What is the recommended management for a patient presenting with erectile dysfunction?

Management of Erectile Dysfunction

Initial Evaluation

Begin with a comprehensive sexual, medical, and psychosocial history focusing on ED symptom characteristics (onset, duration, severity, situational factors), cardiovascular risk factors (hypertension, diabetes, dyslipidemia, obesity), medications (particularly antihypertensives, antidepressants, tranquilizers), smoking status, alcohol use, physical activity level, and relationship dynamics. 1, 2

Key History Components

• Document whether ED onset was sudden (suggesting psychogenic causes) or gradual (suggesting organic causes), presence of morning erections (preserved in psychogenic ED), and whether erections collapse early during intercourse 3
• Screen specifically for depression, anxiety, diabetes, hypertension, cardiovascular disease, neurologic disease, and obesity as these are major risk factors 2
• Review all current medications, as antihypertensives, antidepressants (tricyclics, SSRIs), and tranquilizers commonly cause ED 4
• Assess for symptoms of hypogonadism including decreased libido, decreased spontaneous erections, testicular atrophy, and muscle atrophy 4

Physical Examination

• Measure blood pressure, waist circumference, and body mass index 4
• Perform genital examination to assess for penile skin lesions, urethral meatus placement, occult deformities, plaque lesions (Peyronie's disease), and testicular abnormalities 1, 3
• Conduct cardiovascular examination including cardiac auscultation, assessment for carotid bruits, and palpation of femoral and pedal pulses 4

Laboratory Testing

• Obtain morning serum total testosterone level in all men with ED, as this is essential for diagnosis and guides treatment decisions 1, 2
• Measure fasting glucose or HbA1c and lipid profile in all patients to identify cardiovascular risk factors 1, 3
• The Princeton III Consensus specifically recommends testosterone measurement in all men with organic ED, particularly those who fail PDE5 inhibitor therapy, as 36% of men seeking consultation for sexual dysfunction have hypogonadism 4

Cardiovascular Risk Stratification

ED in men over 30 years should be considered a risk marker for underlying cardiovascular disease and requires appropriate cardiovascular evaluation before initiating treatment. 1, 2, 3

• Obtain resting electrocardiogram in men with hypertension or diabetes 4
• Categorize patients into low, intermediate, or high cardiovascular risk groups before starting PDE5 inhibitor therapy 2
• ED symptoms often present 3 years earlier than coronary artery disease symptoms, making this evaluation critical 5

First-Line Treatment

Phosphodiesterase type 5 inhibitors (PDE5i) are the most effective first-line oral treatment for ED and should be initiated after completing initial evaluation. 1, 2, 3

PDE5 Inhibitor Efficacy and Selection

• Sildenafil, vardenafil, and tadalafil all demonstrate clinically meaningful improvement in erectile function, with 60-65% of men successfully completing intercourse, including those with diabetes, hypertension, and spinal cord injury 2, 6, 7
• Tadalafil at 10-20 mg doses showed 57-54% successful penile insertion and 48-42% maintenance of erection in diabetic patients, compared to 30% and 20% with placebo 8
• Tadalafil demonstrates efficacy at 24 hours (61% vs 37% placebo) and 36 hours (64% vs 37% placebo) after dosing 8
• Vardenafil should be taken approximately 60 minutes before sexual activity 9

Important PDE5 Inhibitor Precautions

• PDE5 inhibitors are absolutely contraindicated with concurrent nitrate use (regular or intermittent) due to risk of severe hypotension, syncope, heart attack, or stroke 9
• Start with lowest dose in patients taking alpha-blockers due to risk of symptomatic hypotension 9
• Patients with moderate hepatic impairment (Child-Pugh B) should start vardenafil at 5 mg with maximum 10 mg; avoid in severe hepatic impairment (Child-Pugh C) 9
• Avoid vardenafil in patients with congenital QT prolongation or those taking Class IA or Class III antiarrhythmic medications 9
• Do not use PDE5 inhibitors in patients with unstable angina, hypotension (<90 mmHg systolic), uncontrolled hypertension (>170/110 mmHg), recent stroke, life-threatening arrhythmia, or myocardial infarction within 6 months 9

