Erectile dysfunction

Last reviewed: 7 Jan 2023
Last updated: 01 Feb 2019



History and exam

Key diagnostic factors

  • abnormalities on exam of penis
  • abnormal androgenization
More key diagnostic factors

Other diagnostic factors

  • premature ejaculation
  • abnormal prostate exam
  • psychosocial stressors
  • Peyronie disease
  • genital pain or numbness
Other diagnostic factors

Risk factors

  • coronary arterial disease
  • peripheral arterial disease
  • hyper/hypothyroidism
  • psychosexual/relationship problems
  • excess alcohol intake
  • hypertension
  • hyperlipidemia
  • diabetes mellitus
  • obesity
  • smoking
  • metabolic syndrome
  • neurologic disease
  • radical pelvic surgery
  • spinal cord injury
  • pelvic fracture
  • Peyronie disease
  • depression
  • premature ejaculation
  • hypogonadism
  • long-distance cycling
  • antihypertensive use
  • antidepressant use
  • corticosteroid use
  • antiandrogenic agent use
  • desire/libido disorders
  • benign prostatic hyperplasia
More risk factors

Diagnostic investigations

1st investigations to order

  • International Index of Erectile Dysfunction
  • Sexual Health Inventory for Men
  • fasting blood glucose
  • lipid profile
More 1st investigations to order

Investigations to consider

  • hemoglobin A1c in diabetic men
  • testosterone (morning)
  • follicle-stimulating hormone and luteinizing hormone
  • thyroid-stimulating hormone
  • prolactin
  • Doppler ultrasonography
  • pelvic/penile angiography
More investigations to consider

Treatment algorithm


all patients (except those with Peyronie disease, psychogenic ED, and previous pelvic injury with arterial compromise)

Peyronie disease

previous pelvic injury with arterial compromise

psychogenic ED



Edward D. Kim, MD

Professor of Surgery

Division of Urology

University of Tennessee Graduate School of Medicine




EDK declares that he has no competing interests.


Dr Edward D. Kim would like to gratefully acknowledge Dr Andrew C. Kramer, Dr Daniel H. Williams, and Dr James K. Kuan, previous contributors to this topic.


ACK, DHW, and JKK declare that they have no competing interests.

Peer reviewers

Justin Vale, MS, FRCS

Urological Surgeon

Imperial Healthcare NHS Trust




JV declares that he has no competing interests.

Arthur L. Burnett, MD

Professor of Urology

Cellular and Molecular Medicine

The James Buchanan Brady Urological Institute

The Johns Hopkins Hospital




ALB declares that he has no competing interests.

  • Differentials

    • Premature ejaculation
    • Priapism
    More Differentials
  • Guidelines

    • Peyronie’s disease and congenital penile curvature
    • Guidelines on male sexual dysfunction
    More Guidelines
  • Patient leaflets

    Erection problems

    Erection problems: questions to ask your doctor

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer