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 = confirmed hypogonadism requiring replacement 1, 2
  • Testosterone 230-350 ng/dL = consider replacement if symptomatic 1
  • Testosterone >350 ng/dL = replacement not indicated 1

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

These interventions reduce cardiovascular mortality and improve erectile function independently of other treatments:

• 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 endothelial function 2
• Weight loss and Mediterranean diet (fruits, vegetables, whole grains, fish, limited red meat) 1, 2
• Moderate alcohol consumption: <14 units/week for women, <21 units/week for men 1
• Optimize 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 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 initial failure without dose adjustment 2, 3
• Provide proper instructions to maximize benefit: timing relative to sexual activity, food interactions, adequate sexual stimulation required 2, 3
• PDE5 inhibitors require adequate testosterone levels for full efficacy—always check testosterone in non-responders 1, 2
• Tadalafil 20 mg demonstrates efficacy at 24 hours (61% success rate) and 36 hours (64% success rate) post-dosing 4
• Once-daily tadalafil (2.5-5 mg) is effective when timing of sexual activity is not restricted relative to dosing 4

Special Population Considerations:

• Diabetic men have more severe baseline ED and respond less robustly to PDE5 inhibitors but still achieve meaningful benefit 1
• Patients with hypertension, spinal cord injury, and other comorbidities can successfully use PDE5 inhibitors 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)

When oral medications fail or are contraindicated, escalate in this order:

Intracavernosal Injection Therapy:

• Alprostadil, papaverine, or phentolamine injected directly into the corpus cavernosum 1, 2, 3
• Highly effective alternative for PDE5 inhibitor failures 5

Intraurethral Alprostadil:

• Suppositories placed in the urethra for local absorption 1, 2, 3
• Option for patients unable to use oral medications or injections 2

Vacuum Constriction Devices:

• Non-invasive mechanical option creating erection through negative pressure 1, 2, 3
• For patients who cannot use or do not respond to pharmacological treatments 2

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, 3, 5

• Multicomponent inflatable penile implants provide the highest satisfaction 5
• Arterial reconstructive surgery only for healthy individuals with recently acquired ED from focal arterial occlusion without generalized vascular disease 1
• Penile revascularization and venous ligation surgery show relatively poor outcomes in men with atherosclerotic disease 5

Psychosexual Therapy (Adjunctive to All Treatments)

Psychosexual therapy should be offered as adjunct to medical treatment for all patients, particularly those with psychogenic ED or psychological contributors. 1, 2, 3

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

Critical Pitfalls to Avoid

• Failure to recognize ED as a marker of underlying cardiovascular disease—always assess cardiovascular risk 1, 3
• Not checking testosterone levels in PDE5 inhibitor non-responders 1, 2
• Accepting initial PDE5 inhibitor failure without dose titration 2, 3
• Not discussing treatment options with both patient and partner when possible 3
• Treating high-risk cardiac patients before cardiac stabilization 2, 3
• Ignoring psychological factors that contribute to or exacerbate ED 3