How should I evaluate and manage a male adult with several weeks of erectile dysfunction, assuming no urgent urologic or cardiovascular emergencies?

Evaluation and Management of Erectile Dysfunction

Begin with a morning serum total testosterone measurement (drawn between 8–10 AM) in every man presenting with erectile dysfunction, alongside a detailed sexual history that documents onset pattern, severity, presence of morning/nocturnal erections, and situational factors—this combination identifies both hormonal deficiency and distinguishes psychogenic from organic causes. 1, 2, 3

Initial Clinical Assessment

Sexual History (Key Elements)

• Document onset pattern: Sudden onset with preserved morning/nocturnal erections strongly suggests psychogenic ED, while gradual progressive loss of all erections indicates organic (typically vascular) dysfunction. 1, 2, 4

• Assess situational factors: ED occurring only with specific partners or in specific contexts points to performance anxiety or relationship issues rather than organic pathology. 1, 2

• Quantify severity: Use the Sexual Health Inventory for Men (SHIM) or Erection Hardness Score to establish baseline severity and track treatment response. 1, 3

• Evaluate libido: Loss of libido specifically suggests testosterone deficiency or depression and requires targeted evaluation. 2

Medical and Medication Review

• Screen for cardiovascular risk factors: Diabetes, hypertension, dyslipidemia, smoking, obesity, and family history of coronary disease—ED shares common pathophysiology with cardiovascular disease and may precede cardiac symptoms by 2–5 years. 1, 3, 5

• Review all current medications: Antidepressants (especially SSRIs and tricyclics), antihypertensives (beta-blockers, thiazides), antipsychotics, and sedatives commonly cause or worsen ED. 1, 3

• Assess psychological factors: Screen for depression, anxiety, performance anxiety, and relationship conflicts using direct questioning—these factors contribute even when organic causes are present. 1, 2, 3

Physical Examination

• Measure blood pressure, pulse, waist circumference, and body mass index to assess cardiovascular risk and metabolic syndrome. 1, 3

• Perform focused genital examination: Identify penile plaques (Peyronie's disease), urethral abnormalities, testicular size/consistency (hypogonadism), and gynecomastia. 1, 3

• Assess lower extremity pulses to evaluate for peripheral vascular disease. 3

Mandatory Laboratory Testing

• Morning total testosterone (8–10 AM): Testosterone <300 ng/dL defines deficiency and requires hormonal therapy before or alongside PDE5 inhibitors. 1, 2, 3

• Fasting glucose or HbA1c: Identifies diabetes, a major organic cause of ED. 1, 3

• Fasting lipid panel (total cholesterol, LDL, HDL, triglycerides): Dyslipidemia is both a cardiovascular risk factor and contributor to endothelial dysfunction. 1, 3

Cardiovascular Risk Counseling

Inform every patient that erectile dysfunction is an independent predictor of cardiovascular disease with prognostic strength comparable to cigarette smoking or family history of myocardial infarction—this mandates cardiovascular risk assessment and modification regardless of cardiac symptoms. 1, 2, 3

Treatment Algorithm

Step 1: Lifestyle Modification (All Patients)

• Smoking cessation: Reduces overall mortality by ~36% in cardiac patients and improves endothelial function. 1

• Weight loss to BMI <30 kg/m² through caloric restriction and increased physical activity. 1, 2

• Regular aerobic exercise: Lowers diabetes and cardiovascular disease incidence by 30–50%. 1

• Mediterranean-style diet: Rich in fruits, vegetables, whole grains, fish, with limited red meat. 1

• Limit alcohol to ≤14 units per week to avoid exacerbating ED and cardiovascular risk. 1

• Optimize control of diabetes, hypertension, and hyperlipidemia. 1, 3

Step 2: Testosterone Replacement (If Deficient)

• Initiate testosterone replacement therapy when morning testosterone is <300 ng/dL and the patient reports reduced libido or erectile dysfunction—this improves sexual function and enhances PDE5 inhibitor efficacy. 1, 2, 3

• Before starting testosterone therapy: Obtain baseline hemoglobin/hematocrit (withhold if hematocrit >50%), PSA in men >40 years (refer to urology if elevated on repeat testing), and liver function tests. 1

• Monitor hematocrit on therapy: If it rises above 54%, reduce dose or temporarily discontinue to prevent thrombotic risk. 1

