Editing Erectile dysfunction (section)

==Diagnosis==
In many cases, the diagnosis can be made based on the person's history of symptoms. In other cases, a physical examination and [[blood test|laboratory investigations]] are done to rule out more serious causes such as [[hypogonadism]] or [[prolactinoma]].<ref name="LMCC"/>

One of the first steps is to distinguish between physiological and psychological ED. Determining whether involuntary erections are present is important in eliminating the possibility of psychogenic causes for ED.<ref name="LMCC"/> Obtaining full erections occasionally, such as [[nocturnal penile tumescence]] when asleep (that is, when the mind and psychological issues, if any, are less present), tends to suggest that the physical structures are functionally working.<ref name="pmid7483128">{{cite journal |vauthors=Levine LA, Lenting EL | title = Use of nocturnal penile tumescence and rigidity in the evaluation of male erectile dysfunction | journal = Urol. Clin. North Am. | volume = 22 | issue = 4 | pages = 775–88 | year = 1995 | pmid = 7483128 }}</ref><ref name="WebMD">{{cite web|title = Tests for Erection Problems| work=WebMD |publisher = [[WebMD]], Inc|url = http://www.webmd.com/erectile-dysfunction/tests-for-erection-problems|access-date = 2007-03-03|archive-date = 2018-03-08|archive-url = https://web.archive.org/web/20180308142404/https://www.webmd.com/erectile-dysfunction/tests-for-erection-problems|url-status = live}}</ref> Similarly, performance with [[masturbation|manual stimulation]], as well as any performance anxiety or acute situational ED, may indicate a psychogenic component to ED.<ref name="LMCC"/>

Another factor leading to ED is [[diabetes mellitus]], a well known cause of [[neuropathy]].<ref name="LMCC"/> ED is also related to generally poor physical health, poor dietary habits, [[obesity]], and most specifically [[cardiovascular disease]], such as [[coronary artery disease]] and [[peripheral vascular disease]].<ref name="LMCC"/>  Screening for cardiovascular risk factors, such as [[smoking]], [[dyslipidemia]], [[hypertension]], and [[alcoholism]], is helpful.<ref name="LMCC"/>

In some cases, the simple search for a previously undetected [[groin hernia (disambiguation)|groin hernia]]<!--intentional link to DAB page--> can prove useful since it can affect sexual functions in males and is relatively easily curable.<ref name="groin-cause"/>

The current{{Dash}}{{As of|2025|April|lc=y}}<ref>{{Cite web |title=DSM |url=https://www.psychiatry.org/psychiatrists/practice/dsm |url-status=live |archive-url=https://web.archive.org/web/20250425142756/https://www.psychiatry.org/psychiatrists/practice/dsm |archive-date=25 April 2025 |access-date=2025-04-25 |website=www.psychiatry.org |publisher=[[American Psychiatric Association]] |language=en |quote=The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) features the most current text updates based on scientific literature with contributions from more than 200 subject matter experts.}}</ref>{{Dash}}edition of the ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' ([[DSM-5-TR]]) lists ''Erectile Disorder'' ([[ICD-10-CM]] code: F52.21) as a diagnosis.<ref name=":2">{{Cite book |title=Diagnostic and statistical manual of mental disorders: DSM-5-TR™ |title-link=DSM-5-TR |date=2022 |publisher=American Psychiatric Association Publishing |isbn=978-0-89042-575-6 |editor-last=American Psychiatric Association |edition=Fifth edition, text revision |location=Washington, DC |pages=481–483}}</ref> According to the DSM, it "is the more specific DSM-5 diagnostic category in which erectile dysfunction persists for at least 6 months and causes distress in the individual."<ref name=":2" /> The [[ICD-10]], to which the DSM refers regarding ''Erectile dysfunction'',<ref name=":2" /> lists it under ''Failure of genital response'' (F52.2).<ref>{{Cite web |title=ICD-10 Version:2019 |url=https://icd.who.int/browse10/2019/en#/F52.2 |url-status=live |archive-url=https://web.archive.org/web/20250422021426/https://icd.who.int/browse10/2019/en#/F52.2 |archive-date=2025-04-22 |access-date=2025-04-25 |website=icd.who.int |language=en }}</ref> The latest edition of the [[International Classification of Diseases|ICD]]{{Dash}}namely, the [[ICD-11]]{{Dash}}lists the condition as ''Male erectile dysfunction'' ([https://icd.who.int/browse/2025-01/mms/en#97556145 HA01.1]).

===Ultrasonography===
[[File:Ultrasonography of dilated penile sinusoids during erection.jpg|thumb|Transverse ultrasound image, ventral view of the penis. Image obtained after induction of an erection, 15 min after injection of prostaglandin E1, showing dilated sinusoids (arrows).<ref name="FernandesSouza2018"/>]]
[[Penile ultrasonography]] with [[doppler ultrasound|doppler]] can be used to examine the erect penis. Most cases of ED of organic causes are related to changes in blood flow in the corpora cavernosa, represented by occlusive artery disease (in which less blood is allowed to enter the penis), most often of atherosclerotic origin, or due to failure of the veno-occlusive mechanism (in which too much blood circulates back out of the penis). Before the Doppler sonogram, the penis should be examined in B mode, in order to identify possible tumors, fibrotic plaques, calcifications, or hematomas, and to evaluate the appearance of the cavernous arteries, which can be tortuous or atheromatous.<ref name="FernandesSouza2018">Originally copied from:<br>{{cite journal | vauthors = Fernandes MA, de Souza LR, Cartafina LP | title = Ultrasound evaluation of the penis | journal = Radiologia Brasileira | volume = 51 | issue = 4 | pages = 257–261 | year = 2018 | pmid = 30202130 | pmc = 6124582 | doi = 10.1590/0100-3984.2016.0152 }}<br>[[Creative Commons|CC BY]] 4.0 license</ref>

