What is the appropriate workup for premature erectile dysfunction (ED)?

From the Guidelines

A workup for premature erectile dysfunction should begin with a comprehensive medical history and physical examination, focusing on modification of risk factors such as smoking cessation, weight loss, and avoiding excess alcohol consumption, as well as treatment of psychosocial problems, as recommended by the Journal of the National Comprehensive Cancer Network 1. The initial evaluation should include assessment of cardiovascular risk factors, medication review, and screening for depression, anxiety, and relationship issues.

• Laboratory tests should include fasting glucose or HbA1c, lipid profile, and morning total testosterone.
• If testosterone is low, additional hormonal testing including luteinizing hormone, prolactin, and thyroid function tests may be warranted.
• Specialized tests like nocturnal penile tumescence testing or penile Doppler ultrasound are typically reserved for complex cases. First-line treatment usually involves addressing modifiable risk factors such as smoking cessation, weight loss, and improved diabetes control.
• Phosphodiesterase-5 inhibitors like sildenafil, tadalafil, or vardenafil are typically the initial pharmacologic treatment, as recommended by the American College of Physicians 1.
• These medications work by enhancing nitric oxide-mediated relaxation of smooth muscle in the penis, increasing blood flow. If these are ineffective, second-line options include vacuum erection devices, intracavernosal injections, or intraurethral suppositories.
• Psychological counseling may be beneficial, particularly for patients with significant anxiety or relationship concerns contributing to their erectile dysfunction. It is essential to individualize decisions to measure hormone levels based on the clinical presentation and physical findings that suggest hormonal abnormality, as the evidence is inconclusive about the effectiveness of hormonal treatment in the management of patients with erectile dysfunction, even in patients with low testosterone levels 1.

From the Research

Appropriate Workup for Premature Erectile Dysfunction (ED)

The workup for premature ED involves a comprehensive evaluation, including:

• A full medical and personally and culturally sensitive sexual history 2, 3, 4
• A focused clinical examination, including assessment of the cardiovascular, neurological, and urogenital systems 2, 4
• Laboratory tests, such as:
  • Fasting glucose levels 2, 3, 4
  • Fasting lipid profile 2, 3, 4
  • Total testosterone level, particularly in men over 50 years or if hypogonadism is suspected 2, 4
  • Prostate-specific antigen test, in select cases 2

Diagnosis and Treatment

Diagnosis is based on medical and sexual history, including validated questionnaires, and physical examination and laboratory testing tailored to the patient's complaints and risk factors 3. Treatment options include:

• Lifestyle modification and reduction of comorbid vascular risk factors 2
• Pharmacotherapy, such as phosphodiesterase type 5 inhibitors (PDE5Is), including sildenafil, tadalafil, vardenafil, and avanafil 2, 3, 5, 6
• Patient-administered intracorporal injection therapy using vasodilator drugs, such as alprostadil 2, 6
• Surgical treatment, including multicomponent inflatable penile implants, penile arterial revascularisation, and venous ligation surgery 2