What is the best treatment for a 75-year-old man with erectile dysfunction?

Treatment of Erectile Dysfunction in a 75-Year-Old Male

Initiate treatment with an oral phosphodiesterase-5 (PDE5) inhibitor—either sildenafil, tadalafil, vardenafil, or avanafil—as first-line therapy, provided the patient is not taking nitrates and has acceptable cardiovascular risk. 1, 2

Pre-Treatment Safety Assessment

Before prescribing any PDE5 inhibitor, perform these critical safety checks:

Absolute Contraindications

• Verify the patient is not using nitrates in any form (sublingual nitroglycerin, long-acting nitrates, isosorbide mononitrate/dinitrate, or recreational "poppers"), as co-administration causes potentially fatal hypotension. 1, 2, 3
• Confirm the patient is not taking riociguat (a guanylate cyclase stimulator), which is also absolutely contraindicated with PDE5 inhibitors. 2

Cardiovascular Risk Stratification

• Assess functional cardiac capacity by asking if the patient can walk 1 mile in 20 minutes or climb 2 flights of stairs without symptoms—this approximates the cardiac demand of sexual activity. 1, 2, 3
• Low-risk patients (controlled hypertension, mild stable angina, successful coronary revascularization, uncomplicated prior MI, NYHA Class I heart failure, asymptomatic CAD with <3 risk factors) can safely receive PDE5 inhibitors. 1, 2
• High-risk patients (unstable angina, uncontrolled hypertension, recent MI or stroke within 2 weeks, NYHA Class ≥II heart failure, severe valvular disease, high-risk arrhythmias) should defer ED treatment until cardiac condition stabilizes. 1, 2
• Refer to cardiology if cardiovascular risk is indeterminate or if the patient cannot perform moderate physical activity. 1, 2

Baseline Laboratory Testing

• Obtain morning serum total testosterone level before initiating therapy, as testosterone deficiency reduces PDE5 inhibitor efficacy and may require combination therapy. 1, 2

Choosing the Specific PDE5 Inhibitor

All FDA-approved PDE5 inhibitors have comparable efficacy (approximately 69% successful intercourse attempts versus 33% with placebo), so selection is based on patient preference and clinical context. 1, 2, 4

Tadalafil

• Choose tadalafil when the patient values spontaneous sexual activity without timing medication, as it remains effective for up to 36 hours. 2, 3, 5
• Tadalafil 5 mg once daily is FDA-approved to treat both ED and benign prostatic hyperplasia (BPH) simultaneously, making it ideal for patients with both conditions. 2, 3
• Tadalafil does not show dose-dependent efficacy between 5 mg, 10 mg, and 20 mg—dose selection should be based on tolerability rather than expecting dramatically better results at higher doses. 3
• Tadalafil has lower rates of flushing compared to sildenafil, which may be preferred if this side effect is particularly bothersome. 3
• After tadalafil use, wait 48 hours before administering emergency nitrates. 2, 3

Sildenafil

• Choose sildenafil when the patient prefers scheduled sexual activity with a more predictable 4-6 hour window of action. 2, 3
• Sildenafil requires only a 24-hour nitrate-free interval (versus 48 hours for tadalafil), which may be relevant in patients at higher cardiovascular risk. 2, 3
• Sildenafil shows dose-dependent efficacy, with 50 mg more effective than 25 mg (though 100 mg shows minimal additional benefit over 50 mg). 3

Vardenafil and Avanafil

• Vardenafil demonstrates dose-dependent efficacy and has an intermediate duration of action. 2
• Avanafil is also effective but less commonly prescribed; all agents have similar adverse event profiles. 1, 2

Proper Dosing and Patient Education

Defining an Adequate Trial

• An adequate trial requires at least 5 separate attempts at the maximum tolerated dose with proper technique before declaring treatment failure. 2, 3
• Sexual stimulation is necessary for PDE5 inhibitors to work—they enhance but do not replace natural arousal. 1, 2, 3
• Avoid taking medication with large or fatty meals, as this reduces efficacy. 2, 3
• Limit alcohol consumption, as heavy alcohol use impairs erectile function independent of medication. 2, 3

Starting Doses and Titration

• For tadalafil as-needed dosing, start with 10 mg taken 30 minutes before sexual activity, or use 5 mg once daily for spontaneous activity. 3
• For sildenafil, start with 50 mg taken 1 hour before sexual activity. 3
• Titrate to maximum dose (tadalafil 20 mg, sildenafil 100 mg) if erectile function remains suboptimal after completing an adequate trial at the starting dose. 2, 3

Addressing Modifiable Factors

Before escalating doses or switching agents, systematically evaluate and correct these factors:

