What is the best stepwise approach for managing erectile dysfunction (ED) in an adult male patient with no significant medical history?

Stepwise Management of Erectile Dysfunction

The best approach to erectile dysfunction begins with a comprehensive evaluation followed by first-line treatment with oral PDE5 inhibitors, progressing to more invasive therapies only if initial treatment fails or is contraindicated. 1

Step 1: Initial Evaluation

History Taking

• Initiate the sexual health conversation yourself, as most men are uncomfortable raising this topic 1
• Document onset pattern (gradual suggests organic cause; sudden suggests psychogenic), severity, ability to attain versus maintain erections, and presence of morning/nocturnal erections (suggests psychogenic component if present) 1, 2
• Screen for cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking), medications causing ED, depression/anxiety, relationship quality, and partner sexual function 1, 3
• Use validated questionnaires like the Sexual Health Inventory for Men (SHIM) or Erection Hardness Score to quantify severity 1

Physical Examination

• Measure blood pressure and pulse 1
• Perform focused genital examination: assess for penile plaques (Peyronie's disease), urethral abnormalities, and testicular size (hypogonadism) 1
• Assess secondary sexual characteristics and lower extremity pulses 1

Laboratory Testing

• Morning serum total testosterone (mandatory for all men with ED; testosterone <300 ng/dL defines deficiency) 1, 4
• Fasting glucose or HbA1c (diabetes significantly reduces PDE5i efficacy) 4, 3
• Fasting lipid profile (ED is a cardiovascular risk marker as strong as smoking or family history of MI) 1, 4, 3

Critical Counseling Point

Inform every patient that ED is a substantial independent risk marker for cardiovascular disease and future cardiac events, warranting evaluation and treatment of underlying conditions 1

Step 2: First-Line Treatment - Oral PDE5 Inhibitors

PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are the first-line treatment for ED, with 60-65% success rates even in men with comorbidities like diabetes, hypertension, and spinal cord injury. 1, 3, 5

Prescribing Instructions (Critical for Success)

• Take tadalafil at least 30 minutes before sexual activity; effects last up to 36 hours 6
• Titrate the dose to optimize efficacy (start lower, increase as needed) 1
• Sexual stimulation is required for the medication to work 6
• Avoid substantial alcohol consumption (≥5 units) as it increases risk of orthostatic hypotension, dizziness, and headache 6

Absolute Contraindications

• Never prescribe with nitrates (nitroglycerin, isosorbide) or recreational "poppers" (amyl/butyl nitrite) - can cause life-threatening hypotension 6
• Never prescribe with guanylate cyclase stimulators (riociguat) 6

Reassessment

• Follow up at 4-6 weeks using validated questionnaires to assess response 7

Step 3: Adjunctive Mental Health Referral

Consider referral to a mental health professional for all patients, particularly those under 30 or with psychogenic factors, to reduce performance anxiety, improve treatment adherence, and integrate therapy into the sexual relationship. 1, 7

• Cognitive behavioral therapy and couples counseling are effective for psychogenic ED 7
• Psychotherapy helps even when combined with medical treatment 1, 8

Step 4: Second-Line Therapies (If PDE5i Fails or Contraindicated)

Intracavernosal Injection Therapy

• Alprostadil injections are effective in men who fail oral agents 3, 5
• Requires patient training on self-administration 1, 5

Vacuum Erection Devices

• Non-invasive mechanical option suitable for many patients 1, 5

Intraurethral Alprostadil

• Less effective than injections but less invasive 1

Step 5: Third-Line Therapy - Penile Prosthesis

Surgical implantation of multicomponent inflatable penile prostheses is reserved for men who fail medical therapies, with high patient satisfaction rates and low device failure/infection risks. 3, 5

Common Pitfalls to Avoid

• Failing to provide clear PDE5i instructions (timing, need for sexual stimulation, dose titration) leads to perceived treatment failure 1
• Missing cardiovascular disease screening - ED may be the first presentation of significant vascular disease 1, 4
• Not checking testosterone - hypogonadism requires separate management and explains poor PDE5i response 1, 4
• Ignoring psychogenic factors - even organic ED benefits from addressing performance anxiety and relationship issues 1, 7
• Prescribing PDE5i without screening for nitrate use - potentially fatal drug interaction 6

Important Safety Warning

Advise patients to seek emergency care for erections lasting >4 hours (priapism can cause irreversible erectile tissue damage) or sudden vision/hearing loss (rare but serious adverse events). 6