How an Erectile Dysfunction Specialist Diagnoses ED: The Tests Explained

Most of an erectile dysfunction assessment is talking. Men who arrive braced for something cold and clinical are usually surprised by that, and it is worth knowing before you book.

The tests that follow are chosen based on what the conversation turns up. Nobody gets every investigation on this page: some men need bloods and nothing more, and a smaller number need specialist imaging.

The reason any of it happens is simple. Erectile dysfunction is a symptom with a long list of possible causes, and the cause determines the treatment. Here is what an erectile dysfunction specialist actually does, in the order it usually happens

Step 1: The medical and sexual history

The history takes up more of the assessment than anything else, and it is the part that gets skipped when ED is handled through an online form. Done properly it fills most of the first appointment. Every question rules something in or out.

When did it start, and how?

Arteries fur up slowly and hormone levels drift slowly, so a decline you have watched happen over a year or two tends to be physical. Men who can name the month it started are a different picture. That pattern usually points to a new medication, or to stress, mood or something happening in the relationship.

Do you still get morning erections?

Waking with an erection tells us the equipment still works, which pushes the focus towards stress, mood or the situation you are in. Lose them completely, and something physical becomes more likely. On its own the answer proves nothing. It is one piece of a much bigger picture.

Is the difficulty getting an erection, or keeping one?

Trouble achieving an erection suggests a problem with blood flowing in. Trouble maintaining one, where the erection starts well and fades quickly, can suggest blood is not being held in. Different mechanism, different treatment.

The specialist will also ask for a complete medication list including anything bought over the counter or online, and go through cardiovascular history, diabetes, neurological conditions, previous pelvic or prostate surgery, smoking, alcohol, sleep quality, mood and relationship context. Sleep apnoea and low mood both affect erectile function and both get missed regularly.

Standardised questionnaires (IIEF and IIEF-5)

The International Index of Erectile Function puts a number on something that is otherwise hard to describe. Rosen and colleagues published it in 1997, and it has been in steady use in research and in clinics since.

The full questionnaire runs to 15 questions covering erectile function, orgasm, desire and satisfaction. Clinics more often use the shorter five-question version, the IIEF-5 or SHIM. It is scored out of 25, and the lower the score, the more severe the difficulty.

The score is worth more as a baseline than as a diagnosis. Answer the same questions three months into treatment and you can see whether things have actually shifted, or whether you simply filled it in after a good week.

Step 2: The physical examination

Yes, there is usually a physical examination. It is brief and routine. Men worry about it beforehand far more than they think about it afterwards.

What is checked, and the reason for each:

• Blood pressure and cardiovascular signs, because the same disease process affects the arteries supplying the penis and the arteries supplying the heart.
• The penis, checking for lumps, plaques or curvature that would suggest Peyronie’s disease, which changes the treatment plan completely.
• The testes, for size and firmness, which can point to a hormonal cause.
• Body habitus and secondary sexual characteristics, which can suggest low testosterone.
• A prostate examination, where your age or urinary symptoms make it relevant.

The examination often turns up something the history missed. Peyronie’s disease is the common example, found in men who had assumed the curve was simply how they were built.

Step 3: Blood tests

Bloods are not ordered to tick a box. Erectile dysfunction often turns out to be the first sign of something systemic that nobody had thought to look for.

• Fasting glucose or HbA1c. Diabetes is among the most common contributors to ED, and for some men the erection problem is what leads to the diagnosis.
• Lipid profile. High cholesterol narrows arteries, which cuts the blood flow an erection depends on.
• Morning total testosterone. Levels peak in the morning, so when the sample is taken matters. A low reading is normally repeated, with further hormone tests, before anyone draws a conclusion.
• Thyroid function, where symptoms point that way, since an overactive or an underactive thyroid can both affect sexual function.
• PSA, which may come up depending on your age and any urinary symptoms. In Australia, PSA testing is decided with you, after a conversation about what it can and cannot tell you, rather than added automatically.

