Workup for Erectile Dysfunction
Begin with a detailed medical and sexual history focusing on onset, duration, severity, and distinguishing ED from ejaculatory or orgasmic disorders, followed by a focused physical examination and targeted laboratory testing including morning testosterone, fasting glucose/HbA1c, and lipid profile. 1
Initial History
The history is the most critical component of ED evaluation and should systematically address: 2
- Symptom characterization: Determine if the problem is truly erectile dysfunction versus premature ejaculation, delayed ejaculation, or orgasmic dysfunction 2
- Onset pattern: Sudden onset suggests psychogenic etiology, while gradual onset suggests organic causes 2
- Duration and severity: Establish chronology using validated tools like the Sexual Health Inventory for Men (SHIM) or International Index of Erectile Function (IIEF) 1, 3
- Situational factors: Presence of morning erections or ability to achieve erections with masturbation suggests psychogenic component 2
Critical Risk Factors to Assess
- Cardiovascular disease and risk factors: ED often precedes cardiovascular disease by approximately 3 years and serves as a sentinel marker for underlying vascular disease 1, 4
- Diabetes mellitus, hypertension, hyperlipidemia, and obesity 2, 1
- Medication review: Antidepressants, antihypertensives (especially beta-blockers), and tobacco use are common culprits 2, 5
- Pelvic trauma, surgery, or radiation: Including prostatectomy, pelvic fractures, or perineal injury 2
- Neurologic conditions: Spinal cord injury, multiple sclerosis, Parkinson's disease 2
- Psychiatric conditions: Depression, anxiety, relationship problems, body dysmorphic disorder, alcoholism 2
- Substance use: Tobacco, alcohol, recreational drugs 1
Partner and Relationship Assessment
- Evaluate partner's sexual function and relationship quality, as this impacts treatment selection and outcomes 2, 1
- Assess patient and partner expectations for therapy 2
Physical Examination
Perform a focused examination including vital signs (blood pressure), cardiovascular assessment (lower extremity pulses), and genital examination. 2
Key Examination Components
- Blood pressure measurement: Essential given cardiovascular associations 2
- Genital examination: 2
- Testicular size and consistency (evaluate for hypogonadism)
- Penile shaft palpation for fibrosis or Peyronie's plaques
- Foreskin retractability
- Urethral meatus placement
- Secondary sexual characteristics: Body hair distribution, gynecomastia (suggests hypogonadism) 2
- Lower extremity pulses: Assess for peripheral vascular disease 2
- Abdominal examination: When indicated by history 2
Additional cardiovascular, neurological, or endocrine examination should be performed when suggested by history or age 2
Laboratory Testing
Order morning serum total testosterone level for all men with ED, plus fasting glucose/HbA1c and lipid profile to evaluate cardiovascular risk factors. 1
Essential Tests
- Morning total testosterone level: Mandatory for all ED patients to identify hypogonadism 1
- Fasting glucose or HbA1c: Screen for diabetes mellitus 1, 4
- Lipid profile: Assess cardiovascular risk 1, 4
Additional Testing When Indicated
- Thyroid-stimulating hormone (TSH): When thyroid disorder suspected 4
- Prostate-specific antigen (PSA) and digital rectal examination: 2
- Offer annually to men over 50 with >10 year life expectancy
- Mandatory baseline before initiating testosterone replacement therapy
- Prolactin level: If hypogonadism or decreased libido present 2
Specialized Testing Requiring Referral
Refer to urology or sexual medicine specialist for: 2
- Young patients with lifelong ED
- History of pelvic or perineal trauma
- Abnormal findings on genital examination (testicular abnormalities, penile plaques)
- Abnormal initial screening tests
- Vascular or neurological assessment needs
- Nocturnal penile tumescence monitoring
Important Clinical Considerations
Cardiovascular Risk Assessment
ED is a risk marker for cardiovascular disease; consider cardiac evaluation, especially in men with multiple cardiovascular risk factors. 1, 4
- Men with ED have increased risk of coronary, cerebrovascular, and peripheral vascular disease 4
- Screen and optimize management of hypertension, diabetes, hyperlipidemia 1
Psychiatric Screening
Address psychiatric conditions before treating ED, as they may be primary contributors: 2
- Generalized anxiety, depression, psychosis
- Performance anxiety and relationship issues
- Body dysmorphic disorder, gender identity problems
- Alcoholism
Medication-Induced ED
Review all medications and consider alternatives when possible, as many drugs contribute to ED: 2, 5
- Antidepressants (especially SSRIs)
- Antihypertensives (beta-blockers, thiazides)
- Antipsychotics
- 5-alpha reductase inhibitors
Treatment Framework
Management begins with identifying and treating organic comorbidities and psychosexual dysfunction, followed by stepwise pharmacotherapy starting with oral PDE5 inhibitors. 2
First-Line Interventions
- Lifestyle modifications: Weight loss, increased physical activity, smoking cessation, moderate alcohol consumption 1
- Optimize management of diabetes, hypertension, hyperlipidemia 2
- Oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil): Most effective first-line treatment, successful in 60-65% of men including those with diabetes, hypertension, and spinal cord injury 2, 6, 7
Second-Line Options
When PDE5 inhibitors fail or are contraindicated: 2
- Intracavernosal injection therapy (alprostadil)
- Intraurethral alprostadil suppositories
- Vacuum erection devices
Third-Line Treatment
- Penile prosthesis implantation: For refractory cases, associated with high patient satisfaction 2, 7
Adjunctive Therapies
- Testosterone replacement: For documented hypogonadism, improves ED and libido but requires monitoring of hemoglobin, liver function, and PSA 1, 4
- Psychosexual therapy: Useful alone or combined with medical treatment, especially for psychogenic ED or relationship issues 2, 5
Critical Safety Considerations
- Absolute contraindication: PDE5 inhibitors are contraindicated with nitrate use (regular or intermittent) due to risk of severe hypotension 8
- Caution with alpha-blockers: Start PDE5 inhibitors at lowest dose in men taking alpha-blockers due to additive hypotensive effects 8
- QT prolongation: Avoid vardenafil in patients with congenital QT prolongation or taking Class IA/III antiarrhythmics 8