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The physical examination in patients presenting with erectile dysfunction (ED) extends beyond the genital area. Clinicians must look for systemic signs of hypogonadism, which include the development of gynaecomastia (breast tissue enlargement) and a noticeable reduction in beard or body hair growth. These physical markers serve as vital clues for underlying hormonal imbalances that may be contributing to the patient's sexual health issues.
A thorough assessment of the peripheral vascular system is a mandatory component of the diagnostic work-up. This involves checking the characteristics of the pulse to ensure adequate blood flow and listening for arterial bruits. An arterial bruit is a specific vascular sound caused by turbulent blood flow, which often indicates the presence of arterial stenosis or underlying vascular disease that could be affecting penile blood supply.
General health metrics are equally critical in this diagnostic phase. Practitioners must measure the patient's blood pressure, waist circumference, and body mass index (BMI). These measurements are not merely routine; they are essential for assessing the patient's overall metabolic and cardiovascular risk profile, which is frequently linked to the etiology of erectile dysfunction.
The examination of the penis, specifically in the flaccid state, is designed to identify anatomical abnormalities that might impede erectile function. One such condition is Peyronie disease, which is characterized by the presence of palpable fibrous plaques within the penile tissue. These plaques can cause curvature and pain, directly impacting the ability to achieve or maintain an erection.
Other congenital or structural issues include phimosis and frenulum breve. Phimosis refers to the congenital narrowing of the foreskin opening, preventing it from being retracted. Frenulum breve involves a shortened tissue connection under the glans penis, which restricts the movement of the foreskin. Both conditions can cause mechanical discomfort and contribute significantly to erectile dysfunction.
Identifying these structural pathologies is crucial because they often require specific surgical or mechanical interventions rather than simple pharmacological management. By documenting these findings early in the diagnostic process, clinicians can determine whether the ED is primarily anatomical or if it requires a broader systemic investigation.
Biochemical screening is essential for risk stratification. Key parameters include cholesterol, triglycerides, fasting glucose, and glycosylated haemoglobin (HbA1c). These markers are not only indicators of metabolic health but are also primary determinants for assessing cardiovascular risk, which is a major co-morbidity in men with erectile dysfunction.
To rule out hypogonadism, the measurement of total testosterone and sex hormone-binding globulin (SHBG) is considered sufficient. These values allow for the calculation of free testosterone, which is the biologically active form of the hormone. It is important to note that the evaluation of prolactin and thyroid hormones is not routine for every patient; these tests are reserved for a specific subset of individuals based on clinical suspicion.
When abnormal hormonal or biochemical values are detected, the management strategy shifts from primary care to a second-line evaluation. For instance, if fasting plasma glucose levels fall between 100–126 mg dl−1 or HbA1c exceeds 5.7%, an oral glucose tolerance test is recommended to definitively rule out overt type 1 or type 2 diabetes mellitus.
Advanced cardiovascular evaluation is guided by the Princeton III Consensus Panel criteria. Furthermore, if hypogonadism is confirmed through low testosterone levels, clinicians must investigate the source of the deficiency—whether it is central (pituitary/hypothalamic) or peripheral (testicular)—by measuring gonadotropin and prolactin levels.
Penile duplex Doppler ultrasound (PDDU) has emerged as a sophisticated tool for stratifying cardiovascular risk. It can be performed in both the flaccid state and the dynamic state (following vasodilator stimulation). This allows for a detailed analysis of penile blood flow, providing insights into the vascular integrity of the patient.
Other specialized tests like nocturnal penile tumescence (NPT) monitoring using the RigiScan device are now rarely used. Their application is mostly restricted to medico-legal cases where the presence of spontaneous erections must be proven. Similarly, invasive procedures like arteriography, dynamic infusion cavernosometry, and cavernosography are reserved strictly for young patients who are potential candidates for vascular reconstructive surgery.