My clinical approach
ED is a vascular disease of the penis in most men >50 years — and a significant marker of systemic atherosclerosis. The integrated approach includes individualized diagnosis of subtype (arterial, veno-occlusive, mixed) and cardiovascular prevention.
Per the guidelines of EAU Sexual Health 2024:
- Complete sexual, medical and pharmacological history.
- Psychosocial assessment (relationship, stress, depression).
- Assessment with IIEF-5 (SHIM): mild 17-21, moderate 12-16, severe ≤11.
- Targeted genital examination: penile palpation (Peyronie), testes, inguinal area.
- Laboratory work-up: fasting glucose, HbA1c, lipid profile, morning testosterone 8-11 AM, TSH, PSA.
- Cardiovascular stratification: BP, ECG, SCORE2 risk assessment.
- In vasculogenic suspicion: penile PDDU for arterial vs veno-occlusive differentiation.
- Discussion of all therapeutic options — decision together with patient and partner.
What is erectile dysfunction
Erectile dysfunction (ED) is defined as the persistent or recurrent inability to achieve or maintain an erection sufficient for satisfactory sexual performance, lasting ≥3 months (NIH Consensus 1992, confirmed definition EAU 2024).
It is mainly a vascular disease of the corpora cavernosa — the penis is the sensitive target organ for early detection of generalized atherosclerosis (small penile arteries 1-2 mm vs coronary arteries 3-4 mm).
Prevalence: 40% at 40 years, 50% at 50, 60% at 60, 70% at 70 (MMAS). After age 50, vasculogenic etiology accounts for >70% of cases.
Penile erection anatomy
Understanding erection physiology = understanding ED subtypes.
Corpora cavernosa
Two spongy bodies (corpora cavernosa) of smooth muscle and vascular spaces (sinusoids) covered by fibrous tunica albuginea. During erection they fill with blood and compress veins — veno-occlusive mechanism.
Vascular supply
Arterial inflow: internal pudendal artery → penile artery → cavernous artery → helicine arteries that empty into sinusoids. Venous outflow: emissary veins pierce the tunica albuginea and are compressed during erection (veno-occlusive mechanism).
Neural regulation
Parasympathetic (S2-S4, nervi erigentes) — pro-erectile. Release of nitric oxide (NO) from endothelium and neurons → cGMP → smooth muscle relaxation → erection. Sympathetic (T11-L2) — anti-erectile (noradrenaline, ejaculation). Self-regulating cycle continuously in resting state.
Erection phases
Phases: latent → tumescence (volume increase) → full erection → rigid erection (emissary veins compressed) → ejaculation → detumescence. Disruption at any stage = ED.
Etiology (vascular, neurogenic, hormonal)
1. Vasculogenic (>70% in >50 years)
- • Arterial insufficiency: penile artery atherosclerosis — hypertension, diabetes, hyperlipidemia, smoking.
- • Veno-occlusive leakage: insufficient compression of emissary veins — tunica albuginea aging, Peyronie disease, diabetic neuropathy.
- • Mixed: combination — very common after age 60.
- • Endothelial dysfunction: reduced NO production — generalized marker of systemic disease.
2. Neurogenic (10-20%)
Diabetic neuropathy (up to 75% of diabetics), multiple sclerosis, Parkinson disease, stroke, spinal cord injury, radical prostatectomy/cystectomy (penile nerve injury), penile trauma.
3. Hormonal (5-10%)
Hypogonadism (testosterone <3 ng/mL), hyperprolactinemia, hypo/hyperthyroidism, Cushing syndrome, diabetes (metabolic connection).
4. Drug-induced
Beta-blockers, thiazides, psychotropics (SSRIs, neuroleptics), antiandrogens, opioids, alcohol, smoking, marijuana.
5. Psychogenic (young adults)
Performance anxiety, depression, relationship problems, stress. Features: sudden onset, good morning erection, good erection with masturbation.
6. Penile structural disorders
Peyronie disease (plaques, curvature), penile fracture (post-traumatic venous leakage), priapism (ischemia and fibrosis).
Clinical evaluation
Important questions for distinguishing organic vs psychogenic ED:
- Onset: sudden (psychogenic) vs gradual (organic).
- Morning erections: present (psychogenic/hormonal) vs absent (vasculogenic/neurogenic).
