What are the treatment recommendations for an adult male patient with erectile dysfunction (ED) and no significant medical history?

Treatment Recommendations for Erectile Dysfunction

First-Line Treatment: PDE5 Inhibitors

Start with a phosphodiesterase-5 (PDE5) inhibitor as first-line therapy, as these medications achieve 60-65% success rates even in men with comorbidities like diabetes, hypertension, and spinal cord injury. 1, 2

• Tadalafil, sildenafil, vardenafil, and avanafil are all effective options 2, 3
• Titrate the dose to maximum before declaring treatment failure—patients should attempt at least 5 separate trials at the maximum dose 4
• Tadalafil should be taken at least 30 minutes before sexual activity, with effects lasting up to 36 hours 1, 5
• Provide clear instructions on proper use, as inadequate patient education is a common cause of perceived treatment failure 1

Critical Safety Contraindications

• Never prescribe PDE5 inhibitors with nitrates or guanylate cyclase stimulators (like riociguat), as this combination causes life-threatening hypotension 1, 5
• Avoid substantial alcohol consumption, which increases risk of orthostatic hypotension, dizziness, and headache 1
• Use caution with alpha-blockers—start PDE5 inhibitors at the lowest dose in patients taking these medications 6
• Avoid in patients with congenital or acquired QT prolongation or those taking Class IA or III antiarrhythmics 6

Mandatory Initial Evaluation

Before prescribing treatment, complete the following assessments:

• Measure morning serum total testosterone in all men with ED—testosterone <300 ng/dL defines deficiency and requires separate management 1, 4
• Check fasting glucose or HbA1c and fasting lipid profile 1
• Measure blood pressure and assess cardiovascular risk factors 7, 1
• Use validated questionnaires like the Sexual Health Inventory for Men (SHIM) to quantify severity 1, 3
• Inform every patient that ED is an independent risk marker for cardiovascular disease and future cardiac events, warranting evaluation of underlying conditions 7, 1, 4

Key History Elements

• Document onset pattern, severity, ability to attain versus maintain erections, and presence of morning/nocturnal erections 1
• Screen for medications causing ED—antidepressants, antihypertensives, and tobacco use are the most common culprits 3, 8
• Assess for depression, anxiety, relationship quality, and partner sexual function 1, 3

Testosterone Deficiency Management

• Treat testosterone deficiency first in men with documented low testosterone and symptoms of hypogonadism, as this improves both erectile function and libido 4
• Testosterone optimization may improve response to PDE5 inhibitors 4
• The combination of sudden ED onset with loss of libido makes testosterone deficiency highly likely and treatable 4

Lifestyle Modifications

Implement these evidence-based interventions concurrently with pharmacotherapy:

• Tobacco cessation 3
• Weight loss if BMI >30 kg/m² 4
• Regular exercise 3
• Reduced alcohol consumption 4
• Optimization of cardiovascular risk factors including blood pressure, lipids, and glycemic control 4, 3

Mental Health Considerations

• Consider referral to a mental health professional for all patients, particularly those under 30 or with psychogenic factors 1
• Cognitive behavioral therapy and couples counseling are effective for psychogenic ED 1
• Psychotherapy helps even when combined with medical treatment 1
• PDE5 inhibitors work for both psychogenic and organic ED and should be initiated concurrently with psychological therapy 4

Second-Line Therapies

If two different PDE5 inhibitors at maximum dose fail after adequate trials, proceed to:

• Alprostadil intracavernosal injections—effective in men who fail oral agents but require patient training on self-administration 1, 2
• Vacuum erection devices—a non-invasive mechanical option suitable for many patients 1, 2
• Intraurethral alprostadil—less effective than injections but less invasive 1

Third-Line Treatment

• Penile prosthesis implantation is reserved for medical therapy failures and has high satisfaction rates 4, 2

Follow-Up Protocol

• Reassess at 4-6 weeks using validated questionnaires to assess response 1
• Adjust dosing based on efficacy and tolerability 7

Critical Pitfalls to Avoid

• Do not treat ED without addressing cardiovascular risk—men with organic ED should be considered at increased cardiovascular disease risk until proven otherwise, even without cardiac symptoms 7, 4
• Do not miss testosterone testing, as hypogonadism explains poor PDE5 inhibitor response and requires separate management 1, 4
• Do not ignore psychogenic factors, as even organic ED benefits from addressing performance anxiety and relationship issues 1
• Do not assume treatment failure after inadequate trials—ensure maximum dosing with at least 5 attempts before switching therapies 4
• Do not delay addressing underlying depression when present, as antidepressants themselves may worsen sexual function 4, 8