What is the recommended evaluation and management plan for erectile dysfunction?

Erectile Dysfunction Management

Initial Evaluation

Initiate the conversation about sexual health yourself, as most men will not bring it up, and use validated questionnaires like the Sexual Health Inventory for Men (SHIM) or Erection Hardness Score to quantify severity. 1, 2

History Taking

• Document the onset pattern (sudden versus gradual), severity, ability to attain versus maintain erections, and presence of morning or nocturnal erections—preserved morning erections suggest a psychogenic component 1, 2, 3
• Identify situational factors: does ED occur only with specific partners, in certain contexts, or during masturbation versus partnered activity 1, 3
• Review all current medications, particularly antihypertensives (thiazide diuretics, beta-blockers), antidepressants (tricyclics, SSRIs), and tranquilizers, as these commonly cause ED 3, 4
• Screen for cardiovascular risk factors, diabetes, hypertension, hyperlipidemia, obesity, depression, anxiety, relationship quality, and partner sexual function 2, 3, 5
• Assess for symptoms of hypogonadism including decreased libido, decreased spontaneous erections, testicular atrophy, and muscle atrophy 3

Physical Examination

• Measure blood pressure, pulse, waist circumference, and body mass index 1, 3
• Perform genital examination to assess penile skin lesions, urethral meatus placement, penile plaques (palpate from pubic bone to coronal sulcus with penis stretched), and testicular size 1, 2, 3
• Conduct cardiovascular examination including cardiac auscultation, assessment for carotid bruits, and palpation of femoral and pedal pulses 3
• Assess secondary sexual characteristics and lower extremity pulses 2

Laboratory Testing

• Measure morning serum total testosterone in all men with ED—this is mandatory, with levels <300 ng/dL defining deficiency 1, 2, 3
• Check fasting glucose or HbA1c and fasting lipid profile, as diabetes and cardiovascular disease impact ED treatment 2, 6
• Obtain resting electrocardiogram in men with hypertension or diabetes 3

Critical Counseling Point

Inform every patient that ED is a substantial independent risk marker for cardiovascular disease and future cardiac events—as strong a predictor as cigarette smoking or family history of myocardial infarction—warranting evaluation and treatment of underlying conditions. 1, 2, 3 Communicate this increased risk to the patient, his partner, and his primary care provider so appropriate referrals and interventions can be implemented 1.

Treatment Algorithm

First-Line: PDE5 Inhibitors

Start PDE5 inhibitors (sildenafil, tadalafil, vardenafil, or avanafil) as first-line treatment, with 60-65% success rates even in men with comorbidities like hypertension, diabetes, and spinal cord injury. 2, 6

• Titrate from the lowest dose to maximum as needed, monitoring for efficacy and side effects 2, 3
• Advise patients to take tadalafil at least 30 minutes before sexual activity, with effects lasting up to 36 hours 2
• Consider daily low-dose PDE5 inhibitors rather than on-demand dosing for patients with performance anxiety 3
• Never prescribe PDE5 inhibitors with nitrates or guanylate cyclase stimulators—this combination causes life-threatening hypotension 2, 7
• Avoid substantial alcohol consumption, as it increases the risk of orthostatic hypotension, dizziness, and headache 2
• Follow up at 4-6 weeks using validated questionnaires to assess response 2

Special Dosing Considerations

• For patients with moderate hepatic impairment (Child-Pugh B), start vardenafil at 5 mg with a maximum dose of 10 mg 7
• Patients should be stable on alpha-blocker therapy before initiating a PDE5 inhibitor; start PDE5 inhibitors at the lowest recommended dose in these patients 7
• Exercise caution in patients with known QT prolongation or those taking medications that prolong the QT interval 7

Testosterone Replacement Therapy

• Add testosterone replacement therapy if morning testosterone is <300 ng/dL and the patient has reduced libido or sexual satisfaction 1, 3
• Hypogonadism is a potential cause of PDE5 inhibitor non-response, and testosterone replacement improves PDE5 inhibitor efficacy 1, 3
• For men with testosterone levels between 231-346 ng/dL, consider a 4-6 month trial of testosterone replacement after discussing risks and benefits 3
• Continue testosterone replacement beyond 6 months only if clinical benefit is demonstrated 3
• Avoid testosterone therapy in men actively trying to conceive, as it suppresses spermatogenesis 3

Lifestyle Modifications

Recommend lifestyle changes to all patients, as these reduce cardiovascular risk and improve erectile function: smoking cessation, regular dynamic exercise, weight loss to achieve BMI <30 kg/m², Mediterranean diet (emphasizing fruits, vegetables, whole grains, nuts, fish, lean meats), and moderate alcohol consumption (<14 units/week for women, <21 units/week for men). 1, 2, 5, 8

• Smoking cessation reduces total mortality by 36% in patients with coronary heart disease 1
• Physical activity improves lipid profiles, blood pressure, glucose-insulin homeostasis, endothelial function, and reduces incident diabetes and coronary heart disease by 30-50% 1
• Weight loss may reverse ED through decreased inflammation, increased serum testosterone, and improved mood and self-esteem 8

Psychotherapy and Mental Health Referral

Combine PDE5 inhibitors with psychosocial interventions such as cognitive behavioral therapy, sexual skills training, or couples counseling, as this integrated approach is superior to either treatment alone. 3

• Consider referral to a mental health professional for all patients, particularly those under 30 or with psychogenic factors, to reduce performance anxiety and improve treatment adherence 2, 3
• Refer when complex psychiatric disorders are present, performance anxiety persists despite initial interventions, or relationship conflicts dominate the clinical picture 3
• Include the partner in both assessment and treatment whenever possible, as this improves treatment adherence, addresses relationship dynamics, and ensures shared decision-making 3
• Address significant psychiatric illness before proceeding with ED treatment 3

Second-Line Therapies

• Alprostadil intracavernosal injections are effective in men who fail oral agents, but require patient training on self-administration 2, 6
• Vacuum erection devices are a non-invasive mechanical option suitable for many patients 2
• Intraurethral alprostadil is less effective than injections but less invasive 2

Third-Line: Surgical Options

• Surgically implanted multicomponent inflatable penile prostheses are associated with high satisfaction rates and are reserved for patients with contraindications to nonsurgical interventions, those refractory to medical therapy, or those with penile fibrosis or vascular insufficiency 6, 9

Specialist Referral Indications

Refer for specialist assessment when: 3

• Young age with lifelong erectile difficulty
• History of pelvic or genital trauma
• Abnormal testicular or penile findings on examination
• Abnormal initial screening laboratory results
• Complex histories requiring specialized testing (nocturnal penile tumescence, intracavernosal injection testing) 1

Common Pitfalls to Avoid

• Failing to provide clear PDE5 inhibitor instructions leads to perceived treatment failure 2
• Missing cardiovascular disease screening, as ED may be the first presentation of significant vascular disease 2, 3
• Not checking testosterone, as hypogonadism requires separate management and explains poor PDE5 inhibitor response 2, 3
• Ignoring psychogenic factors, as even organic ED benefits from addressing performance anxiety and relationship issues 2, 3
• Overlooking medication-induced ED—consider alternatives with lower ED risk 3, 4