What is the diagnosis and treatment approach for a patient presenting with erectile dysfunction (ED), considering their medical history, age, and potential underlying conditions such as diabetes, cardiovascular disease, and hormonal imbalances?

Diagnosis and Treatment of Erectile Dysfunction

Initial Diagnostic Evaluation

All men presenting with ED must undergo a comprehensive sexual, medical, and psychosocial history, focused physical examination, and targeted laboratory testing to identify both organic causes and psychogenic factors. 1

History Taking

The physician must initiate the sexual health inquiry, as most men are uncomfortable discussing sexual concerns 1. Key historical elements include:

• Onset pattern: Sudden onset suggests psychogenic etiology, while gradual onset indicates organic causes 1, 2, 3
• Erectile characteristics: Distinguish inability to attain versus maintain erections, presence of morning/nocturnal erections (suggests psychogenic component), and masturbatory erections 1, 2
• Severity assessment: Use validated questionnaires such as the International Index of Erectile Function (IIEF), Sexual Health Inventory for Men, or Erection Hardness Score 1, 2
• Cardiovascular risk factors: Hypertension, atherosclerosis, hyperlipidemia, diabetes mellitus, smoking, family history of vascular disease, and obesity 1, 2
• Neurological factors: Prior pelvic/perineal/penile trauma or surgery, spinal cord injury, neurologic disease, and Peyronie's disease 1, 2
• Medication review: Antihypertensives (β-blockers, diuretics, ACE inhibitors), antidepressants (tricyclics, SSRIs), tranquilizers, and recreational drugs 1, 2
• Psychosocial assessment: Depression, anxiety, performance anxiety, relationship quality, partner's sexual function, major life stressors, and alcoholism 1, 2
• Other sexual dysfunctions: Premature ejaculation, decreased libido, orgasmic dysfunction, and genital pain 1

Physical Examination

Perform a focused examination including vital signs (pulse and blood pressure), genital examination for penile deformities or Peyronie's plaques (palpate from pubic bone to coronal sulcus with penis stretched), assessment of testicular size, secondary sexual characteristics, and lower extremity pulses. 1, 2

Laboratory Testing

Mandatory tests for all patients include: 1, 2

• Morning serum total testosterone levels 1, 2
• Fasting glucose or HbA1c 1, 2, 4
• Fasting lipid profile 1, 2, 4

Additional testing in select patients: 1, 2

• Free testosterone or bioavailable testosterone if total testosterone is borderline 1, 2
• Prostate-specific antigen (PSA) and digital rectal examination in men over 50 with life expectancy >10 years, particularly if considering testosterone therapy 1, 2

Critical Clinical Principle

ED is a sentinel marker for cardiovascular disease and warrants comprehensive cardiovascular risk assessment. 1, 2 The AUA emphasizes that men with ED should be counseled about this association, as ED and cardiovascular disease share common pathophysiologic pathways 1.

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Treatment Approach

Framework for Treatment Selection

Treatment should follow a shared decision-making model where all non-contraindicated options are discussed, and patients may begin with any treatment regardless of invasiveness. 1 The AUA explicitly states that while many men choose the least invasive option first, it is valid to begin with any type of treatment 1.

Step 1: Address Modifiable Factors

Before or concurrent with pharmacotherapy 2:

• Lifestyle modifications (smoking cessation, weight loss, exercise) 2, 5
• Optimize glycemic control in diabetic patients 1
• Manage cardiovascular risk factors 2, 5
• Switch medications contributing to ED when possible 1, 2
• Consider psychosexual counseling, as most ED is multifactorial 2, 6

Step 2: First-Line Pharmacotherapy

Oral phosphodiesterase-5 (PDE5) inhibitors are the first-line treatment for most patients with ED, with 60-65% success rates even in men with comorbidities including hypertension, diabetes, and spinal cord injury. 1, 2, 5

Available PDE5 inhibitors include sildenafil, tadalafil, vardenafil, and avanafil. 5 For tadalafil specifically:

• On-demand dosing: 10-20 mg taken prior to sexual activity, effective for up to 36 hours 7
• Daily dosing: 2.5-5 mg once daily, provides continuous efficacy without timing restrictions relative to sexual activity 7
• Daily tadalafil 5 mg is also effective for men with both ED and benign prostatic hyperplasia 7

Critical contraindications and precautions: 7

• Absolute contraindication: Concurrent nitrate use (must wait at least 48 hours after last tadalafil dose before nitrate administration) 7
• Relative contraindications: Myocardial infarction within 90 days, unstable angina, NYHA Class 2+ heart failure within 6 months, uncontrolled arrhythmias, hypotension (<90/50 mmHg), uncontrolled hypertension, stroke within 6 months 7
• Caution in patients with left ventricular outflow obstruction (aortic stenosis, hypertrophic subaortic stenosis) 7

Step 3: Psychosexual Counseling Integration

Referral to a mental health professional should be considered to promote treatment adherence, reduce performance anxiety, and integrate treatments into the sexual relationship. 1 This is particularly important in younger men where psychogenic factors predominate 6.

Step 4: Second-Line Therapies

For patients who fail or cannot tolerate PDE5 inhibitors, second-line options include: 1, 2

• Intracavernosal alprostadil injection 1, 2, 5
• Intraurethral alprostadil suppositories 1
• Vacuum constriction devices 1, 2

Intracorporal injection therapy with vasodilator drugs is effective and useful in men who fail oral agents 5.

Step 5: Third-Line Therapy

Penile prosthesis implantation is reserved for patients who fail less invasive therapies and is associated with high satisfaction rates. 1, 5

Step 6: Specialized Interventions

Testosterone replacement therapy should only be initiated in men with documented hypogonadism (low morning total testosterone). 2 Testosterone alone does not treat ED but may improve response to other therapies in hypogonadal men 1.

Penile arterial revascularization and venous ligation surgery have relatively poor outcomes and are not routinely recommended. 5

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Special Considerations and Referral Indications

Specialist referral to urology or mental health may be necessary for: 1, 2

• Young patients with lifelong ED 2
• History of pelvic trauma requiring specialized vascular or neurological assessment 1, 2
• Patients not responding to first-line therapy requiring specialized testing 1
• Complex psychosexual issues requiring cognitive behavioral therapy or couples counseling 6

Reassess patients at 4-6 weeks after initiating PDE5 inhibitor therapy using validated questionnaires to measure treatment effectiveness. 2, 6

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Common Pitfalls to Avoid

• Do not skip cardiovascular risk assessment: ED may be the first manifestation of cardiovascular disease 1, 2
• Do not forget testosterone measurement: Hypogonadism is a treatable cause that affects treatment response 1, 2
• Do not overlook partner involvement: Including the partner in discussions improves outcomes 1
• Do not prescribe PDE5 inhibitors without screening for nitrate use: This combination can cause life-threatening hypotension 7
• Do not assume all ED is organic: Psychogenic factors are common, especially in younger men, and benefit from specific interventions 2, 6