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

Step 3: First-Line Pharmacotherapy—PDE5 Inhibitors

Prescribe a phosphodiesterase-5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line drug therapy for all men with ED—organic, psychogenic, or mixed—provided no contraindications exist. 1, 3, 6, 7

Absolute Contraindication

• Concurrent use of oral nitrates (nitroglycerin, isosorbide) due to risk of life-threatening hypotension. 8, 9, 10

• Counsel patients: If anginal chest pain occurs after taking a PDE5 inhibitor, at least 48 hours must elapse before nitrate administration; seek immediate medical attention. 9

Relative Contraindications

• Myocardial infarction within 90 days 9, 10
• Unstable angina or angina during intercourse 9, 10
• NYHA Class II or higher heart failure within 6 months 9, 10
• Stroke within 6 months 9, 10
• Systolic blood pressure <90 mmHg or uncontrolled hypertension (>170/110 mmHg) 9, 10

Dosing and Patient Education

• Start at the lowest dose and titrate to maximum tolerated dose—patients should attempt at least 5 separate trials at the maximum dose before declaring treatment failure. 1, 2, 3

• Tadalafil: Take at least 30 minutes before sexual activity; effects last up to 36 hours. 3

• Critical instruction: Sexual stimulation is necessary for PDE5 inhibitors to work—the drug does not cause automatic erection. 1

• Avoid substantial alcohol consumption when taking PDE5 inhibitors, as this increases risk of orthostatic hypotension, dizziness, and headache. 3

• Follow up at 4–6 weeks using validated questionnaires (SHIM) to assess response. 3

Adverse Effects to Counsel

• Visual disturbances: Non-arteritic anterior ischemic optic neuropathy (NAION) has been reported; advise patients to seek immediate medical attention for sudden vision loss in one or both eyes. 8

• Hearing loss: Sudden decrease or loss of hearing, sometimes with tinnitus and dizziness, requires prompt medical evaluation. 8

• Priapism: If erection persists >4 hours, seek immediate medical assistance to prevent permanent penile tissue damage. 8, 10

Step 4: Psychosexual Counseling (Concurrent with Pharmacotherapy)

Combine PDE5 inhibitors with psychosexual counseling or cognitive-behavioral therapy—this integrated approach is superior to either treatment alone, particularly for psychogenic ED or performance anxiety. 1, 2

• Refer to mental health professional when: Complex psychiatric disorders are present, performance anxiety persists despite initial interventions, or relationship conflicts dominate the clinical picture. 1, 2, 3

• Involve the partner in both assessment and treatment whenever possible—this improves adherence, addresses relationship dynamics, and ensures shared decision-making. 1

Step 5: Second-Line Therapies (After PDE5 Inhibitor Failure)

If two different PDE5 inhibitors at maximal tolerated doses fail after adequate trial (≥5 attempts at highest dose), refer to urology for second-line therapies. 1, 2

• Intracavernosal injection of alprostadil: Highly effective but requires patient training on self-administration. 3, 6

• Intraurethral alprostadil suppositories: Less effective than injections but less invasive. 3

• Vacuum erection devices: Non-invasive mechanical option suitable for many patients. 3, 6

Step 6: Third-Line Therapy (Refractory Cases)

• Penile prosthesis implantation (multicomponent inflatable devices): Reserved for medical therapy failures; associated with high patient satisfaction rates. 2, 6

Common Clinical Pitfalls to Avoid

• Failing to provide clear PDE5 inhibitor instructions (need for sexual stimulation, adequate dosing trials) leads to perceived treatment failure when the drug would have worked. 3, 11

• Missing cardiovascular disease screening: ED may be the first presentation of significant vascular disease—every patient requires cardiovascular risk assessment and modification. 1, 2, 3

• Not checking testosterone: Hypogonadism requires separate management and explains poor PDE5 inhibitor response—this test is mandatory, not optional. 1, 2, 3

• Ignoring psychogenic factors: Even organic ED benefits from addressing performance anxiety and relationship issues—pharmacotherapy alone is suboptimal. 1, 2, 3

• Discontinuing effective cardiovascular medications: Do not stop proven mortality-reducing therapies (e.g., beta-blockers in heart failure) without specialist input—treat the ED instead. 1

• Attributing ED solely to medications in stable patients: When morning erections are preserved, medication is unlikely to be the primary cause—evaluate for psychogenic factors. 2