Erectile Dysfunction: AUA Guideline (2018)

For each treatment, the clinician should ensure that the man and his partner have a full understanding of the benefits and risk/burdens associated with that choice. The sexual response cycle is conceptualized as a sequential series of psychophysiological states that usually occur in an orderly progression.

Use caution with unproven ED treatments

Men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychosocial history; a physical examination; and selective laboratory testing. For the man with ED, validated questionnaires are recommended to assess the severity of ED, to measure treatment effectiveness, and to guide future management. 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. In men with ED, morning serum total testosterone levels should be measured. For some men with ED, specialized testing and evaluation may be necessary to guide treatment.

Factors mediating contraction and relaxation

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. 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. 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. When men are prescribed an oral PDE5i for the treatment of ED, instructions should be provided to maximize benefit/efficacy. For men who are prescribed PDE5i, the dose should be titrated to provide optimal efficacy.

3.1 Basic parameters of penile erection

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. 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 with ED should be informed regarding the treatment option of a vacuum erection device (VED), including discussion of benefits and risks/burdens. 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. These phases were characterized by Masters and Johnson as desire, arousal, orgasm, and resolution. Erectile dysfunction (ED) can be conceptualized as an impairment in the arousal phase of sexual response and is defined as the consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction, including satisfactory sexual performance.1,2 The Panel believes that shared decision-making is the cornerstone of the treatment and management of ED, a model that relies on the concepts of autonomy and respect for persons in the clinical encounter. It is also a process in which the patient and the clinician together determine the best course of therapy based on a discussion of the risks, benefits and desired outcome. Using this approach, all men should be informed of all treatment options that are not medically contraindicated to determine the appropriate treatment. Although many men may choose to begin with the least invasive option, the Panel notes that it is valid for men to begin with any type of treatment, regardless of invasiveness or reversibility.

Men also may choose to forego treatment.

Treatment for Erectile Dysfunction

In each scenario, the clinician's role is to ensure that the man and his partner have a full understanding of the benefits and risks/burdens of the various management strategies. A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1965 to 7/29/17) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of ED. The review yielded an evidence base of 999 articles after application of inclusion/exclusion criteria. These publications were used to create the guideline statements. If sufficient evidence existed, then the body of evidence for a particular treatment was assigned a strength rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty). Evidence-based statements of Strong, Moderate, or Conditional Recommendation, which can be supported by any body of evidence strength, were developed based on the balance of benefits and risks/burdens to men and their partners. Additional information is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. Men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychosocial history; a physical examination; and selective laboratory testing.

Why Choose University of Utah Health?

For the man with ED, validated questionnaires are recommended to assess the severity of ED, to measure treatment effectiveness, and to guide future management. 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. In men with ED, morning serum total testosterone levels should be measured. For some men with ED, specialized testing and evaluation may be necessary to guide treatment. 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. 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. 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.

• Medications for ED are available by prescription and should be used safely.
• A balanced diet rich in fruits, vegetables, and whole grains supports heart health.
• Addressing relationship issues can reduce performance pressure.
• Alternative medicine approaches include herbal remedies, though evidence varies.
• Increased physical activity boosts nitric oxide production, aiding erections.
• Hormonal evaluation helps determine if testosterone therapy is appropriate.
• Caring for mental health reduces psychological barriers to sexual function.

When men are prescribed an oral PDE5i for the treatment of ED, instructions should be provided to maximize benefit/efficacy. For men who are prescribed PDE5i, the dose should be titrated to provide optimal efficacy. 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.

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 with ED should be informed regarding the treatment option of a vacuum erection device (VED), including discussion of benefits and risks/burdens. 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.

Related Issues

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. Men with ED should be informed regarding the treatment option of penile prosthesis implantation, including vardenafil vilitra 60 mg discussion of benefits and risks/burdens. Men with ED who have decided on penile implantation surgery should be counseled regarding post-operative expectations. Penile prosthetic surgery should not be performed in the presence of systemic, cutaneous, or urinary tract infection.

Hormonal imbalances

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. For men with ED, penile venous surgery is not recommended. For men with ED, low-intensity extracorporeal shock wave therapy (ESWT) should be considered investigational. For men with ED, intracavernosal stem cell therapy should be considered investigational: (Conditional Recommendation; Evidence Level: Grade C) For men with ED, platelet-rich plasma (PRP) therapy should be considered experimental. This guideline's purpose is to provide direction to clinicians and to men who have ED.

