Management of Erectile Dysfunction
Initial Evaluation
Begin with a comprehensive cardiovascular risk assessment, as erectile dysfunction in men over 30 years is an independent predictor of future cardiac events with prognostic strength comparable to cigarette smoking. 1, 2
Essential History Components
Sexual history specifics: Document onset pattern (sudden suggests psychogenic, gradual suggests organic), severity using validated tools (Sexual Health Inventory for Men or Erection Hardness Score), presence of morning/nocturnal erections (preserved suggests psychogenic component), and ability to achieve versus maintain erections 1, 2, 3
Cardiovascular risk factors: Age, diabetes, hypertension, dyslipidemia, smoking, obesity, family history of premature cardiovascular disease (father <55 years, mother <65 years), and symptoms of obstructive sleep apnea 1, 2
Medication review: Identify antihypertensives, antidepressants (especially SSRIs and tricyclics), opioids, hormone therapy, and tranquilizers—all commonly cause erectile dysfunction 1, 3
Psychosocial screening: Depression, anxiety, relationship conflict, performance anxiety, recent major life stressors, alcohol use, and drug use 1, 2
Hypogonadism symptoms: Decreased libido, decreased spontaneous erections, testicular atrophy, muscle atrophy, and gynecomastia 1, 3
Physical Examination
Vital signs and anthropometrics: Blood pressure, pulse, waist circumference, body mass index 1, 2, 3
Cardiovascular examination: Cardiac auscultation, carotid bruits, femoral and pedal pulses 1, 3
Genital examination: Penile skin lesions, urethral meatus placement, palpate stretched penis from pubic bone to coronal sulcus for plaques or deformities (Peyronie's disease), testicular size 1, 2, 3
Resting electrocardiogram: Obtain in men with hypertension or diabetes 1
Laboratory Testing
Morning total testosterone (8-10 AM): Measure in ALL men with erectile dysfunction, especially those who fail PDE5 inhibitor therapy—36% of men seeking consultation for sexual dysfunction have hypogonadism 1, 2, 3
Additional tests: Fasting glucose/HbA1c and lipid profile to assess cardiovascular risk 3
Cardiovascular Risk Stratification
Men unable to walk 1 mile in 20 minutes on flat surface or climb 2 flights of stairs in 20 seconds without symptoms MUST be referred to cardiology before any erectile dysfunction treatment, as sexual activity is equivalent to this level of exertion. 1, 2
Step 1: Lifestyle Modifications (Foundation of Treatment)
Lifestyle modifications should be implemented immediately as they can reverse erectile dysfunction, particularly in men without established comorbidities. 2
Smoking cessation: Stop immediately—tobacco directly impairs erectile function through vascular mechanisms and reduces total mortality by 36% in patients with coronary disease 2
Weight loss: Achieve BMI <30 kg/m² through diet and exercise 2
Physical activity: Regular aerobic exercise improves erectile function through improved cardiovascular fitness and endothelial function, and reduces diabetes/coronary disease incidence by 30-50% 2
Alcohol limitation: Excessive alcohol impairs erectile function and reduces treatment response 2
Psychosocial interventions: Address depression, anxiety, and relationship issues through sex therapy or couples counseling—these interventions can resolve erectile dysfunction when psychological factors dominate 1, 2, 3
Step 2: First-Line Pharmacological Treatment
PDE5 Inhibitors (Primary Treatment)
Oral PDE5 inhibitors are the first-line treatment for erectile dysfunction, effective in 60-70% of men including those with hypertension, diabetes, and spinal cord injury. 1, 2
Dosing and Administration
Start conservatively and titrate to maximum dose: Begin with lowest dose and increase as needed 1, 3
Adequate trial definition: At least 5 separate attempts at maximum dose before declaring treatment failure, unless unacceptable side effects occur 1, 2
Timing: Requires sexual stimulation to work; not automatic erection 2
Drug Selection
For patients prioritizing maximum efficacy, sildenafil 50 mg is the treatment of choice; for those prioritizing tolerability, tadalafil 10 mg is preferred. 4
