What are the causes and management options for erectile dysfunction (ED)?

Causes and Management of Erectile Dysfunction

The management of erectile dysfunction begins with identifying underlying causes and should follow a stepwise approach, starting with oral PDE5 inhibitors for most patients, followed by more invasive options based on efficacy and patient preference. 1, 2

Causes of Erectile Dysfunction

Erectile dysfunction results from a complex interplay between vascular, neurologic, hormonal, and psychological factors:

• Cardiovascular conditions: Hypertension, atherosclerosis, hyperlipidemia, and endothelial dysfunction are common vascular causes 1, 3
• Endocrine disorders: Diabetes mellitus, hypogonadism, hyperprolactinemia, and thyroid disorders 1
• Neurological conditions: Spinal cord injury, multiple sclerosis, Parkinson's disease, and peripheral neuropathy 1
• Anatomical/structural: Peyronie's disease, penile trauma, and surgical complications 1
• Medication-induced: Antihypertensives (especially thiazide diuretics and beta-blockers), antidepressants (particularly SSRIs), and other prescription drugs 4
• Lifestyle factors: Smoking, obesity, sedentary lifestyle, excessive alcohol consumption 1, 5
• Psychological factors: Depression, anxiety, stress, and relationship problems 1, 2

Diagnostic Evaluation

A comprehensive evaluation should include:

• Medical history: Focus on identifying risk factors, comorbidities, and medication use 1
• Sexual history: Distinguish ED from other sexual dysfunctions (ejaculation/orgasm disorders), establish chronology and severity 1
• Physical examination: Focused examination of abdomen, genitalia, secondary sexual characteristics, and lower extremity pulses 1
• Laboratory tests:
  • Fasting glucose and lipid profile 1
  • Total testosterone (especially in patients who don't respond to PDE5 inhibitors) 1
  • PSA and digital rectal examination in men over 50 with life expectancy >10 years 1

Management Approach

First-Line: Lifestyle Modifications and Risk Factor Management

• Lifestyle changes: Weight loss, regular physical activity, smoking cessation, and moderate alcohol consumption can improve erectile function 1, 5
• Management of comorbidities: Optimal control of diabetes, hypertension, and cardiovascular disease 1, 2

Second-Line: Pharmacological Therapy

• Oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil):

  • First-line pharmacological treatment for most patients 1, 2
  • Effective in 60-65% of men with ED, including those with comorbidities 6
  • Proper titration and instructions are essential for optimal efficacy 2, 7
  • Contraindicated in patients taking nitrates and those with unstable cardiovascular disease 7, 8

• Cardiovascular risk assessment:

  • Patients should be categorized as low, intermediate, or high risk based on cardiovascular status 1, 2
  • High-risk patients should have cardiac condition stabilized before ED treatment 1

Third-Line: Invasive Therapies

For patients who fail or cannot use oral medications:

• Intracavernous injection therapy: Using vasodilator drugs (alprostadil, papaverine, phentolamine) 1, 9
• Intraurethral alprostadil suppositories: Alternative local therapy 1, 2
• Vacuum constriction devices: Non-invasive mechanical option 1, 2

Fourth-Line: Surgical Options

• Penile prosthesis implantation: High satisfaction rates for patients with refractory ED 1, 6
• Vascular surgery: Limited role, generally poor outcomes in most patients with vascular ED 6

Adjunctive Treatments

• Psychosexual therapy: Useful in combination with medical treatments, particularly for patients with psychological factors 1, 2
• Testosterone replacement: For confirmed hypogonadism, but contraindicated in men seeking fertility 2, 10

Special Considerations

• ED as a cardiovascular risk marker: ED may be an early sign of cardiovascular disease, warranting evaluation of cardiovascular risk factors 2, 3
• Drug-induced ED: Consider medication review and possible alternatives when drug-related ED is suspected 4
• Partner involvement: When possible, include the partner in treatment decisions 1

Common Pitfalls to Avoid

• Failing to recognize ED as a potential marker of underlying cardiovascular disease 2
• Not discussing treatment options with both patient and partner 1
• Inadequate titration of PDE5 inhibitors before declaring treatment failure 2
• Not considering psychosexual factors that may contribute to or exacerbate ED 1, 2