Guideline sources The following summarized guidelines for the evaluation and management of erectile dysfunction (ED) are prepared by our editorial team based on guidelines from the Italian Society of Andrology and Sexual Medicine (SIAMS 2023), the European Association of Urology (EAU 2023; 2022), the European Society for Sexual Medicine (ESSM 2022), the American Urological Association (AUA/SMSNA 2022), the Italian Society of Endocrinology (SIE/SIAMS 2022), the Canadian Urological Association (CUA 2022), the American Urological Association (AUA 2021; 2018; 2015; 2014), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the European Academy of Andrology (EAA 2020), the European Huntington's Disease Network (EHDN 2019), and the Canadian Neurological Sciences Federation (CNSF 2019). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 17 17 17 Definition https://web.pathway.md/diseases/recsRPAiXiNov4aap 1/12 6/29/23, 4:18 AM Erectile dysfunction Pathway ED is a male sexual dysfunction characterized by an inability to achieve or maintain a penile erection sufficient for sexual satisfaction. 17 Epidemiology ED is caused due to endocrine (reduced serum testosterone levels), psychogenic (stress, depression, anxiety), nonendocrine (spinal cord injury, multiple sclerosis, TBI, diabetes, hypertension, dyslipidemia, radical pelvic surgery, medications) factors. 17 Disease course Clinical manifestations of ED may include gynecomastia, a decrease in beard and body hair due to hypogonadism, tachycardia, arterial bruit, bradycardia, arrhythmia, Peyronie disease, phimosis, frenulum breve, in addition to comorbidities (hypertension, diabetes, obesity). 17 Prognosis and risk of recurrence ED is not associated with increased mortality. 17 Guidelines 1. Screening and diagnosis Indications for screening: Assess sexual function and screen for ED in all patients with any of the following: obesity A diabetes mellitus A arterial hypertension, A including taking certain antihypertensive agents B dyslipidemia A low testosterone A taking antidepressants or antipsychotics A history of pelvic surgery for malignancies A gout B systemic diseases, especially in patients with organ failure. B Consider assessing sexual functuon and screening for ED in all patients with any of the following: COPD and obstructive sleep apnea C central and peripheral neurological diseases potentially affecting male sexual response C endocrine conditions, such as thyroid, adrenal, and pituitary diseases C chronic prostatitis/chronic pelvic pain syndrome C Peyronie's disease C young patients with a history of previous treatment with drugs affecting the serotoninergic pathway or the conversion of testosterone to dihydrotestosterone C couple infertility, particularly when undergoing assisted reproduction techniques. C https://web.pathway.md/diseases/recsRPAiXiNov4aap 2/12 6/29/23, 4:18 AM Erectile dysfunction Pathway 2. Classification and risk stratification Severity assessment: use validated questionnaires to assess the severity of ED. E 3. Diagnostic investigations History and physical examination: As per EAU 2023 guidelines, elicit a comprehensive medical and sexual history in all patients with ED. Take into consideration psychosexual development, including life stressors, cultural aspects, and cognitive/thinking style of the patient regarding their sexual performance. A Show 2 more As per SIAMS 2023 guidelines, consider obtaining educational, psychological, psycho- sexological, and marital assessments in all patients with ED. C Show 6 more As per AUA 2018 guidelines, elicit a thorough medical, sexual, and psychosocial history and perform a physical examination in patients with symptoms of ED. B Doppler ultrasound: consider obtaining penile color Doppler ultrasound, at least in flaccid condition, in all patients with ED. C Nocturnal penile tumescence and rigidity monitoring: consider obtaining nocturnal penile tumescence and rigidity test or other instrumental examinations only in selected patients. C Laboratory tests: As per EAU 2023 guidelines: Obtain routine laboratory tests, including glucose and lipid profile and total testosterone, to identify and treat any reversible risk factors and modifiable lifestyle factors. A Obtain specific diagnostic tests in the initial evaluation of ED in