Why Can’t I Get an Erection?

The guideline focuses on how to recognize ED, how to conduct a valid diagnostic process, and how to approach treatment with the goals of restoring sexual function and enhancing the man and his partner's quality of life (QoL) while minimizing adverse events (AEs) and diagnosis- and treatment-associated burden. The strategies and approaches recommended in this document were derived from evidence-based and consensus-based processes. There is a continually expanding literature on ED; the Panel notes that this document constitutes a clinical strategy; it is intended to be interpreted with appreciation for the dynamic, evolving understanding of ED causes and treatments. The most effective approach for a particular man is best determined by that man (in consultation with his partner, when applicable) in collaboration with the clinician and with full consideration of the relevant history, values, and goals for treatment using a shared decision-making (SDM) approach. As our understanding of ED evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care. 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. Men with ED should be informed regarding the treatment option of penile prosthesis implantation, including vardenafil vilitra 60 mg discussion of benefits and risks/burdens.

Surgical treatments

For each treatment, the clinician should ensure that the man and his partner have a full understanding of the benefits and risk/burdens associated with that choice. The sexual response cycle is conceptualized as a sequential series of psychophysiological states that usually occur in an orderly progression. These phases were characterized by Masters and Johnson as desire, arousal, orgasm, and resolution. Erectile dysfunction (ED) can be conceptualized as an impairment in the arousal phase of sexual response and is defined as the consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction, including satisfactory sexual performance.1,2 The Panel believes that shared decision-making is the cornerstone of the treatment and management of ED, a model that relies on the concepts of autonomy and respect for persons in the clinical encounter. It is also a process in which the patient and the clinician together determine the best course of therapy based on a discussion of the risks, benefits and desired outcome.

Hormonal optimization

Using this approach, all men should be informed of all treatment options that are not medically contraindicated to determine the appropriate treatment. Although many men may choose to begin with the least invasive option, the Panel notes that it is valid for men to begin with any type of treatment, regardless of invasiveness or reversibility. Men also may choose to forego treatment. In each scenario, the clinician's role is to ensure that the man and his partner have a full understanding of the benefits and risks/burdens of the various management strategies. A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1965 to 7/29/17) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of ED.

Sex and Romance: Working Together to Relight the Fire

The review yielded an evidence base of 999 articles after application of inclusion/exclusion criteria. These publications were used to create the guideline statements. If sufficient evidence existed, then the body of evidence for a particular treatment was assigned a strength rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty). Evidence-based statements of Strong, Moderate, or Conditional Recommendation, which can be supported by any body of evidence strength, were developed based on the balance of benefits and risks/burdens to men and their partners. Additional information is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. Men with ED who have decided on penile implantation surgery should be counseled regarding post-operative expectations. Penile prosthetic surgery should not be performed in the presence of systemic, cutaneous, or urinary tract infection. 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. For men with ED, penile venous surgery is not recommended.

For men with ED, low-intensity extracorporeal shock wave therapy (ESWT) should be considered investigational. For men with ED, intracavernosal stem cell therapy should be considered investigational: (Conditional Recommendation; Evidence Level: Grade C) For men with ED, platelet-rich plasma (PRP) therapy should be considered experimental. This guideline's purpose is to provide direction to clinicians and to men who have ED. The guideline focuses on how to recognize ED, how to conduct a valid diagnostic process, and how to approach treatment with the goals of restoring sexual function and enhancing the man and his partner's quality of life (QoL) while minimizing adverse events (AEs) and diagnosis- and treatment-associated burden. The strategies and approaches recommended in this document were derived from evidence-based and consensus-based processes. There is a continually expanding literature on ED; the Panel notes that this document constitutes a clinical strategy; it is intended to be interpreted with appreciation for the dynamic, evolving understanding of ED causes and treatments. The most effective approach for a particular man is best determined by that man (in consultation with his partner, when applicable) in collaboration with the clinician and with full consideration of the relevant history, values, and goals for treatment using a shared decision-making (SDM) approach. As our understanding of ED evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care. A systematic review was conducted to identify published articles relevant to the diagnosis and treatment of ED.

