What is the initial workup and treatment for erectile dysfunction?

Erectile Dysfunction Workup

Begin with a detailed sexual, medical, and psychosocial history focusing on symptom onset (sudden versus gradual), presence of morning erections, cardiovascular risk factors, current medications, and substance use, followed by a focused physical examination of blood pressure and genitalia, and obtain morning total testosterone, fasting glucose/HbA1c, and lipid panel as your initial laboratory workup. 1

History Taking

The history is the most critical component of ED assessment and should distinguish between psychogenic and organic causes 2:

Psychogenic features suggesting non-organic ED:

• Sudden onset of symptoms 2
• Early collapse of erection during intercourse 2
• Preserved quality morning, spontaneous, or self-stimulated erections 2
• Associated premature ejaculation or inability to ejaculate 2
• Recent relationship problems or major life stressors 2

Organic features suggesting vascular, neurologic, or endocrine causes:

• Gradual onset over time 2
• Complete lack of tumescence in all situations 2
• History of diabetes, hypertension, dyslipidemia, or cardiovascular disease 1, 3
• Prior pelvic surgery, radiotherapy, or trauma 2
• Current use of medications associated with ED (antihypertensives, antidepressants, antipsychotics) 2
• Heavy smoking, alcohol consumption, or recreational drug use 2

Critical psychiatric screening: Rule out generalized anxiety, depression, psychosis, body dysmorphic disorder, gender identity problems, and alcoholism before initiating ED treatment, as these require primary psychiatric management 2

Physical Examination

Perform a focused examination including: 2

• Blood pressure measurement (screen for hypertension) 2
• Genital examination checking for testicular size abnormalities, penile fibrosis or plaque (Peyronie's disease), and retractable foreskin 2
• Extended cardiovascular, neurological, and endocrine examination only if indicated by history or age 2

Laboratory Investigations

Obtain these baseline tests for all men with ED: 1

• Morning serum total testosterone level (essential for all patients) 1
• Fasting glucose or HbA1c (screen for diabetes) 1, 3
• Fasting lipid profile (assess cardiovascular risk) 1, 3

Additional testing in select cases: 2

• Free testosterone or androgen index if hypogonadism suspected clinically (preferred over total testosterone alone to prevent unnecessary endocrine workup) 2
• Luteinizing hormone only if testosterone is low 2
• Prostate-specific antigen and digital rectal examination if age >50 years with >10 years life expectancy, or as baseline before testosterone replacement therapy 2, 4

When to Refer for Specialist Assessment

Refer patients with: 2

• Young age with lifelong erectile difficulty 2
• History of pelvic or genital trauma 2
• Abnormal testicular or penile findings on examination 2
• Abnormal initial screening laboratory results 2

Critical Cardiovascular Consideration

ED in men over 30 years is a risk marker for underlying cardiovascular disease and typically presents 3 years before coronary artery disease symptoms—counsel patients accordingly and assess cardiovascular risk factors. 1, 5

Common Pitfalls to Avoid

• Do not overlook medication-induced ED; review all current drugs and consider alternatives with lower ED risk (ACE inhibitors, calcium channel blockers, loop diuretics instead of thiazides or beta-blockers) 2
• Do not miss testosterone deficiency; always check morning total testosterone regardless of age 1
• Do not ignore the cardiovascular connection; ED shares common pathophysiologic pathways with coronary disease and warrants periodic cardiovascular risk reassessment 1, 5
• Do not proceed with ED treatment if significant psychiatric illness is present; address this first 2