the presence of the following conditions: Situation Guidance Asymptomatic, < 3 risk factors for coronary artery disease (excluding sex) Low-risk category Mild, stable angina (evaluated and/or being treated) Uncomplicated previous myocardial infarction LV dysfunction/congestive HF (NYHA class I or II) Post-successful coronary revascularization Controlled hypertension Mild valvular disease > 3 risk factors for coronary artery disease (excluding sex) Intermediate-risk category https://web.pathway.md/diseases/recsRPAiXiNov4aap 3/12 6/29/23, 4:18 AM Erectile dysfunction Pathway Moderate, stable angina Recent myocardial infarction (> 2, < 6 weeks) LV dysfunction/congestive HF (NYHA class III) Non-cardiac sequelae of atherosclerotic disease (such as stroke, peripheral vascular disease) High-risk arrhythmias High-risk category Unstable or refractory angina Recent myocardial infarction (< 2 weeks) LV dysfunction/congestive HF (NYHA class IV) Hypertrophic obstructive and other cardiomyopathies Uncontrolled hypertension Moderate-to-severe valvular disease. A As per SIAMS 2023 guidelines, obtain routine laboratory tests, including fasting blood glucose, HbA1c, total and high-density lipoprotein cholesterol, and triglycerides, in all patients with ED. A Show 2 more As per AUA 2018 guidelines, obtain selective laboratory testing in patients with symptoms of ED. B Show 2 more Screening for cardiovascular diseases: As per SIAMS 2023 guidelines: Elicit symptoms of coronary artery disease in all patients with ED at each visit and assess the cardiovascular risk profile using cardiovascular algorithms, such as SCORE2 and SCORE2-Older Persons. A Consider assessing CAC score (if permitted by local expertise and availability) as a further diagnostic test in patients with calculated risks around decision thresholds (low-to- intermediate cardiovascular risk profile) to relocate them to different risk groups. C As per AUA 2018 guidelines, counsel patients that ED is a risk marker for underlying CVD and other health conditions that may warrant evaluation and treatment. B Screening for benign prostatic hyperplasia: screen patients with ED with the IPSS and patients with benign prostate obstruction with the IEF. B 4. Medical management Avoidance of drugs affecting erectile function: Consider prescribing drugs with the lowest impact on sexual function. C https://web.pathway.md/diseases/recsRPAiXiNov4aap 4/12 6/29/23, 4:18 AM Erectile dysfunction Pathway Avoid using -blockers as first-line therapy in patients with newly diagnosed arterial hypertension in the absence of specific cardiological indications. D Phosphodiesterase-5 inhibitors: As per EAU 2023 guidelines, offer PDE5 inhibitors as first-line therapy for ED. A As per SIAMS 2023 guidelines: Initiate short- or long-acting PDE5 inhibitors as first-line therapy in patients with ED. A Consider preferring short-acting PDE5 inhibitors in patients with high cardiovascular risk B and long-acting PDE5 inhibitors in patients with LUTS. A Consider combining chronic and on-demand PDE5 inhibitors in patients not responding to conventional therapy. E As per AUA 2018 guidelines, offer approved oral PDE5 inhibitors, unless contraindicated, as a treatment option in patients with ED. B Titrate the dose of PDE5 inhibitors to provide optimal efficacy. B Provide instructions to patients prescribed oral PDE5 inhibitors, to maximize benefit/efficacy. B Testosterone replacement therapy: As per AUA 2018 guidelines, inform patients with ED and testosterone deficiency that treatment with a PDE5 inhibitor may be more effective if combined with testosterone therapy. B As per AUA 2018 guidelines, avoid prescribing testosterone to men with ED who have normal testosterone levels. D 5. Nonpharmacologic interventions Lifestyle modifications: As per EAU 2023 guidelines: Offer lifestyle changes and risk factor modification before or at the same time as initiating ED treatments. A Treat a curable cause of ED first, when found. B As per SIAMS 2023 guidelines, advise adopting healthy diets to reduce the risk of ED. B Advise a Mediterranean dietary pattern to prevent the development or reduce the progression of ED in patients with diabetes, obesity, or metabolic syndrome. B Show 3 more As per AUA 2018 guidelines, offer lifestyle modifications, including