Erectile dysfunction - clinical fact sheet and MCQ

Overview of erectile dysfunction

Erectile dysfunction (ED), (impotence), is defined as the persistent or recurrent inability to achieve or maintain a penile erection sufficient for satisfactory sexual activity. Other manifestations of sexual dysfunction, such as low libido or premature ejaculation, are common associations.^1,2,3

About 30% of the male population have ED, increasing to over 60% in men aged 70 years and older.²

Assessment

A comprehensive physical, sexual, and psychosocial history and health evaluation is essential, as ED often coexists with other conditions such as diabetes and cardiovascular disease.^1,2,3 About half of men with confirmed coronary artery disease have ED, while in others, ED is an early marker of cardiovascular disease, preceding coronary symptoms by up to five years.³ In younger patients, ED is an independent risk factor for future atherosclerotic events. ED also is often associated with symptomatic benign prostatic hyperplasia (BPH).¹

Consider screening for ED as part of routine consultations for male patients.

Risk factors for ED include:^1,3,4

• older age

• cardiovascular disease and associated risk factors (eg, sedentary lifestyle, diabetes, hypertension, dyslipidaemia, obstructive sleep apnoea, smoking)

• diabetes and other endocrine conditions (eg, androgen deficiency, hypogonadism, and thyroid disease)

• certain medications (eg, antihypertensives, psychotropic medications, antiandrogens)

• radical prostatectomy or radiation therapy for prostate cancer

• penile disorders eg, Peyronie disease, venous leak (venogenic erectile dysfunction or penile venous insufficiency) 

• prostate conditions including BPH

• substance use, including alcohol and recreational drugs (eg, amphetamines and barbiturates)

• psychological factors (eg, history of sexual abuse, depression, stress and anxiety)

• neurological disorders of the autonomic nervous system, brain, and spinal cord

• obesity

Clinical evaluation involves:

• medical history:²

• medication review

• common comorbidities such as diagnosed diabetes or cardiovascular disease

• general health, including history of pelvic surgery/radiation or genital disease

• lifestyle, including smoking, drug use, and alcohol consumption

• mental health evaluation, such as presence of depression/anxiety, partner-related issues, and history of sexual abuse

• physical examination:^2,3

• erectile dysfunction may be a marker for asymptomatic cardiovascular disease so cardiovascular risk assessment is indicated (blood pressure, heart rate, body mass index, carotid bruits, waist circumference, cardiac assessment)

• examination of penis and testes 

• neurological assessment, such as for peripheral neuropathy

• further tests should be guided by history and clinical exam, and may include:³

• full blood count

• kidney and liver function tests

• thyroid stimulating hormone (to screen for thyroid disorders)

• fasting blood glucose (to screen for diabetes)

• lipid profile (to screen for dyslipidaemia)

• morning testosterone assay (to screen for hypogonadism)

• cardiovascular workup if indicated

Approximately 20% have a psychogenic aetiology (particularly in those new to sexual activity). Referral for psychosexual or relationship counselling may be indicated in these situations.¹ 

Erectile dysfunction management

First-line treatment involves addressing modifiable lifestyle and risk factors, including optimising management of comorbid conditions such as diabetes, hypertension, or dyslipidaemia.

ED from organic causes commonly leads to psychological responses, which may confound diagnosis and management. Comprehensive management should involve both partners and include counselling and realistic treatment goals.³

1. Exercise tolerance should be evaluated for all patients with ED

To help inform advice regarding sexual exertion.¹ High risk of death or significant morbidity from sexual exertion is considered with:^1,5

• unstable or refractory angina

• poorly controlled hypertension

• congestive heart failure

• myocardial infarction within the last fortnight without intervention

• exercise-induced ventricular tachycardia

• poorly controlled atrial fibrillation

• symptomatic hypertrophic obstructive cardiomyopathy

• moderate to severe aortic stenosis

Patients with ED in this category should be advised against sexual intercourse until a formal cardiology assessment has been completed.¹

2. Pharmacological treatment: 

• oral phosphodiesterase type 5 (PDE5) inhibitors (eg, avanafil, sildenafil, tadalafil, vardenafil) are first-line pharmacological therapy unless contraindicated (eg, concurrent nitrate therapy due to risk of severe hypotension)¹

• choice of initial drug can be based on patient preference¹ - see comparison table below

• dosages are tailored based on response and adverse effects¹ 

• higher doses may be required in the presence of vascular disease or neuropathy¹

• adverse effects (eg, headache, dizziness, facial flushing, dyspepsia, dizziness) are dose-dependent¹

• take caution in the presence of kidney or liver impairment¹

• trial at least two different oral PDE5 inhibitors at full dose seven to eight times  before deciding to escalate therapy³

• note that sexual stimulation is still required to achieve an erection¹

Image credit:  Jannini E, Droupy S. Needs and Expectations of Patients with Erectile Dysfunction: An Update on Pharmacological Innovations in Phosphodiesterase Type 5 Inhibition with Focus on Sildenafil. Sex Med. 2019;7:1-10

• intracavernosal vasodilator injections are second-line treatment if oral PDE5 inhibitor therapy fails or is contraindicated¹

• alprostadil is preferred for monotherapy; if this is unsuccessful despite maximum dose, consider referral

• papaverine and phentolamine have a higher risk of priapism (abnormally sustained erection with risk of permanent tissue damage)

• patient must be properly trained to self-administer injections and given clear instructions on priapism management 

3. Non-pharmacological treatments:

• considered if pharmacological interventions are ineffective or contraindicated²

• vacuum erection devices are safe, relatively inexpensive,^1,3 and may be preferable to intracavernosal injections¹

• semirigid or inflatable penile implants by a urologist are effective but also expensive and preclude future natural erections¹

4. Testosterone therapy:

• reserved for confirmed hypogonadism and androgen deficiency if PDE5 inhibitor therapy fails³

• is more effective at treating low libido than ED³

• may improve erectile function modestly though monotherapy with testosterone supplements is not considered effective³

• unclear benefit in androgen-deficient males already on PDE5 inhibitors¹

References

1. Therapeutic Guidelines. Erectile dysfunction. 2023. (last viewed February 2025).

2. Healthy Male. Erectile dysfunction. 2024. (last viewed February 2025). 

3. Leslie SW, Sooriyamoorthy T. Erectile Dysfunction. [Updated 2024 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.

4. Lowy M, Ramanathan V. Erectile dysfunction: causes, assessment and management options. Aust Prescr. 2022;45:159-61.

5. Nehra A, Jackson G, Miner M, et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012;87(8):766-78.

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