What is the best course of treatment for a patient with erectile dysfunction, normal testosterone levels, and early morning erections of unknown rigidity?

Management of Erectile Dysfunction with Normal Testosterone and Preserved Morning Erections

Start oral PDE5 inhibitors immediately as first-line therapy, regardless of whether the ED is psychogenic or organic, while simultaneously referring to a mental health professional with sexual health expertise. 1, 2, 3

Clinical Significance of Morning Erections

The presence of early morning erections strongly suggests a psychogenic component to the erectile dysfunction, even if their rigidity is uncertain. 1 However, this finding does not mean you should delay pharmacological treatment or rely solely on psychological therapy. 3, 4 The modern evidence-based approach treats both psychogenic and organic ED with PDE5 inhibitors from the outset. 2, 3

Immediate Treatment Algorithm

First-Line Pharmacotherapy

• Initiate a PDE5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) immediately, as these agents are effective in 60-65% of men with ED regardless of etiology. 2, 3

• Start conservatively and titrate to maximum dose, requiring at least 5 separate attempts at maximum dose before declaring treatment failure. 2, 3

• Educate the patient that sexual stimulation is required for the medication to work, and that timing of sexual activity relative to dosing varies by agent (sildenafil/vardenafil: 30-60 minutes; tadalafil: effective for up to 36 hours). 5

• Screen for absolute contraindications: concurrent nitrate use, guanylate cyclase stimulators (riociguat), severe hepatic impairment, recent stroke or myocardial infarction, and hereditary degenerative retinal disorders. 1, 3

Concurrent Psychological Intervention

• Refer to a mental health professional with sexual health expertise concurrently with starting PDE5 inhibitors, not sequentially. 1, 2, 3 This dual approach addresses both the physiological and psychological components simultaneously.

• Psychosexual therapy focuses on: reducing performance anxiety, improving communication about sexual concerns with the partner, and integrating ED treatments into the sexual relationship. 1, 4

• Success rates for psychosexual therapy range from 50-80% when combined with medical therapy, particularly for secondary psychogenic ED (where the patient previously had normal function). 1, 6

Cardiovascular Risk Assessment

• Counsel the patient that ED is a risk marker for underlying cardiovascular disease, even in the absence of cardiac symptoms. 1, 2, 3 ED symptoms typically precede coronary artery disease by approximately 3 years. 3

• Assess cardiovascular risk factors including blood pressure, lipids, and glycemic control, and optimize these parameters. 2, 3

Lifestyle Modifications (Initiated Simultaneously)

• Smoking cessation is essential, as smoking directly impairs erectile function. 2, 3

• Weight loss if BMI >30 kg/m², increased physical activity, and reduced alcohol consumption all improve erectile function. 2, 3

• Review all medications for agents that may contribute to ED (antihypertensives, antidepressants, antipsychotics) and consider switching to alternatives with lower ED risk. 1, 2, 3

Management of Treatment Failure

If Initial PDE5 Inhibitor Fails

• Trial a second PDE5 inhibitor at maximum dose for at least 5 attempts before declaring PDE5 inhibitor class failure. 2, 3 Different agents have varying pharmacokinetics and may work when another has failed.

• Reassess for unrecognized testosterone deficiency if response is poor, as even "normal" testosterone may be suboptimal for erectile function. 2, 3

Second-Line Therapies (After Two PDE5 Inhibitor Failures)

• Refer to urology for consideration of: 1, 3
  • Intracavernosal injection therapy (alprostadil, papaverine, phentolamine) with 66-94% efficacy
  • Intraurethral alprostadil suppositories
  • Vacuum erection devices (90% initial efficacy, though satisfaction drops to 50-64% at 2 years)
  • Low-intensity shockwave therapy (emerging evidence for mild vasculogenic ED)

Third-Line Therapy

• Penile prosthesis implantation is reserved for patients who fail all medical therapies and is associated with high satisfaction rates (80-90%). 1, 3

Critical Pitfalls to Avoid

• Do not delay PDE5 inhibitor therapy while waiting for psychological evaluation or therapy to "work first." 3, 4 The evidence clearly supports concurrent initiation of both approaches.

• Do not assume psychogenic ED requires only counseling. 3 PDE5 inhibitors work for both psychogenic and organic ED and should be prescribed immediately.

• Do not declare PDE5 inhibitor failure prematurely. 3 Patients need proper education about dosing, timing, and the need for sexual stimulation, as many "failures" are due to incorrect use.

• Do not ignore the partner. 1 Including the partner in discussions and treatment planning significantly improves outcomes and treatment adherence.

• Do not overlook depression, anxiety, or relationship conflict as primary or contributing factors. 1, 2 These conditions require specific treatment and may worsen with certain antidepressants.

Distinguishing from Other Sexual Dysfunctions

• Rule out premature ejaculation, which frequently coexists with ED in younger men and is often confused with ED. 3 If both conditions are present, treat the ED first. 3

• Assess for orgasmic or ejaculatory disorders, which may require different interventions (vibratory therapy, pelvic physical therapy, SSRIs). 1