Sildenafil 50 mg: Greatest efficacy but highest rate of adverse events; rapid onset (erections as early as 16 minutes) 5, 4
Tadalafil 10 mg: Intermediate efficacy with lowest overall adverse event rate; preferred by patients and physicians due to longer duration allowing more spontaneous sexual activity 6, 4
Vardenafil 10 mg: Similar adverse events to sildenafil but markedly lower global efficacy; may benefit patients with concurrent premature ejaculation 6, 4
Avanafil 100 mg: Similar profile to vardenafil 4
Critical Safety Warning
PDE5 inhibitors are ABSOLUTELY CONTRAINDICATED with any form of nitrate use (including recreational "poppers") due to potentially fatal hypotension. 1, 2
- Common adverse effects: Headache, flushing, rhinitis, dyspepsia, nasal congestion—typically mild-to-moderate and attenuate with continued use 1, 5
Testosterone Replacement Therapy (Adjunctive)
When morning testosterone is <300 ng/dL, testosterone replacement therapy combined with PDE5 inhibitors is more effective than either alone, but testosterone alone is NOT effective monotherapy for erectile dysfunction. 2, 3
Indication: Low testosterone (<300 ng/dL) with reduced libido or sexual satisfaction 2, 3
Mechanism: Improves PDE5 inhibitor efficacy in hypogonadal men 1, 3
Contraindication: Men actively trying to conceive (suppresses spermatogenesis) 3
Step 3: Second-Line Options (After PDE5 Inhibitor Failure)
If the first PDE5 inhibitor fails, try a different PDE5 inhibitor before proceeding to more invasive options. 1, 7
Non-Invasive Salvage Strategies
Switch to different PDE5 inhibitor: 30-50% of non-responders can be salvaged with detailed counseling on proper use and switching agents 7
Daily low-dose PDE5 inhibitor: Consider instead of on-demand dosing, particularly for performance anxiety 3
Add testosterone if deficient: Enhances PDE5 inhibitor response 3, 7
Combination with vacuum erection device: May improve outcomes 7
Invasive Second-Line Options (Refer to Urology)
After failure of two different PDE5 inhibitors at maximum dose, refer to urology for second-line interventions. 1
Intraurethral alprostadil suppositories 1
Intracavernous vasoactive drug injection therapy 1
Vacuum constriction devices: Also useful for preventing penile length loss when used daily 1
Step 4: Third-Line Definitive Treatment
Penile prosthesis implantation is a definitive third-line intervention for men not responding to conventional medical therapy or experiencing unacceptable adverse effects. 1
Indication: Failure of all medical therapies or patient preference 1
Referral: Urology consultation required 1
Special Considerations and Pitfalls
Arterial Reconstructive Surgery
Arterial reconstructive surgery is ONLY an option for healthy young men with recently acquired erectile dysfunction from focal arterial occlusion without generalized vascular disease—this represents an extremely narrow patient population. 1
Partner Involvement
Include the sexual partner in both assessment and treatment whenever possible, as this improves treatment adherence, addresses relationship dynamics, and ensures shared decision-making. 3
Monitoring and Follow-Up
Regular re-evaluation: Assess treatment efficacy, side effects, and changes in health status periodically 1, 3
Cardiovascular risk factor management: Reassess periodically as erectile dysfunction and cardiovascular disease share pathophysiologic pathways 1, 3
Common Pitfalls to Avoid
Do not assume preserved morning erections definitively confirm psychogenic cause—they suggest but do not prove it 3
Do not overlook medication-induced erectile dysfunction—review all medications and consider alternatives 3
Do not prescribe PDE5 inhibitors to patients on nitrates—life-threatening hypotension can occur 1, 2
Do not fail to measure testosterone—low testosterone is present in 36% of men with sexual dysfunction and predicts PDE5 inhibitor failure 1, 2
Do not ignore cardiovascular risk—erectile dysfunction predicts future cardiac events and warrants risk factor modification 1, 2, 3