changes in diet and increased physical activity to improve overall health and erectile function in patients with ED having comorbidities known to negatively affect erectile function. B Dietary supplements: insufficient evidence to support the use of nutritional supplements in patients with ED. I Erection rehabilitation: Start pro-erectile treatments at the earliest opportunity after radical prostatectomy/pelvic surgery and other curative treatments for prostate cancer. B Insufficient evidence to recommend any specific regimen for penile rehabilitation after radical prostatectomy. I https://web.pathway.md/diseases/recsRPAiXiNov4aap 5/12 6/29/23, 4:18 AM Erectile dysfunction Pathway Vacuum erection devices: As per EAU 2023 guidelines, offer vacuum erection devices as an alternative first-line therapy in well-informed patients with infrequent sexual intercourse and in patients with comorbidities requiring noninvasive, drug-free management of ED. B As per SIAMS 2023 guidelines, consider offering vacuum erection devices alone or combined with other therapies in patients with ED if PDE5 inhibitors and intracavernosal/transurethral therapies are contraindicated, ineffective, or not tolerated. C As per AUA 2018 guidelines, offer vacuum erection devices as a treatment option in patients with ED. B Psychosocial interventions: As per EAU 2023 guidelines, offer CBT (including the partner) combined with medical treatment to maximize treatment outcomes. A As per SIAMS 2023 guidelines, consider integrating psycho-sexological therapies with lifestyle changes and medical, physical, and surgical therapies. C Show 2 more As per AUA 2018 guidelines, consider referring patients being treated for ED to a mental health professional, in order to promote treatment adherence, reduce performance anxiety, and integrate treatments into a sexual relationship. C 6. Therapeutic procedures Intraurethral alprostadil: As per EAU 2023 guidelines, offer topical/intraurethral alprostadil as an alternative first-line therapy in well-informed patients not wishing or not suitable for oral vasoactive therapy, not wishing to have intracavernous injections, or in patients preferring a less invasive therapy. B As per SIAMS 2023 guidelines, consider offering topical or intraurethral alprostadil in patients with ED if PDE5 inhibitors are contraindicated, ineffective, or not tolerated, as well as in patients preferring a less-invasive treatment. C As per AUA 2018 guidelines: Offer intraurethral alprostadil as a treatment option in patients with ED. B Perform an in-office test in patients considering the use of intraurethral alprostadil. B Intracavernosal injections: As per EAU 2023 guidelines: Administer intracavernous injections as an alternative first-line therapy in well-informed patients or as second-line therapy. A Do not use platelet-rich plasma for the treatment of ED outside of a clinical trial. D As per SIAMS 2023 guidelines: Administer intracavernosal alprostadil in patients with ED if PDE5 inhibitors are contraindicated, ineffective for organic reasons, or not tolerated. A Insufficient evidence to recommend stem cells or platelet-rich plasma and penile mechanical hemodynamic revascularization procedures. I https://web.pathway.md/diseases/recsRPAiXiNov4aap 6/12 6/29/23, 4:18 AM Erectile dysfunction Pathway As per AUA 2018 guidelines, offer intracavernosal injections as a treatment option in patients with ED. B Show 2 more Extracorporeal shock wave therapy: As per EAU 2023 guidelines, offer low-intensity shock wave therapy (with or without PDE5 inhibitors) in patients with mild vasculogenic ED or poor responders to PDE5 inhibitors, or as an alternative first-line therapy in well-informed patients not wishing or not suitable for oral vasoactive therapy or desiring a curable option. B As per SIAMS 2023 guidelines, consider offering low-intensity shockwave therapy in patients with mild vasculogenic ED not responding to PDE5 inhibitors. C As per AUA 2018 guidelines, insufficient evidence to recommend low-intensity extracorporeal shock wave therapy in patients with ED, except in an investigational setting. I 7. Surgical interventions Penile vascular surgery: Consider performing penile arterial reconstruction in young patients with ED and focal pelvic/penile arterial