When should a male patient, particularly those over 40 with a history of cardiovascular disease, diabetes, or other comorbidities, be referred for evaluation and treatment of erectile dysfunction (ED)?

When to Refer for Erectile Dysfunction

Refer men with ED to a mental health professional when psychogenic factors predominate, when first-line medical therapy fails to achieve satisfactory results, or when psychological issues interfere with treatment adherence; refer to cardiology when cardiovascular risk stratification is indeterminate or high-risk features are present; and refer to urology/sexual medicine specialists when specialized testing is needed, when patients have complex presentations including young men with lifelong ED, penile abnormalities, or trauma history, or when second-line therapies are being considered. 1

Mental Health/Psychology Referral

Psychogenic ED or psychological comorbidities:

• Refer men with predominantly psychogenic ED (sudden onset, situational ED, preserved morning/nocturnal erections, relationship conflicts, performance anxiety) to a psychotherapist as either an alternative or adjunct to medical treatment. 1
• Men with depression, anxiety, relationship conflict, or psychosexual issues should be referred to promote treatment adherence, reduce performance anxiety, and integrate treatments into the sexual relationship. 1
• Young men under 30 warrant strong consideration for mental health referral, as psychogenic factors predominate in this age group. 2
• Important psychiatric problems requiring referral before ED treatment include generalized anxiety states, depressive illness, psychosis, body dysmorphic disorder, gender identity problems, and alcoholism. 1

Cardiology Referral

Cardiovascular risk stratification:

• Men with ED aged 30-60 years should be considered at increased cardiovascular risk until proven otherwise, as ED is as strong a predictor of future cardiac events as cigarette smoking or family history of myocardial infarction. 1
• Refer patients with indeterminate cardiovascular risk for further cardiologic evaluation before initiating ED treatment. 1

High-risk cardiovascular features requiring cardiology referral before ED treatment: 1

• Unstable or refractory angina
• Uncontrolled hypertension
• Left ventricular dysfunction/CHF (NYHA class II or greater)
• MI or stroke within previous 2 weeks (some sources say 90 days)
• High-risk arrhythmias
• Hypertrophic obstructive or other cardiomyopathies
• Moderate-to-severe valvular disease

Urology/Sexual Medicine Specialist Referral

Complex presentations requiring specialized evaluation: 1

• Young patients who have always had erectile difficulty (lifelong ED)
• Patients with history of pelvic, perineal, or penile trauma
• Abnormalities found on genital examination (testicular abnormalities, penile plaques suggesting Peyronie's disease, penile deformities)
• Suspected Peyronie's disease requiring additional diagnostic procedures
• Initial screening tests indicating important abnormalities (severe testosterone deficiency, uncontrolled diabetes)

Specialized testing needs: 1

• Men requiring nocturnal penile tumescence and rigidity testing
• Patients needing intracavernosal injection testing
• Those requiring penile Doppler ultrasound or other vascular studies
• Neurological assessment requirements

Treatment failure or advanced therapies: 1

• Failure of first-line PDE5 inhibitor therapy despite adequate trials and dose optimization
• Patients warranting second-line therapies (intracavernosal injections, intraurethral suppositories)
• Consideration of surgical treatments (penile prosthesis implantation)
• Patients requiring vacuum constriction device instruction and monitoring

Primary Care Management Before Referral

Most men can be initially managed in primary care with: 1

• Comprehensive sexual, medical, and psychosocial history
• Physical examination (blood pressure, waist circumference, BMI, genital examination)
• Morning serum total testosterone measurement (mandatory for all men with ED)
• Fasting glucose or HbA1c
• Lipid profile assessment
• First-line PDE5 inhibitor therapy for low cardiovascular risk patients

Common pitfall: Do not delay cardiovascular risk assessment and communication to the patient, his partner, and other relevant clinicians (primary care provider), as this represents a critical window of opportunity for intervention. 1, 3