When you go to your doctor complaining of sexual problems, he will first ask you questions to make sure that what you mean is really a problem with erection.

After this, a good history and physical examination with a few specialized tests will tell your doctor the cause of your problem. Your doctor knows you have diabetes, but many patients may have multiple causes and therefore, it is important to correctly diagnose the reason for the erectile dysfunction.

At the same time, you must have an idea of what tests are available and what their use is so that you can discuss this intelligently with your doctor. Whilst the evaluation must be comprehensive there should not be a "Test…because a test is available!" approach.

The other main reason for knowing about these tests is that they are often a clue to the best possible therapy available for you and your having this knowledge will allow you to actively interact with your doctor to choose the best possible treatment for your erectile problem.

Often one can get an excellent clue to the etiology by the history and physical examination which can then be tested by precise laboratory tests. At the same time, some have multiple causes, such as a person with diabetes who is also on certain antihypertensive medications.

It is essential to see that the evaluation is comprehensive without having a "Test…because a test is available!" approach.

History and Clinical Examination
As we have discussed above, your doctor will take a thorough history. He will want to identify your concern about your sexual function and make sure that you are indeed complaining about erectile problems, or impotency as many patients call it. Once your concern about your sexual problem is brought up, the next step is to differentiate erectile dysfunction from other sexual problems, such as loss of libido or ejaculatory problems. The history would include the duration of impotence, level of libido, and a complete inventory of sexual partners, if relevant. The sexual history is often the most helpful piece of information in directing further evaluation and treatment.

He may ask you to take a questionnaire test which we discussed above and which you could take in the privacy of your own home and tell the doctor the results.

The International Index of Erectile Function (IIEF) is a valuable tool for defining the area of sexual dysfunction. The IIEF is designed to be a self-administered measure of erectile dysfunction, but it also assesses a patient's function in other phases of sexual function. The IIEF also establishes a reliable baseline that can be used to monitor changes related to treatment.

The full 15 question IIEF which helps in distinguishing what type of sexual dysfunction is present can be accessed here.

The shortened 5 question IIEF which helps in judging the severity of true erectile dysfunction can be accessed here.

Even if you have diabetes, it may be that the major role for your impotency is caused by psychological factors. Early recognition of psychogenic disturbances allows the physician to avoid costly and confusing evaluation for other etiologies of impotence

Anatomic, psychogenic, endocrinologic, neurologic, and vascular abnormalities may all contribute to impotence. Therefore, the evaluation of impotence begins with a comprehensive history and physical examination.

A thorough history is the most important factor in the evaluation of the patient with erectile dysfunction. The initial step is to identify the patient's concern with his sexual function. A careful sexual history and knowledge of concurrent illnesses and medications are essential. The sexual history should include the duration of impotence, level of libido, and a complete inventory of sexual partners. The sexual history is often the most helpful piece of information in directing further evaluation and treatment.

Psychogenic disorders may occasionally be primary factors contributing to erectile dysfunction. In order to improve treatment for patients with psychogenic impotence, Lue has suggested classifying psychogenic impotence into 5 broad categories:

a) anxiety and fear of failure;

b) depression;

c) marital conflict or strained relationship;

d) ignorance or misinformation about normal anatomy and sexual function; and

e) obsessive-compulsive personality disorder, anhedonia, sexual deviation, and psychotic disorders. Recognition of these patient characteristics should lead the clinician to entertain the possibility of a primary psychogenic etiology of impotence.

Once a concern with the patient's sexual function is identified, the next step is to differentiate erectile dysfunction from other sexual problems, such as loss of libido or ejaculatory problems. The 15 Question International Index of Erectile Function (IIEF), which we have discussed above is a valuable tool for defining this area of sexual dysfunction.

Early recognition of psychogenic disturbances allows the physician to avoid costly and confusing evaluation for other etiologies of impotence. Moreover, many patients complain of erectile dysfunction when they mean something lese such as premature ejaculation etc., and again this needs to be recognized before embarking on the detailed evaluation.

Because impotence is known to be associated with many common medical conditions and medications, a careful medical history may yield insights into the etiology of impotence. A history of peripheral vascular disease, coronary artery disease, diabetes, renal failure, tobacco and/or alcohol use, or psychogenic, neurologic, or other chronic debilitating diseases is often very helpful in directing further evaluation and treatment. Many common medications such as psychotropic drugs and antihypertensives have been associated with impotence.

Similarly, a patient's surgical history may also provide clues to the possible causes of impotence. Prior radical pelvic surgery (eg, prostatectomy, abdominoperineal resection), radiation, and pelvic trauma are known to be associated with impotence.

Physical Examination
The physical examination should assess the patient's overall health. Particular attention should be given to the cardiovascular, neurologic and genitourinary systems, as these systems are directly involved with erectile function.

Careful physical examination with particular attention to sexual and genital development may occasionally reveal an obvious cause of impotence. Careful examination of the penis may reveal an anatomic abnormality such as a micropenis, the presence of chordee, or a Peyronie's plaque. The finding of small, soft, atrophic testes (the typical adult testis is 4.5 cm long with a range of 3.5 to 5 cm.) or gynecomastia should prompt an endocrine evaluation for hypogonadism (beard, body hair and voice should be evaluated for signs of hypogonadism) or hyperprolactinemia. Certain genetic syndromes such as Kallmann's or Klinefelter's syndrome may present with obvious physical signs of hypogonadism or distinctive body habitus. The prostate gland should be assessed for size, consistency and symmetry.

A careful neurologic examination should also be performed on all patients. Patients with diabetes or neurodegenerative disorders may show evidence of peripheral neuropathy. Several reflexes can be tested to evaluate sacral cord function. The superficial anal reflex, indicative of normal somatic function of sacral cord levels S24, is assessed by touching the perianal skin and noting contraction of the external anal sphincter muscles. The bulbocavernosus reflex also demonstrates normal sacral cord function. It is performed by placing a finger in the rectum and noting contraction of the anal sphincter and bulbocavernosus muscle when the glans penis is squeezed. External anal sphincter tone can be assessed during this maneuver as well.