What is the initial evaluation and management approach for a 59-year-old male with erectile dysfunction (ED)?

Initial Evaluation and Management of Erectile Dysfunction in a 59-Year-Old Male

Begin with a comprehensive sexual, medical, and psychosocial history, followed by targeted physical examination, morning serum total testosterone measurement, and consideration of glucose/HbA1c and lipid testing, then initiate treatment with a PDE5 inhibitor while addressing cardiovascular risk factors and considering mental health referral. 1

History Taking

The physician must initiate the sexual health inquiry, as most men are uncomfortable broaching this topic 1. Use validated questionnaires such as the Erection Hardness Score or Sexual Health Inventory for Men to facilitate discussion 1.

Key Sexual History Elements

• Onset and duration of symptoms (acute vs. gradual onset) 1
• Severity and degree of bother to the patient 1
• Specific nature of dysfunction: difficulty attaining erection, maintaining erection, or both 1
• Situational factors: occurs only with specific partners, only in certain contexts, or consistently 1
• Presence of nocturnal or morning erections (suggests psychogenic component if present) 1
• Masturbatory erections (ability to achieve erections with self-stimulation) 1
• Prior use of erectogenic therapy and response 1
• Libido, ejaculatory function, and orgasmic capacity 2

Medical History Focus

• Comorbid conditions: diabetes mellitus, hypertension, cardiovascular disease, depression, anxiety 1
• Prior surgeries, particularly pelvic or vascular procedures 1
• Current medications (many cause ED as side effect) 1
• Family history of vascular disease 1
• Substance use including tobacco, alcohol, and recreational drugs 1

Psychosocial Assessment

• Depression and anxiety symptoms 1
• Relationship quality and partner sexual function 2
• Performance anxiety and stress levels 1

Physical Examination

Vital Signs

• Pulse and resting blood pressure to assess cardiovascular status 1

Genital Examination

• Penile skin lesions and urethral meatus placement/configuration 1
• Palpation of stretched penis from pubic bone to coronal sulcus for occult deformities or plaque lesions (Peyronie's disease) 1
• Note: Digital rectal examination is not required for ED evaluation, though benign prostatic hyperplasia commonly coexists and may merit separate evaluation 1

Laboratory Testing

Essential Test

• Morning serum total testosterone is mandatory for all men with ED 1. Testosterone deficiency is defined as total testosterone <300 ng/dL with presence of symptoms 1

Selective Testing Based on Risk Factors

• Fasting glucose or HbA1c to screen for diabetes, as it significantly reduces PDE5 inhibitor efficacy and ED may be the first presenting symptom 3, 2
• Fasting lipid profile (total cholesterol, LDL, HDL, triglycerides) because ED is a substantial independent risk marker for cardiovascular disease, as strong as cigarette smoking or family history of myocardial infarction 1, 3

Most other routine serum studies are unlikely to alter ED management 1

Critical Cardiovascular Risk Discussion

ED is a sentinel marker for underlying cardiovascular disease and must trigger cardiovascular risk assessment. 1 The Princeton Consensus Conference identified ED as a substantial independent predictor of future cardiac events 1.

• Communicate this cardiovascular risk to the patient, his partner, and the primary care provider 1
• Ensure appropriate referrals and interventions are discussed for cardiovascular risk reduction 1

Initial Treatment Approach

First-Line Pharmacotherapy

Offer an FDA-approved oral phosphodiesterase type 5 (PDE5) inhibitor as first-line treatment 1. PDE5 inhibitors achieve 60-65% success rates even in men with comorbidities including hypertension, diabetes, and spinal cord injury 4.

• Tadalafil 20 mg showed clinically meaningful improvements in erectile function, with 62-77% successful vaginal insertion and 50-64% successful intercourse maintenance in US trials 5
• Treatment effect does not diminish over time 5
• Patients should be free to choose timing between dose administration and sexual attempts 5

Mental Health Referral

Consider referral to a mental health professional to promote treatment adherence, reduce performance anxiety, and integrate treatments into the sexual relationship 1, 3. This is particularly important as psychological factors (depression, anxiety, relationship conflict) are primary or secondary contributors in most cases 1.

• Psychotherapy and psychosexual counseling help patients and partners improve communication, reduce anxiety, and integrate ED treatments into their sexual relationship 1
• For predominantly psychogenic ED, offer mental health referral as alternative or adjunct to medical treatment 1

Follow-Up and Monitoring

• Reassess at 4-6 weeks after initiating PDE5 inhibitor therapy using validated questionnaires 2
• Monitor cardiovascular risk factors periodically 2
• Use validated questionnaires to measure treatment effectiveness and guide future management 1

When to Consider Specialized Testing

For men with complex histories, specialized testing may be necessary 1. These include:

• Nocturnal penile tumescence and rigidity testing 1
• Intracavernosal injection (ICI) 1
• Penile duplex ultrasound (may be combined with ICI) 1
• Cavernosometry and selective internal pudendal angiography 1

Common Pitfalls to Avoid

• Failing to initiate the sexual health conversation (physician must take the lead) 1
• Neglecting cardiovascular risk assessment (ED is as strong a predictor as smoking) 1
• Omitting testosterone measurement (mandatory for all ED patients) 1
• Ignoring psychosocial factors (present in most cases as primary or secondary contributors) 1
• Not involving the partner in evaluation and treatment planning 1