Determining the cause of erection problems is often the key to reversing them. Since both physical and psychological factors are often involved, it can be complicated to make an exact diagnosis.

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As part of the initial evaluation, your doctor may do the following:

• History taking. He may ask about your sex life, diseases you’ve had and drugs prescribed to you. This will enable him to review risk factors.
• A complete physical exam (including the abdomen, penis, prostate, rectum, and testicles). If the penis does not respond as expected to certain touch stimuli, there may be a problem with the nervous system. Abnormal secondary sex characteristics, such as loss of armpit or pubic hair, can suggest problems in the endocrine system affecting hormone levels. A circulatory problem might be indicated by, for example, an aneurysm in the abdomen (such as disease of the large artery, the aorta, which supplies blood to the abdomen and lower limbs).
• Routine lab tests. These include blood counts, urine analysis, lipid profile, and measurement of liver enzymes and creatinine (a waste product of protein metabolism). If sexual desire is low, the levels of testosterone in the blood may be measured to determine if there are any endocrine abnormalities.
• Nocturnal penile tumescence testing. This test, which monitors if you have erections while asleep, can often help to determine whether the cause is predominantly psychological or physical. Physically healthy men have involuntary erections in their sleep; if these occur, the cause is more likely to be psychological. However, these tests are not completely reliable, and have not been standardised. The modern era of effective oral treatment has reduced the indications for penile tumescence testing drastically.
• Tests to evaluate the penile arteries and veins. This includes the use of medication to assess erections, ultrasound and angiography (a radiographic technique for examining the anatomy of a blood vessel).
• Extensive nervous system tests. These are not well standardised and are generally done only at major medical centres.
• Psychological evaluation. This may be recommended when a major psychological cause is suspected.

You and your doctor will use the results of the examination and tests to develop a treatment plan that may include medications, other non-surgical treatments or surgery.

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