Erectile Dysfunction

Persistent inability to achieve/maintain erection sufficient for satisfactory sexual performance, ≥3 months.

Vascular (most common, shares risk factors with CAD, can precede overt cardiac disease by 2-5 years), neurological, hormonal, psychogenic, drug-induced, or mixed.

Gradual onset suggests organic; sudden onset suggests psychogenic.

Situational (present with partner, absent with masturbation) suggests psychogenic; global suggests organic.

Preserved morning/nocturnal erections suggest psychogenic; absent suggests organic.

Reduced libido suggests hormonal cause.

• History: onset pattern, psychosexual history, medication review (beta-blockers, thiazides, SSRIs, antipsychotics, finasteride), substance use, cardiovascular risk assessment
• Examination: BP, BMI, genital exam (Peyronie's plaques, testicular size), secondary sexual characteristics
• Bloods: fasting glucose/HbA1c, lipids, morning total testosterone (repeat if low, with LH/FSH/prolactin), TSH
• IIEF questionnaire: severity assessment
• Further specialist testing (nocturnal tumescence, duplex ultrasound): reserved for diagnostic uncertainty/treatment failure

Differentials: vascular, neurological (diabetic neuropathy, spinal cord injury), hormonal (hypogonadism, hyperprolactinemia, thyroid dysfunction), psychogenic, drug-induced, Peyronie's disease.

• Address modifiable risk factors: smoking cessation, weight loss, exercise, alcohol moderation, optimize diabetes/hypertension/lipids
• PDE5 inhibitors: first-line: sildenafil 25-100mg (30-60 min pre-activity, avoid fatty meal), tadalafil 10-20mg (up to 36h duration, also daily 5mg option), vardenafil 10-20mg
• Absolute contraindication: concurrent nitrates (life-threatening hypotension); caution in unstable cardiac disease, recent MI/stroke
• Side effects: headache, flushing, dyspepsia, nasal congestion
• Testosterone replacement: if confirmed hypogonadism, monitor PSA, hematocrit, prostate health
• Vacuum erection devices: non-pharmacological option
• Intracavernosal alprostadil injection: second-line, priapism risk (counsel on emergency care if erection >4h)
• Penile prosthesis: refractory cases
• Psychosexual therapy: for psychogenic component

Referral: urology for treatment failure/prosthesis consideration, endocrinology for confirmed hypogonadism, cardiology if cardiac risk uncertainty, psychosexual counseling.