What is the best approach to treating erectile dysfunction in a man over 40, considering potential underlying health conditions and interactions with other medications?

Treating Erectile Dysfunction in Men Over 40

Begin treatment with an oral phosphodiesterase-5 (PDE5) inhibitor as first-line therapy for men over 40 with erectile dysfunction who have no contraindications to these medications. 1

Initial Evaluation

Men presenting with ED require a structured assessment that directly impacts treatment decisions:

• Obtain a comprehensive medical and sexual history focusing on onset (gradual vs. sudden), severity, presence of morning/nocturnal erections (suggests psychogenic component), comorbid conditions (diabetes, hypertension, cardiovascular disease), current medications, and substance use 1

• Recognize ED as a cardiovascular risk marker: ED is an independent predictor of coronary artery disease and cardiovascular mortality, with predictive value similar to traditional risk factors like smoking and hypertension 1

• Perform targeted physical examination including vital signs (blood pressure, pulse), genital examination for penile deformities or plaques (Peyronie's disease), and assessment of secondary sexual characteristics 1

• Order selective laboratory testing: Morning serum total testosterone (mandatory in all men with ED), fasting glucose/HbA1c, and lipid profile 1

  • Testosterone deficiency is defined as total testosterone <300 ng/dL with symptoms 1
  • Digital rectal examination is not required for ED evaluation 1

First-Line Treatment: PDE5 Inhibitors

The American College of Physicians strongly recommends initiating therapy with a PDE5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line treatment. 1

Medication Selection and Dosing

• Base the choice of specific PDE5 inhibitor on patient preference, considering cost, ease of use, duration of action, and side effect profile 1

• Tadalafil offers flexible dosing options 2:

  • As-needed dosing: Take 30 minutes before sexual activity; effects last up to 36 hours
  • Daily dosing: Lower dose taken at the same time daily, allowing spontaneous sexual activity
  • Sexual stimulation is required for efficacy with all PDE5 inhibitors 2

• Success rates: 60-65% of men with ED, including those with hypertension, diabetes, spinal cord injury, and other comorbidities, can successfully complete intercourse with PDE5 inhibitors 3

Critical Contraindications and Drug Interactions

Absolute contraindications 2:

• Concurrent nitrate use (nitroglycerin, isosorbide dinitrate/mononitrate) - can cause life-threatening hypotension
• Guanylate cyclase stimulators (riociguat)
• Recreational "poppers" (amyl nitrite, butyl nitrite)

Use with caution in patients with 2:

• Recent myocardial infarction (within 90 days)
• Unstable angina or angina during intercourse
• New York Heart Association Class 2 or greater heart failure (within 6 months)
• Uncontrolled hypertension or hypotension (<90/50 mmHg)
• Recent stroke (within 6 months)
• Severe hepatic or renal impairment

Important drug interactions 2:

• Alpha-blockers: May cause additive hypotension; use caution
• CYP3A4 inhibitors (erythromycin, ketoconazole): May require dose adjustment
• Antihypertensives: Monitor for excessive blood pressure lowering

Patient Counseling on PDE5 Inhibitors

• Provide clear instructions: Many treatment failures result from improper use, anxiety, or unrealistic expectations 4
• Timing matters: Take as-needed formulations 30-60 minutes before sexual activity on an empty stomach for optimal absorption 2
• Avoid excessive alcohol: More than 5 drinks can increase side effects (headache, dizziness, hypotension) 2
• Common side effects include headache, indigestion, back pain, muscle aches, flushing, and nasal congestion; these typically resolve within hours 2

When to Seek Emergency Care

Instruct patients to seek immediate medical attention for 2:

• Erection lasting >4 hours (priapism risk)
• Sudden vision loss in one or both eyes (NAION risk)
• Sudden hearing loss or decrease
• Chest pain during sexual activity

Second-Line and Alternative Treatments

When PDE5 inhibitors fail or are contraindicated:

• Intracavernosal injection therapy with alprostadil (FDA-approved) or combination therapy (papaverine, phentolamine) is highly effective 1, 5, 3

  • Requires proper patient education and dose titration 5
  • Contraindicated in patients with bleeding disorders, anticoagulation therapy, or priapism history 5

• Intraurethral alprostadil suppositories offer a less invasive injection alternative 1

• Vacuum erection devices provide a non-pharmacologic mechanical option 1, 6

• Penile prosthesis implantation for refractory cases, with high patient satisfaction rates 3, 6

Addressing Underlying Conditions

Testosterone replacement therapy: Consider only in men with documented testosterone deficiency (<300 ng/dL) and symptoms 1

• The American College of Physicians notes insufficient evidence for routine hormonal treatment in ED management 1

Cardiovascular risk modification 1:

• Men with organic ED should be considered at increased cardiovascular risk until proven otherwise
• Optimize management of diabetes, hypertension, and dyslipidemia
• Encourage smoking cessation, weight loss, and regular exercise 1, 3

Psychosexual counseling: Refer to mental health professionals to promote treatment adherence, reduce performance anxiety, and integrate treatments into the sexual relationship 1

• Psychogenic factors may be primary or secondary contributors, even in men with organic causes 1
• Depression and anxiety are common comorbidities requiring treatment 1, 7

Common Pitfalls to Avoid

• Don't overlook cardiovascular screening: New or progressive ED warrants cardiovascular evaluation, even in asymptomatic men 1
• Don't assume psychogenic etiology in younger men: 15-72% of men under 40 with ED have organic causes, particularly vascular disease 8
• Don't prescribe PDE5 inhibitors without checking for nitrate use: This combination can be fatal 2
• Don't dismiss treatment failures prematurely: Ensure proper medication use, adequate dosing, and address performance anxiety before escalating therapy 4