Diagnosis of Erectile Dysfunction

How is erectile dysfunction diagnosed?

The aim of the assessment is to answer three questions:

• What is the main cause of your erection problem?

• Is there an underlying health issue, such as diabetes, heart disease or low testosterone, that needs attention in its own right?

• Which treatment is most likely to work for you?

For most men, the diagnosis is made from a careful conversation, a short examination and a few blood tests. More specialised tests are only needed in selected cases.

1. Your history – the most important part

You will be asked, in a private and unhurried way, about:

• When the problem started, and whether it came on suddenly or gradually

• Whether the difficulty is getting an erection, keeping it, or both

• Morning and night-time erections

• Sex drive (libido), ejaculation and orgasm

• Any bend or pain in the erect penis

• Your general health: heart disease, blood pressure, diabetes, cholesterol, previous operations or radiotherapy

• All medicines and supplements you take, including anything bought online

• Smoking, alcohol, exercise and recreational drugs

• Stress, mood and your relationship – and whether your partner has any health issues that affect your sex life

• What you have already tried, and how you took it

Partners are always welcome at the consultation if you would like them there.

2. Questionnaires

You may be asked to fill in a short questionnaire such as the IIEF-5 (also called SHIM). It scores how severe the ED is and helps to measure how well treatment is working later on.

3. Physical examination

A brief, respectful examination usually includes:

• Blood pressure and pulse

• Weight and waist measurement

• Examination of the penis, looking for a tight foreskin, scar tissue or plaques (Peyronie's disease)

• Examination of the testicles, looking at their size and consistency

• Signs of low testosterone, such as reduced body hair or breast tissue enlargement

• In some men, a prostate examination

4. Blood tests

Usual blood tests include:

• Testosterone – taken in the morning (ideally before 11am), as levels are highest early in the day. A low result is always repeated before any diagnosis is made, together with other hormones (LH, FSH, prolactin and SHBG) to find the cause

• Blood sugar (HbA1c) – to check for diabetes or pre-diabetes

• Cholesterol – to assess heart and blood vessel risk

Other tests that may be helpful in some men:

• Thyroid function

• Kidney and liver function

• PSA (a prostate blood test), after discussing the pros and cons with you

5. Penile Doppler ultrasound

This is the key specialist test for erections. It is not needed for everyone, but is very useful when:

• Tablets have not worked

• A younger man has ED with no obvious cause

• There is a bend or plaque in the penis (Peyronie's disease)

• Surgery or other advanced treatment is being considered

• There has been injury to the pelvis or penis

What happens?

• A small amount of medicine is injected into the side of the penis with a very fine needle. This produces an erection, the same way Caverject injections work

• An ultrasound probe with gel is placed on the underside of the penis

• The scan measures how fast blood flows into the penis through the arteries, and whether blood is leaking back out through the veins too early

• The test takes around 20–30 minutes

What does it show?

• Normal blood flow – suggests the cause is more likely nerve, hormonal or psychological

• Reduced inflow – narrowing of the arteries (arterial insufficiency)

• Fast drainage out – a "venous leak", where the penis cannot hold on to blood

The test also gives a useful "trial run" of how well injection treatment is likely to work for you.

Possible side-effects: a small bruise at the injection site, and occasionally an erection that lasts longer than expected. You will not be allowed home until the erection has gone down, and you will be given clear advice on what to do if it returns.

6. Other tests (rarely needed)

• Night-time erection testing – a small device worn overnight records erections during sleep. Healthy night-time erections suggest the "hardware" works and the cause is more likely psychological

• Specialised nerve tests or blood vessel imaging, mainly in men who have had pelvic trauma

What happens after the tests?

Once the results are back, Mr Keskin will explain:

• What is causing your ED, in plain language

• Any health issues that need attention, such as raised blood sugar, cholesterol or low testosterone

• Your treatment options, starting with the simplest and most effective for your situation

In most men, a clear plan can be agreed at the first or second appointment.