The first step after the thorough evaluation, diagnosis determination, and patient education should be the modification of reversible causes, such as alcohol abuse, smoking, prescription or nonprescription drugs, and cardiovascular risk factors (e.g. hypertension).
Some authors divide the possible treatment interventions into first-, second-, and third-line ones. According to Goldstein (1999), the first-line interventions include oral erectogenic agents (e.g., sildenafil, oral apomorphine, oral phentolamine), vacuum erectile devices, and psychosexual therapy. These interventions are easy to administer, noninvasive, and reversible. Mobley and Baum (1998) also include all of these modalities in their first-line therapies, with the addition of yohimbine.
The second-line treatment interventions (Goldstein 1999) include intraurethral or intracavernous administration of alprostadil. The second-line therapies are selected in the event of failure of, insufficient response to, or excessive or intolerable side effects from one or more first-line therapy options. The third-line treatment interventions (Goldstein 1999) include surgical implantation of semirigid or inflatable penile prostheses.
Two additional treatment options for unique populations are hormone replacement therapy and revascularization surgery.
Goldstein (1999) has recommended a six-step algorithm for the assessment and management of erectile dysfunction:
1. Identification of erectile dysfunction (diagnosis confirmed, further tests or referrals)
2. Patient and partner assessment and education
3. Modification of reversible causes (if dysfunction unresolved, progress to step 4)
4. First-line therapy (if dysfunction unresolved, progress to step 5)
5. Second-line therapy (if dysfunction unresolved, progress to step 6)
6. Third-line therapy
One should always consider referral to a specialist if more specialized tests are needed (e.g., in young patients with a history of pelvic or perineal trauma), in patients with Peyronie’s disease and other deformities, or for medico-legal reasons.
Revision date: June 21, 2011
Last revised: by Andrew G. Epstein, M.D.