- Erection with masturbation: present (psychogenic) vs absent (organic).
- Loss of erection mid-coitus: veno-occlusive leakage.
- Inability to achieve erection: arterial insufficiency.
- Associated libido loss: hormonal (low testosterone).
- Concomitant lower urinary tract symptoms (LUTS): correlation with BPH, metabolic syndrome.
- Curvature or pain on erection: Peyronie disease.
Diagnosis & PDDU
History & IIEF-5 (SHIM)
International Index of Erectile Function — 5 questions, classification: 22-25 no ED, 17-21 mild, 12-16 mild-moderate, 8-11 moderate, 5-7 severe.
Physical examination
Inspection and palpation of penis (Peyronie plaques, fibrous tunica), testes (volume, consistency), inguinal arteries, perineal neurological exam.
Laboratory work-up
Fasting glucose, HbA1c, complete lipid profile, morning testosterone (repeat if <3 ng/mL), SHBG, LH/FSH, prolactin, TSH, PSA, urinalysis.
Penile PDDU (gold standard for vasculogenic ED)
Color Doppler after intracavernosal injection of 10-20 μg alprostadil. Parameters: PSV (Peak Systolic Velocity) <25 cm/s = arterial insufficiency. EDV (End Diastolic Velocity) >5 cm/s = veno-occlusive leakage. RI (Resistive Index) <0.8 = pathological.
Nocturnal penile tumescence (NPT/RigiScan)
Rarely used now — assessment of organic vs psychogenic. Normal 3-5 erections/night lasting ≥10 minutes. Alternative: stamp test.
Neurophysiological testing
In neurogenic suspicion: BCR (bulbocavernosus reflex), penile nerve conduction, SSEPs.
Dynamic cavernosometry
Rare — only in young candidates for surgical venous ligation. DICC (Dynamic Infusion Cavernosometry & Cavernosography).
Cardiovascular assessment
Princeton III consensus: ED = "window of opportunity" for cardiovascular prevention. In high SCORE2 risk: cardiology referral.
Therapeutic ladder
Per EAU 2024 — individualization based on subtype, severity and patient preference:
First line: PDE5 inhibitors
- • Sildenafil 25-100 mg, duration 4-6 hours, take 30-60 minutes before.
- • Tadalafil 10-20 mg PRN or 5 mg daily, duration up to 36 hours.
- • Vardenafil 5-20 mg, duration 4-6 hours.
- • Avanafil 100-200 mg, rapid onset 15-30 minutes.
Efficacy 60-70% overall, 80% in psychogenic, 40-50% in diabetics. Contraindications: nitrates, severe heart failure NYHA III-IV, recent MI <6 months, hypotension.
Vacuum Erection Device (VED)
Mechanical vacuum system for passive blood inflow + constriction ring at base. Drug-free, suitable for elderly, PDE5i-risk patients. Satisfaction 60-70% with proper training.
Second line: Intracavernosal injections
Alprostadil (PGE1) 5-40 μg intracavernosally — efficacy 70-90% even in diabetics and post-prostatectomy. Trimix (alprostadil + papaverine + phentolamine) in resistant cases. Side effects: prolonged erection/priapism (1%), pain, fibrosis. Intraurethral alprostadil (MUSE) 125-1000 μg — milder alternative.
Li-ESWT (shock waves)
Low-intensity extracorporeal shock wave therapy — microvascular regeneration in mild-moderate vasculogenic ED. Protocol 4-6 weekly sessions. EAU 2024: weak recommendation (level 2b). Non-invasive, no significant side effects.
Third line: Penile prosthesis
For failure of PDE5i + injections + vacuum, severe venous leakage, post-prostatectomy with rehabilitation failure. 3-piece inflatable prosthesis (AMS 700, Coloplast Titan) — patient satisfaction 90-95%, partner 85-90%, lifespan 15-20 years. Complications: infection 1-3%, mechanical failure 5%, erosion <1%.
Adjunctive interventions
Testosterone TRT in confirmed hypogonadism (testosterone <3 ng/mL with symptoms). Discontinuation of culprit drug (beta-blocker, SSRI). Sex therapy / CBT in psychogenic or mixed ED. Lifestyle modification: smoking cessation, weight loss, aerobic exercise — improve IIEF.
