What is the recommended evaluation and treatment plan for an adult male presenting with erectile dysfunction?

Erectile Dysfunction: Evaluation and Treatment

Initial Assessment

Begin with a morning (8–10 AM) serum total testosterone measurement in every man presenting with erectile dysfunction, regardless of age or symptom severity. 1, 2 This single test is mandatory because testosterone deficiency (defined as <300 ng/dL) occurs in approximately 36% of men with sexual dysfunction and directly impairs response to phosphodiesterase-5 inhibitors. 3, 1

Essential History Elements

• Sexual history specifics: Document onset pattern (sudden versus gradual), severity using validated tools (Sexual Health Inventory for Men or International Index of Erectile Function), presence of morning or nocturnal erections (preserved morning erections strongly indicate psychogenic etiology), and ability to achieve erections during masturbation. 1, 2

• Cardiovascular risk stratification: Screen for diabetes, hypertension, dyslipidemia, smoking, obesity (BMI >30), family history of premature cardiovascular disease (father <55 years, mother <65 years), and symptoms of obstructive sleep apnea. 3 Erectile dysfunction in men aged 30–60 years is an independent predictor of future cardiac events with risk magnitude comparable to cigarette smoking or family history of myocardial infarction. 1, 2

• Medication review: Identify antidepressants (tricyclics, SSRIs), antihypertensives (beta-blockers, diuretics, ACE inhibitors), antipsychotics, and sedatives—all commonly cause erectile dysfunction. 1, 2

• Psychological screening: Systematically assess for depression, anxiety, performance anxiety, relationship conflict, and recent major life stressors, as these frequently precipitate sudden sexual dysfunction. 1, 2

Physical Examination

• Measure blood pressure, pulse, waist circumference, and body mass index. 3, 2
• Perform genital examination to identify penile plaques (Peyronie's disease), urethral abnormalities, testicular size/atrophy, and gynecomastia (suggests hypogonadism). 1, 2
• Conduct cardiovascular examination including cardiac auscultation, assessment for carotid bruits, and palpation of femoral and pedal pulses. 3, 2

Laboratory Testing

• Mandatory: Morning total testosterone (8–10 AM), fasting glucose or HbA1c, fasting lipid panel (total cholesterol, LDL, HDL, triglycerides). 1, 2, 4
• Conditional: Resting electrocardiogram in men with hypertension or diabetes. 3
• **If testosterone is low (<300 ng/dL):** Repeat measurement for confirmation, then check prolactin (>35 ng/mL suppresses testosterone and libido), hemoglobin/hematocrit (baseline before testosterone therapy), PSA in men >40 years (exclude prostate cancer), and liver function tests. 1

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Treatment Algorithm

Step 1: Lifestyle Modification (All Patients)

Implement comprehensive cardiovascular risk reduction regardless of erectile dysfunction etiology. 1, 2

• Smoking cessation reduces total mortality by 36% in cardiac patients and improves endothelial function. 1
• Weight loss to achieve BMI <30 kg/m² through Mediterranean-style diet (fruits, vegetables, whole grains, fish, limited red meat). 1
• Regular aerobic exercise lowers diabetes and coronary disease incidence by 30–50% and improves lipid profiles, blood pressure, and endothelial function. 1
• Limit alcohol to ≤14 units per week. 1
• Optimize chronic conditions: Achieve tight glycemic control in diabetes, blood pressure <140/90 mmHg, and LDL <100 mg/dL. 1

Step 2: Address Testosterone Deficiency (If Present)

If morning testosterone is <300 ng/dL with compatible symptoms (decreased libido, loss of morning erections), initiate testosterone replacement therapy before or alongside PDE5 inhibitors. 1, 2 Testosterone therapy improves both erectile function and libido, and critically enhances PDE5 inhibitor efficacy in hypogonadal men. 3, 1, 2

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

Monitoring requirements:

• Withhold testosterone if baseline hematocrit >50%; investigate cause first. 1
• If on-treatment hematocrit rises >54%, reduce dose or temporarily discontinue. 1
• Two consecutively elevated PSA results mandate urologic evaluation before initiating therapy. 1

Step 3: First-Line Pharmacotherapy

Prescribe a phosphodiesterase-5 (PDE5) inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line therapy for all men with erectile dysfunction—organic, psychogenic, or mixed etiology—provided no contraindications exist. 1, 2, 5 PDE5 inhibitors achieve successful intercourse in 60–65% of men, including those with hypertension, diabetes, spinal cord injury, and other comorbidities. 5

Absolute contraindication: Concurrent use of oral nitrates (nitroglycerin) due to risk of life-threatening hypotension. 1, 2

Relative contraindications:

• Myocardial infarction within 90 days 1
• Unstable angina or angina during intercourse 1
• NYHA class II or higher heart failure within 6 months 1
• Stroke within 6 months 1
• Systolic blood pressure <90 mmHg or uncontrolled hypertension 1

Dosing strategy:

• Start at the lowest dose and titrate to maximum tolerated dose. 1
• Educate patients that sexual stimulation is required for PDE5 inhibitors to work and that at least 5 separate attempts at maximum dose must be made before declaring treatment failure. 1, 2
• Consider daily low-dose PDE5 inhibitors (rather than on-demand) for men with performance anxiety. 1

Step 4: Psychosexual Counseling (When Indicated)

Combine PDE5 inhibitors with psychosexual counseling for superior outcomes compared to either modality alone. 1 This integrated approach is particularly important when:

• Preserved morning/masturbatory erections indicate psychogenic component 1, 2
• Depression, anxiety, or relationship conflict is identified 1, 2
• Situational erectile dysfunction occurs (only with specific partners or contexts) 1

Involve the sexual partner in both assessment and treatment whenever possible to improve adherence and address relationship dynamics. 1

Refer to mental health professional when:

• Complex psychiatric disorders are present 1
• Performance anxiety persists despite initial interventions 1
• Relationship conflicts dominate the clinical picture 1

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

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

• Intracavernosal injection of vasoactive agents (alprostadil) 1, 5
• Intraurethral alprostadil suppositories 1
• Vacuum erection devices 1

Step 6: Third-Line Therapy

Penile prosthesis implantation (multicomponent inflatable devices) is reserved for medical therapy failures and offers high patient satisfaction rates. 1, 5

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Critical Clinical Pitfalls to Avoid

• Do not treat erectile dysfunction without addressing cardiovascular risk. Men with organic erectile dysfunction should be considered at increased cardiovascular disease risk until proven otherwise, even without cardiac symptoms. 3, 1

• Do not delay testosterone testing when loss of libido is reported. The combination of erectile dysfunction with decreased desire makes testosterone deficiency highly probable and treatable. 1

• Do not assume psychogenic erectile dysfunction requires only counseling. PDE5 inhibitors are effective for psychogenic erectile dysfunction and should be initiated concurrently with psychological therapy. 1

• Do not attribute erectile dysfunction solely to medications in stable patients. Evaluate for underlying cardiovascular, metabolic, and hormonal etiologies. 1

• Do not discontinue beta-blockers or other guideline-directed heart failure therapies without cardiology input. These are mortality-reducing agents that must be preserved. 1

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When to Refer to Specialist

Refer to urology or sexual medicine specialist when: 1, 2

• Young age with lifelong erectile difficulty 2
• History of pelvic or genital trauma 2
• Abnormal testicular or penile findings on examination 2
• PDE5 inhibitor failure after adequate trial 1
• Complex diagnostic testing needed (nocturnal penile tumescence monitoring, intracavernosal injection testing) 1
• Patient requests specialist evaluation 2

Refer to cardiology when:

• Multiple cardiovascular risk factors are present 3
• Erectile dysfunction occurs in men aged 30–60 years without obvious cause (high risk for subclinical atherosclerosis) 3
• Abnormal resting electrocardiogram 3

3, 1, 2, 4, 5, 6, 7, 8