A man who books about his erections and walks out with a new diagnosis of diabetes or high cholesterol has arguably got the more valuable result.

Step 4: Specialist imaging, where it is needed

Imaging is not routine. It is used in selected cases, and the main investigation is a penile duplex Doppler ultrasound.

Penile duplex Doppler ultrasound

This scan measures blood flow into and out of the penis while it is erect, with an injection of medication used to produce the erection first. It shows how quickly blood arrives in the cavernosal arteries and whether it stays there, which separates two problems that look identical from the outside:

• Arterial insufficiency, where too little blood is getting in.
• Veno-occlusive dysfunction, usually called venous leak, where blood arrives normally but drains away before a firm erection can be held.

The two are treated differently, so guessing between them is not much use. The scan also shows Peyronie’s plaque clearly, including how far it extends.

Two caveats. The first is that the test depends heavily on who performs it, so it should be done by a clinician experienced in the technique, including managing a prolonged erection if one occurs. The second is that when arterial inflow is well down, venous function cannot be judged reliably in the same study. In practice the scan is reserved for men whose tablets have not worked, younger men with severe ED, and men being assessed before surgery.

Other investigations

Two older tests are worth a mention. Nocturnal penile tumescence testing records overnight erections, which is useful when nothing else has settled the question. Cavernosometry and penile arteriography have largely fallen out of use. Both are invasive, and these days they are mostly limited to younger men heading towards vascular surgery.

Step 5: Putting it together into a treatment plan

All of it feeds one decision: what to do next.

Morning erections intact, an obvious trigger, nothing worrying in the bloods: that man usually does better with first-line medication and psychological support than with anything more aggressive. Arterial insufficiency on the ultrasound changes the order of business. Cardiovascular risk comes first, and linear shockwave therapy is worth discussing with some men, though the evidence behind it is still building.

With a venous leak, tablets often disappoint, so what gets discussed instead is injection therapy or, for suitable patients, penile prosthetic surgery. Testosterone that stays low across repeat tests is treated as its own problem first. For some men, sorting that out is enough on its own.

How long does the whole process take?

Most men complete the process across two appointments over roughly four to six weeks.

The usual sequence is an initial consultation with history and examination, blood tests arranged that day or shortly after, and a follow-up to review results and agree on a plan. A penile duplex Doppler ultrasound, where indicated, is arranged between the two. If your GP has already organised bloods before you come in, the first appointment does considerably more work. Our guide on preparing for an ED appointment is worth a look beforehand.

Why choose Dr Katelaris as your erectile dysfunction specialist in Sydney & North Shore

Dr Phillip Katelaris is a specialist urologist and urological surgeon with more than 35 years in clinical practice. He holds Fellowship of the Royal Australasian College of Surgeons (FRACS), belongs to the Urological Society of Australia and New Zealand (USANZ), trained postgraduately in surgery in Germany and in robotic surgery in the United States, and operates at Sydney Adventist Hospital.

None of that is theory. Assessment comes before any prescription. Tests get ordered to answer a question, not to pad a file, and results are explained in plain language so the decision about treatment makes sense to the man making it. Patients are given time to ask questions, and written informed financial consent is provided before any procedure.

Treatment, when needed, spans the full range: medical management and dose optimisation, penile injection therapy, linear shockwave therapy and penile prosthetic surgery. Dr Katelaris has performed penile prosthetic surgery in Sydney for many years, and performed the first vasectomy reversal in Australia using the ROBOTICSCOPE platform.

Consultations are held at three locations across Sydney and the North Shore:

• Hornsby: Level 1, 51 Palmerton Road, Hornsby NSW 2077
• Castle Hill: 60 Cecil Avenue, Castle Hill NSW 2077
• St Leonards: Level 3, Suite 11, North Shore Private Hospital, Westbourne Street, St Leonards NSW 2065

You can confirm Dr Katelaris’s registration and credentials on any of these independent profiles:

• HealthDirect
• Doctify
• Medilaw
• LinkedIn

Further background is available on the about Dr Phillip Katelaris page.