One-liner#

Erectile dysfunction is often a marker of cardiovascular disease—evaluation should address both sexual function and underlying vascular risk factors.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Priapism (erection >4 hours) → urologic emergency; can cause permanent damage
• Peyronie’s disease with acute painful curvature → urology referral (not ED, but urgent)
• ED after pelvic trauma → may indicate vascular or neurologic injury

Key history#

Characterize the dysfunction:

• Onset: gradual (vascular, metabolic) vs sudden (psychogenic, medication)
• Duration: how long has this been a problem
• Severity: unable to achieve any erection vs unable to maintain vs decreased rigidity
• Situational: with partner only vs all situations (masturbation, morning erections)
• Morning/nocturnal erections: presence suggests psychogenic; absence suggests organic

Sexual history:

• Libido: decreased desire suggests hypogonadism or depression
• Ejaculation: premature, delayed, or absent
• Relationship factors: partner issues, stress
• Sexual practices and expectations

Key differentiating questions:

• “Do you wake up with erections?” (Yes = likely psychogenic or medication-related)
• “Can you achieve erection with masturbation?” (Yes = likely psychogenic or partner-related)
• “Did this start suddenly or gradually?” (Sudden = psychogenic or medication; gradual = vascular)

Medical history (vascular risk factors):

• Diabetes (most common medical cause)
• Hypertension
• Hyperlipidemia
• Coronary artery disease, PAD
• Smoking
• Obesity

Other medical conditions:

• Depression, anxiety
• Neurologic disease (MS, Parkinson’s, spinal cord injury)
• Chronic kidney disease
• Sleep apnea
• Peyronie’s disease (penile curvature)
• Prior pelvic surgery or radiation (prostatectomy, colorectal surgery)

Medication review (common culprits):

• Antihypertensives: beta-blockers (especially non-selective), thiazides, spironolactone
• Antidepressants: SSRIs, SNRIs (very common)
• Antipsychotics
• Antiandrogens: finasteride, dutasteride, spironolactone
• Opioids
• Alcohol, marijuana, other substances

Psychosocial factors:

• Depression, anxiety
• Relationship stress
• Performance anxiety
• Work/life stress
• History of sexual trauma

Focused exam#

General:

• Body habitus: obesity, gynecomastia (hypogonadism)
• Secondary sexual characteristics: hair distribution, muscle mass

Cardiovascular:

• Blood pressure
• Peripheral pulses (femoral, dorsalis pedis)
• Bruits (carotid, femoral)

Genital exam:

• Penis: plaques (Peyronie’s), phimosis, lesions
• Testes: size (small suggests hypogonadism), masses
• Prostate: size, nodules (if indicated)

Neurologic:

• Perineal sensation (S2-S4)
• Bulbocavernosus reflex (if neurogenic cause suspected)
• Lower extremity reflexes

When exam changes management:

• Small testes → check testosterone
• Penile plaque → Peyronie’s disease
• Absent peripheral pulses → significant vascular disease
• Gynecomastia → check testosterone, prolactin

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Initial evaluation (all patients):

• Fasting glucose or HbA1c (screen for diabetes)
• Lipid panel (cardiovascular risk)
• Consider: TSH, morning testosterone (if low libido, fatigue, or exam findings)

When to check testosterone:

• Decreased libido (not just ED)
• Fatigue, decreased energy
• Small testes on exam
• Other signs of hypogonadism
• ED not responding to PDE5 inhibitors

Testosterone testing:

• Morning level (8-10 AM); testosterone has diurnal variation
• If low-normal or low, repeat to confirm
• If confirmed low: LH, FSH (distinguish primary vs secondary)
• If secondary: prolactin, consider pituitary MRI

Cardiovascular risk assessment:

• ED is a marker for CVD; often precedes cardiac events by 3-5 years
• Calculate 10-year ASCVD risk
• Consider stress testing if: high CV risk, planning to resume vigorous sexual activity, symptoms suggestive of CAD

When NOT to order:

• Do NOT order penile Doppler or nocturnal penile tumescence in primary care—these are specialty tests
• Do NOT check testosterone in every patient with ED—only if low libido or other signs
• Do NOT delay PDE5 inhibitor trial for extensive workup in straightforward cases

Initial management#

First-line: PDE5 inhibitor trial

• Appropriate for most patients without contraindications
• Effective regardless of etiology (vascular, psychogenic, mixed)
• Trial of 4-6 attempts before declaring failure

Address modifiable risk factors:

• Smoking cessation
• Weight loss
• Exercise
• Optimize diabetes, hypertension, lipids
• Reduce alcohol

Medication review:

• Consider switching antihypertensives (ACE inhibitors, ARBs, CCBs less likely to cause ED)
• Consider switching antidepressants (bupropion less likely to cause ED)
• Discuss risks/benefits with patient

Psychogenic component:

• Reassurance that ED is common and treatable
• Address performance anxiety
• Consider sex therapy or couples counseling
• PDE5 inhibitors often help break the cycle

Management by diagnosis#

Vasculogenic/Mixed ED (Most Common)#

Education:

• ED is often an early sign of blood vessel problems
• Same risk factors as heart disease: diabetes, high BP, high cholesterol, smoking
• Medications work well for most men
• Lifestyle changes can improve ED and overall health

Treatment:

PDE5 inhibitor counseling:

• Take on empty stomach (except tadalafil) for faster onset
• Sexual stimulation still required—these are not aphrodisiacs
• Try at least 4-6 times before declaring failure
• Common side effects: headache, flushing, nasal congestion, dyspepsia
• Rare: vision changes (blue tinge), hearing loss (stop and seek care)
• NEVER combine with nitrates (severe hypotension)

