First-Line Treatment for Erectile Dysfunction in a 47-Year-Old Man

Phosphodiesterase type 5 inhibitors (PDE5i) are the most effective first-line treatment for erectile dysfunction in a 47-year-old man. 1, 2, 3

Initial Evaluation

A thorough medical, sexual, and psychosocial history is essential to identify potential underlying causes of ED, including comorbid conditions, medications, and lifestyle factors 1
Physical examination and laboratory testing should include morning total testosterone level, fasting glucose/HbA1c, and lipid profile to evaluate for underlying conditions 1, 4
ED in men over 30 years old is considered a risk marker for underlying cardiovascular disease, requiring appropriate evaluation 5, 1

PDE5 inhibitors (sildenafil, tadalafil, vardenafil) are FDA-approved and should be offered with proper dosing instructions before considering alternative therapies 4, 2, 3
Vardenafil (Levitra) is specifically indicated for the treatment of erectile dysfunction 2
Tadalafil offers the advantage of a longer duration of action, allowing for more spontaneous sexual activity 3, 6

PDE5 inhibitors should never be taken with nitrates or guanylate cyclase stimulators due to risk of dangerous hypotension 3
Patients should be counseled about potential side effects including headache, flushing, dyspepsia, and nasal congestion 6
Between 60-65% of men with ED, including those with comorbidities like hypertension and diabetes, can successfully complete intercourse with PDE5 inhibitors 6

Weight loss, increased physical activity, and smoking cessation can improve erectile function, particularly in men without established comorbidities 7, 8
Dietary modifications and moderate alcohol consumption may help reduce cardiovascular risk factors associated with ED 5, 7

Patient-administered intracorporal injection therapy using vasodilator drugs such as alprostadil is effective for men who fail to respond to oral agents 6
Vacuum erection devices are a non-invasive alternative for men who cannot take or do not respond to PDE5 inhibitors 9, 6

For men with documented low testosterone (<230 ng/dL), testosterone replacement therapy (TRT) may be beneficial 5
Men with testosterone levels between 231-346 ng/dL may be considered for a 4-6 month trial of TRT after discussing risks and benefits 5
TRT should be continued beyond 6 months only if clinical benefit is demonstrated 5

ED may be the first sign of cardiovascular disease; consider cardiac assessment, especially with multiple risk factors 5, 1
Psychological factors such as performance anxiety and relationship issues should be addressed, potentially with psychosexual counseling 4, 9
Treatment decisions should be made jointly by the physician and patient, considering preferences, expectations, and clinical judgment 4

Evaluate treatment efficacy and adjust dosing as needed 1
Monitor for side effects and drug interactions 3
Reassess cardiovascular risk factors periodically, as ED and cardiovascular disease share common pathophysiologic pathways 5, 1