Erectile Dysfunction Diagnosis
An experienced doctor will be able to gauge how severe are your erection issues and the potential contributing causes by obtaining a good medical (including an in-depth lifestyle evaluation) and sexual history. Having said that, there are various tools and diagnostic tests that your doctor might request or perform in order to assist him with his evaluation. The most common are the following:
IEEF-5 Questionnaire
The first tool is a short questionnaire called the IEEF-5. This multiple choice questionnaire has been very widely used and researched for over 20 years. The answer to each question is scored (0 – 5) and a total score (out of 25) is calculated. Low scores are correlated with severe ED and vice versa. A low IEEF-5 score does not necessarily imply that treating your ED will be more difficult or that there is a very severe underlying organic cause, it just gives an initial indication. A more meaningful use of the IEEF-5 questionnaire is to use it to track how successful is your treatment plan by monitoring your IEEF-5 score before and after treatment. You can take the IEEF test here.
Artificial Erection Test
The Artificial Erection Test (AET) involves your doctor injecting a powerful erection inducing medication (most common compound is Alprostadil) in one of the corpora cavernosa of your penis. Although this may sound painful, the reality is that you will hardly feel anything. After the injection, the doctor will evaluate your erection hardness score using the following scale:
0 – Penis does not enlarge.
1 – Penis is larger, but not hard.
2 – Penis is hard, but not hard enough for penetration.
3 – Penis is hard enough for penetration, but not completely hard.
4 – Penis is completely hard and fully rigid.
If you have a low score then the doctor might gradually increase the dose of the medication until you get a 3 or 4 score. Based on your response and the maximum dose administer, the doctor will be able to assess the severity of your ED. The AET is a very useful tool to identify patients whose erections are very severely damaged and who do not get any response from the injection. In such rare cases (less than 10% of men suffering from ED) the only viable treatment option is usually a penile implant surgery (see the dedicated section for more details). In addition, the doctor is able to examine the penis in the erect state and note any abnormalities such as plaques or curvature seen in Peyronie’s disease.
Blood & Hormonal Testing
Typical blood tests that your doctor might request are the following:
- Testosterone and other hormones such as LH, FSH (affecting your testosterone levels) and prolactin
- Lipids, fasting blood glucose, insulin and HbA1C (an average longer term measurement of blood glucose levels) so as to evaluate your cardiovascular and metabolic health
- Vitamin D
- ADMA, SDMA, Homocysteine to evaluate endothelium function
More specialised tests might be requested by your doctor if other underlying pathologies are suspected.
Sleep monitoring
This test involves monitoring erections during sleep. It has been long established that healthy men will experience a number of erections (3-5) during a good night’s sleep. This test may be useful in a young patient where the diagnosis of psychogenic ED is suspected. If erections occur and are documented, the patient’s ED is most likely psychogenic. Another use of this test is to check whether your treatment or lifestyle adjustments are helping to restore/improve your night erections, which would indicate that your erection mechanism is healing and your natural erections are improving, as opposed to deteriorating which is what happens for most patients who just take ED meds and leave the underlying causes untreated.
Ultrasound Examination
A duplex ultrasound is a test to examine the blood flow through the arteries and veins in the penis. It combines traditional ultrasound with doppler ultrasound. Traditional ultrasound uses sound waves that bounce off blood vessels to create images. Doppler ultrasound records sound waves reflecting off moving objects (example: blood cells), to measure their speed and other aspects of how they flow.
This procedure involves the injection of erection inducing medication into the penis. The drugs cause a dilation of the blood vessels supplying the penis, thus causing an erection. Men with diseased blood vessels which may be caused by high blood pressure, arteriosclerosis, diabetes, etc., will not develop a full erection. Therefore, the test will tell us whether the erectile dysfunction is due to arterial vascular disease.
Moreover, the ultrasound allows the doctors to visualize the cavernosal arteries and muscle tissue, allowing for the detection of abnormalities such as fibrosis and calcifications of the erectile muscle.
Lastly, the ultrasound examination can detect the presence of a veno-occlusive dysfunction, which would prevent trapping and storing of blood in the penis sufficient to maintain an erection. Measuring the ratio of blood flow into the penis while the heart is pumping versus when it is at rest can assess this. This measurement is called the resistive index, and is based on the observation that in a normal erect penis, the pressure inside the erectile chamber of the penis exceeds the pressure in the arteries when the heart is at rest, and therefore no blood should be flowing into the penis. If blood flow occurs in this situation, the diagnosis of veno-occlusive dysfunction is confirmed.