What diagnostic workup should be performed for a 27-year-old depressed male presenting with erectile dysfunction?

Diagnostic Evaluation for a 27-Year-Old Depressed Male with Erectile Dysfunction

In a 27-year-old depressed man with erectile dysfunction, you must immediately obtain a morning serum total testosterone level (drawn between 8–10 AM), perform a detailed sexual and psychosocial history focusing on onset pattern and presence of morning erections, screen for antidepressant-induced sexual dysfunction, and assess cardiovascular risk factors—while recognizing that the depression itself may be either the cause or consequence of the ED. 1, 2, 3

Critical History Elements

Sexual Function Assessment:

• Document whether onset was sudden (suggesting psychogenic etiology) or gradual (suggesting organic causes) 1, 2
• Ask specifically about morning and nocturnal erections—their presence indicates intact neurovascular function and strongly points to a psychogenic component, essentially ruling out significant vascular insufficiency 1, 2
• Determine whether erections occur during masturbation or only fail in partnered contexts, as situational ED with preserved spontaneous erections is pathognomonic for psychogenic etiology 1, 2
• Quantify severity using the Sexual Health Inventory for Men (SHIM) or Erection Hardness Score 1, 3

Depression and Medication Review:

• Review all current and recent antidepressants—SSRIs and tricyclics commonly cause erectile dysfunction and decreased libido, and this medication-induced dysfunction would not spare morning erections 1, 4
• Screen for symptoms of major depression versus minor depression, as the causal relationship between ED and depression is bidirectional: major depression typically causes ED that resolves with successful depression treatment, while in minor depression, restoring erectile function can improve mood 5, 6, 7, 8
• Assess for anxiety, relationship conflicts, performance anxiety, and recent life stressors 1, 2

Cardiovascular and Metabolic Screening:

• Even at age 27, ED serves as an independent risk marker for cardiovascular disease with predictive strength comparable to smoking or family history of myocardial infarction—screen for diabetes, hypertension, dyslipidemia, smoking, obesity, and family history of heart disease 1, 3
• Review use of antihypertensives, sedatives, and other medications that can impair erectile function 1, 3

Mandatory Laboratory Testing

Hormonal Evaluation:

• Measure morning serum total testosterone (≈8 AM) in every man with ED regardless of age—testosterone <300 ng/dL defines deficiency and requires treatment before or alongside other ED therapies 1, 2, 3
• Loss of libido specifically points toward testosterone deficiency or depression; if testosterone is low, repeat the test to confirm hypogonadism before initiating therapy 2
• If testosterone is borderline but morning erections are preserved and there are no hypogonadal symptoms (decreased libido, testicular atrophy, muscle loss), immediate testosterone replacement is not required 2

Metabolic and Cardiovascular Labs:

• Obtain fasting glucose or HbA1c to diagnose or exclude diabetes 1, 3
• Order fasting lipid panel (total cholesterol, LDL, HDL, triglycerides) as dyslipidemia is a modifiable cardiovascular risk factor 1, 3

Physical Examination

• Measure blood pressure, pulse, waist circumference, and body mass index 1, 3
• Perform focused genital examination to assess for penile plaques (Peyronie's disease), urethral abnormalities, and testicular size 9, 1, 3
• Assess secondary sexual characteristics and lower extremity pulses 3
• Examine for gynecomastia if hypogonadism is suspected 9

Cardiovascular Risk Stratification

Inform the patient that ED at any age is a marker for underlying cardiovascular disease and warrants evaluation even without cardiac symptoms 1, 3

• In men over 30, ED can precede coronary artery symptoms by 2–5 years 1
• Consider obtaining a resting electrocardiogram if hypertension or diabetes is present 1

Specialist Referral Indications

Refer to mental health professional when:

• Complex psychiatric disorders are present (major depression, anxiety, PTSD) 1, 2
• Performance anxiety persists despite initial interventions 1
• Relationship conflicts dominate the clinical picture 1
• The patient is under 30 with psychogenic factors 3

Refer to urology when:

• Young age with lifelong erectile difficulty 1
• History of pelvic or genital trauma 1
• Abnormal testicular or penile findings on examination 1
• Abnormal initial screening laboratory results 1
• Complex diagnostic testing is required (nocturnal penile tumescence monitoring) 1

Common Diagnostic Pitfalls

• Do not assume psychogenic ED requires only counseling—PDE5 inhibitors work for both psychogenic and organic ED and should be initiated concurrently with psychological therapy 1, 3
• Do not delay testosterone testing when loss of libido is present—the combination of sudden ED onset with decreased libido makes testosterone deficiency highly likely and treatable 2
• Do not treat ED alone when depression is present—address the underlying psychiatric condition, recognizing that antidepressants themselves may worsen sexual function 1, 4
• Do not overlook medication-induced ED—antidepressants would cause loss of all erections, not just situational failure, and alternatives with lower ED risk (bupropion, nefazodone, mirtazapine) should be considered 1, 4
• Do not fail to screen for cardiovascular disease—ED may be the first presentation of significant vascular disease even in a young patient 1, 3