Dose Adjustments for Drug Interactions

• For patients taking ritonavir: maximum single 2.5 mg dose of vardenafil in 72 hours 9
• For patients taking indinavir, saquinavir, atazanavir, clarithromycin, ketoconazole 400 mg daily, or itraconazole 400 mg daily: maximum vardenafil 2.5 mg once daily 9
• For patients taking ketoconazole 200 mg or itraconazole 200 mg daily: maximum vardenafil 5 mg in 24 hours 9

Lifestyle Modifications

Implement lifestyle modifications alongside pharmacotherapy, including weight loss, increased physical activity, and smoking cessation, as these improve erectile function and address underlying cardiovascular risk. 2, 3

• Tobacco cessation, regular exercise, and weight loss are recommended initial interventions 10, 5
• Optimize glycemic control in diabetic patients 2
• Reduce alcohol consumption and improve dietary habits 1
• Obesity, sedentary lifestyle, and smoking greatly increase ED risk 5

Testosterone Replacement Therapy

For men with documented low testosterone levels, testosterone replacement therapy may be beneficial and should be considered after discussing risks and benefits. 1, 2

• The Princeton III Consensus recommends measuring testosterone in all men with organic ED, especially those who fail PDE5 inhibitor therapy 4
• Men with testosterone levels between 231-346 ng/dL may be considered for a 4-6 month trial of testosterone replacement therapy 1
• Continue testosterone replacement beyond 6 months only if clinical benefit is demonstrated 1
• Hypogonadism is a potential cause of PDE5 inhibitor non-response, and testosterone replacement improves PDE5 inhibitor efficacy 4
• Monitor hemoglobin, serum transaminase, and prostate-specific antigen levels during testosterone therapy due to increased prostate cancer risk 5

Psychosexual Counseling

Sexual counseling should involve the partner and address psychological factors, as these are present in nearly all men with ED regardless of organic etiology. 2

• Cognitive behavioral therapy and relationship-focused therapy improve ED outcomes 3, 5
• Screen for and address depression, anxiety, performance anxiety, and relationship issues 1, 10
• Significant psychiatric illness should be addressed before proceeding with ED treatment 1

Second-Line Treatments

For patients who do not respond to PDE5 inhibitors, consider intracavernosal alprostadil injections or vacuum erection devices. 3, 6, 7

• Intracavernosal injection therapy using vasodilator medications like alprostadil is effective in PDE5 inhibitor non-responders 6, 7
• Vacuum erection devices are non-invasive alternatives 6, 10
• Intraurethral alprostadil is another option 5

Third-Line Treatment

Surgically implanted penile prostheses are reserved for patients who fail medical management and provide high satisfaction rates with low device failure and infection risks. 3, 6, 7

• Multicomponent inflatable penile implants are associated with high patient satisfaction 7
• This option should be discussed with patients as it is effective though irreversible 6

Referral Indications

Refer to urology/andrology specialist for: young age with lifelong erectile difficulty, history of pelvic or genital trauma, abnormal testicular or penile examination findings, or abnormal initial laboratory results. 1, 2

• Young men with lifelong ED require specialist evaluation 2
• Patients with anatomical penile deformities (Peyronie's disease, cavernosal fibrosis) need specialist assessment 1
• Conditions predisposing to priapism (sickle cell anemia, multiple myeloma, leukemia) warrant specialist involvement 9

Critical Safety Warnings

• Advise patients to stop PDE5 inhibitors and seek immediate medical attention for sudden vision loss in one or both eyes, as this may indicate non-arteritic anterior ischemic optic neuropathy (NAION) 9
• Instruct patients to stop PDE5 inhibitors and seek prompt medical attention for sudden hearing loss, which may be accompanied by tinnitus and dizziness 9
• Patients should seek immediate medical assistance for erections lasting longer than 4 hours, as priapism can cause permanent penile tissue damage and loss of potency 9