# ED Symptoms and How It Is Diagnosed

> What counts as erectile dysfunction, what a proper assessment involves, and which tests are worth asking for. Diagnosis is mostly conversation — the tests are about finding the cause.

- **Source:** ED Treatment Guides (https://www.edtreatmentguides.com/guides/symptoms-and-diagnosis)
- **Last updated:** 2025-11-18
- **Type:** guide
- **Topic:** Getting started

## Key points

- ED is the persistent inability to get or keep an erection firm enough for satisfactory sex — persistent being the key word. Occasional difficulty is normal.
- The usual threshold used clinically is difficulty on most attempts over about three months.
- Diagnosis is made from history. Tests exist to find the **cause**, not to confirm the symptom.
- A minimum sensible workup is blood pressure, HbA1c or glucose, a lipid panel and a morning testosterone.
- Specialised tests such as penile ultrasound are for specific situations, not routine cases.

## What actually counts as ED

The clinical definition is the persistent or recurrent inability to attain or maintain an erection sufficient for satisfactory sexual performance. Two words carry the weight: **persistent** and **satisfactory**.

- One bad night after too much alcohol, too little sleep or too much stress is not erectile dysfunction. It is being human.
- Most clinicians use a threshold of difficulty on the majority of attempts, over roughly three months.
- It is also defined by what bothers you. A pattern that neither you nor your partner finds a problem does not need treatment.

> **Related but distinct problems**
>
> Premature ejaculation, delayed ejaculation, low libido and painful sex are separate conditions with separate treatments. They frequently coexist with ED, so it is worth naming exactly which one is bothering you.

## Assessing yourself before you go

The most widely used screening tool is the Sexual Health Inventory for Men (SHIM), also known as the IIEF-5 — five questions about the last six months, scored 5 to 25.

**How SHIM scores are usually interpreted**

| Score | Interpretation |
| --- | --- |
| 22–25 | No erectile dysfunction |
| 17–21 | Mild |
| 12–16 | Mild to moderate |
| 8–11 | Moderate |
| 5–7 | Severe |

_A screening score is not a diagnosis. It is a way of describing severity consistently — including to yourself, over time._

> **Take it before your appointment**
>
> Our [free self-assessment](https://www.edtreatmentguides.com/tools/ed-self-assessment) runs entirely in your browser and sends nothing anywhere. Bring the score with you — it gives the conversation a concrete starting point and a baseline to measure treatment against.

## The questions that matter most

The history is where the diagnosis is actually made. These are the questions a good clinician will ask, and they are worth thinking about beforehand.

- **Did it start suddenly or gradually?** — Sudden onset, especially traceable to an event, points towards psychological causes. Gradual decline over months to years points towards vascular causes.
- **Do you get erections on waking or when alone?** — Perhaps the single most useful question. If yes, the physical machinery works — which points towards psychological or relational factors.
- **Is it the getting or the keeping?** — Difficulty maintaining an erection that starts well can suggest venous leak or anxiety; difficulty achieving one at all more often suggests arterial or neurological causes.
- **Is it every time, or situational?** — Variation by partner, setting or mood strongly suggests a psychological component.
- **What has changed?** — New medication, new diagnosis, weight change, new stress, relationship change. Timing is diagnostic.
- **What about desire and ejaculation?** — Low desire points towards testosterone, mood or medication. Painful or absent ejaculation raises different questions again.

## Examination and tests

### Physical examination

- Blood pressure and pulse, plus a check of peripheral pulses.
- Waist circumference and BMI.
- Genital examination — testicular size and consistency, and palpation of the penile shaft for Peyronie's plaque.
- Assessment of secondary sexual characteristics and any breast tissue development.
- A prostate examination where symptoms or age make it relevant.

### Blood tests worth having

| Test | Why |
| --- | --- |
| HbA1c or fasting glucose | Screens for diabetes and prediabetes — a leading cause |
| Fasting lipid profile | Cardiovascular risk assessment |
| Morning total testosterone | Especially if libido is reduced. Needs a second confirmatory test if low |
| Full blood count | Anaemia and, if testosterone is being considered, baseline haematocrit |
| Thyroid function | Both over- and underactive thyroid can affect sexual function |
| PSA | Where age and symptoms make prostate assessment appropriate — a shared decision |

### Specialised tests

These are not routine. They belong to specific situations, usually in a urology clinic:

- **Penile duplex Doppler ultrasound** — measures blood flow after an injected vasodilator. Used when arterial disease or venous leak is suspected, or before reconstructive surgery.
- **Nocturnal penile tumescence testing** — measures erections during sleep. Rarely used now, occasionally relevant in medico-legal contexts.
- **LH, FSH and prolactin** — where testosterone is confirmed low, to find out why.

> **What a good assessment does not look like**
>
> A two-minute questionnaire that ends in a prescription with no blood pressure, no bloods and no discussion of cardiovascular risk is not an assessment. Convenience is valuable, but not at the cost of missing the diabetes or heart disease your symptom was announcing.

## Frequently asked questions

### How do I know if I have ED or just an off night?

The clinical threshold is difficulty on most attempts over roughly three months. Occasional difficulty is normal and extremely common.

### Do I need tests, or can I just get a prescription?

You can get a prescription without tests, and many telehealth services work that way. But ED is a recognised early warning sign of cardiovascular disease and diabetes, so skipping the workup means potentially missing something more important than the symptom.

### What does it mean if I still get morning erections?

It suggests the nerves, hormones and blood vessels are working, which points towards psychological or relational factors as the main driver.

### Should I see a GP or a urologist first?

A primary care clinician is the right starting point for most men — they can assess cardiovascular risk and initiate treatment. See a urologist if tablets fail, if there is curvature or pain, or after prostate surgery.

## Sources

- American Urological Association. [Erectile Dysfunction: AUA Guideline](https://www.auanet.org/guidelines-and-quality/guidelines/erectile-dysfunction-(ed)-guideline) (2018)
- National Institute of Diabetes and Digestive and Kidney Diseases. [Definition & Facts for Erectile Dysfunction](https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction)
- Mayo Clinic. [Erectile dysfunction — symptoms and causes](https://www.mayoclinic.org/diseases-conditions/erectile-dysfunction/symptoms-causes/syc-20355776)
- Urology Care Foundation. [What is Erectile Dysfunction?](https://www.urologyhealth.org/urology-a-z/e/erectile-dysfunction-(ed))

## Related pages

- [Free ED self-assessment](https://www.edtreatmentguides.com/tools/ed-self-assessment)
- [How to Bring Up ED With Your Doctor](https://www.edtreatmentguides.com/guides/talking-to-your-doctor)
- [What Happens at Your First ED Appointment](https://www.edtreatmentguides.com/guides/first-appointment)
- [ED and Heart Disease: Why This Symptom Is a Warning](https://www.edtreatmentguides.com/causes/cardiovascular-disease)

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_This page is general health information, not medical advice. It cannot account for your own history, medications or risk factors. Talk to a licensed clinician before starting, stopping or changing any treatment._

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