Erectile dysfunction has vascular, hormonal, neurological, pharmacological and psychological causes, and frequently several at once. Our workup identifies which apply to you before any treatment is recommended, because the same symptom can require entirely different answers.
Also referred to as: ED, impotence, erektil disfonksiyon, sertleşme sorunu, male sexual dysfunction.
Why the diagnosis comes first
Erectile dysfunction is not a diagnosis in itself. It is the endpoint of a mechanism — arterial inflow that is inadequate, venous outflow that will not close, nerve signalling that does not arrive, hormones that are absent, a medication that blocks the pathway, or anxiety that overrides all of it. Treating the symptom without knowing the mechanism is how men spend years cycling through prescriptions that were never going to work.
It also matters beyond the bedroom. The arteries of the penis are narrow, and they silt up before the coronary arteries do. Vasculogenic erectile dysfunction in a man in his forties or fifties precedes a cardiac event by an average of three to five years. For a meaningful number of the men we assess, the most valuable outcome of the visit is not a prescription but a cardiology referral.
What the assessment includes
The full workup is completed within a single day so that international patients can be diagnosed and counselled in one visit.
- Structured history, including onset, whether morning erections persist, and situational variability
- IIEF-5 questionnaire to quantify severity and to give a baseline for measuring treatment response
- Medication review — antihypertensives, antidepressants, finasteride and others are common and reversible contributors
- Blood panel: morning total testosterone, SHBG, prolactin, LH, HbA1c, fasting lipids, thyroid function, PSA where age-appropriate
- Cardiovascular risk assessment, with blood pressure, waist circumference and a referral pathway where risk is elevated
- Genital and prostate examination, including plaque palpation for Peyronie’s disease
- Penile duplex Doppler ultrasound after intracavernosal vasoactive injection — the definitive vascular test
Penile Doppler ultrasound, explained
A small dose of a vasoactive agent is injected into the corpus cavernosum to produce an erection under controlled conditions, and blood flow is then measured with ultrasound at intervals over twenty to thirty minutes. Two numbers carry most of the information. Peak systolic velocity reflects arterial inflow: above 30 cm/s is normal, and consistently lower values indicate arterial insufficiency. End-diastolic velocity reflects whether the veins close properly: above 5 cm/s with a poorly sustained erection indicates a venous leak.
The distinction changes the treatment entirely. Arterial insufficiency in a younger man may respond to shockwave therapy and aggressive cardiovascular risk management. A significant venous leak will not respond to tablets at any dose, and pursuing them wastes years. Severe combined disease points toward an implant, and knowing that early spares a man a long detour through treatments that cannot work for him.
The injection is given with a very fine needle and is far less uncomfortable than most men expect. We keep you in the department until the erection has fully resolved, and a reversal agent is available if needed.
The treatment ladder
Treatment escalates only as far as it needs to. Most men never reach the top of this ladder — but everyone should know what the whole ladder looks like before starting to climb it.
Risk factor modification
Smoking cessation, weight reduction, glycaemic control, exercise and reviewing contributory medications. Unglamorous, and in men with early vascular disease genuinely capable of restoring function without any drug.
PDE5 inhibitors
Sildenafil, tadalafil, vardenafil. Effective in roughly 70% of unselected men. Many "non-responders" have simply never been shown how to take them correctly, or have been under-dosed — we check that before declaring failure.
Testosterone replacement
Only where hypogonadism is confirmed on two morning samples with symptoms. It improves libido reliably and erections variably, and requires ongoing monitoring of haematocrit and prostate health.
Low-intensity shockwave therapy
A course of energy applications intended to stimulate neovascularisation in mild to moderate vasculogenic ED. Evidence is encouraging but modest, and it does not help venous leak or severe disease. We only recommend it where the Doppler suggests it can work.
Intracavernosal injection
Alprostadil or a combination preparation, self-injected before intercourse. Highly effective even in severe disease, including venous leak. Discontinuation rates are high not because it fails but because men tire of the routine.
Vacuum erection device
A non-invasive mechanical option, and a useful tool in penile rehabilitation after prostate surgery. The erection feels different — hinged at the base and cooler — which limits long-term acceptance for some.
Penile implant
The end of the ladder and the treatment with the highest satisfaction rate. Appropriate once the options above have genuinely failed, and irreversible, which is why it comes last.
Questions we are asked about erectile dysfunction
Can I be assessed and treated on the same trip?
For medical treatment, shockwave therapy or injection training, yes — the assessment and the first treatment fit comfortably into two or three days. For implant surgery we normally review your records remotely first so that surgery can be scheduled for the same visit, with the in-person workup completed the day before the operation.
Does erectile dysfunction mean I have heart disease?
Not necessarily, but vasculogenic ED is a recognised early warning of it, particularly in men under sixty. Our workup includes a cardiovascular risk assessment for exactly that reason, and we will refer you if the picture warrants it.
Is my problem psychological?
Preserved morning erections, good erections in some situations and not others, and a sudden onset all point toward a psychogenic component. That is genuinely treatable, and it is also a strong reason not to proceed to irreversible surgery. The Doppler helps separate the two objectively.
Do the tablets stop working over time?
The tablets do not lose potency; the underlying vascular disease usually progresses. A drug that has become ineffective is a signal to reassess the mechanism rather than simply to increase the dose.
Is shockwave therapy worth it?
For carefully selected men with mild to moderate vascular ED, it can produce a real improvement. For severe disease, venous leak or post-prostatectomy nerve injury, it does not. We recommend it only when the Doppler findings support it, and we will tell you if a course would be money wasted.
Clinically reviewed by the Santa Urology surgical team. This page describes typical outcomes reported in the surgical literature and in our own practice; individual results vary and nothing here is a substitute for a personal consultation. See our medical disclaimer.