Erectile Dysfunction Screening in Type 2 Diabetes: Developing an Evidence-Based Policy forPrimary Care

By Yanet Alvarez and Rachel Quintana, DNP

Men with type 2 diabetes mellitus (T2DM) have a significantly increased risk of developing erectile dysfunction (ED), which frequently precedes the diagnosis of heart disease by several years. Because of the stigma around it, many men never raise it, and many clinicians wait for the patient to bring it up, so it often goes unaddressed. The American Diabetes Association’s 2025 Standards of Care recommend screening for ED using a brief, validated questionnaire during routine diabetes visits. However, at a primary care practice in Southwest Florida, no standardized process for ED screening existed. Screening was inconsistent, depended on the individual clinician, and was not reliably documented or followed up.

Yanet Alvarez, APRN, MSN, FNP-C, a family nurse practitioner and Doctor of Nursing Practice (DNP) candidate at Ana G. Méndez University, addressed this gap as her capstone project, entitled “Standardizing Erectile Dysfunction Screening and Referral: An Institutional Policy Evaluation for Southwest Florida Primary Care.” She implemented the project at the practice where her preceptor, Victor R. Benitez, APRN, FNP-C, provides care, with guidance from faculty mentor Rachel Quintana, DNP. The university’s Institutional Review Board acknowledged the project.

Alvarez began by watching how the practice actually worked. No screening tool was in use, no field in the electronic health record (EHR) captured ED, and no referral route existed for a positive result. She then read through peer-reviewed literature published from 2020 through 2025, along with the 2025 Standards of Care. The articles covered how common ED is in men with T2DM, its link to heart disease, which questionnaires hold up, and why patients and clinicians both tend to avoid the subject. Each recommendation in the policy she wrote traces back to that reading. She also drew on the Theory of Planned Behavior from psychologist Icek Ajzen, which says what people do depends on their attitudes, the expectations around them, and how doable the task seems.

The policy applies to men aged 50 and older with T2DM and lays out four steps. A medical assistant hands the patient the Sexual Health Inventory for Men (SHIM), a five-question form also called the International Index of Erectile Function-5, when he checks in. The provider reviews and scores it on a scale of 1 to 25. The provider then documents the score and any counseling in a standard EHR template, using short action codes for counseling, referral, lab orders, or continuing the current plan. A patient who scores below 22 is referred to Cardiology, Urology, or Endocrinology, depending on his presentation.

After a short huddle to introduce the workflow to the medical assistants and providers, Alvarez observed clinic visits over time. Each step fit into the way the practice already roomed patients, documented, and referred. The project did not track screening rates or clinical results; its product is the policy itself.

The policy is designed to make ED screening a normal part of a diabetes visit. It is meant to help clinicians catch early signs of vascular disease, provide every eligible patient with the same counseling, and refer them to the right specialist. It is also written so other primary care practices with the same gap can adapt it.

Alvarez’s main takeaway is that clinicians usually know why a screening matters, and a questionnaire like the SHIM takes only a few minutes. What a practice often lacks is a written expectation, a tool, and somewhere to record the result. Once those exist, screening stops depending on who is in the exam room. Building that kind of structure is a large part of what DNP-prepared nurses are trained to do.