occlusion in the absence of documented generalized vascular disease or veno-occlusive dysfunction. C Do not perform penile venous surgery for the treatment of ED. D Penile prosthesis implantation: As per EAU 2023 guidelines, offer penile prosthesis implantation when other treatments fail or depending upon patient preference. A As per SIAMS 2023 guidelines, offer penile prosthesis implantation in patients with ED if all other therapies are ineffective or contraindicated. A As per AUA 2018 guidelines, inform patients with ED regarding the treatment option of penile prosthesis implantation, including a discussion of benefits and risks/burdens. B Show 2 more 8. Specific circumstances Patients with obesity (indications for bariatric surgery): consider offering bariatric surgery to decrease ED in patients with morbid obesity. C Patients with obesity (after bariatric surgery): assess for zinc deficiency in patients with unexplained hypogonadism or ED after a bariatric procedure. B Patients with hypogonadism: As per EAU 2023 guidelines, initiate testosterone replacement therapy as first-line treatment in patients with symptomatic hypogonadism and mild ED. A Initiate a combination of PDE5 inhibitors and testosterone therapy in more severe forms of ED. B As per SIAMS 2023 guidelines, initiate testosterone in patients with hypogonadal ED, recognizing that the best results are obtained in patients with overt hypogonadism (total testosterone < 8 nmol/L). A https://web.pathway.md/diseases/recsRPAiXiNov4aap 7/12 6/29/23, 4:18 AM Erectile dysfunction Pathway As per SIAMS 2022 guidelines, initiate testosterone replacement therapy in patients with hypogonadism with low sexual desire and/or ED. A As per EAA 2020 guidelines, initiate testosterone replacement therapy to improve libido, erectile function, and sexual satisfaction in patients with hypogonadism with sexual/ED. A Patients with hyperprolactinemia: treat ED in patients with severe hyperprolactinemia to improve sexual desire, testosterone levels, and erectile function. B Patients with Peyronie's disease (surgical management): Perform surgical treatment in patients with Peyronie's disease when the inadequate quality of erections does not allow satisfactory sexual intercourse. B Perform revision surgery, if necessary, at least 6 months after the initial procedure to allow for complete healing and stabilization of the deformity and for adequate assessment of postoperative erectile function. B Patients with other endocrine disorders: consider treating patients with hypothyroidism, hyperthyroidism, C and hypocortisolism with specific therapies to also improve erectile function. C Patients with Peyronie's disease (PDE-5 inhibitors): consider offering PDE5 inhibitors to treat concomitant ED or to optimize penetration when the deformity results in difficulty in penetrative intercourse in patients with Peyronie's disease. C Patients with Peyronie's disease, penile prosthesis: As per EAU 2023 guidelines, perform penile prosthesis implantation, with or without any additional procedure (modeling, plication, incision or excision with or without grafting) in patients with Peyronie's disease with ED not responding to pharmacotherapy. A As per ESSM 2022 guidelines, consider performing penile prosthesis implantation, alone or in combination with straightening maneuvers, during revision surgery, in order to minimize further penile length loss or to avoid worsening of erectile function. C As per AUA 2015 guidelines, consider performing penile prosthesis implantation in patients with Peyronie's disease with ED and/or penile deformity sufficient to prevent coitus despite pharmacotherapy and/or vacuum device therapy. C Patients with benign prostatic hyperplasia: As per CUA 2022 guidelines, offer long-acting PDE5 inhibitors as monotherapy in patients with LUTS/benign prostatic hyperplasia, particularly in patients with both LUTS and ED. B As per EAU 2022 guidelines, offer PDE5 inhibitors in patients with moderate-to-severe LUTS, with or without ED. A As per AUA 2021 guidelines, consider offering tadalafil 5 mg daily as a treatment option in patients with LUTS secondary/attributed to benign prostatic hyperplasia, irrespective of comorbid ED. C Patients with premature ejaculation: consider addressing the erectile function