What is the initial approach to managing erectile dysfunction in a male patient in an outpatient internal medicine setting?

Erectile Dysfunction Dot Phrase for Outpatient Internal Medicine

Chief Complaint & History

Patient presents with erectile dysfunction, defined as consistent or recurrent inability to attain/maintain penile erection sufficient for sexual satisfaction. 1

Essential History Elements:

• Onset and duration: Distinguish sudden onset (suggests psychogenic) vs. gradual progression (suggests organic cause) 2
• Severity and situational factors: Preserved morning/spontaneous erections suggest psychogenic etiology; complete lack of tumescence indicates organic cause 2
• Sexual history: Assess libido, ejaculation, orgasm function, and partner's sexual function 1
• Cardiovascular risk factors: Hypertension, diabetes, hyperlipidemia, atherosclerosis, smoking history 1, 2
• Medication review: Antihypertensives (β-blockers, diuretics, ACE inhibitors), antidepressants (TCAs, SSRIs), other medications associated with ED 1, 3
• Psychosocial screening: Depression, anxiety, relationship quality, performance anxiety 1, 2
• Comorbidities: Diabetes, neurological disease (MS, Parkinson's, spinal cord injury), pelvic trauma/surgery, Peyronie's disease 1, 3

Physical Examination

Focused examination includes: 1

• Vital signs with blood pressure measurement 2
• Cardiovascular: Lower extremity pulses 1
• Genitourinary: Penile examination for plaques, deformities, testicular size, secondary sexual characteristics 1
• Abdominal examination 1

Laboratory Testing

Mandatory initial labs: 1, 2

• Morning serum total testosterone (essential for all men with ED) 1, 2
• Fasting glucose or HbA1c (screen for diabetes) 2, 3
• Fasting lipid profile (assess cardiovascular risk) 2, 3

Cardiovascular Risk Counseling

ED is a sentinel marker for cardiovascular disease, often preceding coronary symptoms by 2-5 years. 1, 2 Patient counseled that ED indicates substantially increased cardiovascular mortality risk equivalent to smoking or family history of MI. 3 Cardiovascular risk assessment performed and communicated to patient and primary care provider for appropriate referrals. 3

Treatment Plan

First-Line: Lifestyle Modifications

All patients counseled on: 2, 3

• Smoking cessation (reduces total mortality by 36% in men with coronary disease) 3
• Weight loss if BMI >30 kg/m² 2, 4
• Regular physical activity 2, 4
• Mediterranean diet emphasizing fruits, vegetables, whole grains, fish, limiting red meat 3
• Moderate alcohol consumption (<14 units/week for women, <21 units/week for men) 3
• Optimal diabetes control if diabetic 3, 5

Second-Line: Pharmacotherapy

PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are first-line pharmacological treatment, effective in 60-65% of patients. 1, 3

Patient counseled on: 6, 7, 8

• Take approximately 30-60 minutes before sexual activity 6, 7
• Sexual stimulation required for efficacy 7
• Absolute contraindication: Concurrent nitrate use (regular or intermittent) due to risk of severe hypotension 6, 7
• Caution with alpha-blockers: Start lowest PDE5i dose due to additive hypotensive effects 7
• Avoid substantial alcohol consumption (≥5 units) with PDE5i due to increased orthostatic symptoms 6

Adverse effects discussed: 6, 7, 8

• Seek emergency care if erection >4 hours (priapism risk) 6, 8
• Stop medication and seek immediate care for: Sudden vision loss (NAION risk) or sudden hearing loss 6, 7, 8

If inadequate response to PDE5i: Recheck testosterone level, as adequate testosterone required for full PDE5i efficacy. 3

Testosterone Replacement (if indicated)

For confirmed hypogonadism (testosterone <230 ng/dL) with symptoms: 3

• Testosterone replacement improves sexual function and enhances PDE5i response 3
• Men with testosterone 230-350 ng/dL: Consider 4-6 month trial if symptomatic, continue only if clinical benefit demonstrated 2, 3
• Testosterone >350 ng/dL: Replacement not indicated 3

Third-Line Options (if PDE5i fails or contraindicated)

Discussed with patient: 1, 3, 9

• Intracavernosal injection therapy (alprostadil) 1, 3
• Intraurethral alprostadil suppositories 1, 3
• Vacuum constriction devices 1, 3

Referral Indications

Refer to urology/sexual medicine specialist if: 2

• Young age with lifelong ED 2
• History of pelvic/genital trauma 2
• Abnormal penile/testicular findings 2
• Peyronie's disease 1
• Failure of oral therapy and patient desires further intervention 1
• Consideration for penile prosthesis 1, 3

Refer to mental health professional if: 1, 2

• Significant depression, anxiety, or psychosis requiring primary psychiatric management 2
• Predominantly psychogenic ED 3
• Performance anxiety or relationship issues 1
• To promote treatment adherence and integrate treatments into sexual relationship 1

Partner Involvement

Partner included in treatment discussions when possible, as partner involvement essential for improving treatment outcomes. 3

Follow-Up

Patient instructed to follow up in [timeframe] to assess treatment response, adjust therapy as needed, and monitor cardiovascular risk factors. 1, 3