What is the best approach to treating a patient with erectile dysfunction, considering potential underlying medical conditions such as diabetes (Diabetes Mellitus), hypertension (High Blood Pressure), or cardiovascular disease (CVD)?

Treatment of Erectile Dysfunction

Oral phosphodiesterase type 5 (PDE5) inhibitors—sildenafil, tadalafil, or vardenafil—should be offered as first-line therapy for erectile dysfunction unless contraindicated, particularly in patients with diabetes, hypertension, or cardiovascular disease. 1, 2

Initial Diagnostic Evaluation

Before initiating treatment, perform a focused assessment to identify comorbidities and contraindications:

• Obtain sexual, medical, and psychosocial history focusing on cardiovascular disease (hypertension, atherosclerosis, hyperlipidemia), diabetes mellitus, depression, smoking, obesity, neurologic disease, and current medications that may contribute to ED (thiazide diuretics, beta-blockers, SSRIs) 1, 3

• Perform focused physical examination evaluating cardiovascular status, secondary sexual characteristics, genital examination, and lower extremity pulses 1

• Order laboratory tests including fasting glucose, lipid profile, and testosterone levels (especially in men with treatment failure or suspected hypogonadism) 1, 2

Cardiovascular Risk Stratification

All patients with ED require cardiovascular risk assessment before treatment initiation, as ED itself is an independent predictor of cardiovascular disease. 1

Risk Categories

Low-Risk Patients (can receive all first-line therapies):

• Controlled hypertension 1
• Successfully revascularized coronary disease 1
• Uncomplicated past MI (>6-8 weeks) 1
• Mild valvular disease 1
• Heart failure NYHA class I-II with exercise capacity ≥5 METs 1

Intermediate-Risk Patients (require exercise stress testing before treatment):

• Mild-to-moderate stable angina 1
• Recent MI (2-8 weeks) without intervention 1
• Heart failure NYHA class III 1
• Patients unable to achieve 4 minutes on Bruce protocol (5-6 METs) 1

High-Risk Patients (defer ED treatment until cardiac condition stabilized):

• Unstable or refractory angina 1
• Uncontrolled hypertension 1
• MI within previous 2 weeks 1
• Heart failure NYHA class IV 1
• High-risk arrhythmias 1
• Moderate-to-severe valvular disease, particularly aortic stenosis 1, 4

First-Line Treatment: PDE5 Inhibitors

PDE5 inhibitors are equally effective with no evidence supporting superiority of one agent over another; selection should be based on patient preference regarding onset/duration of action and contraindications. 1, 2

Dosing Options

• Tadalafil: 5 mg daily for continuous therapy, or 10-20 mg on-demand 2, 4
• Sildenafil: On-demand dosing 1, 2
• Vardenafil: On-demand dosing 1, 2

Efficacy in High-Risk Populations

• Diabetic patients: 60-65% success rate with PDE5 inhibitors, independent of diabetes duration or glycemic control 2, 4, 5
• Hypertensive patients: Similar efficacy to general population without increasing cardiovascular adverse events 2, 5
• Post-MI patients: Safe in low-risk category after appropriate stabilization period 1

Absolute Contraindications

PDE5 inhibitors are absolutely contraindicated in patients taking nitrates or nicorandil due to synergistic hypotensive effects. 1, 2, 4, 6

• Minimum washout period: At least 48 hours must elapse after last PDE5 inhibitor dose before nitrate administration in life-threatening situations 4
• Patients with left ventricular outflow obstruction (aortic stenosis, hypertrophic cardiomyopathy) are particularly sensitive to vasodilatory effects 4

Adjunctive Management

All patients should receive lifestyle modification counseling and optimization of comorbid conditions regardless of pharmacotherapy choice:

• Optimize glycemic control targeting HbA1c <7% to prevent progression of diabetic autonomic neuropathy 2, 7
• Weight loss for obese patients (BMI >30) 1, 2
• Smoking cessation 1
• Review and modify medications contributing to ED when alternatives exist (switch from thiazide diuretics or beta-blockers to alternative antihypertensives) 2, 7, 3
• Treat dyslipidemia and hypertension to reduce cardiovascular risk 1

Second-Line Therapies

If PDE5 inhibitors fail or are contraindicated:

• Intracavernous alprostadil injection: Effective in 60-65% of PDE5 inhibitor non-responders 1, 5
• Intraurethral alprostadil suppositories: Alternative delivery method 1
• Vacuum constriction devices: Non-pharmacologic option 1

Third-Line Treatment

Penile prosthesis implantation is reserved for patients who fail all conservative therapies and should be performed by urologists specializing in ED 1, 5, 8

Critical Pitfalls to Avoid

• Never prescribe PDE5 inhibitors without assessing nitrate use—this combination can cause life-threatening hypotension 1, 4
• Do not assume ED is purely psychogenic in younger patients without ruling out organic causes, particularly early cardiovascular disease 1, 8
• Avoid overlooking ED as a sentinel marker for undiagnosed diabetes or cardiovascular disease—screen appropriately 1, 5, 9
• Do not continue ineffective antihypertensive medications (thiazides, beta-blockers) that worsen ED when equally effective alternatives exist 7, 3