A comprehensive evaluation of erectile dysfunction is the cornerstone of the management plan. The evaluation should include an initial assessment; a detailed psychosexual, medical, and psychosocial history; a physical examination; and, if indicated, laboratory testing. Administration of various questionnaires focused on sexual dysfunction in general and erectile dysfunction in particular could be a part of the initial assessment. Examples include the Brief Sexual Function Questionnaire and the Derogatis Sexual Functioning Inventory. However, no questionnaire can replace direct questioning by the physician.

The initial assessment should focus on identification of the actual presence of the consensus definition of erectile dysfunction (Goldstein 1999). One should ask questions such as the following: Does this problem meet diagnostic criteria for erectile dysfunction? Is the erectile dysfunction of sufficient duration and degree to warrant intervention? Is erectile dysfunction the primary complaint, or is it associated with other sexual dysfunction, such as premature ejaculation or hypoactive sexual desire ? What are the patient’s expectations and degree of satisfaction? What is the degree of confidence needed to keep an erection?

The detailed psychosexual history should focus on the description and circumstances of erectile dysfunction. Was the onset of erectile dysfunction sudden or gradual? What is the duration of erectile dysfunction? Is masturbatory erection gone?

Are morning erections present or gone? Is the erectile dysfunction related to any psychological difficulties, life events, or health problems? Are other parts of sexual functioning, such as sexual desire, intact? How firm is the erection? Is it difficult to maintain the erection after penetration? In both the initial assessment and psychosexual history taking, an interview with the patient’s partner could provide invaluable information. What are the partner’s expectations in the sexual relationship and reaction to the problem? What is the partner’s expectation about the treatment of erectile dysfunction? One might be able to diagnose erectile dysfunction due to psychological factors (e.g., when morning erections are intact or when the patients is able to maintain erection during masturbation or during an “extramarital” intercourse). In this case, the patient might benefit more from sexual counseling.

A further step in the evaluation includes a detailed medical history (cardiovascular, neurological, endocrine problems?), psychiatric history (depression? anxiety? substance abuse?), psychosocial assessment (interpersonal relationships? self-esteem? coping skills and abilities?), assessment of lifestyle factors (smoking? alcohol abuse? drug abuse? sexually transmitted diseases?), and medication review, including over-the-counter drugs (these have been implicated in up to 25% of erectile dysfunction cases).

Physical examination should be comprehensive, with a focus on genitourinary, vascular, and neurological systems and inspection of secondary sexual characteristics. Inspection of external genitalia should include palpation of the penis and testes. The examination should also include neurological and sensory testing (including perineum; pinprick-light touch discrimination, cremasteric reflex) and vascular evaluation of lower extremities. Rectal examination is useful in revealing prostatic abnormalities and assessing sacral root function (bulbocavernous reflex, sphincter tone). Patients who should be referred to appropriate specialists may be identified on the basis of the physical examination findings. As Goldstein pointed out, the physical examination also provides an excellent opportunity for the clinician to provide patient education and reassurance regarding aspects of normal anatomy and functioning.

Laboratory testing should be tailored to the individual patient and should focus on the possible etiological factor(s) of erectile dysfunction. The blood screening may involve a complete blood count; routine chemistry, including a fasting blood sugar and a lipid panel; and a morning serum testosterone (note, however, that the value of determining testosterone levels in erectile dysfunction remains controversial). Urinalysis could be useful if glycosuria or infection is detected. Further focused, specialized laboratory testing could include additional hormonal assessment (prolactin levels, thyroid hormone levels), vascular assessment (nocturnal penile tumescence assessment, intracorporeal pharmacological testing, color duplex ultrasonography, cavernosometry), and neurological testing (penile biotensiometry, dorsal nerve conduction velocity). If erectogenic treatment is being considered, a more detailed evaluation of cardiac status and activity may be necessary.

As previously noted, the selection of more specialized methods should be tailored to the individual patient and based on data obtained from the history and the physical evaluation. Further factors, such as the test’s validity and reliability, the patient’s acceptance of testing, and the test’s cost, should also be considered.