Management of Erectile Dysfunction
Begin with cardiovascular risk stratification, testosterone measurement, and lifestyle modifications, followed by PDE5 inhibitors as first-line pharmacotherapy—this stepwise approach addresses both the sexual dysfunction and the critical cardiovascular warning signal that ED represents. 1
Initial Assessment and Mandatory Cardiovascular Evaluation
Erectile dysfunction precedes coronary artery disease symptoms by 2-5 years, making cardiovascular assessment non-negotiable in every patient. 1, 2
Risk Stratification Protocol
- Stratify patients into low, intermediate, or high cardiovascular risk categories before initiating any ED treatment 1, 3
- High-risk patients must not receive ED treatment until cardiac stabilization is achieved 1, 3
- Screen for diabetes (fasting glucose, HbA1c), hypertension, hyperlipidemia, and metabolic syndrome—these conditions both cause ED and signal increased cardiovascular mortality 1, 2
Laboratory Testing Requirements
- Measure total testosterone levels in all men with ED, particularly those who fail PDE5 inhibitors 1, 2
- Testosterone <230 ng/dL indicates hypogonadism requiring replacement therapy 1
- Testosterone 230-350 ng/dL may benefit from replacement if symptomatic 1, 2
- Obtain fasting glucose, lipid profile, and HbA1c to identify metabolic contributors 1, 2
First-Line Management: Lifestyle Modifications
Implement these changes immediately—they reduce cardiovascular mortality and improve erectile function through endothelial restoration. 1, 2
- Smoking cessation reduces total mortality by 36% in men with coronary disease and improves endothelial function 1, 2
- Regular dynamic exercise reduces incident coronary disease by 30-50% and improves lipid profiles, blood pressure, glucose-insulin homeostasis, and endothelial function 1
- Weight loss and Mediterranean diet (emphasizing fruits, vegetables, whole grains, fish, limiting red meat) 1, 2
- Moderate alcohol consumption: <14 units/week for women, <21 units/week for men 2
Second-Line Management: PDE5 Inhibitors (First-Line Pharmacotherapy)
PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are effective in 60-65% of patients and should be offered as first-line pharmacotherapy unless contraindicated. 1, 2, 3
Critical Implementation Details
- Titrate doses to achieve optimal efficacy—do not accept suboptimal response without dose adjustment 3
- Provide proper instructions to maximize benefit: timing relative to sexual activity, food interactions, and realistic expectations 3
- PDE5 inhibitors require adequate testosterone levels for full efficacy—check testosterone in all non-responders 1, 2
Tadalafil-Specific Efficacy Data
- Tadalafil 20 mg demonstrates efficacy at 24 hours (61% successful intercourse vs 37% placebo) and 36 hours (64% vs 37% placebo) post-dosing 4
- Tadalafil 20 mg shows 35% of patients achieving successful erections within 30 minutes, increasing to 52% with proper timing 4
- Once-daily tadalafil (2.5-5 mg) is effective for continuous readiness, with treatment effect maintained over 6 months 4
- Tadalafil 20 mg as-needed improves erectile function domain scores from baseline by 6.9-9.3 points (vs 0.3 for placebo) 4
Adjunctive Testosterone Replacement Therapy
For men with confirmed hypogonadism (testosterone <230 ng/dL) and symptoms, testosterone replacement improves sexual function and enhances PDE5 inhibitor response. 1, 2
- Testosterone replacement is contraindicated in men seeking fertility 1, 2
- Men with testosterone 230-350 ng/dL may benefit if symptomatic 2
- Testosterone >350 ng/dL does not usually require replacement 2
- Testosterone alone improves libido but requires minimal threshold levels for complete PDE5 inhibitor efficacy 2
Third-Line Management: Invasive Therapies
When PDE5 inhibitors fail, escalate to these proven alternatives in order of invasiveness. 1, 2, 3
Intracavernosal Injection Therapy
- Alprostadil, papaverine, or phentolamine injections are effective for PDE5 inhibitor failures 1, 2, 3
- Patient-administered intracorporal injection therapy is useful in men who fail oral agents 5
Alternative Local Therapies
- Intraurethral alprostadil suppositories for patients unable to use oral medications or injections 1, 2, 3
- Vacuum constriction devices are non-invasive mechanical options for patients who cannot use or do not respond to pharmacological treatments 1, 2, 3
Fourth-Line Management: Surgical Options
Penile prosthesis implantation is reserved for patients with refractory ED who fail all less invasive treatments. 1, 2, 3
- Multicomponent inflatable penile implants are associated with high satisfaction rates 5
- Arterial reconstructive surgery is an option only for healthy individuals with recently acquired ED secondary to focal arterial occlusion, in the absence of generalized vascular disease 2
- Penile arterial revascularization and venous ligation surgery show relatively poor outcomes in men with penile atherosclerotic disease or corporal veno-occlusive dysfunction 5
Adjunctive Psychosexual Therapy
Psychosexual therapy should be combined with medical and surgical treatments, particularly for psychogenic ED. 1, 2, 3
- Cognitive-behavioral therapy and relationship counseling improve communication about sexual concerns and reduce performance anxiety 1, 2
- Partner involvement is essential for improving treatment outcomes 2, 3
Common Pitfalls to Avoid
- Failing to recognize ED as a cardiovascular disease marker—always evaluate cardiovascular risk factors 2, 3
- Not discussing treatment options and risks/benefits with both patient and partner 3
- Not titrating PDE5 inhibitor doses to achieve optimal efficacy 3
- Not considering psychosexual factors that may contribute to or exacerbate ED 3
- Treating high-risk cardiovascular patients before cardiac stabilization 1, 3
- Not checking testosterone levels in PDE5 inhibitor non-responders 1, 2