What is the initial workup for a patient presenting with erectile dysfunction?

Initial Workup for Erectile Dysfunction

All men presenting with erectile dysfunction require a comprehensive sexual, medical, and psychosocial history, focused physical examination, morning serum total testosterone level, fasting glucose or HbA1c, and lipid profile. 1, 2

History Components

Sexual History

• Onset pattern: Sudden onset suggests psychogenic causes; gradual onset indicates organic etiology 2, 3
• Symptom characteristics: Difficulty attaining versus maintaining erections, severity, and degree of bother 1
• Situational factors: Whether ED occurs only with specific partners, in certain contexts, or during all sexual encounters 1
• Presence of nocturnal/morning erections: Suggests (but does not confirm) psychogenic component requiring further investigation 1
• Masturbatory erections: Assess whether patient can achieve erections during masturbation 1
• Prior treatments: Document any previous erectogenic therapy and response 1

Medical History

• Age and comorbidities: Diabetes mellitus, hypertension, hyperlipidemia, cardiovascular disease, obesity, neurological conditions 1, 2
• Surgical history: Prior pelvic or perineal surgery, spinal cord injury 2, 3
• Medications: Antihypertensives (β-blockers, diuretics, ACE inhibitors), antidepressants, tranquilizers, recreational drugs 1, 2
• Family history: Vascular disease 1, 2
• Substance use: Smoking, alcohol, illicit drugs 1, 2

Psychosocial Assessment

• Relationship factors: Partner's sexual function, relationship quality, major life events 2, 3
• Psychiatric conditions: Depression, anxiety, body dysmorphic disorder 3

Validated Questionnaires

• Use standardized tools such as the International Index of Erectile Function (IIEF), Sexual Health Inventory for Men (SHIM), or Erection Hardness Score to objectively assess severity and facilitate discussion 1

Physical Examination

Vital Signs

• Blood pressure and pulse: Essential for cardiovascular risk assessment 1, 2

Genital Examination

• Penile assessment: Examine for skin lesions, urethral meatus placement/configuration 1
• Palpation for deformities: With penis stretched, palpate from pubic bone to coronal sulcus for occult deformities or plaque lesions suggestive of Peyronie's disease 1
• Testicular examination: Assess size and consistency 2

Secondary Sexual Characteristics

• Signs of hypogonadism: Body hair distribution, gynecomastia, testicular atrophy 2, 3

Cardiovascular Assessment

• Lower extremity pulses: Check for peripheral vascular disease 2, 3

Digital Rectal Examination

• Not required for ED evaluation but may be indicated if benign prostatic hyperplasia is suspected as a comorbid condition 1

Laboratory Testing

Essential Tests for All Patients

• Morning serum total testosterone: Measure in all men with ED to identify testosterone deficiency (defined as <300 ng/dL with symptoms) 1, 2
• Fasting glucose or HbA1c: Screen for diabetes mellitus 1, 2, 4
• Lipid profile: Assess cardiovascular risk 1, 2, 4

Selective Additional Testing

• Free testosterone or bioavailable testosterone: Consider if total testosterone is borderline or patient doesn't respond to PDE5 inhibitors 1, 2
• Thyroid-stimulating hormone: Based on clinical suspicion 2, 4
• Prostate-specific antigen: In select patients based on age and examination findings 2, 3

Tests NOT Routinely Indicated

• With the exception of glucose/HbA1c and lipids, no routine serum study is likely to alter ED management 1

Critical Counseling Point

Counsel all men that ED is a risk marker for underlying cardiovascular disease and other health conditions warranting evaluation and treatment. 1 ED symptoms typically present three years earlier than coronary artery disease symptoms. 4

When to Consider Specialized Testing

Specialized testing may be necessary for patients who do not respond to initial PDE5 inhibitor therapy and includes: 1, 2

• Nocturnal penile tumescence evaluation
• Penile Doppler ultrasound
• Neurological testing (bulbocavernosus reflex, dorsal sensory nerve conduction)
• Intracavernosal injection testing with PGE1
• Urodynamic studies

Mental Health Referral

Consider referral to a mental health professional to promote treatment adherence, reduce performance anxiety, and integrate treatments into the sexual relationship. 1 This is particularly important since almost all men with ED are affected psychologically, even when the cause is organic. 1

Common Pitfalls

• Do not assume absence of palpable plaque excludes Peyronie's disease: Additional diagnostic procedures are needed if suspected 1
• Do not rely solely on presence of morning erections to diagnose psychogenic ED: This suggests but does not confirm psychogenic etiology 1, 2
• Do not delay cardiovascular risk assessment: ED shares common risk factors with cardiovascular disease and requires comprehensive evaluation 1
• Initiate the conversation: Many men are uncomfortable discussing sexual concerns, so physicians must proactively inquire 1