Prevention & cardiovascular risk
ED as an early marker of cardiovascular disease (penile arteries 1-2 mm, coronary 3-4 mm) — may precede a cardiac event by 3-5 years.
- Smoking cessation — significantly reduces ED risk.
- Mediterranean diet — improves IIEF (PREDIMED study).
- Aerobic exercise 150 min/week of moderate intensity.
- Maintain normal weight (BMI 20-25).
- Control of hypertension, diabetes, hyperlipidemia.
- Limit alcohol <14 units/week.
- Treatment of sleep apnea.
- Periodic cardiovascular check-up (age-appropriate).
Frequently asked questions (FAQ)
What is erectile dysfunction (ED)?
The persistent or recurrent inability to achieve or maintain an erection sufficient for satisfactory sexual performance, lasting ≥3 months. Per EAU 2024, defined as dysfunction of the vascular, neural, muscular or hormonal function of the penis.
How common is it?
Worldwide ~150 million men (Massachusetts Male Aging Study). Prevalence 40% at 40, 70% at 70 years. After age 50, vasculogenic etiology predominates (>70% of cases).
Is it a vascular problem?
In men >50, vasculogenic ED (arterial and/or venous leakage) accounts for >70% of cases. ED is considered an early marker of systemic vascular disease — may precede a cardiac event by 3-5 years.
Which examination is important?
Today the color penile Doppler ultrasound after intracavernosal vasoactive injection (PDDU) is the gold standard for distinguishing arterial (PSV <25 cm/s) from veno-occlusive insufficiency (EDV >5 cm/s). Also IIEF-5, laboratory work-up, hormones.
What are the treatment options?
First line: PDE5i (sildenafil, tadalafil, vardenafil, avanafil). Second line: vacuum device, intracavernosal injections (alprostadil), intraurethral alprostadil. Third line: penile prosthesis implantation. Adjunctive: Li-ESWT (low-intensity shock wave therapy).
How do PDE5 inhibitors work?
They inhibit PDE5 in cavernous bodies → cGMP increase → smooth muscle relaxation → arterial dilation and tumescence. They require sexual stimulation. Efficacy 60-70% in general population. Contraindicated with nitrates.
Are shock waves effective?
Li-ESWT (Low-intensity extracorporeal shock wave therapy) has shown IIEF improvement in mild-moderate vasculogenic ED — microvascular regeneration. EAU 2024: weak recommendation (level 2b). Non-invasive, no side effects — reasonable option before injections in selected patients.
When is penile prosthesis suggested?
In failure of PDE5i + injections + vacuum, severe venous leakage, Peyronie disease with severe ED, after radical prostatectomy with rehabilitation failure. 3-piece (inflatable) prosthesis — patient satisfaction 90-95%, partner satisfaction 85-90%.
Is ED reversible?
In younger men with psychogenic or reversible causes (hormonal, drugs): yes. In chronic vasculogenic ED it is treatable but not curable — requires continuous therapy. Early intervention (<2 years from onset) gives better results.
Related topics
Difficulty achieving or maintaining erection?
Contact us for comprehensive evaluation with IIEF-5, laboratory work-up, color penile Doppler (PDDU) and individualized therapeutic approach — from PDE5i to penile prosthesis.
Scientific literature
- EAU Guidelines on Sexual and Reproductive Health (2024) — uroweb.org
- Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. J Urol 2018;200(3):633-641 — auanet.org
- Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151(1):54-61 — pubmed.ncbi.nlm.nih.gov
- Nehra A, Jackson G, Miner M, et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc 2012;87(8):766-78 — pubmed.ncbi.nlm.nih.gov
- Sokolakis I, Hatzichristodoulou G. Clinical studies on low intensity extracorporeal shockwave therapy for erectile dysfunction: a systematic review and meta-analysis. Int J Impot Res 2019;31(3):177-194 — pubmed.ncbi.nlm.nih.gov
Meet the doctor
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas offers comprehensive diagnosis of erectile dysfunction with IIEF-5, laboratory work-up, color penile Doppler (PDDU) for arterial vs veno-occlusive leakage differentiation, and therapeutic escalation from PDE5i through intracavernosal injections, Li-ESWT to penile prosthesis per EAU 2024 and AUA 2018 guidelines.
View full profile
