For a 50-year-old obese man with new-onset erectile dysfunction and normal examination, after initiating sildenafil, which is the most appropriate next step: no further testing, order hemoglobin A1c and fasting lipid panel, check luteinizing hormone and follicle‑stimulating hormone, or refer for couples therapy?

Hemoglobin A1c and Lipid Panel

In addition to starting a phosphodiesterase-5 inhibitor, the most appropriate next step is to order a hemoglobin A1c and fasting lipid panel. 1

Rationale for Cardiovascular Risk Assessment

Erectile dysfunction is a powerful risk marker for systemic cardiovascular disease, presenting on average three years before symptoms of coronary artery disease. 1, 2 The Princeton Consensus Conference identified ED as a substantial independent predictor of future cardiac events—as strong as cigarette smoking or family history of myocardial infarction. 1 This 50-year-old man with obesity (BMI 32 kg/m²) and borderline hypertension (134/85 mm Hg) already has multiple cardiovascular risk factors, making screening for diabetes and dyslipidemia essential. 1, 2

Why Hemoglobin A1c and Lipid Panel Are Critical

• Diabetes screening is mandatory because diabetes increases ED risk approximately 4-fold and is present in 35-90% of men with ED. 3 Undiagnosed diabetes is extremely common in this demographic, and poor glycemic control independently worsens erectile function. 3, 4

• Lipid screening identifies dyslipidemia, a key component of metabolic syndrome and endothelial dysfunction—the shared pathophysiology underlying both ED and cardiovascular disease. 5, 2

• With the possible exception of glucose/hemoglobin A1c and serum lipids, no routine serum study is likely to alter ED management. 1 This statement from the 2018 AUA guideline explicitly prioritizes these two tests above all others in the initial workup.

• The diagnosis of ED provides a pivotal opportunity to discuss cardiovascular risk and implement appropriate referrals and interventions. 1 Identifying diabetes or dyslipidemia now allows for early treatment that improves both cardiovascular outcomes and erectile function. 4, 6

Why Other Options Are Inappropriate

LH and FSH levels (option c) are not indicated because this patient has normal libido and no other symptoms suggesting hypogonadism. 1 Serum total testosterone should be measured in all men with ED to screen for testosterone deficiency, but gonadotropins are only measured after confirming low testosterone on repeat testing to distinguish primary from secondary hypogonadism. 1, 7 His preserved libido makes clinically significant hypogonadism unlikely.

Couples therapy (option d) is premature because there is no evidence of relationship conflict, psychosexual issues, or predominantly psychogenic ED. 1 The presence of nocturnal/morning erections would suggest a psychogenic component warranting further investigation, but this history is not provided. 1 Psychotherapy should be offered when psychological factors are primary or secondary contributors, or as an adjunct to medical treatment—not as the initial step in a man with organic risk factors. 1

No additional testing (option a) is incorrect because it ignores the critical opportunity to screen for life-threatening cardiovascular disease. 1, 2 Men with ED are at increased risk of coronary, cerebrovascular, and peripheral vascular diseases, and this patient's obesity and borderline hypertension amplify that risk. 2

Clinical Algorithm

1. Order hemoglobin A1c and fasting lipid panel immediately. 1, 2
2. Initiate PDE5 inhibitor therapy (already planned). 1, 2
3. Counsel on lifestyle modification: weight loss, smoking cessation (if applicable), increased physical activity, and dietary changes to address obesity and cardiovascular risk. 1, 2
4. Consider morning total testosterone if libido decreases or PDE5 inhibitor fails, as hypogonadism can reduce PDE5 inhibitor efficacy. 1, 2
5. Refer to primary care or cardiology if diabetes or significant dyslipidemia is identified, ensuring appropriate management of these conditions. 1, 2

Common Pitfalls to Avoid

• Do not skip cardiovascular screening in men with ED and metabolic risk factors—this is a missed opportunity to prevent myocardial infarction or stroke. 1, 2
• Do not order extensive hormonal panels (LH, FSH, prolactin) without first confirming low testosterone, as this wastes resources and delays appropriate care. 1
• Do not assume ED is purely psychogenic in a middle-aged obese man with hypertension—organic causes predominate in this population. 1, 2