How to approach a case of erectile dysfunction?

Approach to Erectile Dysfunction Evaluation and Management

A comprehensive evaluation of erectile dysfunction should include medical history, physical examination, laboratory testing, and cardiovascular risk assessment, as ED is often an early marker of cardiovascular disease and requires thorough investigation even in young men. 1

Initial Evaluation

Medical History

• Obtain detailed information about:
  • Onset and duration of ED (gradual onset suggests physical cause; sudden onset suggests psychogenic cause)
  • Severity (using validated tools like Sexual Health Inventory for Men)
  • Comorbidities (diabetes, hypertension, cardiovascular disease, hyperlipidemia)
  • Current medications (antihypertensives, antidepressants, etc.)
  • Surgical history (particularly pelvic or prostate surgery)
  • Family history of vascular disease
  • Substance use (alcohol, tobacco, recreational drugs)
  • Psychological factors (depression, anxiety, relationship issues)
  • Sexual history (including partner relationship quality)

Physical Examination

• Vital signs (especially blood pressure)
• Genital examination (looking for Peyronie's disease, testicular abnormalities)
• Secondary sexual characteristics assessment
• Body mass index (BMI)
• Cardiovascular assessment

Laboratory Testing

• Serum total testosterone (morning sample)
• Fasting glucose or HbA1c
• Lipid profile
• Consider PSA if testosterone therapy is being considered

Cardiovascular Risk Assessment

ED is a significant independent marker for cardiovascular disease 1. Assess:

• Exercise capacity (ability to walk 1 mile in 20 minutes or climb 2 flights of stairs in 20 seconds)
• Consider referral to cardiology for high-risk patients (recent cardiac events, unstable angina, uncontrolled hypertension)

Treatment Algorithm

First-Line Therapy

1. Lifestyle Modifications

   • Weight loss
   • Regular physical exercise
   • Smoking cessation
   • Moderation of alcohol consumption
   • Management of cardiovascular risk factors

2. PDE5 Inhibitors

   • Effective in 60-65% of men with ED regardless of comorbidities 1
   • Options include sildenafil, tadalafil, vardenafil, and avanafil
   • Titrate for optimal efficacy
   • Important contraindications:
     • Concurrent nitrate use (absolute contraindication) 2
     • Guanylate cyclase stimulators 2
     • Severe cardiovascular disease 2, 3
     • Uncontrolled hypertension or hypotension 3

Second-Line Therapy (for PDE5 inhibitor failures or contraindications)

1. Vacuum Erection Devices

   • Non-invasive mechanical option
   • Effective regardless of etiology

2. Intracavernosal Injection Therapy

   • Alprostadil or combination therapy (papaverine, phentolamine)
   • High efficacy rate even in severe ED

Third-Line Therapy

1. Penile Prosthesis Implantation
   • For patients who fail or cannot use other treatments
   • High satisfaction rates

Adjunctive Therapy

1. Psychosexual Therapy

   • Beneficial for predominantly psychogenic ED (success rates of 50-80%) 1
   • Can be used alone or in combination with medical treatments
   • Especially important for younger men with primarily psychogenic ED

2. Testosterone Therapy

   • Only if testosterone deficiency is confirmed (<300 ng/dL with symptoms)
   • May improve response to PDE5 inhibitors 1

Special Considerations

Young Men with ED

• At least 15-20% have an organic etiology, warranting thorough evaluation 1
• Organic ED in young men can predict increased future morbidity and mortality 1
• Consider vascular, hormonal, neurological, and medication-related causes

Common Pitfalls to Avoid

1. Assuming ED in young men is purely psychogenic without proper evaluation
2. Failing to measure testosterone levels
3. Not addressing psychological aspects of ED
4. Overlooking ED as a potential marker for underlying cardiovascular disease
5. Not discussing potential side effects of PDE5 inhibitors before prescribing 1
6. Failing to warn patients about contraindications with nitrates 2
7. Not advising patients to seek immediate medical attention for erections lasting >4 hours 2
8. Not warning about potential vision or hearing loss with PDE5 inhibitors 2, 3

Safety Monitoring

• Regular follow-up examinations to assess treatment effectiveness
• Monitor for penile changes or adverse effects
• Reassess cardiovascular risk periodically

By following this structured approach, clinicians can effectively evaluate and manage erectile dysfunction while potentially identifying underlying conditions that may affect long-term health outcomes.