Physical Examination A focused physical examination is mandatory in assessing the patient complaining of ED. Although not always revealing the exact etiology, it will certainly help in determining risk factors such as gynecomastia, hair distribution, abdominal circumference, peripheral pulses and measurement of the blood pressure and weight.

Special attention should be given to external genitalia including penile size, consistency, presence of penile plaques, foreskin retraction, prepubic fat, and testis shape and consistency. Rectal exam is important to assess rectal tone and reflexes as well in men over 50 years old who have a risk for prostate cancer.

One important aspect when evaluating a patient with ED is to consider the degree of cardiovascular risk. Laboratory Tests In view of the strong relationship of ED with vascular risk factors, it is important to dosed fasting glucose and lipids in every patient consulting for ED if these have not already been performed. Serum testosterone needs to be dosed, especially in those subjects with low libido and/or poor response to PDE5-Is, although many clinicians consider it mandatory in every patient with ED, since sexual function could be a marker for hypogonadism.

This controversy rises from many factors: clinical manifestations of hypogonadism is diverse and rarely complete, severity is also variable, and more than one laboratory measurement is required as there is a 40% rate of false positive results.

If this test is not part of the initial assessment, a more complete hormonal evaluation could be ordered when considering additional testing. Since the majority of the circulating testosterone is bound to the SHBG and to the albumin (bioavailable testosterone), the free portion of circulating testosterone is most important in terms of function, though a reliable laboratory dosing is very expensive and not widely performed. Calculated free testosterone (CFT) is a safe and reliable method to assess free testosterone using the values of total testosterone and SHBG on a table designed by Vermuelen.

Gonadotrophins (LH and FSH), dehydroepiandrosterone (DHEA) and its sulfated form (DHEAS), prolactin, and thyroid hormones are only part of advanced hormonal assessment in special endocrine situations and treatment monitoring; routine use of these studies should be discouraged.