How should I evaluate and manage an adult male who presents with inability to achieve an erection?

Evaluation and Management of Non-Erectile Penis (Erectile Dysfunction)

Immediate First Steps

Begin with a morning (8–10 AM) serum total testosterone measurement in every man presenting with erectile dysfunction, regardless of age, because testosterone deficiency is present in up to 36% of men with ED and directly impairs response to all other therapies. 1

• Obtain a detailed sexual history focusing on: sudden versus gradual onset, presence of morning or nocturnal erections (which strongly indicate psychogenic rather than organic ED), ability to achieve erections during masturbation, and whether ED is situational (occurs only with specific partners or contexts). 1, 2

• Review all current medications immediately, as antihypertensives (β-blockers, thiazides, ACE inhibitors), antidepressants (SSRIs, tricyclics), antipsychotics, and sedatives commonly cause ED and may be the primary etiology. 1, 2

• Screen for cardiovascular risk factors (diabetes, hypertension, dyslipidemia, smoking, obesity) because ED is an independent predictor of future cardiac events with strength comparable to cigarette smoking or family history of MI—ED often precedes coronary symptoms by 2–5 years. 1, 2

• Assess for depression, anxiety, relationship conflicts, and recent trauma or stressors, as these psychological factors frequently coexist with or cause ED. 1, 2

Physical Examination Essentials

• Measure blood pressure, pulse, waist circumference, and BMI. 1, 2

• Perform a focused genital examination to identify penile plaques (Peyronie's disease), urethral abnormalities, testicular atrophy (suggesting hypogonadism), and assess secondary sexual characteristics including gynecomastia. 1, 2

• Evaluate lower extremity pulses and perform cardiac auscultation to assess for vascular disease. 1

Laboratory Work-Up

• Morning total testosterone (drawn 8–10 AM): A level <300 ng/dL defines testosterone deficiency and mandates hormonal therapy. 1, 2

• Fasting glucose or HbA1c to screen for diabetes. 1, 2

• Fasting lipid panel (total cholesterol, LDL, HDL, triglycerides) to evaluate dyslipidemia. 1, 2

• If testosterone is low, repeat the measurement to confirm before initiating replacement therapy. 1

• Before starting testosterone therapy in men >40 years: obtain baseline hemoglobin/hematocrit (withhold if hematocrit >50%) and PSA (two consecutively elevated values require urology referral before hormone therapy). 1

Treatment Algorithm

Step 1: Address Testosterone Deficiency First (If Present)

In men with confirmed morning testosterone <300 ng/dL plus symptoms (low libido, reduced spontaneous erections), initiate testosterone replacement therapy before or alongside other ED treatments, as this improves erectile function and enhances PDE5 inhibitor efficacy. 1, 2

• Testosterone therapy alone does not reliably resolve ED; patients will still require PDE5 inhibitors or other ED-specific treatments. 1

• Avoid testosterone in men actively trying to conceive, as it suppresses spermatogenesis. 1

Step 2: Prescribe PDE5 Inhibitor as First-Line Therapy

Prescribe a phosphodiesterase-5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line medical therapy for all men with ED—organic, psychogenic, or mixed—provided no contraindications exist. 3, 1, 2

• Absolute contraindication: Concurrent use of oral nitrates (nitroglycerin, isosorbide) due to risk of life-threatening hypotension. 1, 4

• Relative contraindications: MI within 90 days, unstable angina or angina during intercourse, NYHA class II or higher heart failure within 6 months, stroke within 6 months, systolic BP <90 mmHg or uncontrolled hypertension. 1, 4

• Critical patient education: Sexual stimulation is necessary for PDE5 inhibitors to work; at least 5 separate attempts at the maximum tolerated dose are required before declaring treatment failure. 1

• Start at the lowest dose and titrate upward based on efficacy and side effects. 1

• For men with performance anxiety, consider daily low-dose PDE5 inhibitors rather than on-demand dosing. 1

• If tadalafil is used, at least 48 hours must elapse after the last dose before nitrate administration can be considered in a life-threatening situation. 4

Step 3: Combine with Psychosexual Counseling (When Indicated)

For men with psychogenic ED (preserved morning erections, sudden onset, situational dysfunction), combine PDE5 inhibitors with psychosexual counseling or cognitive-behavioral therapy, as this integrated approach is superior to either treatment alone. 1

• Involve the partner in both assessment and treatment whenever possible, as this improves adherence and addresses relationship dynamics. 1

• Refer to a mental health professional when complex psychiatric disorders are present, performance anxiety persists despite initial interventions, or relationship conflicts dominate. 1

Step 4: Lifestyle Modifications (For All Patients)

Implement comprehensive lifestyle changes: smoking cessation (reduces cardiac mortality by 36%), weight loss to BMI <30 kg/m², regular aerobic exercise (reduces diabetes and CAD incidence by 30–50%), Mediterranean-style diet, and limit alcohol to ≤14 units/week. 1, 2

• Optimize control of diabetes, hypertension, and hyperlipidemia. 1, 2

Step 5: Second-Line Therapies (If Two Different PDE5 Inhibitors Fail)

If two different PDE5 inhibitors at maximal doses fail after adequate trials (≥5 attempts each at highest dose), refer to urology for second-line therapies: 3, 1

• Intracavernosal injection of vasoactive agents (alprostadil). 3, 1
• Intra-urethral alprostadil suppositories. 3, 1
• Vacuum erection devices. 3, 1

Step 6: Surgical Options (Third-Line)

• Penile prosthesis implantation (multicomponent inflatable devices) offers high patient satisfaction rates but is reserved for medical therapy failures. 3, 1

Critical Clinical Pitfalls to Avoid

Do not treat ED without addressing cardiovascular risk—all men with organic ED should be considered at increased cardiovascular disease risk until proven otherwise, even without cardiac symptoms. 1, 2

• Communicate the cardiovascular implications to the patient's primary care provider. 1, 2

Do not delay testosterone testing when loss of libido accompanies ED—the combination makes testosterone deficiency highly likely and treatable. 1

Do not assume psychogenic ED requires only counseling—PDE5 inhibitors work for both psychogenic and organic ED and should be initiated concurrently with psychological therapy. 1

Do not overlook medication-induced ED—consider alternatives with lower ED risk before pursuing extensive work-up. 1, 2

Do not prescribe PDE5 inhibitors to patients on oral nitrates—this combination causes dangerous hypotension. 1, 4

When to Refer to Urology

• Young age with lifelong erectile difficulty. 1
• History of pelvic or genital trauma. 1
• Abnormal testicular or penile findings on examination (plaques, deformities). 1, 2
• Abnormal initial screening laboratory results requiring specialized testing. 1
• Failure of two different PDE5 inhibitors at maximum doses. 3, 1