Guidelines Summary

American Urological Association (AUA) guidelines on erectile dysfunction (ED) contain the following recommendations on evaluation and diagnosis^[1]:

Men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychosocial history; a physical examination; and selective laboratory testing. (Clinical Principle)
For the man with ED, validated questionnaires are recommended to assess the severity of ED, to measure treatment effectiveness, and to guide future management. (Expert Opinion)
Men should be counseled that ED is a risk marker for underlying cardiovascular disease (CVD) and other health conditions that may warrant evaluation and treatment. (Clinical Principle)
In men with ED, morning serum total testosterone levels should be measured. (Moderate Recommendation; Evidence Level: Grade C)
For some men with ED, specialized testing and evaluation may be necessary to guide treatment. (Expert Opinion)

AUA recommendations for treatment of ED are as follows:

Referral to a mental health professional should be considered to promote treatment adherence, reduce performance anxiety, and integrate treatments into a sexual relationship. (Moderate Recommendation; Evidence Level: Grade C)
Men with ED who have comorbidities known to negatively affect erectile function should be counseled that lifestyle modifications, including changes in diet and increased physical activity, improve overall health and may improve erectile function. (Moderate Recommendation; Evidence Level: Grade C)
Men with ED should be informed regarding the treatment option of an FDA-approved oral phosphodiesterase type 5 inhibitor (PDE5i), including discussion of benefits and risks/burdens, unless contraindicated. (Strong Recommendation; Evidence Level: Grade B)
When men are prescribed an oral PDE5i for the treatment of ED, instructions should be provided to maximize benefit/efficacy. (Strong Recommendation; Evidence Level: Grade C)
For men who are prescribed PDE5i, the dose should be titrated to provide optimal efficacy. (Strong Recommendation; Evidence Level: Grade B)
Men who desire preservation of erectile function after treatment for prostate cancer by radical prostatectomy (RP) or radiotherapy (RT) should be informed that early use of PDE5i post-treatment may not improve spontaneous, unassisted erectile function. (Moderate Recommendation; Evidence Level: Grade C)
Men with ED and testosterone deficiency (TD) who are considering ED treatment with a PDE5i should be informed that PDE5i may be more effective if combined with testosterone therapy. (Moderate Recommendation; Evidence Level: Grade C)
Men with ED should be informed regarding the treatment option of a vacuum erection device (VED), including discussion of benefits and risks/burdens. (Moderate Recommendation; Evidence Level: Grade C
Men with ED should be informed regarding the treatment option of intraurethral (IU) alprostadil, including discussion of benefits and risks/burdens. (Conditional Recommendation; Evidence Level: Grade C) For men with ED who are considering the use of IU alprostadil, an in-office test should be performed. (Clinical Principle)
Men with ED should be informed regarding the treatment option of intracavernosal injections (ICI), including discussion of benefits and risks/burdens. (Moderate Recommendation; Evidence Level: Grade C)
For men with ED who are considering ICI therapy, an in-office injection test should be performed. (Clinical Principle)
Men with ED should be informed regarding the treatment option of penile prosthesis implantation, including discussion of benefits and risks/burdens. (Strong Recommendation; Evidence Level: Grade C)
Men with ED who have decided on penile implantation surgery should be counseled regarding postoperative expectations. (Clinical Principle)
Penile prosthetic surgery should not be performed in the presence of systemic, cutaneous, or urinary tract infection. (Clinical Principle)
For young men with ED and focal pelvic/penile arterial occlusion and without documented generalized vascular disease or veno-occlusive dysfunction, penile arterial reconstruction may be considered. (Conditional Recommendation; Evidence Level: Grade C)
Penile venous surgery is not recommended for men with ED. (Moderate Recommendation; Evidence Level: Grade C)
Low-intensity extracorporeal shock wave therapy (ESWT) should be considered investigational for ED. (Conditional Recommendation; Evidence Level: Grade C)
Intracavernosal stem cell therapy should be considered investigational for ED. (Conditional Recommendation; Evidence Level: Grade C)
Platelet-rich plasma (PRP) therapy should be considered experimental for ED. (Expert Opinion)

