ED Diagnosis - Erection Hardness Score

As clinicians, we know that there can be several ways to assess symptoms and conditions. This is true for sexual function, too.

The Erection Hardness Score (EHS) can be a helpful tool to evaluate erectile dysfunction (ED) – a man’s inability to get or maintain an erection firm enough for sex.

Developed in 1998, the EHS is a single-item Likert scale that men can use on their own. The tool asks them to consider the question “How would you rate the hardness of your erection?” and select one of the following options:

Penis does not enlarge 
1 Penis is larger, but not hard
2 Penis is hard, but not hard enough for penetration
3 Penis is hard enough for penetration, but not completely hard
Penis is completely hard and fully rigid

Like most assessment tools, the EHS does have its advantages and disadvantages. Let’s take a look at these aspects more closely.

Advantages of the EHS
For many, the EHS is attractive because it is short and simple to use. With just one question, men can easily assess their erection hardness and report back to their physician.

This feature is in contrast to the International Index of Erectile Function (IIEF), which is considered the gold standard for assessing a man’s erections. The IIEF is a 15-item self-reported questionnaire that evaluates five domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. The IIEF allows clinicians to diagnose erectile dysfunction and determine how severe a case may be.

Some experts are concerned clinicians may be less likely to use the IIEF because of its length, making the EHS a viable alternative in some cases.

Disadvantages of the EHS and Recent Research
The shortness of the EHS can also be a disadvantage. With just one item, the EHS does not evaluate other factors related to erectile dysfunction. It cannot give clinicians the whole picture like the IIEF can, with its five domains.

Also, the EHS might not be appropriate for all clinical situations. For example, a recent study in The Journal of Sexual Medicine examined the validity of the EHS for men who had erectile dysfunction following radical prostatectomy. The 75 participants were using alprostadil injections to treat their ED.

At 6-month and 12-month follow-up points, the researchers used several assessment tools, including the EHS and the IIEF. (Other tools used were the Global Assessment Questionnaire and the Numeric Pain Scale.)

They found that the EHS had good convergent validity. The men’s scores aligned with the other assessment tools used. The EHS had “adequate” known-groups validity and treatment responsiveness. However, it also had limited time responsiveness and limited predictive validity when compared to the IIEF.

These results led the authors to suggest that the EHS be considered carefully when used for clinical follow-up with post-prostatectomy patients using injections for ED.

“Despite being simple and easily repeated, its use for clinical follow-up should rather complement than replace more comprehensive scales like the [15-item IIEF], given its limited responsiveness to changes over a 1-year follow-up and the conceptual nature of the instrument strictly focused toward erection hardness while evaluation of sexual rehabilitation should ideally be multidimensional,” they wrote.

The study was first published online in The Journal of Sexual Medicine.

The Journal of Sexual Medicine
Mulhall, John P., MD, et al.
“Validation of the Erection Hardness Score”
(Full-text. First published online: September 21, 2007)

Parisot, Juliette, MD, et al.
“Erection Hardness Score for the Evaluation of Erectile Dysfunction: Further Psychometric Assessment in Patients Treated by Intracavernous Prostaglandins Injections after Radical Prostatectomy”
(Full-text. First published online: May 20, 2014)