In a 50-year-old obese man with new-onset erectile dysfunction, normal genital exam, unchanged libido, stable relationship, and borderline hypertension, which is the most appropriate next step in addition to starting a phosphodiesterase‑5 inhibitor: no further testing, screening hemoglobin A1c and fasting lipid panel, follicle‑stimulating hormone measurement, or referral for couples therapy?

Testing Hemoglobin A1c and Lipid Panel is Most Appropriate

In this 50-year-old obese man with new-onset erectile dysfunction and borderline hypertension, you should order hemoglobin A1c and fasting lipid panel in addition to starting a phosphodiesterase-5 inhibitor. 1, 2

Rationale for Metabolic Screening

Erectile Dysfunction as a Cardiovascular Sentinel Event

• Erectile dysfunction presents on average 3 years before symptoms of coronary artery disease, making it a critical window for cardiovascular risk modification 2
• Men with ED are at significantly increased risk for coronary, cerebrovascular, and peripheral vascular disease 2
• The pathophysiology of ED shares common endothelial dysfunction pathways with hypertension, atherosclerosis, hypercholesterolemia, and diabetes 3

Guideline-Recommended Laboratory Testing

• Routine laboratory tests for new-onset ED should include HbA1c, fasting blood glucose, and lipid profile 1
• Initial diagnostic workup should be limited to fasting serum glucose and lipid panel (along with TSH and morning total testosterone if clinically indicated) 2
• This patient's obesity (BMI 32) and borderline hypertension (134/85 mmHg) substantially increase his cardiovascular and metabolic risk 2

Why Other Options Are Not Appropriate

FSH Levels Are Not Indicated

• FSH measurement is unnecessary because this patient has normal libido and normal testicular examination 1
• Testosterone measurement (not FSH) is only necessary in patients who do not respond to PDE5 inhibitors or who present with decreased libido, premature ejaculation, fatigue, testicular atrophy, or muscle atrophy 1
• The preserved libido and normal genital exam make primary hypogonadism extremely unlikely 1

Couples Therapy Is Not Indicated

• This patient reports a stable 20-year marriage with no relationship problems and unchanged libido, making psychogenic ED unlikely as the primary etiology 1
• Sexual counseling and couples therapy are appropriate when psychological factors or relationship issues are identified during history, which is not the case here 1
• The sudden onset in a man with cardiovascular risk factors (obesity, borderline hypertension) strongly suggests organic rather than psychogenic etiology 1

No Additional Testing Would Miss Critical Opportunities

• Failing to screen for diabetes and dyslipidemia in this high-risk patient represents a missed opportunity for cardiovascular risk reduction and mortality prevention 2
• ED is increasingly recognized as a sentinel marker of future cardiovascular disease, and the presence of ED with cardiovascular risk factors mandates screening 4

Clinical Approach to This Patient

Immediate Management

• Start a PDE5 inhibitor (sildenafil, tadalafil, or vardenafil) as first-line therapy 1
• Verify the patient is not taking nitrates in any form before prescribing, as this is an absolute contraindication 1, 5
• Order HbA1c and fasting lipid panel 1, 2

Cardiovascular Risk Stratification

• Assess cardiovascular fitness by asking if he can walk 1 mile in 20 minutes or climb 2 flights of stairs without symptoms 1, 5
• This patient's borderline hypertension (134/85) and obesity place him at intermediate cardiovascular risk, but he likely falls into the low-risk category if asymptomatic with activity 5

Lifestyle Modification Counseling

• Obesity, sedentary lifestyle, and smoking greatly increase the risk of ED and should be addressed 2
• Weight loss, increased physical activity, and smoking cessation improve erectile function and cardiovascular outcomes 1, 2

Common Pitfalls to Avoid

• Do not order FSH levels in men with normal libido and normal testicular exam—this is not indicated and wastes resources 1
• Do not refer for couples therapy without evidence of relationship problems or psychogenic factors—this delays appropriate medical management 1
• Do not skip metabolic screening in obese patients with ED and borderline hypertension—this represents a critical opportunity for cardiovascular risk reduction 2
• Ensure an adequate trial of PDE5 inhibitor (at least 5 separate attempts at maximum dose with proper technique) before declaring treatment failure 1, 5