A urologist’s evaluation for erectile dysfunction typically starts with a detailed conversation about your symptoms and medical history, followed by a focused physical exam and blood work. Most first visits don’t involve anything invasive. The goal is to figure out whether the cause is vascular, hormonal, neurological, or psychological, because that determines which treatment will actually work.
The Conversation Comes First
The largest part of your first appointment is talking. Your urologist will ask about your medical history, medications, and lifestyle factors like smoking, alcohol use, and exercise. They’ll also ask about your mental health, relationship stress, and sleep quality. This isn’t small talk. Conditions like diabetes, high blood pressure, heart disease, and depression are closely tied to erectile dysfunction, and medications for those conditions (especially blood pressure drugs and antidepressants) can contribute to the problem.
Expect specific questions about your erections: how firm they get, whether you can maintain them, and whether you still get erections during sleep or in the morning. Morning erections are a useful diagnostic clue. If your body produces normal erections while you sleep but not during sex, that points toward a psychological cause rather than a physical one. In clinical studies, adding detailed questions about sexual activity and relationship factors improved the accuracy of distinguishing psychological from physical ED to about 87%.
You’ll likely fill out a standardized questionnaire called the IIEF-5 (International Index of Erectile Function). It has five questions that ask you to rate things like your confidence in getting an erection, how often erections are firm enough for intercourse, and how often sex is satisfactory. Each answer is scored, and the total helps your urologist categorize the severity of your ED and track whether treatment is working over time.
What the Physical Exam Involves
The physical exam is focused and relatively brief. Your urologist will check your general body type, looking at things like weight, hair distribution, and breast tissue, which can signal hormonal imbalances. Severe obesity, for instance, raises suspicion for sleep apnea or elevated estrogen levels, both of which can contribute to ED.
The genital exam includes checking the size and firmness of your testicles. Small or soft testicles suggest low testosterone. The urologist will also examine the shaft of the penis for any hardened plaques or scar tissue, which could indicate Peyronie’s disease (a condition where internal scarring causes curved, painful erections).
A brief neurological check is part of the exam as well. This involves testing sensation in the groin area, checking reflexes in the lower body, and sometimes testing how the muscles around the base of the penis respond to stimulation. If there’s concern about nerve damage (common in men with diabetes or after pelvic surgery), the urologist may use a small vibrating device on the penis to measure sensation and compare it against normal ranges for your age.
A digital rectal exam is also standard. The urologist inserts a gloved, lubricated finger into the rectum to check the prostate for enlargement, unusual firmness, nodules, or tenderness. An inflamed or enlarged prostate can contribute to sexual dysfunction, and this exam also checks the tone of the anal sphincter, which provides information about the nerves that control erections.
Blood Tests and What They Reveal
Your urologist will order blood work, and you may need to fast beforehand. The most important test is a morning total testosterone level, which the American Urological Association recommends for all men being evaluated for ED. Testosterone is measured in the morning because levels peak early in the day and drop later. Research shows that libido tends to decline when testosterone falls below about 430 ng/dL, and erectile function is more directly affected at levels between 230 and 300 ng/dL.
If total testosterone comes back low or borderline, additional hormone tests may follow: free testosterone, sex hormone-binding globulin, prolactin, and luteinizing hormone. These help determine whether the problem originates in the testicles or in the brain’s signaling to the testicles.
Beyond hormones, the standard panel includes a hemoglobin A1C (a three-month average of blood sugar levels) and a full lipid profile covering total cholesterol, HDL, LDL, and triglycerides. Hemoglobin A1C is strongly associated with ED, with one analysis finding that elevated levels tripled the odds of erectile dysfunction. These tests matter because ED is often an early warning sign of cardiovascular disease or undiagnosed diabetes. Thyroid function tests may be added if your urologist suspects a thyroid disorder based on other symptoms.
Specialized Tests (Not Always Needed)
Most men get a diagnosis from the history, physical exam, and blood work alone. But when the cause remains unclear or surgery is being considered, your urologist may order more targeted tests.
Penile Doppler Ultrasound
This is the most common specialized test. A medication (usually prostaglandin E1) is injected into the side of the penis with a very small needle to trigger an erection by dilating the penile arteries. Within minutes, the urologist uses an ultrasound probe to measure blood flow into and out of the penis. Normal arterial blood flow produces a peak speed above 30 cm/s on the ultrasound. If blood flows in well but leaks back out too quickly (called venous leak), the end-diastolic velocity will be elevated above 5 cm/s. The test also lets the urologist see any internal scarring or calcification in the erectile tissue. If the erection persists after the test is complete, a small dose of adrenaline can be injected to reverse it before you leave.
Injection Test Without Ultrasound
Sometimes the injection alone serves as a diagnostic tool. If a low dose of medication produces a full, rigid erection, it suggests your blood vessels are working fine and the cause is more likely neurological or psychological. If the erection is weak or incomplete even with medication, vascular disease is the probable culprit.
Nocturnal Erection Monitoring
Healthy men have three to five erections during sleep, each lasting about 25 to 35 minutes. A nocturnal penile tumescence (NPT) test involves wearing a device overnight that records whether erections occur. If you have normal erections during sleep, your body’s hardware is working and the issue is likely psychological. This test is rarely used today. It’s mostly reserved for cases that are hard to diagnose, younger patients, or legal and forensic situations.
How to Prepare for Your Appointment
Bring a complete list of every medication you take, including vitamins, supplements, and herbal remedies with their dosages. Many common medications affect erectile function, and your urologist needs the full picture. Write down your symptoms before you arrive: when the problem started, whether it came on gradually or suddenly, and whether it happens in some situations but not others (for example, with a partner but not during masturbation).
If blood work will be drawn at the visit, you may be asked to fast and to schedule the appointment in the morning so testosterone can be measured at its daily peak. Note any major life changes or stressors, since these are relevant to the evaluation. If you have a partner, some urologists welcome them at the appointment, as relationship dynamics can play a role in both diagnosis and treatment planning.
The whole first visit typically lasts 30 to 60 minutes. If specialized testing like a Doppler ultrasound is needed, that’s usually scheduled as a separate appointment.