Lifestyle Modifications

• Smoking cessation improves treatment outcomes and overall cardiovascular health. 1, 2
• Weight loss if BMI >30 kg/m², increased physical activity, and reduced alcohol consumption all improve erectile function. 2
• Optimize glycemic control in diabetics, as men with diabetes have more severe ED at baseline and may respond less robustly to PDE5 inhibitors. 2, 3, 4

Medication Review

• Identify and modify medications that worsen ED, such as certain antihypertensives (beta-blockers, thiazide diuretics), antidepressants (SSRIs), and opioids. 2
• Consider switching antihypertensives to agents with lower ED risk (ACE inhibitors, ARBs, calcium channel blockers). 2

Hormonal Evaluation

• If testosterone is low (<230 ng/dL), men usually benefit from testosterone replacement therapy (TRT). 1
• For testosterone 231-346 ng/dL, consider a 4-6 month trial of TRT in symptomatic men after discussing risks and benefits. 1
• Combining PDE5 inhibitors with testosterone therapy is more effective than PDE5 inhibitors alone in hypogonadal men. 1, 2, 3
• Testosterone monotherapy is not effective for ED—it must be combined with PDE5 inhibitors. 2, 3

Psychosocial Factors

• Screen for depression, anxiety, and relationship conflict, as these significantly impact treatment response. 2
• Refer for psychosexual therapy or couples counseling concurrently with PDE5 inhibitor initiation, not sequentially. 2

Managing PDE5 Inhibitor Non-Response

Before Declaring Failure

• Verify the patient completed at least 5 attempts at maximum dose with proper technique. 2, 3
• Confirm adequate sexual stimulation occurred—many apparent failures are due to incorrect use. 1, 2, 3
• Address all modifiable factors listed above (hormonal abnormalities, medications, lifestyle, psychological issues). 2, 3

Switching to Another PDE5 Inhibitor

• Try a different PDE5 inhibitor (e.g., switch from tadalafil to sildenafil or vice versa), as individual response variability may result in success with an alternative agent. 2, 3
• Complete a maximum-dose trial of the second agent before proceeding to second-line therapies. 2, 3

Second-Line Therapies

Proceed to second-line therapies only after failure of at least two different PDE5 inhibitors at maximum dose with proper technique and correction of all modifiable factors. 2

Options in Order of Invasiveness

• Vacuum erection devices (VEDs) show 90% initial efficacy with no systemic side effects, though satisfaction drops to 50-64% at 2 years. 1, 2
• Intraurethral alprostadil suppositories are less effective than injections but less invasive; the first dose should be supervised due to ~3% risk of syncope. 2
• Intracavernosal injection therapy (alprostadil, papaverine, phentolamine) is the most effective non-surgical option but carries the highest risk of priapism. 1, 2
• Low-intensity shockwave therapy (LI-SWT) may benefit mild vasculogenic ED and has shown benefit even in PDE5 inhibitor non-responders, though standardized protocols are lacking. 1, 2

Surgical Management

• Penile prosthesis implantation is reserved for patients who fail all medical therapies and is associated with high satisfaction rates. 1, 2
• Three-piece inflatable devices provide more natural erections, while semirigid prostheses offer simpler implantation and use. 1

Special Considerations for a 75-Year-Old Patient

• No dose adjustment is warranted based on age alone, though greater sensitivity to medications should be considered. 4
• In placebo-controlled studies, diarrhea was reported more frequently in patients ≥65 years treated with tadalafil (2.5% versus younger patients). 4
• For patients >70 years with chronic illness, use easily titratable testosterone formulations (gel, spray, patch) rather than long-acting injectables if TRT is indicated. 1
• Repletion goals for testosterone should be in the middle range (350-600 ng/dL) in older patients, especially those with heart failure risk. 1

Common Pitfalls to Avoid

• Do not declare PDE5 inhibitor failure prematurely—most apparent failures are due to inadequate trials, improper timing, lack of sexual stimulation, or modifiable factors. 2, 3
• Do not prescribe testosterone monotherapy for ED—it is ineffective without concurrent PDE5 inhibitor use. 2, 3
• Do not perform penile prosthesis surgery in the presence of systemic, cutaneous, or urinary tract infection. 2
• Do not use vacuum devices without a vacuum limiter. 2

Ongoing Management and Follow-Up

• Periodically reassess cardiovascular health status and any changes that might affect PDE5 inhibitor safety. 2, 3
• Verify no new medications have been started, particularly nitrates or other contraindicated drugs. 2, 3
• Assess treatment effectiveness and side effects at follow-up visits. 2, 3
• Evaluate relationship dynamics and psychosocial factors that influence treatment outcomes. 2, 3