What is the management approach for a patient with erectile dysfunction (ED)?

Management of Erectile Dysfunction

First-Line Treatment: PDE5 Inhibitors

Phosphodiesterase type 5 inhibitors (PDE5i) are the most effective first-line oral treatment for erectile dysfunction and should be initiated after completing initial evaluation. 1

Specific PDE5i Dosing Recommendations

• Tadalafil for as-needed use: Start with 10 mg taken at least 30 minutes before sexual activity, with effectiveness lasting up to 36 hours; maximum dose is 20 mg, not to exceed once daily 2
• Tadalafil for daily use: 2.5-5 mg taken at approximately the same time each day without regard to timing of sexual activity 2
• Sildenafil, vardenafil, and tadalafil all demonstrate clinically meaningful improvement in erectile function, with 60-65% of men successfully completing intercourse, including those with diabetes, hypertension, and spinal cord injury 3, 4

Dose Adjustments for Special Populations

• Renal impairment (CrCl 30-50 mL/min): Start tadalafil at 5 mg maximum once per day for as-needed use, or 2.5 mg for daily use 2
• Severe renal impairment (CrCl <30 mL/min or hemodialysis): Maximum 5 mg once every 72 hours for as-needed use; daily use not recommended 2
• Hepatic impairment (Child-Pugh A or B): Maximum 10 mg once daily; use caution with daily dosing 2
• Severe hepatic impairment (Child-Pugh C): PDE5i not recommended 2
• Concomitant CYP3A4 inhibitors (ketoconazole, ritonavir): Maximum tadalafil 10 mg once every 72 hours for as-needed use, or 2.5 mg for daily use 2

Initial Evaluation Components

Essential History Elements

• Document onset (sudden suggests psychogenic; gradual suggests organic), duration, severity, and situational factors of erectile symptoms 3, 1
• Screen for cardiovascular disease, diabetes, hypertension, depression, neurologic disease, and obesity as these are major risk factors 1, 5
• Review all medications, particularly antihypertensives (beta-blockers, diuretics, ACE inhibitors), antidepressants (tricyclics, SSRIs), and tranquilizers which commonly cause ED 3
• Assess for pelvic/perineal trauma, pelvic surgery, radiation therapy, and Peyronie's disease 5
• Evaluate presence of nocturnal/morning erections and masturbatory erections, which suggest psychogenic etiology if preserved 5
• Screen for psychiatric conditions including generalized anxiety, depression, psychosis, body dysmorphic disorder, and alcoholism—these require primary psychiatric management before ED treatment 3, 1

Physical Examination

• Measure blood pressure and pulse to assess cardiovascular status 3, 5
• Perform genital examination checking for penile skin lesions, urethral meatus placement, testicular size abnormalities, and retractable foreskin 3, 5
• Palpate the penis from pubic bone to coronal sulcus while stretching to detect Peyronie's plaques 5
• Assess secondary sexual characteristics and lower extremity pulses for vascular disease 5

Laboratory Testing

• Morning serum total testosterone is essential for all men with ED 1, 5
• Fasting glucose or HbA1c and lipid profile should be obtained to identify cardiovascular risk factors and diabetes 3, 1, 5
• Free testosterone or androgen index is preferred if hypogonadism is suspected clinically 3
• Prostate-specific antigen and digital rectal exam are indicated only if testosterone replacement is planned 3

Cardiovascular Risk Assessment

ED in men over 30 years should be considered a risk marker for underlying cardiovascular disease, requiring appropriate cardiovascular evaluation before initiating treatment. 1, 5

• Assess cardiac risk factors and categorize patients into low, intermediate, or high-risk groups before starting PDE5i therapy 3
• Sedentary men with multiple cardiovascular risk factors require formal cardiovascular assessment before treatment initiation 5
• Nitrates in any form are absolutely contraindicated with PDE5i use 2

Lifestyle Modifications and Risk Factor Management

• Weight loss, increased physical activity, and smoking cessation improve erectile function and should be implemented alongside pharmacotherapy 1
• Optimize glycemic control in diabetic patients, though evidence for direct improvement in ED is limited 3
• Moderate alcohol consumption (avoid >5 units with PDE5i due to additive vasodilation and orthostatic symptoms) 2
• Switch medications with lower ED risk when possible, particularly antihypertensives 1, 5

Psychosexual Counseling

• Sexual counseling should involve the partner and address psychological factors present in nearly all men with ED, regardless of organic etiology 3
• Refer to mental health professionals for men with predominantly psychogenic ED or significant psychiatric comorbidity 5
• Relationship quality, partner sexual dysfunction (e.g., vaginal dryness), and psychosocial factors must be addressed 3

Second-Line Therapies

• Intracavernosal injection therapy with alprostadil is effective for men who fail or have contraindications to oral PDE5i 4, 6
• Vacuum erection devices are non-invasive alternatives for PDE5i non-responders 6

Third-Line and Specialized Treatments

• Penile prosthesis implantation provides high satisfaction rates and is reserved for men failing medical therapies 4, 6
• Testosterone replacement therapy may be beneficial for documented low testosterone (consider trial for levels 231-346 ng/dL after discussing risks/benefits; continue beyond 6 months only if clinical benefit demonstrated) 1

Referral Indications

• Young men with lifelong erectile difficulty require specialist evaluation 3, 1
• History of pelvic/genital trauma or abnormal testicular/penile findings on examination 1, 5
• Abnormal initial screening laboratory results 1
• Failure to respond to first-line PDE5i therapy (may require specialized vascular, neurological, or hormonal testing) 3, 5

Critical Safety Warnings

• Seek emergency care for erections lasting >4 hours to prevent irreversible erectile tissue damage 2
• Stop PDE5i immediately and seek medical attention for sudden vision loss (possible NAION) or sudden hearing loss with tinnitus/dizziness 2
• Alpha-blockers require caution: patients must be stable on alpha-blocker therapy before starting PDE5i for ED; combination not recommended for BPH treatment 2