I’m a man who can’t achieve an erection even with a partner; what evaluation and treatment steps should I take?

Evaluation and Management of Erectile Dysfunction

You need an immediate morning (8–10 AM) serum total testosterone measurement, a comprehensive sexual and medical history focusing on morning erections and libido, and first-line treatment with a phosphodiesterase-5 (PDE5) inhibitor—regardless of whether the cause is organic or psychogenic. 1

Initial Diagnostic Workup

Mandatory Laboratory Testing

• Obtain morning total testosterone (8–10 AM) in every man presenting with erectile dysfunction; this is non-negotiable and should never be delayed. 1, 2
• A testosterone level below 300 ng/dL defines testosterone deficiency and warrants hormonal therapy before or alongside other treatments. 1
• Order fasting glucose or HbA1c to screen for diabetes mellitus. 1
• Obtain a fasting lipid panel (total cholesterol, LDL, HDL, triglycerides) as part of cardiovascular risk assessment. 1

Critical History Elements

• Ask specifically about the presence of morning or nocturnal erections—if these are preserved, a psychogenic component is highly likely. 1, 2
• Document whether erections occur during masturbation; preserved masturbatory erections similarly point toward psychogenic etiology. 1
• Inquire about onset pattern: sudden onset strongly suggests psychogenic causes (performance anxiety, relationship conflict, depression), while gradual onset indicates organic vascular or neurologic disease. 1, 2
• Screen systematically for depression, anxiety, recent major life stressors, and relationship conflict—these psychological factors commonly precipitate sudden sexual dysfunction. 1
• Review all current medications, particularly antidepressants (SSRIs, TCAs), antihypertensives (beta-blockers, diuretics), and sedatives, as these frequently cause ED. 1, 2
• Ask about loss of libido; the combination of erectile dysfunction with decreased sexual desire makes testosterone deficiency highly probable. 1

Physical Examination

• Measure blood pressure, pulse, waist circumference, and body mass index. 1, 2
• Perform a focused genital examination to identify penile plaques (Peyronie's disease), urethral abnormalities, and testicular size. 1, 2
• Assess for signs of hypogonadism, including gynecomastia and reduced secondary sexual characteristics. 2

Cardiovascular Risk Assessment

• Recognize that erectile dysfunction is an independent predictor of cardiovascular disease with prognostic strength comparable to cigarette smoking or a family history of myocardial infarction. 1, 2
• ED can precede coronary artery symptoms by 2–5 years; therefore, all men with organic ED should be considered at increased cardiovascular risk until proven otherwise. 1
• Communicate this cardiovascular risk to the patient's primary care provider and ensure appropriate risk-factor management. 1, 2

First-Line Treatment: PDE5 Inhibitors

Prescribe a phosphodiesterase-5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line therapy for any man with erectile dysfunction, regardless of whether the underlying cause is organic, psychogenic, or mixed. 1, 2

Dosing Strategy and Patient Education

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

Absolute Contraindications

• Never prescribe PDE5 inhibitors to patients taking oral nitrates (e.g., nitroglycerin) due to the risk of life-threatening hypotension. 2, 3
• If a patient on tadalafil experiences anginal chest pain requiring nitroglycerin, at least 48 hours must elapse after the last tadalafil dose before nitrate administration. 3

Relative Contraindications

• Myocardial infarction within the past 90 days 1, 3
• Unstable angina or angina occurring during intercourse 1, 3
• NYHA Class 2 or greater heart failure within the past 6 months 1, 3
• Stroke within the past 6 months 1, 3
• Systolic blood pressure < 90 mm Hg or uncontrolled hypertension 1, 3

Testosterone Replacement Therapy

• If morning testosterone is < 300 ng/dL with compatible symptoms (low libido, loss of morning erections), initiate testosterone replacement therapy—this improves both erectile function and libido and enhances response to PDE5 inhibitors. 1, 2
• Combining PDE5 inhibitors with testosterone replacement yields greater improvement in erectile function than PDE5 inhibitors alone in hypogonadal men. 1
• Counsel patients that testosterone therapy alone does not reliably resolve ED; additional ED-specific treatments (PDE5 inhibitors) will still be required. 1
• Avoid testosterone therapy in men actively trying to conceive, as it suppresses spermatogenesis. 2

Monitoring for Testosterone Therapy

• Obtain baseline hemoglobin, hematocrit, and prostate-specific antigen (PSA) in men over 40 years before starting testosterone. 1
• Withhold testosterone if baseline hematocrit exceeds 50%; if on-treatment hematocrit rises above 54%, reduce the dose or temporarily discontinue therapy. 1

Psychological and Psychosexual Management

• Refer patients with identified psychological contributors (depression, anxiety, performance anxiety, relationship conflict) to a mental health or sexual health specialist for counseling or cognitive-behavioral therapy. 1, 2
• Combine PDE5 inhibitors with psychosexual counseling—this integrated approach is superior to either treatment alone. 2
• Involve the partner in both assessment and treatment whenever possible; this improves treatment adherence and addresses relationship dynamics. 2
• Do not assume that psychogenic ED requires only counseling; PDE5 inhibitors are effective for psychogenic erectile dysfunction and should be initiated concurrently with psychological therapy. 1

Lifestyle Modifications (Essential for All Patients)

• Smoking cessation—this reduces overall mortality by approximately 36% in cardiac patients and improves endothelial function. 1
• Weight loss to achieve a BMI < 30 kg/m². 1
• Regular aerobic exercise—this lowers the incidence of diabetes and cardiovascular disease by 30–50%. 1
• Limit alcohol intake to ≤ 14 units per week. 1
• Optimize control of diabetes, hypertension, and hyperlipidemia. 1, 2

Second-Line and Surgical Options

• If two different PDE5 inhibitors at maximum dose fail after adequate trials (≥ 5 attempts at the highest dose), refer to urology for second-line therapies. 1
• Second-line options include intraurethral alprostadil suppositories, intracavernosal vasoactive drug injection therapy, and vacuum erection devices. 1, 4
• Penile prosthesis implantation is a third-line option with high satisfaction rates but is reserved for medical therapy failures. 1, 4

Critical Clinical Pitfalls to Avoid

• Do not postpone testosterone testing when loss of libido is reported; the combination of sudden erectile dysfunction with decreased desire makes testosterone deficiency highly probable and treatable. 1
• Do not treat ED without addressing cardiovascular risk; men with organic ED should be considered at increased cardiovascular disease risk until proven otherwise, even without cardiac symptoms. 1
• Do not treat ED alone when depression is present; addressing the underlying psychiatric condition is essential, though antidepressants themselves may worsen sexual function. 1
• Do not discontinue medications causing ED (e.g., antihypertensives) without consulting the prescribing physician and considering safer alternatives. 2