before any therapeutical attempt to improve ejaculatory control in patients with loss of control of erection and ejaculation. C Patients with urethral injury: monitor patients for ED for at least one year after urethral injury. B https://web.pathway.md/diseases/recsRPAiXiNov4aap 8/12 6/29/23, 4:18 AM Erectile dysfunction Pathway Patients with Parkinson's disease: Offer the following in patients with Parkinson's disease and ED: discontinue drugs associated with ED such as alpha-blockers, or anorgasmia such as SSRIs; recognize that dopaminergic therapy can have both negative and positive effects on this symptom B consider offering sildenafil 50-100 mg 1 hour before sex in patients with Parkinson's disease with ED B consider offering other drugs, such as tadalafil 10 mg 30 min-12 hours before sex, or vardenafil 10 mg 1 hour before sex as alternative choices B consider administering apomorphine injections 5-10 min before sex as an alternative option in some patients B consider administering intracavernous injections of papaverine or alprostadil in selected patients. B Patients with Huntington's disease: attempt to identify sexual disorders and determine their triggers and their impact on relationships in patients with Huntington's disease. Consider offering psychological support and/or referral to a specialist in psychosexual disorders. Show 2 more 9. Patient education Counseling before arterial embolization for priapism: inform patients with non-ischemic priapism that embolization carries a risk of ED. B Counseling before radical prostatectomy: As per EAU 2023 guidelines, discuss with patients undergoing radical prostatectomy (any technique) about the risk of sexual changes other than ED, including libido reduction, changes in orgasm, anejaculation, Peyronie's-like disease, and penile size changes. A As per AUA 2018 guidelines, inform patients desiring preservation of erectile function after treatment of prostate cancer by radical prostatectomy or radiotherapy that early use of PDE5 inhibitors post-treatment may not improve spontaneous, unassisted erectile function. B Counseling before intracavernosal injections: instruct patients receiving intracavernosal teaching or an in-office pharmacologically-induced erection to return to the office or emergency department if they have an erection lasting > 4 hours. E 10. Preventative measures Counseling before anti-androgenic therapy: inform all patients treated with antiandrogenic agents about possible negative effects on erectile function. B 11. Follow-up and surveillance Assessment of treatment response: https://web.pathway.md/diseases/recsRPAiXiNov4aap 9/12 6/29/23, 4:18 AM Erectile dysfunction Pathway As per EAU 2023 guidelines, assess for inadequate/incorrect information about the mechanism of action and the ways the drugs are taken as they are the main causes of a lack of response to PDE5 inhibitors. B As per AUA 2018 guidelines, use validated questionnaires to assess treatment effectiveness and to guide future management. E Management of iatrogenic priapism: administer intracavernous phenylephrine as the initial treatment in patients with prolonged erection of 4 hours following intracavernous injection pharmacotherapy for ED. E Clinical findings Patient demographics Symptoms Hispanic Anorgasmia Anxiety Past medical history Decreased libido Decreased sexual response Adrenal insufficiency Depression Alzheimer's disease Difficulty attaining an erection Ankylosing spondylitis Difficulty maintaining an erection Atherosclerotic disease Sleeping disorder CVD Chronic prostatitis/chronic pelvic pain syndrome Past surgical history Coronary artery disease Pelvic surgery Cushing's syndrome Prostatectomy Diabetes mellitus Lab findings Dyslipidemia Gout serum testosterone Huntington's disease Hyperprolactinemia Hypertension Hypogonadism Hypospadias Hypothyroidism Metabolic syndrome Multiple sclerosis Nonalcoholic fatty liver disease Obesity Parkinson's disease Pelvic radiation therapy Penile cancer Penile injury Peyronie's disease Phimosis Prostate cancer Psoriasis https://web.pathway.md/diseases/recsRPAiXiNov4aap 10/12 6/29/23, 4:18 AM Erectile dysfunction Pathway Spinal cord injury Stroke Urethral injury Social history Tobacco use References 1. 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