Medication

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Media Gallery

These images depict penile anatomy. Note the sinusoidal makeup of the corpora and thick fascia (ie, Buck fascia) that covers the corpora cavernosa. The major blood vessels to the corpora cavernosa enter through tributaries from the main vessels running along the dorsum of the penis.
Vascular anatomy of the penis.
This penile tumescence monitor is placed at the base and near the corona of the penis. It is connected to a monitor that records a continuous graph depicting the force and duration of erections that occur during sleep. The monitor is strapped to the leg. The nocturnal penile tumescence test is conducted on several nights to obtain an accurate indication of erections that normally occur during the alpha phase of sleep.
The presence of normal skin sensation adequate to produce an erection is measured with this device.
A vasodilator such as prostaglandin E1 can be injected into one of the corpora cavernosa. If the blood vessels are capable of dilating, a strong erection should develop within 5 minutes.
Erectile dysfunction. This diagram depicts a cross-section of penile anatomy and is used to instruct patients in the technique of administering intracorporeal medications.
The Medicated Urethral System for Erections (MUSE) is a small suppository placed into the urethra with this device.
This image depicts a vacuum device used to produce an erection (also see next image). In this image, the elements are shown. They include the cylinder, a pump to create a vacuum, and a constriction ring to be placed at the base of the penis after an erection has been obtained in order to maintain the erection.
This image demonstrates the vacuum device in place (see previous image). Note the presence of the constricting ring at the base of the penis.
This is one of many types of constricting devices placed at the base of the penis to diminish venous outflow and improve the quality and duration of the erection. This is particularly useful in men who have a venous leak and are only able to obtain partial erections that they are unable to maintain. These constricting devices may be used in conjunction with oral agents, injection therapy, and vacuum devices.
Two rigid cylinders have been placed into the corpora cavernosa. This type of implant has no inflation mechanism but provides adequate rigidity to the penis to allow penetration.
This inflatable penile prosthesis has 3 major components. The 2 cylinders are placed within the corpora cavernosa, a reservoir is placed beneath the rectus muscle, and the pump is placed in the scrotum. When the pump is squeezed, fluid from the reservoir is transferred into the 2 cylinders, producing a firm erection. The deflation mechanism is also located on the pump and differs by manufacturer.

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Table 1. Diseases and Conditions Associated With Erectile Dysfunction

Vascular causes	Atherosclerosis Peripheral vascular disease Myocardial infarction Arterial hypertension Vascular injury from radiation therapy Vascular injury from prostate cancer treatment Blood vessel and nerve trauma (eg, from long-distance bicycle riding) Medications for treatment of vascular disease
Systemic diseases	Diabetes mellitus Scleroderma Renal failure Liver cirrhosis Idiopathic hemochromatosis Cancer and cancer treatment Dyslipidemia Hypertension
Neurologic causes	Epilepsy Stroke Multiple sclerosis Guillain-Barré syndrome Alzheimer disease Trauma
Respiratory disease	Chronic obstructive pulmonary disease Sleep apnea
Endocrine conditions	Hyperthyroidism Hypothyroidism Hypogonadism Diabetes
Penile conditions	Peyronie disease Epispadias Priapism
Psychiatric conditions	Depression Widower syndrome Performance anxiety Posttraumatic stress disorder
Nutritional states	Malnutrition Zinc deficiency
Hematologic diseases	Sickle cell anemia Leukemias
Surgical procedures	Brain and spinal cord procedures Retroperitoneal or pelvic lymph node dissection Aortoiliac or aortofemoral bypass Abdominal perineal resection Proctocolectomy Transurethral resection of the prostate Radical prostatectomy Cryosurgery of the prostate Cystectomy
Medications	Antihypertensives Antidepressants Antipsychotics Antiulcer agents (eg, cimetidine) 5-Alpha reductase inhibitors (eg, finasteride and dutasteride) Cholesterol-lowering agents Methadone

Table 2. Advantages and Disadvantages of Different Types of Penile Implants for Erectile Dysfunction

Treatment	Advantages	Disadvantages
Semirigid or malleable rod implants	Simple surgery Relatively few complications No moving parts Least expensive implant Success rate of 70-80% Highly effective	Constant erection at all times May be difficult to conceal Does not increase width of penis Risk of infection Permanently alters or may injure erection bodies Most likely implant to cause pain or erode through skin If unsuccessful, interferes with other treatments
Fully inflatable implants	Mimics natural process of rigidity-flaccidity Patient controls state of erection Natural appearance No concealment problems Increases width of penis when activated Success rate of 70-80% Highly effective	Relatively high rate of mechanical failure Risk of infection Most expensive implant Permanently alters or may injure erection bodies If unsuccessful, interferes with other treatments
Self-contained inflatable unitary implants	Mimics natural process of rigidity-flaccidity Patient controls state of erection Natural appearance No concealment problems Simpler surgical procedure than that required for fully inflatable prosthesis Success rate of 70-80% Highly effective	Sometimes difficult to activate the inflatable device Does not increase width of penis Mechanical breakdowns possible Long-term results not available Risk of infection Relatively expensive Permanently alters or may injure erection bodies If unsuccessful, interferes with other treatments

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