnostic workup for erectile dysfunction?

Initial Diagnostic Workup for Erectile Dysfunction

The initial diagnostic workup for erectile dysfunction should include a comprehensive sexual and medical history, focused physical examination of vital signs and genitalia, and laboratory testing limited to morning total testosterone, fasting glucose/HbA1c, and lipid panel. 1

Comprehensive History Taking

The history is the most critical component of the initial assessment and should systematically address multiple domains 2:

Sexual History

• Document the specific nature of the erectile problem to distinguish it from other sexual dysfunctions such as premature ejaculation, orgasm difficulties, or penile curvature 2
• Assess onset pattern: sudden onset suggests psychogenic etiology, while gradual onset suggests organic causes 2, 3
• Evaluate the presence of nocturnal/morning erections and masturbatory erections, which when present suggest a psychogenic component 1
• Quantify symptom severity and degree of bother using validated questionnaires such as the Sexual Health Inventory for Men 1
• Assess relationship quality and consider interviewing the partner, as this may reveal contributing factors like vaginal dryness 2

Medical History and Risk Factors

• Screen for cardiovascular disease, diabetes mellitus, depression, and alcoholism as these are strongly associated with erectile dysfunction 1
• Identify additional risk factors including smoking, obesity, pelvic/perineal/penile trauma or surgery, neurologic disease, endocrinopathy, pelvic radiation therapy, and Peyronie's disease 1
• Review all current medications, particularly antihypertensives (beta-blockers, diuretics, ACE inhibitors), antidepressants (tricyclics, SSRIs), and tranquilizers, as these are commonly associated with erectile dysfunction 2

Psychosocial Assessment

• Evaluate for psychiatric problems including generalized anxiety, depressive illness, psychosis, body dysmorphic disorder, and alcoholism, as these should be addressed before treating erectile dysfunction 2
• Assess lifestyle factors including sexual orientation, relationship status, and major life events 2, 1

Focused Physical Examination

The physical examination should be limited to essential components unless history suggests specific abnormalities 2:

• Measure vital signs including pulse and resting blood pressure 1
• Perform genital examination to assess for penile skin lesions, urethral meatus placement/configuration, and testicular size abnormalities 2, 1
• Examine 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
• Check for retractable foreskin 2
• Digital rectal examination is not required specifically for erectile dysfunction but may be appropriate for prostate cancer screening in men over 50 with life expectancy greater than 10 years 1

Laboratory Testing

Initial laboratory workup should be limited and targeted 4:

• Measure morning serum total testosterone levels in all men with erectile dysfunction 1
• Obtain fasting glucose/hemoglobin A1c to screen for diabetes 2, 1, 4
• Measure serum lipid profile to identify cardiovascular risk factors 2, 1, 4
• Consider thyroid-stimulating hormone testing 4
• Additional specialized testing is generally not required for initial evaluation 1

When to Measure Additional Hormones

• If hypogonadism is suspected based on history or examination, measure free testosterone or androgen index rather than total testosterone alone 2
• For patients receiving hormone replacement therapy, obtain baseline prostate-specific antigen and perform rectal examination 2

Cardiovascular Risk Assessment

Erectile dysfunction should be recognized as a potential early marker of cardiovascular disease, as symptoms typically present three years earlier than coronary artery disease symptoms 4:

• Counsel all patients that erectile dysfunction may indicate underlying cardiovascular disease and other health conditions 1
• Evaluate and manage cardiac risk factors in all erectile dysfunction patients 2
• Cardiovascular risk assessment should be performed before initiating treatment, especially in sedentary men with multiple risk factors 1
• Categorize patients into low, intermediate, or high cardiovascular risk categories 2

When to Consider Specialized Testing or Referral

Most patients do not require specialized testing beyond the initial workup 1. However, referral or additional evaluation is indicated for:

• Young patients who have always had erectile difficulty 2
• Patients with history of trauma 2
• Patients with abnormalities of testes or penis found on examination 2
• Patients with abnormal initial screening tests 2
• Patients who do not respond to initial PDE5 inhibitor therapy may warrant specialized testing including nocturnal penile tumescence, penile Doppler ultrasound, bulbocavernosus reflex, or vascular/neurological assessment 2, 1
• Men with predominantly psychogenic erectile dysfunction may require referral to a mental health professional 1

Common Pitfalls to Avoid

• Do not fail to recognize erectile dysfunction as a cardiovascular disease risk marker 1
• Do not overlook medication review, particularly antihypertensives and antidepressants that commonly contribute to erectile dysfunction 1
• Do not ignore psychosexual factors that may contribute to or exacerbate the condition 1
• Do not perform extensive specialized testing in the initial evaluation, as history and physical examination with basic laboratory tests are sufficient for most patients 2, 4