What are the recommended treatment options for an adult male with erectile dysfunction according to the Sexual Medicine Society of North America (SMSNA) guidelines?

SMSNA Guidelines for Erectile Dysfunction Treatment

First-Line Treatment: Oral PDE5 Inhibitors

Men with erectile dysfunction should be prescribed an FDA-approved oral phosphodiesterase type 5 inhibitor (PDE5i) as first-line therapy unless contraindicated. 1

Specific PDE5i Options and Dosing

• Tadalafil (5-20 mg), sildenafil, vardenafil, and avanafil are all effective FDA-approved options 1, 2
• Tadalafil 20 mg demonstrated statistically significant improvements in erectile function domain scores, with 62-77% of men achieving successful vaginal penetration (vs. 39-43% placebo) and 50-64% maintaining erections for successful intercourse (vs. 23-25% placebo) 2
• Dose titration is mandatory to optimize efficacy—start at lower doses and increase as needed 1
• Between 60-65% of men with ED, including those with hypertension, diabetes, spinal cord injury, and other comorbidities, can successfully complete intercourse with PDE5i therapy 3

Critical Instructions for Maximizing PDE5i Efficacy

Providing clear, specific instructions is essential to realize full benefits of PDE5i therapy. 1, 4

• Timing of administration relative to sexual activity must be discussed 1
• Food and alcohol effects on absorption should be explained 2
• Adequate sexual stimulation is required—these drugs do not cause automatic erections 2
• Multiple attempts (4-8 doses) may be needed before determining treatment failure 4

Cardiovascular Screening Before PDE5i Prescription

• Assess cardiovascular status before prescribing, as sexual activity carries cardiac risk 2
• PDE5i are absolutely contraindicated with nitrate use—at least 48 hours must elapse after tadalafil before nitrate administration 2
• Avoid in patients with: myocardial infarction within 90 days, unstable angina, NYHA Class 2+ heart failure within 6 months, uncontrolled arrhythmias, hypotension (<90/50 mmHg), uncontrolled hypertension, or stroke within 6 months 2

Assessment and Diagnosis

Essential History Components

• Duration and rigidity of erections, including presence of nocturnal/morning erections (suggests psychogenic component) 1
• Context-specific patterns: erections only with specific partners, during masturbation, or in certain situations 1
• Medication review is critical—approximately 25% of ED cases are drug-related, particularly from thiazide diuretics, beta-blockers, and SSRIs 5
• Cardiovascular risk factors: ED is as strong a predictor of future cardiac events as smoking or family history of MI 1

Physical Examination Specifics

• Vital signs including pulse and blood pressure 1
• Penile examination: assess for skin lesions, urethral meatus placement, and palpate stretched penis from pubic bone to coronal sulcus for plaques or deformities 1
• Digital rectal exam is not required for ED evaluation 1

Laboratory Testing

• Serum total testosterone should be measured in all men with ED (testosterone deficiency defined as <300 ng/dL with symptoms) 1
• Consider fasting glucose/HbA1c and lipid profile 1, 3
• No other routine serum studies are likely to alter ED management 1

Treatment Algorithm for Non-Responders

When PDE5i Fails or Is Inadequate

For men with inadequate response to oral PDE5i, intracavernosal injection therapy is the next step. 1, 3

• Intracavernosal phenylephrine with or without aspiration/irrigation is recommended for acute treatment needs 1
• Alprostadil (prostaglandin E1) injections are effective in men who fail oral agents 3, 6
• Topical alprostadil can be added to PDE5i therapy in partial responders 6

Penile Rehabilitation Approach

• Penile rehabilitation or prescription of PDE5i should be offered, particularly post-prostatectomy 1
• Tadalafil 20 mg showed efficacy in post-bilateral nerve-sparing radical prostatectomy patients, with 54% achieving successful penetration vs. 32% placebo 2

Surgical Options for Refractory Cases

• Multicomponent inflatable penile prostheses are associated with high satisfaction rates for intractable ED 3, 7
• Vacuum erection devices remain an option for men who cannot or will not use other therapies 7
• Penile arterial revascularization and venous ligation have relatively poor outcomes and are not recommended 3

Addressing Comorbid Conditions

Erectile Dysfunction with Diabetes

• Tadalafil demonstrated efficacy in diabetic men, with 57% (10 mg) and 54% (20 mg) achieving successful penetration vs. 30% placebo 2
• Treat diabetes aggressively as glycemic control impacts erectile function 1, 3

Erectile Dysfunction with Testosterone Deficiency

• Replace testosterone per AUA guidelines in men with biochemically low testosterone (<300 ng/dL) and symptoms 8
• Topical testosterone may benefit selected patients with documented deficiency 6

Erectile Dysfunction with Depression/Anxiety

• Screen for distress/depression at least annually using tools like the Distress Thermometer 1
• Psychotherapy referral should be offered as alternative or adjunct to medical treatment, particularly for psychogenic ED 1
• If SSRI-induced ED, consider medication adjustment, dose reduction, or switching to alternative antidepressant 8, 5

Erectile Dysfunction with Premature Ejaculation

• Treat comorbid ED first according to AUA guidelines, as chronology matters for treatment sequencing 1, 8
• Some acquired PE may be secondary to ED; some lifelong PE may develop ED from performance anxiety 1

Lifestyle Modifications

Lifestyle modification and reduction of vascular risk factors are essential components of ED treatment. 3, 4

• Address obesity, lack of exercise, smoking, hypertension, and dyslipidemia 3
• These interventions improve both erectile function and overall cardiovascular health 1, 3

Partner Involvement

• Include sexual partners in decision-making whenever possible to optimize outcomes 8
• Discuss sexual intimacy with couples and refer to counseling or support services as appropriate 1
• Instruct couples on use of sexual aids to improve erectile function 1

Monitoring and Follow-Up

• Use validated tools such as the Sexual Health Inventory for Men (SHIM) to monitor erectile function over time 1
• Refer to urologist or sexual health specialist for persistent sexual dysfunction to review treatment and counseling options 1

Critical Pitfalls to Avoid

• Never assume PDE5i failure after inadequate trial—many men give up after 1-2 attempts without proper dosing or instructions 4
• Do not overlook drug-induced ED—always review medications before initiating specific ED therapy 5
• Anxiety and unrealistic expectations can result in poor PDE5i response even with adequate vascular function 4
• ED is a cardiovascular risk marker—communicate this to the patient, partner, and primary care provider for appropriate cardiovascular screening 1