Erectile dysfunction, and the warning it carries
The complaint is about sex, but the message is often about the heart. ED is an early marker of vascular disease, and the workup is as much about cardiovascular risk and a missed testosterone as it is about getting an erection back. The treatment is a ladder, and one drug combination can kill.
The one-liner
ED is a cardiovascular warning sign — screen risk and check a morning testosterone. Treat up a ladder: lifestyle/risk modification → PDE5 inhibitor → vacuum device → intracavernosal injection → penile prosthesis. The absolute rule: PDE5 inhibitors plus nitrates cause catastrophic hypotension — never together.
Erectile dysfunction is one of those complaints where the symptom in the room is not the most important thing in the room. An erection is a neurovascular event — parasympathetic nerves release nitric oxide, smooth muscle relaxes, and blood is trapped in the cavernosal sinusoids — so when it fails for vascular reasons, it often fails before the coronary arteries announce themselves. ED is a cardiovascular marker, and treating it without acting on that is a missed opportunity that can cost the man more than his sex life.
The workup looks past the penis
A good ED evaluation is really three evaluations at once: the sexual history (onset, whether it’s situational, partner and psychological factors, a medication review), a cardiovascular risk assessment, and a hunt for treatable contributors. The labs that matter:
- Morning total testosterone × 2 — low T is a common, fixable cause that gets missed.
- Fasting glucose/HbA1c and a lipid panel — the vascular substrate.
- TSH and prolactin where the picture fits.
One clean clinical clue: preserved nocturnal and morning erections point toward a psychogenic cause rather than an organic one.
What everyone gets wrong
The lethal one and the lazy one. The lethal mistake is a PDE5 inhibitor in a man on nitrates — the two together cause profound, sometimes fatal hypotension. It is an absolute contraindication, no exceptions. (α-blockers plus a PDE5 inhibitor is a caution, not an absolute bar — start low.) The lazy mistake is prescribing the pill without ever checking a testosterone, treating the symptom while a fixable endocrine cause sits undiagnosed.
The ladder
- Lifestyle and risk modification — weight, exercise, smoking, glycemic control, and reviewing offending drugs (β-blockers, SSRIs, antiandrogens). Plus treat a low testosterone if you found one.
- PDE5 inhibitors — first-line. Sildenafil and vardenafil last ~4 hours; tadalafil covers up to 36 hours on demand or can be taken as a low daily dose; avanafil is the fastest in onset. The mechanism is the whole reason the nitrate interaction is so dangerous.
- Vacuum erection device — mechanical, drug-free, useful when pills fail or are contraindicated.
- Intracavernosal injection — alprostadil, or bi/tri- mix. Highly effective; counsel firmly about the priapism risk (any erection past 4 hours is an emergency).
- Inflatable penile prosthesis— the gold standard for refractory ED. It reliably works and is concealed, but it is a permanent commitment with a real revision rate and a 1–3% infection risk.
The complaint is about an erection; the duty is also about a heart. Every ED visit is a free cardiovascular screen the man didn’t know he was getting.
If you remember one thing
Treat ED as a window, not just a symptom: check the testosterone, weigh the cardiovascular risk, and climb the ladder from lifestyle to prosthesis. And hold the single line that never bends — PDE5 inhibitor plus nitrate, never.