Management of Erectile Dysfunction
The management of erectile dysfunction should follow a stepwise approach starting with lifestyle modifications, followed by oral PDE5 inhibitors, and progressing to more invasive therapies as needed, with treatment decisions based on cardiovascular risk assessment and testosterone evaluation. 1
Initial Assessment and Risk Stratification
- Cardiovascular Risk Assessment: All men with ED should have their cardiovascular risk assessed, as ED may be an early marker of cardiovascular disease 1
- Testosterone Measurement: Routine testosterone level measurement is recommended for all men with ED, with replacement therapy considered when appropriate 1
- Medical History Focus: Identify organic comorbidities (diabetes, hypertension, dyslipidemia), medications, smoking status, alcohol use, and psychosexual factors 1
- Physical Examination: Focused examination of abdomen, penis, testicles, secondary sexual characteristics, and lower extremity pulses 1
First-Line Treatment: Lifestyle Modifications
- Evidence-Based Lifestyle Changes:
- Smoking cessation
- Regular physical exercise
- Weight loss (target BMI <30 kg/m²)
- Healthy diet (Mediterranean diet recommended)
- Moderate alcohol consumption
- Stress reduction 1
These lifestyle modifications not only improve erectile function but also reduce cardiovascular risk, which is crucial since ED and cardiovascular disease often share common pathophysiological mechanisms 1, 2.
Second-Line Treatment: Oral Medications
- PDE5 Inhibitors (sildenafil, tadalafil, vardenafil, avanafil):
Third-Line Treatment: Injectable/Intraurethral Therapies
Intracavernous Injections (alprostadil):
- Indicated when oral PDE5 inhibitors fail
- Should not be used more than 3 times per week with at least 24 hours between injections 5
- Effective within 5-20 minutes with erection lasting up to one hour 5
- Contraindicated in men with conditions predisposing to priapism (sickle cell anemia, leukemia, multiple myeloma) 5
Intraurethral Alprostadil:
- Alternative to injections with similar efficacy profile 1
Fourth-Line Treatment: Mechanical and Surgical Options
Vacuum Constriction Devices:
Penile Prosthesis Implantation:
- Reserved for patients who fail less invasive treatments
- Associated with high satisfaction rates 3
Vascular Surgery:
- Limited role due to poor outcomes in men with atherosclerotic disease or veno-occlusive dysfunction 3
Special Considerations
Cardiovascular Risk Stratification
High-Risk Patients: Those with unstable/refractory angina, uncontrolled hypertension, heart failure, recent MI/stroke, high-risk arrhythmias, or severe valvular disease should not receive ED treatment until cardiac condition stabilizes 1
Low-Risk Patients: Can be considered for all first-line therapies 1
Testosterone Replacement
- Testosterone levels <230 ng/dL usually benefit from replacement therapy
- Levels >350 ng/dL typically do not require supplementation 1
- Testosterone therapy may improve response to PDE5 inhibitors 1
Monitoring and Follow-up
- Monitor for priapism (erections lasting >6 hours) which requires immediate medical attention 5
- Assess treatment efficacy and adjust therapy as needed
- Continue cardiovascular risk management alongside ED treatment
Common Pitfalls to Avoid
- Neglecting cardiovascular assessment before initiating treatment
- Failing to measure testosterone levels in all men with ED
- Prescribing PDE5 inhibitors to patients on nitrates or with unstable cardiovascular disease
- Not providing adequate injection training for intracavernous therapy
- Overlooking lifestyle modifications which can improve both ED and cardiovascular health
By following this comprehensive approach to ED management, clinicians can effectively address this common condition while simultaneously improving patients' overall health and quality of life.