2015 CUA Practice guidelines for erectile dysfunction

Erectile dysfunction (ED) is the preferred clinical term describing the persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3 months. The initial diagnosis and treatment of ED is most commonly performed in Canada by primary care physicians (PCPs). PCPs, urologists, internists, psychiatrists, and other treating healthcare professionals should be encouraged to initiate an open dialogue of sexual issues to identify men with ED who may not otherwise volunteer their sexual concerns. Frequently a careful history, physical exam, serum glucose or hemoglobin A1C, lipid profile and optional hormonal testing facilitate the diagnosis of ED and effective therapy. Patient history can differentiate ED from other male sexual dysfunctions, including ejaculatory disorders (premature ejaculation and other abnormalities), hypogonadism, disorders of orgasm, and Peyronie's disease. Organic (physical) causes of ED are present in most men, but situational or psychosocial contributing factors often play a contributory role. Addressing these issues may enhance treatment efficacy. Underlying risk factors associated with ED are common to cardiovascular disease in general, and should be identified during evaluation as they may represent the initial clinical sign of generalized endothelial disease (vascular insufficiency). Evaluation of family history, nicotine use, blood pressure, lipid profile, and glucose is required or should be documented if previously performed. Active management of identified cardiac risk factors should be instituted (i.e., smoking cessation, blood pressure treatment). Once reversible causes of ED are ruled out, a trial of oral medication is recommended as first-line therapy, based on treatment efficacy, side effect profile, and minimal invasiveness. Specialized testing and referral are generally reserved for cases where oral first-line treatments fail or are not appropriate, of if greater insight into the etiology is desired by the patient/physician. Second-line therapies, although more invasive than oral agents, are generally well-tolerated and effective. Surgery remains an important option for men refractory to medical management, offering effective and durable ED treatment outcomes.