Erection can be induced by injecting 10–20&nbsp;μg of prostaglandin E1, with evaluations of the arterial flow every five minutes for 25–30&nbsp;min (see image). The use of prostaglandin E1 is contraindicated in patients with predisposition to priapism (e.g., those with sickle cell anemia), anatomical deformity of the penis, or penile implants. Phentolamine (2&nbsp;mg) is often added. Visual and tactile stimulation produces better results. Some authors recommend the use of sildenafil by mouth to replace the injectable drugs in cases of contraindications, although the efficacy of such medication is controversial.<ref name="FernandesSouza2018"/>

Before the injection of the chosen drug, the flow pattern is monophasic, with low systolic velocities and an absence of diastolic flow. After injection, systolic and diastolic peak velocities should increase, decreasing progressively with vein occlusion and becoming negative when the penis becomes rigid (see image below). The reference values vary across studies, ranging from > 25&nbsp;cm/s to > 35&nbsp;cm/s. Values above 35&nbsp;cm/s indicate the absence of arterial disease, values below 25&nbsp;cm/s indicate arterial insufficiency, and values of 25–35&nbsp;cm/s are indeterminate because they are less specific (see image below). The data obtained should be correlated with the degree of erection observed. If the peak systolic velocities are normal, the final diastolic velocities should be evaluated, those above 5&nbsp;cm/s being associated with venogenic ED.<ref name="FernandesSouza2018"/>

<gallery mode="packed" heights="200">
File:Doppler ultrasonography of cavernous artery flow in flaccid and erected state.jpg|Graphs representing the color Doppler spectrum of the flow pattern of the cavernous arteries during the erection phases. A: Single-phase flow with minimal or absent diastole when the penis is flaccid. B: Increased systolic flow and reverse diastole 25 min after injection of prostaglandin.<ref name="FernandesSouza2018"/>
File:Doppler ultrasonography of cavernous arterial insufficiency.jpg|Longitudinal, ventral ultrasound of the penis, with pulsed mode and color Doppler. Flow of the cavernous arteries at 5, 15, and 25 min after prostaglandin injection (A, B, and C, respectively). The cavernous artery flow remains below the expected levels (at least 25–35&nbsp;cm/s), which indicates ED due to arterial insufficiency.<ref name="FernandesSouza2018"/>
</gallery>

===Other workup methods===
;Penile nerves function:Tests such as the [[bulbocavernosus reflex]] test are used to ascertain whether there is enough nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger in the anus.<ref>{{cite journal | vauthors = Vodušek DB, Deletis V | title = Intraoperative Neurophysiological Monitoring of the Sacral Nervous System | journal = Neurophysiology in Neurosurgery, A Modern Intraoperative Approach | pages = 153–165 | date = January 2002 | doi = 10.1016/B978-012209036-3/50011-1 | isbn = 978-0-12-209036-3 | s2cid = 78605592 }}</ref>

;Nocturnal penile tumescence (NPT):It is normal for a man to have five to six erections during sleep, especially during [[Rapid eye movement sleep|rapid eye movement (REM)]]. Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge. A significant proportion{{how many|date=December 2022}} of males who have no sexual dysfunction nonetheless do not have regular nocturnal erections.{{citation needed|date=March 2021}}

;Penile biothesiometry:This test uses electromagnetic vibration to [[Biothesiometry|evaluate sensitivity]] and nerve function in the glans and shaft of the penis.<ref>{{Citation |last1=Mulhall |first1=John P. |title=Biothesiometry |date=2017 |url=http://link.springer.com/10.1007/978-3-319-42178-0_2 |work=Atlas of Office Based Andrology Procedures |pages=9–14 |editor-last=Mulhall |editor-first=John P. |place=Cham |publisher=Springer International Publishing |language=en |doi=10.1007/978-3-319-42178-0_2 |isbn=978-3-319-42176-6 |access-date=2022-02-27 |last2=Jenkins |first2=Lawrence C. |editor2-last=Jenkins |editor2-first=Lawrence C.|url-access=subscription }}</ref>

;Dynamic infusion cavernosometry (DICC):Technique in which fluid is pumped into the penis at a known rate and pressure. It gives a measurement of the vascular pressure in the corpus cavernosum during an erection.{{citation needed|date=December 2020}}

;Corpus cavernosometry:[[#Corpus Cavernosometry|Cavernosography]] measurement of the vascular pressure in the corpus cavernosum.  Saline is infused under pressure into the corpus cavernosum with a butterfly needle, and the flow rate needed to maintain an erection indicates the degree of venous leakage. The leaking veins responsible may be visualized by infusing a mixture of saline and x-ray contrast medium and performing a cavernosogram.<ref>{{cite journal |vauthors=Dawson C, Whitfield H | title = ABC of urology. Subfertility and male sexual dysfunction | journal = BMJ | volume = 312 | issue = 7035 | pages = 902–05 | date = April 1996 | pmid = 8611887 | pmc = 2350600 | doi = 10.1136/bmj.312.7035.902 }}</ref> In Digital Subtraction Angiography (DSA), the images are acquired digitally.{{citation needed|date=December 2020}}

;Magnetic resonance angiography (MRA): This is similar to [[magnetic resonance imaging]]. Magnetic resonance angiography uses magnetic fields and radio waves to provide detailed images of the blood vessels. The doctor may inject into the patient's bloodstream a [[contrast agent]], which causes vascular tissues to stand out against other tissues, so that information about blood supply and vascular anomalies is easier to gather.{{citation needed|date=December 2020}}

;Erection Hardness Score
{{excerpt|Erection Hardness Score}}