Nitrate interaction:

• Absolute contraindication: any nitrate use (nitroglycerin, isosorbide, amyl nitrite/“poppers”)
• If patient takes nitrate after PDE5 inhibitor: no nitrates for 24 hours (sildenafil, vardenafil) or 48 hours (tadalafil)
• If chest pain occurs after PDE5 inhibitor: go to ED; inform them of PDE5 inhibitor use

Alpha-blocker interaction:

• Use with caution; risk of orthostatic hypotension
• Start PDE5 inhibitor at lowest dose
• Tamsulosin is most uroselective and safest to combine

If PDE5 inhibitors fail:

• Confirm proper use (timing, stimulation, adequate trials)
• Try different PDE5 inhibitor
• Check testosterone if not already done
• Urology referral for: vacuum devices, intracavernosal injections, penile implant

Follow-up: 4-6 weeks to assess response. Adjust dose or try alternative if needed.

Hypogonadism#

Education:

• Low testosterone can cause low sex drive and ED
• Testosterone replacement can help but has risks
• Need to monitor for side effects

When to treat:

• Symptoms of hypogonadism (low libido, fatigue, decreased energy) AND
• Confirmed low testosterone (<300 ng/dL on two morning samples)

Treatment options (urology or endocrinology often involved):

Monitoring on testosterone:

• Testosterone level at 3-6 months (trough for injections)
• Hematocrit (risk of polycythemia)—hold if Hct >54%
• PSA at baseline, 3-6 months, then annually
• Lipids annually
• Bone density if osteoporosis was indication

Contraindications to testosterone:

• Prostate cancer (current or history)
• Breast cancer
• Elevated PSA without evaluation
• Severe untreated sleep apnea
• Hematocrit >50%
• Desire for fertility (suppresses spermatogenesis)

Referral: Endocrinology or urology for testosterone initiation and monitoring.

Psychogenic ED#

Education:

• Very common; does not mean “it’s all in your head”
• Performance anxiety creates a cycle that’s hard to break
• Medications can help break the cycle
• Addressing underlying stress/relationship issues is important

Management:

• Reassurance and education
• PDE5 inhibitor to break performance anxiety cycle
• Address underlying stressors
• Consider referral to sex therapist or couples counseling
• Treat depression/anxiety if present

Follow-up: 4-6 weeks; often improves quickly with reassurance and medication.

Medication-Induced ED#

Education:

• Many medications can affect erections
• Often can switch to alternatives with less sexual side effects
• PDE5 inhibitors often work even without changing medications

Common substitutions:

• Beta-blockers → ACE inhibitor, ARB, or CCB
• Thiazide → ACE inhibitor or ARB
• SSRI → bupropion (if appropriate for depression type)
• Spironolactone → eplerenone (less antiandrogen effect)

If unable to change medication:

• PDE5 inhibitor trial
• Often effective despite ongoing medication

Peyronie’s Disease#

Recognition:

• Penile curvature (often dorsal)
• Palpable plaque on penile shaft
• May have pain with erection (acute phase)
• Can cause ED due to curvature or venous leak

PCP role:

• Recognize and refer to urology
• Reassure that it’s not cancer
• PDE5 inhibitors may help with ED component

Referral: Urology for evaluation and treatment options (intralesional injections, surgery).

Follow-up#

After starting PDE5 inhibitor:

• 4-6 weeks to assess response
• Adjust dose or try alternative if inadequate response
• Ensure proper use before declaring failure

On testosterone:

• 3-6 months: testosterone level, Hct, PSA
• Then annually: testosterone, Hct, PSA, lipids

Cardiovascular follow-up:

• Address modifiable risk factors
• Consider cardiology referral if high CV risk

Return precautions:

• Chest pain (especially if took PDE5 inhibitor—go to ED, tell them about medication)
• Prolonged erection >4 hours (priapism—urologic emergency)
• Vision or hearing changes (stop medication, seek care)
• Symptoms of low testosterone worsening

Patient instructions#

• These medications help blood flow to the penis but require sexual stimulation to work
• Take sildenafil or vardenafil about 1 hour before sex, on an empty stomach for best results
• Tadalafil can be taken daily or as needed; it lasts longer (up to 36 hours)
• Common side effects include headache, flushing, and stuffy nose—these usually improve with time
• NEVER take these medications with nitroglycerin or other nitrate medications—this can cause dangerously low blood pressure
• If you have chest pain after taking this medication, go to the emergency room and tell them what you took
• If you have an erection lasting more than 4 hours, go to the emergency room immediately
• Lifestyle changes help: quit smoking, exercise, lose weight, limit alcohol

Smartphrase snippets#

Starting PDE5 inhibitor: “ED discussed. No contraindications to PDE5 inhibitors (no nitrate use, no unstable cardiac disease). Starting sildenafil 50 mg PRN. Counseled on proper use: take 1 hour before, empty stomach, requires stimulation. Reviewed side effects and nitrate contraindication. Follow-up in 4-6 weeks to assess response.”

ED with CV risk assessment: “ED in setting of [diabetes/HTN/hyperlipidemia]. ED is a marker for cardiovascular disease. Cardiovascular risk factors addressed: [statin/BP optimization/smoking cessation discussed]. Starting PDE5 inhibitor. Will reassess CV risk and consider stress testing if symptoms develop.”

Checking testosterone: “ED with decreased libido and fatigue. Checking morning testosterone to evaluate for hypogonadism. If low, will repeat to confirm and check LH/FSH. PDE5 inhibitor offered in the interim.”