What causes erectile dysfunction and genital flaccidity in a 45-year-old male and how can it be treated to restore erectile function similar to that at a younger age?

Erectile Dysfunction at Age 45: Causes and Treatment

For a 45-year-old male experiencing erectile dysfunction, first-line treatment with oral PDE5 inhibitors (sildenafil, tadalafil, or vardenafil) should be initiated after ruling out cardiovascular disease and checking morning testosterone levels. 1, 2

Why This Happens at Age 45

Erectile dysfunction at 45 is primarily due to age-related vascular and neurological changes, though the prevalence at this age mirrors what non-diabetic men experience in their 70s. 1

Key contributing factors include:

• Vascular insufficiency - Reduced arterial blood flow to the penis due to endothelial dysfunction, which is the most common organic cause 1, 3
• Cardiovascular risk factors - Hypertension, diabetes, hyperlipidemia, and smoking significantly increase ED risk at younger ages 1
• Testosterone decline - Age-related decrease in testosterone levels affects erectile rigidity and sexual desire 4
• Psychological factors - Performance anxiety, depression, and relationship stress compound organic causes 1, 5

Critical warning: ED at age 45 is a marker for underlying cardiovascular disease and warrants cardiac risk assessment, as it often precedes coronary artery disease by 3-5 years. 1, 2

Initial Evaluation Required

Before treatment, obtain these specific assessments:

• Two morning serum total testosterone measurements (before 10 AM when levels peak) - required if either measurement is <300 ng/dL 2, 4
• Cardiovascular risk assessment - blood pressure, lipid panel, hemoglobin A1c to screen for diabetes 1
• Sexual history specifics - presence of morning/nocturnal erections (indicates psychogenic component if present), onset pattern (gradual suggests organic, sudden suggests psychogenic), and relationship factors 1, 2
• Medication review - antidepressants, antihypertensives, and other drugs commonly cause ED 1

Treatment Algorithm

First-Line: PDE5 Inhibitors

Start with oral PDE5 inhibitors as they have 73-88% success rates versus 26-32% for placebo. 1

Specific agents and dosing:

• Sildenafil: Start 50 mg, titrate to 25-100 mg taken 1 hour before sexual activity 1
• Tadalafil: Start 10 mg, titrate to 5-20 mg; can be taken daily at lower doses (2.5-5 mg) 1
• Vardenafil: Start 10 mg, titrate to 5-20 mg taken 1 hour before sexual activity 1

Important counseling points:

• Dose titration is essential - initial doses often need adjustment upward to achieve optimal response 1
• Sexual stimulation is required for effectiveness 1
• Timing matters - sildenafil/vardenafil work best on empty stomach 1
• If testosterone deficiency is present, combining PDE5 inhibitors with testosterone therapy is more effective than PDE5 inhibitors alone 1, 4

Contraindications to screen for:

• Nitrate use (absolute contraindication due to severe hypotension risk) 1
• Recent stroke or myocardial infarction 1
• Severe cardiovascular disease 1

Second-Line Options (If PDE5 Inhibitors Fail)

Vacuum Erection Devices (VED):

• Non-pharmacologic option with 60-80% satisfaction rates 1, 6
• Must use devices with vacuum limiter to prevent injury 1
• Avoid in men on anticoagulation due to bruising risk 1

Intraurethral Alprostadil:

• 65% achieve successful intercourse after proper dose titration 1
• Requires in-office test dose and training before home use 1
• Less invasive than injections but lower efficacy 1

Third-Line: Intracavernous Injections

Alprostadil injections (FDA-approved) or combination therapy:

• Success rates exceed 85% when properly dosed 1
• Requires in-office injection training and test dose 1
• Risk of priapism (erection >4 hours) requires emergency treatment 1
• Combination formulas (alprostadil + papaverine + phentolamine) used for non-responders 1

Fourth-Line: Penile Prosthesis

Reserved for men who fail all medical therapies or have severe penile fibrosis. 1, 6

• Three-piece inflatable prostheses provide best cosmetic and functional results 7
• Irreversible procedure - destroys remaining erectile tissue 1
• Cannot be performed during active infection 1
• Patients report shorter length than natural erections due to lack of glans engorgement 7

Adjunctive Strategies

Lifestyle modifications that improve erectile function:

• Smoking cessation - directly improves endothelial function 5
• Weight loss if obese - reduces cardiovascular risk and improves testosterone 5
• Exercise - improves cardiovascular health and erectile function 5
• Glycemic control if diabetic - reduces neuropathy progression 1

Psychosexual counseling:

• Recommended for all patients, especially when psychological factors contribute 2
• Helps with treatment adherence and partner integration 2
• Addresses performance anxiety that perpetuates ED 1

Common Pitfalls to Avoid

• Not checking testosterone - 30-55% of men with ED have testosterone deficiency, which reduces PDE5 inhibitor effectiveness 4
• Inadequate dose titration - many men abandon treatment after single dose failure when higher doses would succeed 1
• Ignoring cardiovascular disease - ED is often the first manifestation of systemic vascular disease requiring cardiac evaluation 1, 2
• Single testosterone measurement - diagnosis requires two separate morning measurements showing levels <300 ng/dL 4
• Overlooking medication causes - antidepressants and antihypertensives frequently cause reversible ED 1

Realistic Expectations

Complete restoration to age 25 erectile function is unlikely, but 70-85% of men achieve erections sufficient for satisfactory intercourse with appropriate treatment. 1 The goal is functional improvement, not perfect replication of youthful performance. Age-related changes in erectile latency and rigidity are normal and should be reframed as part of healthy aging rather than dysfunction requiring aggressive intervention. 5