Most cases of erectile dysfunction can be assessed with a detailed history, focused examination and a small number of targeted health checks.
Erectile dysfunction is diagnosed from the pattern of erection difficulty and its effect on sexual activity, supported by a medical and sexual history. The assessment also looks for causes and associated health risks. Most men do not need a scan or invasive test: a focused examination, blood pressure measurement and selected blood tests are usually the starting point.
The diagnosis is clinical. A man describes recurrent difficulty attaining or maintaining an erection that is adequate for satisfactory sexual activity. “Adequate” depends on the activity and the individual rather than a universal firmness target.
The clinician then considers three separate questions:
A remote consultation can cover much of the history and risk screening. It cannot replace a physical examination or laboratory testing when either is clinically indicated.
A detailed history is the most useful part of the assessment. Expect questions about:
These questions are not intended to assign blame. A situational problem may have a strong psychological component, while gradual ED in every setting may suggest a physical contributor. Neither pattern is conclusive, and mixed causes are common.
The Sexual Health Inventory for Men (SHIM), also known as the five-item International Index of Erectile Function (IIEF-5), asks about confidence, firmness, maintenance and satisfaction over a defined period. A score can help describe severity, create a baseline and measure change after treatment.
The full IIEF covers additional domains including desire, orgasm and intercourse satisfaction. The Erection Hardness Score is a separate brief measure of rigidity. These tools support a clinical discussion; they do not distinguish vascular ED from anxiety, hormone deficiency or another cause.
| Assessment | What it can identify | How it is usually used |
|---|---|---|
| Blood pressure and pulse | Hypertension, hypotension or a cardiovascular concern relevant to treatment safety | Part of the basic assessment if not checked recently |
| BMI or waist measurement | Cardiometabolic risk context | Used alongside history and blood tests, not as a diagnosis of ED |
| Glucose or HbA1c | Diabetes or raised glucose | Basic metabolic testing when there is no recent result |
| Lipid profile | Raised cholesterol and cardiovascular risk | Interpreted as part of overall cardiovascular assessment |
| Early-morning total testosterone | Possible testosterone deficiency | A low result requires clinical interpretation and usually confirmation, not immediate treatment |
| Focused genital examination | Peyronie’s disease, testicular change, anatomical abnormality or signs of hormone deficiency | Performed when relevant and with consent |
| Penile Doppler ultrasound | Blood inflow and venous function after a vasoactive medicine | Specialist test for selected cases, not routine screening |
The extent of examination depends on the history. The EAU recommends a focused assessment of the genitourinary, endocrine, vascular and neurological systems. This may include:
A rectal or prostate examination is not required simply because a man has ED. It may be appropriate if there are urinary symptoms, prostate concerns or another specific indication. The clinician should explain what is proposed and obtain consent.
An HbA1c test estimates average glucose over the preceding two to three months. A fasting glucose is an alternative in some settings. These tests can identify previously unrecognised diabetes or assess control in a man who already has it.
A lipid profile measures cholesterol fractions and triglycerides. It contributes to cardiovascular risk assessment rather than diagnosing the penile problem directly.
The EAU basic work-up includes total testosterone taken early in the morning and fasting. Testosterone varies with time of day, food intake, illness and laboratory method. If it is low, repeat measurement and further endocrine assessment are normally needed before testosterone deficiency is diagnosed. Calculated free testosterone may help in selected cases, particularly where sex hormone-binding globulin is likely to make total testosterone hard to interpret.
Luteinising hormone, prolactin, thyroid tests, full blood count, kidney or liver tests may be useful when symptoms, examination, medication or initial results point to a particular condition. They are not all mandatory for every man with ED. PSA testing should follow its own clinical indications and a discussion of benefits and limitations; ED alone is not a reason to order it automatically.
ED shares risk factors with cardiovascular disease and can act as a risk marker. A UK assessment may include blood pressure, lipids, glucose status, smoking, family history and QRISK3 where appropriate. NICE recommends QRISK3 for eligible people aged 25 to 84 who do not already have cardiovascular disease. ED is included as a risk factor in QRISK3.
Men with known heart disease or symptoms during exertion may need a more specific assessment before sexual activity or an ED medicine is considered safe. Unstable angina, uncontrolled hypertension, severe heart failure, a recent cardiovascular event or a high-risk rhythm problem requires clinician-led management. A consumer risk calculator cannot provide clearance for sexual activity or PDE5 treatment in these situations.
Dynamic penile duplex Doppler ultrasound measures arterial inflow and blood retention after a medicine is used to create an erection. A specialist may consider it when:
The test can produce misleading results if anxiety prevents a full response or if the medicine dose is inadequate. It is not a routine requirement before prescribing sildenafil or tadalafil.
Nocturnal penile tumescence and rigidity testing records erections during sleep over more than one night. Preserved night-time function may support a non-organic component, while an abnormal recording may support a physical contributor. Sleep quality, depression, age and test conditions can affect results, so this is a specialist tool rather than a definitive “physical versus psychological” test.
No. An intracavernosal injection test observes the erection response after a vasoactive medicine is injected into the penis. On its own it provides limited vascular information and is generally combined with Doppler ultrasound when clinically warranted. More invasive vascular studies are used rarely, usually when trauma-related arterial repair is being considered.
MRI and CT are not routine ED investigations. They may be used for another suspected condition, not to confirm ordinary ED.
Referral may be appropriate for:
Urgency depends on the finding. A testicular mass, severe neurological symptoms, suspected acute cardiovascular disease or priapism should follow the relevant urgent pathway rather than a routine ED referral.
Bring or provide an accurate list of medicines and supplements. It can help to note when symptoms began, whether erections occur in different settings, and any change in libido, ejaculation, penile shape or general health. If you use GTN, isosorbide, nicorandil, “poppers” or a medicine for pulmonary hypertension, state this clearly because it can determine whether a PDE5 inhibitor is safe.
You do not need to bring a partner. A partner can join if you want and if the service permits it. The consultation should still allow private discussion of sexual history and safety.
No. UK cardiovascular assessment normally starts with history, examination, standard risk factors and QRISK3 where applicable. Additional cardiac tests are selected according to symptoms, known disease and assessed risk.
