What they will ask
The history does most of the diagnostic work. A doctor who asks these properly can usually narrow the cause before touching a blood test.
- How it started — gradually over years, or fairly suddenly around a particular time. Gradual points vascular; sudden points towards medication or psychological causes.
- Whether you still wake with erections, and how firm. The most informative single question asked. How to answer it usefully.
- Whether it happens in every situation — alone, with a partner, with a different partner. Selectivity points away from a plumbing problem.
- Every medication you take, including ones you consider irrelevant, plus supplements and anything bought online.
- Cardiovascular history — blood pressure, cholesterol, diabetes, smoking, family history.
- Mood, stress, sleep and relationship, because these are causes rather than side topics.
- Libido, which is a separate question from erections and points towards hormones when it is also low.
Answering these accurately is worth more than any test, and it is why arriving with two weeks of observation beats arriving with a vague impression. What to prepare beforehand.
The examination
This is the part men dread and it is usually the shortest. What is typical:
- Blood pressure, and often pulse. If nobody takes your blood pressure at an ED appointment, that is a genuine warning sign about the quality of the assessment.
- A brief look at the genitals — checking for anatomical causes such as Peyronie's disease, and assessing testicular size, which is informative about testosterone.
- Sometimes pulses in the groin and feet, as a quick read on circulation generally.
- Sometimes a check for signs of low testosterone, such as breast tissue changes or reduced body hair.
A rectal examination to feel the prostate is not routinely part of an ED assessment. It may be added if you also have urinary symptoms or are due prostate screening, but it is not automatic and you can ask why if it is proposed.
The blood tests
Standard for a first assessment, and this is where the appointment quietly becomes about more than sex.
| Test | What it is looking for |
|---|---|
| HbA1c or fasting glucose | Undiagnosed diabetes, which is a leading cause and frequently found here first |
| Lipid profile | Cholesterol, as part of the cardiovascular risk picture |
| Morning total testosterone | Needs to be taken before about 11am, and repeated on a second morning if low |
| Thyroid function, prolactin | Less common, added when the picture does not add up or libido is markedly low |
What they usually will not do
Specialist investigation is uncommon at a first appointment, and its absence is not a sign of being fobbed off.
Penile Doppler ultrasound, which images blood flow directly, is generally reserved for younger men, cases following trauma, or where surgery is being considered. Formal overnight erection testing is similarly uncommon now. For most men the history, examination and bloods answer the question, and starting treatment is more informative than more testing.
What you should leave with
Judge the appointment by this list rather than by how thorough it felt.
- A sense of which cause is most likely, even if provisional.
- Blood tests requested, or a good reason why not.
- A treatment to start — usually a pill — at a specific dose, with instructions on how to take it, including timing and food.
- A clear statement of how many attempts to give it before deciding, which should be around eight rather than one or two.
- A defined next step if it does not work, so that failure has somewhere to go.
- A follow-up arrangement, and a review of any medication that might be contributing.
That fifth point is the one most often missing, and it is why so many men stop after a pill that did not work. There is a whole ladder above it. What comes after pills.
When you get referred on
Referral to urology is usual where pills have properly failed, where there is anatomical disease such as Peyronie's, following pelvic surgery or trauma, in younger men where the cause is unclear, or where injections or an implant are being considered.
Referral is a step forward rather than a sign of something worse. The most effective treatments in this field sit on the specialist side of that line, and men who never get referred often never meet them.