Erectile disfunction test need to be done
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Erectile Dysfunction (ED) - Diagnostic Tests & Evaluation
Definition
ED is the persistent inability to attain and/or maintain a penile erection sufficient for satisfactory sexual performance in ≥50% of attempts. It involves complex interactions between the vascular, nervous, endocrine, and psychological systems.
Step 1 - History Taking (Always First)
Medical & Sexual History
- Onset, duration, and severity of ED (gradual vs. sudden onset)
- Presence of morning/nocturnal erections (their presence suggests psychogenic cause)
- Libido, ejaculatory function, orgasm
- Partner relationship and psychosocial factors
- Substance use: alcohol, smoking, recreational drugs
Validated Questionnaire:
- SHIM (Sexual Health Inventory for Men / IIEF-5) - 5 questions scored 1-5; scores 5-25; below 21 indicates ED
Risk Factor Review (Key Comorbidities)
| Category | Examples |
|---|---|
| Cardiovascular | Hypertension, dyslipidaemia, coronary artery disease |
| Endocrine | Diabetes mellitus, hypogonadism, thyroid disorders |
| Neurological | Spinal cord injury, multiple sclerosis, Parkinson's |
| Surgical | Radical prostatectomy, pelvic surgery |
| Psychological | Depression, anxiety, relationship problems |
| Medications | Antidepressants (SSRIs), antihypertensives, antiandrogens (cause ~25% of ED cases) |
- Textbook of Family Medicine 9e, p. 1194
Step 2 - Physical Examination
Focus on:
- Genitourinary - Penile size, Peyronie plaques, testicular size/consistency
- Endocrine - Body habitus, gynecomastia, secondary sexual characteristics (hair, muscle mass)
- Vascular - Peripheral pulses, bruits
- Neurological - Anal sphincter tone, perineal sensation, bulbocavernosus reflex
- Blood pressure measurement
Step 3 - Basic Laboratory Tests (Minimum Workup)
| Test | Rationale |
|---|---|
| Fasting blood glucose / HbA1c | Diabetes is a leading organic cause |
| Lipid profile | Dyslipidaemia - vascular risk |
| Renal function | Uremia impairs sexual function |
| Urinalysis | Renal and metabolic screen |
| Full blood count | Anaemia, systemic disease |
| Morning serum total testosterone | Hypogonadism screen (draw 8-11 AM) |
| LH (luteinizing hormone) | Differentiates primary vs. secondary hypogonadism |
| TSH (thyroid-stimulating hormone) | Hypo/hyperthyroidism can cause ED |
Prolactin is only indicated if testosterone is low or there are signs/symptoms of hypogonadism - it causes ED in <2% of cases.
- Tietz Textbook of Laboratory Medicine 7e, p. 1998-2000
- Textbook of Family Medicine 9e, p. 1194
Step 4 - Specialised Tests (Selected Patients Only)
These are reserved for patients who fail initial treatment, have suspected specific aetiology, or are considering surgery.
Nocturnal Penile Tumescence & Rigidity (NPTR)
- Uses RigiScan device worn overnight
- Normal nocturnal erections suggest psychogenic aetiology
- Abnormal results indicate organic cause
Vascular Studies
| Test | Purpose |
|---|---|
| Intracavernous vasoactive drug injection (ICI) | Prostaglandin E1 or papaverine injected; erection quality assessed |
| Penile Duplex Doppler Ultrasound (after ICI) | Gold standard for vascular ED - measures cavernosal artery flow |
| Cavernosometry/Cavernosography | Assesses venous leak (venoocclusive dysfunction) |
| Internal pudendal arteriography | Pre-operative vascular mapping for arterial reconstruction candidates |
Duplex Ultrasound Parameters (from Grainger & Allison's Diagnostic Radiology):
- Peak systolic velocity (PSV) <25 cm/s after papaverine = arterial insufficiency
- PSV 25-30 cm/s = borderline
- End-diastolic velocity >5 cm/s = venous dysfunction (venous leak)
- <60% increase in cavernosal diameter post-injection = arterial impotence
- Grainger & Allison's Diagnostic Radiology
Neurological Tests (Specialised)
- Biothesiometry (penile vibration perception threshold)
- Somatosensory evoked potentials
- Bulbocavernosus reflex latency
Psychodiagnostic Evaluation
- Minnesota Multiphasic Personality Inventory (MMPI)
- Psychosexual interview
- Indicated when psychogenic cause is suspected or as adjunct
Summary: Basic vs. Specialised Workup
ALL PATIENTS:
├── History + SHIM questionnaire
├── Physical examination
└── Labs: Glucose/HbA1c, lipids, renal function,
FBC, urinalysis, morning testosterone, LH, TSH
SELECTED PATIENTS (fails first-line or pre-surgical):
├── NPTR (RigiScan)
├── ICI + Penile Duplex Doppler US
├── Cavernosometry / Cavernosography
├── Arteriography
├── Neurological tests
└── Prolactin (if low testosterone or hypogonadism signs)
Important Clinical Note
Men with ED - especially those under 60 - should also be evaluated for cardiovascular disease, as ED often precedes cardiac symptoms by 2-3 years. The two conditions share the same vascular pathophysiology (endothelial dysfunction), per the AUA ED guidelines. A cardiac risk assessment is recommended in this group.
The 2024 EAU Guidelines on Sexual and Reproductive Health confirm that most patients with ED can be adequately managed with basic workup alone (history + physical + labs), with specialised tests reserved for select cases.
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