How is erectile dysfunction effectively managed?

Management of Erectile Dysfunction

Begin with cardiovascular risk stratification and lifestyle modifications, followed by oral PDE5 inhibitors as first-line pharmacotherapy, escalating to intracavernosal injections, vacuum devices, or penile prosthesis for refractory cases. 1, 2

Mandatory Initial Assessment

All men presenting with erectile dysfunction require immediate cardiovascular evaluation because ED precedes coronary artery disease symptoms by 2-5 years and signals substantially increased cardiovascular mortality risk. 1, 2

Cardiovascular Risk Stratification:

• Categorize patients as low, intermediate, or high cardiovascular risk before initiating any ED treatment 1, 3
• High-risk patients must not receive ED treatment until cardiac stabilization is achieved 2, 3
• Screen for diabetes, hypertension, hyperlipidemia, and metabolic syndrome—these conditions both cause ED and indicate increased mortality risk 1, 2

Required Laboratory Testing:

• Fasting glucose and HbA1c to assess for diabetes 1, 2
• Lipid profile to screen for hyperlipidemia and atherosclerotic disease 1, 2
• Total testosterone levels in all men with ED, particularly PDE5 inhibitor non-responders 1, 2
  • Testosterone <230 ng/dL indicates hypogonadism requiring replacement 1, 2
  • Testosterone 230-350 ng/dL may benefit from replacement if symptomatic 1
  • Testosterone >350 ng/dL does not usually require replacement 1

First-Line: Lifestyle Modifications (Mandatory for All Patients)

These interventions reduce cardiovascular mortality and improve erectile function directly through endothelial improvement. 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, and glucose-insulin homeostasis 2
• Mediterranean diet emphasizing fruits, vegetables, whole grains, fish, and limiting red meat 1
• Weight loss for overweight/obese patients 1, 2
• Moderate alcohol consumption: <14 units/week for women, <21 units/week for men 1
• Optimal control of diabetes, hypertension, and cardiovascular disease 1, 2

Second-Line: Oral PDE5 Inhibitors (First-Line Pharmacotherapy)

PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are effective in 60-65% of patients with ED, including those with hypertension, diabetes, spinal cord injury, and other comorbidities. 1, 2, 4

Critical Implementation Details:

• Titrate doses to achieve optimal efficacy—do not accept initial failure without dose adjustment 2, 3
• Provide proper instructions to maximize benefit/efficacy 3
• PDE5 inhibitors require adequate testosterone levels for full efficacy—always check testosterone in non-responders 1, 2
• Diabetic men have more severe baseline ED and respond less robustly to PDE5 inhibitors 1

Tadalafil Efficacy Data:

• When taken as needed (10-20 mg), 61-64% of patients report successful intercourse at 24 hours post-dosing, and 62-64% at 36 hours post-dosing 5
• Daily tadalafil (2.5-5 mg) produces clinically meaningful improvements in erectile function without diminishing effect over 6 months 5
• 35-52% of patients achieve successful erections within 30 minutes of dosing 5

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 alone improves libido but requires minimal threshold levels for complete PDE5 inhibitor efficacy 1
• Contraindicated in men seeking fertility 1, 2

Third-Line: Invasive Therapies (For PDE5 Inhibitor Failures)

Intracavernous Injection Therapy:

• Use vasodilator drugs (alprostadil, papaverine, or phentolamine) for patients who fail oral agents 1, 2, 4
• Effective alternative treatment option with high success rates 1, 2

Intraurethral Alprostadil:

• Alternative local therapy for patients unable to use oral medications or injections 1, 2

Vacuum Constriction Devices:

• Non-invasive mechanical option for patients who cannot use or do not respond to pharmacological treatments 1, 2, 3

Fourth-Line: Surgical Options (For Refractory Cases)

Penile prosthesis implantation is reserved for patients who fail all less invasive treatments and is associated with high satisfaction rates. 1, 2, 4

• Multicomponent inflatable penile implants provide the best outcomes 4
• Arterial reconstructive surgery is only appropriate for healthy individuals with recently acquired ED secondary to focal arterial occlusion without generalized vascular disease 1
• Penile arterial revascularization and venous ligation surgery have relatively poor outcomes in men with atherosclerotic disease or veno-occlusive dysfunction 4

Psychosexual Therapy (Adjunctive Treatment)

Psychosexual therapy should be offered as either alternative or adjunct to medical treatment, particularly for psychogenic ED or psychological contributors. 1, 2

• Cognitive-behavioral therapy improves communication about sexual concerns and reduces performance anxiety 1, 2
• Partner involvement is essential for improving treatment outcomes 1, 2
• Depression is both a cause and consequence of ED, with worsening depressive symptoms preceding ED onset 1

Critical Pitfalls to Avoid

• Failure to recognize ED as a marker of underlying cardiovascular disease—always communicate cardiovascular risk to patient, partner, and primary care provider 1
• Not titrating PDE5 inhibitor doses to achieve optimal efficacy 3
• Not checking testosterone levels in PDE5 inhibitor non-responders 1, 2
• Not considering psychosexual factors that contribute to or exacerbate ED 3
• Treating high-risk cardiovascular patients before cardiac stabilization 2, 3