Because erectile dysfunction can be understood as an impairment in the arousal phase, these impairments can impact the subsequent stages of sexual response. Basic inquiry of sexual health is the standard of care in this condition. It is crucial to identify risk factors for ED so those factors can be mitigated through a comprehensive treatment protocol.


Patient inquiry is designed to identify:

  • Onset of symptoms
  • Symptom severity
  • Degree of bother or impairment
  • Specification regarding issues (i.e., attainment or maintenance of erection)
  • Information regarding the situation (i.e., only occurs with one partner, specific partners, specific contexts)
  • Presence of nocturnal and morning erections
  • Presence of masturbatory erections
  • Prior history of erectogenic therapy
  • Progression or stability of symptoms
  • Tobacco use
  • ED risk factors


This is done to distinguish between ED and Premature ejaculation (PE).  There is a bidirectional relationship with ED as one-third of ED patients report PE, and successful treatment of either condition requires treatment of the other.22 Also, it is imperative to get information about changes in libido, orgasm, and penile morphology, which could serve as a proxy for the presence of Peyronie’s disease.  Discussions with the sexual partner can help identify psychosocial issues that can lead to ED.  Clarifying information can help clear up confusion about the sexual response cycle, sexual desire, and the refractory period.  The presence of nocturnal and morning erections suggests a psychological component to ED.


Physical Exam:

  • Vital Signs (BP, HR, Weight)
  • BMI
  • Physical examination for signs of testosterone deficiency (gynecomastia, underdeveloped pubic/facial/axillary hair)
  • Genital examination should include assessment of penile skin lesions or other anatomical abnormalities and a scrotal exam
  • In case of consideration of prosthesis implant or surgical intervention, document flaccid stretched penile length.
  • Digital rectal examination is not required but can be considered if concurrent BPH/LUTS symptoms are present.


Laboratory Tests:

  • AM Serum testosterone
  • Glucose/HemoglobinA1c
  • Serum lipids
  • TSH and T4 levels if there is suspicion of hypothyroidism
  • Prostate specific antigen
  • +/- Prolactin level


Validated Questionnaires for ED

  • Erection Hardness Score
  • Sexual Health and Inventory for Men
  • International Index of Erectile Function (Diagnosis)
  • Male Sexual Health Questionnaire (To monitor treatment progress)


Psychosocial Screening

  • Depression – PHQ-9
  • Anxiety – GAD-7
  • Relationship Conflict
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