What is the approach to a patient with erectile dysfunction, considering their age, medical history, and lifestyle factors?

Approach to Erectile Dysfunction

Initial Evaluation

Begin with a comprehensive sexual, medical, and psychosocial history, followed by a focused physical examination and targeted laboratory testing to identify both organic causes and psychogenic factors. 1

History Taking

The sexual history must establish:

• Onset pattern: Sudden onset suggests psychogenic causes, while gradual onset indicates organic etiology 2, 1
• Symptom characteristics: Difficulty attaining versus maintaining erections, presence of nocturnal/morning erections (suggests psychogenic if present), and situational factors 1
• Severity assessment: Use validated questionnaires like the International Index of Erectile Function (IIEF) or Sexual Health Inventory for Men to objectively quantify severity 1, 3

The medical history should identify:

• Cardiovascular risk factors: Hypertension, atherosclerosis, hyperlipidemia, diabetes mellitus, smoking, and family history of vascular disease 2, 1
• Neurological conditions: Prior pelvic/perineal trauma or surgery, spinal cord injury, and neurologic disease 2
• Endocrine disorders: Signs or symptoms of hypogonadism, obesity 1
• Medication review: Antihypertensives (especially beta-blockers and thiazides), antidepressants, tranquilizers, and recreational drugs are commonly implicated 2, 1

The psychosocial assessment must evaluate:

• Relationship factors: Partner's sexual function, relationship quality, and presence of major life events 2, 1
• Psychiatric conditions: Depression, generalized anxiety, alcoholism, body dysmorphic disorder 2
• Sexual dysfunction patterns: Premature ejaculation, delayed ejaculation, or loss of libido 2

Physical Examination

Perform a focused examination including:

• Vital signs: Blood pressure and pulse to assess cardiovascular status 2, 1
• Genital examination: Assess testicular size (hypogonadism), penile plaques or fibrosis (Peyronie's disease), retractable foreskin, and urethral abnormalities 2, 1
• Secondary sexual characteristics: Evaluate for signs of hypogonadism 2, 1
• Cardiovascular assessment: Check lower extremity pulses for peripheral vascular disease 2, 1

Laboratory Testing

Essential tests for all patients:

• Morning serum total testosterone: Must be drawn in the morning due to diurnal variation; levels <300 ng/dL with symptoms indicate hypogonadism 1, 3
• Fasting glucose or HbA1c: ED may be the first presenting symptom of diabetes 1, 3
• Lipid profile: Total cholesterol, HDL, LDL, and triglycerides to assess cardiovascular risk 1, 3

Additional testing when indicated:

• Free testosterone or androgen index: Preferred if hypogonadism is suspected based on history or examination 2, 3
• Prostate-specific antigen and digital rectal examination: Required as baseline in men over 50 or before initiating testosterone replacement therapy 2
• Thyroid-stimulating hormone: If clinical signs suggest thyroid dysfunction 2

Specialized Testing (Select Patients Only)

Reserve for patients who fail first-line therapy or have specific indications:

• Vascular assessment: Penile Doppler ultrasound for suspected vascular insufficiency 2, 1
• Neurological testing: Bulbocavernosus reflex, dorsal sensory nerve conduction studies, or pudendal nerve somatosensory evoked potentials 3
• Nocturnal penile tumescence and rigidity: Rarely needed, may help differentiate psychogenic from organic causes 2

Treatment Framework

Risk Stratification and Cardiovascular Considerations

ED is a sentinel marker for cardiovascular disease and warrants comprehensive cardiovascular risk assessment. 1, 3 Patients experiencing symptoms during sexual activity should refrain from further activity and seek immediate medical attention 4.

Treatment Algorithm

Step 1: Address Modifiable Factors

• Lifestyle modifications: Smoking cessation, weight loss, increased physical activity, and alcohol reduction 5, 6
• Optimize comorbid conditions: Improve glycemic control in diabetes, manage hypertension and hyperlipidemia 5, 6
• Medication adjustment: Switch to alternatives with lower ED risk when possible (e.g., ACE inhibitors or calcium channel blockers instead of beta-blockers or thiazides) 2

Step 2: First-Line Pharmacotherapy

Oral phosphodiesterase-5 (PDE5) inhibitors are the first-line treatment for most patients with ED. 2, 5, 6

• Tadalafil: Take at least 30 minutes before sexual activity; effective for up to 36 hours; alternatively, daily dosing (2.5-5 mg) provides continuous readiness 4
• Efficacy: 60-65% of men, including those with diabetes, hypertension, and spinal cord injury, achieve successful intercourse 6
• Critical contraindications: Absolutely contraindicated with nitrates (must wait 48 hours after last tadalafil dose before nitrate administration) and guanylate cyclase stimulators 4
• Cautions: Use with alpha-blockers or antihypertensives may cause hypotension; limit alcohol to <5 units to avoid orthostatic symptoms 4

Common pitfall: Many patients fail PDE5 inhibitors due to improper use—provide explicit instructions on timing, need for sexual stimulation, and adequate trial (at least 6-8 attempts at maximum dose) before declaring treatment failure 7.

Step 3: Second-Line Therapy

For patients who fail or cannot tolerate PDE5 inhibitors:

• Intracavernosal alprostadil injection: Produces erection in 5-20 minutes lasting up to 1 hour; use maximum 3 times weekly with at least 24 hours between injections 8, 6
• Contraindications: Sickle cell disease, leukemia, multiple myeloma (risk of priapism), penile implants, severe curvature 8
• Critical warning: Erections lasting >6 hours require emergency treatment to prevent permanent damage 8
• Intraurethral alprostadil: Alternative for patients unwilling to inject 2
• Vacuum constriction devices: Non-pharmacologic option 2

Step 4: Psychosexual Counseling

Combine pharmacotherapy with psychosexual counseling for optimal outcomes, as most ED is multifactorial. 2, 5 This is particularly important when:

• Psychogenic factors are prominent (sudden onset, relationship issues, anxiety) 2
• Patient has unrealistic expectations contributing to treatment failure 7
• Partner involvement is needed 2

Step 5: Specialist Referral

Refer to urology/andrology for:

• Young patients with lifelong ED 2
• History of pelvic trauma or radical prostatectomy 2
• Anatomic abnormalities: Peyronie's disease, testicular abnormalities 2
• Failure of second-line therapy: Consider penile prosthesis implantation (high satisfaction rates) 6
• Vascular surgery candidates: Penile revascularization has poor outcomes and is rarely indicated 6

Testosterone Replacement

Initiate testosterone replacement only in men with documented hypogonadism (total testosterone <300 ng/dL with symptoms). 3 Obtain baseline PSA and digital rectal examination before starting therapy 2. Testosterone alone rarely resolves ED but may improve response to PDE5 inhibitors when combined 5.

Critical Safety Considerations

• Priapism risk: Educate all patients on intracavernosal therapy to seek emergency care for erections lasting >4 hours 4, 8
• Sudden vision loss: Stop all PDE5 inhibitors immediately if sudden vision loss occurs (NAION risk) 4
• Sudden hearing loss: Discontinue PDE5 inhibitors and seek prompt evaluation 4
• Sexually transmitted disease: PDE5 inhibitors and injections offer no protection; counsel on safe sex practices 4
• Needle breakage: With intracavernosal injections, if needle breaks and cannot be retrieved, contact physician immediately 8