• Some men find relief through natural remedies, but evidence may be limited.
• Erectile dysfunction can be an early warning sign of cardiovascular disease.
• Lifestyle counseling is often part of comprehensive ED management.
• Regular exercise improves overall endothelial function.
• Medications like PDE5 inhibitors are most effective when taken properly.
• Psychological therapies are effective for ED with psychological causes.
• Surgery is considered when pharmacological and non-invasive options are ineffective.

Literature searches were performed on English-language publications using the Pubmed, Embase, and Cochrane databases from 1/1/1965 to 7/29/2017. Data from studies published after the literature search cut-off will be incorporated into the next version of this guideline. Preclinical studies (e.g., animal models), commentary, and editorials were excluded.

Practice Essentials

A systematic review was conducted to identify published articles relevant to the diagnosis and treatment of ED. Literature searches were performed on English-language publications using the Pubmed, Embase, and Cochrane databases from 1/1/1965 to 7/29/2017. Data from studies published after the literature search cut-off will be incorporated into the next version of this guideline. Preclinical studies (e.g., animal models), commentary, and editorials were excluded. Additional exclusion criteria included data not relevant to current practice (e.g., reports on medications not in current clinical use, outcomes for prostheses models that are no longer available), articles focused primarily on surgical technique with minimal or no patient information or outcomes reported, no outcomes reported or outcomes data not extractable, or duplicate report of data presented elsewhere.

Figure 2.

Review article references were checked to ensure inclusion of all possibly relevant studies. Multiple reports on the same patient group were carefully examined to ensure inclusion of only non-redundant information. The systematic review yielded a total of 999 publications relevant to preparation of the guideline. Data on study type (e.g., published systematic review/meta-analysis, randomized controlled trial [RCT], controlled clinical trial [CCT], observational study), treatment parameters (e.g., type of treatment, dosing, follow-up), patient characteristics (e.g., age, symptom duration, ED severity), outcomes (e.g., effects on erectile function, QoL), and AEs were extracted. Quality of Studies and Determination of Evidence Strength.

Avoid drugs and limit alcohol

The quality of published systematic reviews was assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR).1 Individual studies that were RCTs or CCTs were assessed using the Cochrane Risk of Bias tool.2 The quality of case-control studies and comparative observational studies was rated using the Newcastle-Ottawa Quality Assessment Scale.1004 Because there is no widely-agreed upon quality assessment tool for single cohort observational studies, the quality of these studies was not assessed. The categorization of evidence strength is conceptually distinct from the quality of individual studies. Evidence strength refers to the body of evidence available for a particular question and includes not only individual study quality but consideration of study design; consistency of findings across studies; adequacy of sample sizes; and generalizability of samples, settings, and treatments for the purposes of the guideline. Additional exclusion criteria included data not relevant to current practice (e.g., reports on medications not in current clinical use, outcomes for prostheses models that are no longer available), articles focused primarily on surgical technique with minimal or no patient information or outcomes reported, no outcomes reported or outcomes data not extractable, or duplicate report of data presented elsewhere. Review article references were checked to ensure inclusion of all possibly relevant studies. Multiple reports on the same patient group were carefully examined to ensure inclusion of only non-redundant information. The systematic review yielded a total of 999 publications relevant to preparation of the guideline. Data on study type (e.g., published systematic review/meta-analysis, randomized controlled trial [RCT], controlled clinical trial [CCT], observational study), treatment parameters (e.g., type of treatment, dosing, follow-up), patient characteristics (e.g., age, symptom duration, ED severity), outcomes (e.g., effects on erectile function, QoL), and AEs were extracted. Quality of Studies and Determination of Evidence Strength. The quality of published systematic reviews was assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR).1 Individual studies that were RCTs or CCTs were assessed using the Cochrane Risk of Bias tool.2 The quality of case-control studies and comparative observational studies was rated using the Newcastle-Ottawa Quality Assessment Scale.1004 Because there is no widely-agreed upon quality assessment tool for single cohort observational studies, the quality of these studies was not assessed. The categorization of evidence strength is conceptually distinct from the quality of individual studies. Evidence strength refers to the body of evidence available for a particular question and includes not only individual study quality but consideration of study design; consistency of findings across studies; adequacy of sample sizes; and generalizability of samples, settings, and treatments for the purposes of the guideline.