What are the treatment options for a 36-year-old man with erectile dysfunction (ED)?

Treatment of Sexual Dysfunction in a 36-Year-Old Man

Phosphodiesterase type 5 inhibitors (PDE5i) are the first-line treatment for erectile dysfunction in this patient, regardless of whether the cause is psychological or physical, with lifestyle modifications initiated simultaneously. 1

Initial Assessment

Before initiating treatment, obtain the following:

• Morning serum total testosterone level is essential for all men with ED 2
• Fasting glucose/HbA1c and lipid profile to evaluate underlying cardiovascular risk factors 2
• Detailed sexual history including onset (sudden vs. gradual), situational factors, quality of morning/spontaneous erections, and presence of partner-related issues 1, 2
• Physical examination including vital signs, genital examination for penile deformities, and assessment of cardiovascular status 2, 3

Distinguishing Psychological from Organic ED

• Psychological ED characteristics: sudden onset, early collapse during intercourse, preserved quality of spontaneous/morning erections 1
• Physical/Organic ED characteristics: gradual onset, lack of tumescence in all situations, presence of cardiovascular disease, diabetes, hypertension, or neurological conditions 1

First-Line Treatment: PDE5 Inhibitors

Start with a PDE5i (sildenafil, tadalafil, vardenafil, or avanafil) as these achieve 60-65% success rates for intercourse completion. 1, 4

Dosing Strategy

• Begin conservatively and titrate to maximum dose 1
• An adequate trial requires at least 5 separate occasions at maximum dose before declaring treatment failure 1
• Tadalafil 20 mg demonstrated clinically meaningful improvements in erectile function, with 62-77% successful vaginal insertion and 50-64% successful intercourse maintenance 3

Absolute Contraindications to PDE5i

• Concurrent nitrate use (nitroglycerin, isosorbide dinitrate/mononitrate) 1, 3
• Guanylate cyclase stimulators (riociguat) 1, 3
• Recreational "poppers" (amyl nitrite, butyl nitrite) 3
• Recent cardiovascular events: myocardial infarction within 90 days, unstable angina, stroke within 6 months, uncontrolled hypertension/hypotension, or NYHA Class 2+ heart failure 3

Important Safety Considerations

• After taking tadalafil, active ingredient remains in the body for more than 2 days; if emergency cardiac care is needed, at least 48 hours must elapse before nitrate administration 3
• Stop sexual activity immediately if chest pain, dizziness, or nausea occurs during sex and seek medical attention 3

Concurrent Lifestyle Modifications

Initiate these simultaneously with PDE5i therapy:

• Smoking cessation 5, 1, 2
• Weight loss if BMI >30 kg/m² 1
• Increased physical activity 1
• Reduced alcohol consumption 1
• Improved glycemic control in diabetics 1
• Optimization of blood pressure and lipid management 1

Etiology-Specific Additional Interventions

For Psychological ED

• Refer to sex therapy or couples counseling concurrently with PDE5i initiation, not sequentially 1
• Address specific psychiatric conditions including generalized anxiety, depression, and substance use disorders 1

For Low Testosterone (if documented)

• Consider testosterone replacement therapy for documented low testosterone 1, 2
• For testosterone levels between 231-346 ng/dL, consider a 4-6 month trial after discussing risks and benefits 2
• Continue TRT beyond 6 months only if clinical benefit is demonstrated 2
• Testosterone monotherapy should not be prescribed for men interested in current or future fertility 5

For Medication-Induced ED

• Review and modify medications that may contribute to ED, such as switching antihypertensives to agents with lower ED risk 1, 6
• Thiazide diuretics, beta-blockers, and SSRI antidepressants are commonly implicated 6

Second-Line Therapies

When two different PDE5i trials at maximum dose fail, refer to urology for:

• Intraurethral alprostadil suppositories 1
• Intracavernous vasoactive drug injection therapy (alprostadil is safe and effective for long-term use) 1, 4
• Vacuum erection devices 1

Third-Line Therapy

• Penile prosthesis implantation is reserved for patients who fail all medical therapies and is associated with high satisfaction rates 1, 4

Critical Pitfalls to Avoid

• Do not delay PDE5i treatment while waiting for psychological therapy results; these should occur concurrently 1
• Do not declare PDE5i failure until at least 5 attempts at maximum dose have been completed 1
• Do not overlook cardiovascular risk assessment, as ED in men over 30 is a risk marker for underlying cardiovascular disease 2
• Do not prescribe testosterone without documented low levels, as it provides no benefit with normal testosterone and compromises fertility 5, 2