As per the American Urological Association guideline on the management of erectile dysfunction, shared decision-making is the cornerstone of the treatment and management of erectile dysfunction (ED). Let us look at the major recommendations put forward by the panel.

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Evaluation and diagnosis of Erectile Dysfunction

Men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychosocial history; a physical examination; and selective laboratory testing.

For a patient with ED, validated questionnaires are recommended to assess the severity of ED, to measure treatment effectiveness, and to guide future management.

Men should be counselled that ED is a risk marker for underlying cardiovascular disease (CVD) and other health conditions that may warrant evaluation and treatment.

• ED is a risk marker for systemic cardiovascular disease. The Prostate Cancer Prevention Trial demonstrated that ED is as strong a predictor of future cardiac events just as cigarette smoking or a family history of myocardial infarction.

In men with ED, morning serum total testosterone levels should be measured.

• Serum total testosterone should be measured in all men with ED to determine if testosterone deficiency (TD), defined as total testosterone <300 ng/dL with the presence of symptoms and signs, is present.

For some men with ED, specialised testing and evaluation may be necessary to guide treatment.

In individuals with ED, who present with complex histories, the following specialized testing and evaluations may be required:

• Nocturnal penile tumescence and rigidity testing
• Intracavernosal injection (ICI)
• Penile duplex ultrasound (which may be combined with ICI to produce a more detailed and quantitative assessment of penile vascular response)
• 12 cavernosometry
• Selective internal pudendal angiography

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Treatment Recommendations for Erectile Dysfunction

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.

Phosphodiesterase type 5 inhibitors (PDE5i) sildenafil, tadalafil, and vardenafil, and avanafil have similar efficacy in the general ED population. When men are prescribed an oral PDE5i for the treatment of ED, instructions should be provided to maximise benefit/efficacy and the dose should be titrated to provide optimal efficacy.

As per trials which focused on special populations, men with diabetes and men who are post-prostatectomy have more severe ED at baseline and respond less robustly to PDE5i.

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.

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.

Clinicians should counsel men with ED who have comorbidities known to negatively affect erectile function that lifestyle modifications, including changes in diet and increased physical activity, improve overall health and may improve erectile function.

• Lifestyle changes such as a healthy diet and increased exercise may have small positive effects on erectile function (EF) and broader, positive effects on overall health.

For men being treated for ED, referral to a mental health professional should be considered to promote treatment adherence, reduce performance anxiety, and integrate treatments into a sexual relationship.

Men with ED should be informed regarding the treatment option of intraurethral (IU) alprostadil, including discussion of benefits and risks/burdens. For men with ED who are considering the use of IU alprostadil, an in-office test should be performed.

IU alprostadil is recommended in the following cases:

• In men in whom PDE5i are contraindicated,
• In men or partners who prefer to avoid oral medication
• In men or partners who prefer not to use the needles required for ICI medications.

Before prescribing IU alprostadil, it is essential for the patient be acquainted with the technique and undergo an initial dose-titration in the office. A detailed counselling regarding the possible adverse events should also be carried out.

Men with ED should be informed regarding the treatment option of intracavernosal injections (ICI), including discussion of benefits and risks/burdens. For men with ED who are considering ICI therapy, an in-office injection test should be performed.

The ICI approach may be used to treat ED in the following situation:

• In patients with contraindications to the use of PDE5i
• In patients who prefer not to take an oral medication
• In patients who feel PDE5i are inadequate or ineffective

ICI medications are found to be effective in men with other conditions such as diabetes, cardiovascular risk factors, men who are post-prostatectomy, and men with spinal cord injuries.

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