Approach to a patient of erectile dysfunction

The physical examination is an essential element in the assessment of ED. Signs of hypertension as well as evidence of thyroid, hepatic, hematologic, cardiovascular, or renal diseases should be sought. An assessment should be made of the endocrine and vascular systems, the external genitalia, and the prostate gland. The penis should be carefully palpated along the corpora to detect fibrotic plaques. Reduced testicular size and loss of secondary sexual characteristics are suggestive of hypogonadism. Neurologic examination should include assessment of anal sphincter tone, the bulbocavernosus reflex, and testing for peripheral neuropathy.
The other test may be done to rule out common causes

1. studies of nocturnal penile tumescence and rigidity;
2. psychological diagnostic tests.
3. vascular testing (in-office injection of vasoactive substances, penile Doppler ultrasound, penile angiography, dynamic infusion cavernosography/cavernosometry)
4. neurologic testing (biothesiometry-graded vibratory perception; somatosensory evoked potentials)
Depending upon cause following steps should be taken
1. Patient counselling & education
2. Oral agents: Sildenafil, tadalafil, and vardenifil are the only approved and effective oral agents for the treatment of erectile dysfunction
3. Androgen therapy
4. Vacuum Constriction Devices: Vacuum constriction devices (VCD) are a well-established, noninvasive therapy.
They are a reasonable treatment alternative for select patients who cannot take sildenafil or do not desire other interventions.
VCD draw venous blood into the penis and use a constriction ring to restrict venous return and maintain tumescence.
Adverse events with VCD include pain, numbness, bruising, and altered ejaculation. Additionally, many patients complain that the devices are cumbersome and that the induced erections have a nonphysiologic appearance and feel.
5. Intraurethral Alprostadil: If a patient fails to respond to oral agents, a reasonable next choice is intraurethral or self-injection of vasoactive substances. Intraurethral prostaglandin E1 (alprostadil), in the form of a semisolid pellet (doses of 125–1000 g), is delivered with an applicator
6. Intracavernosal Self-Injection: Injection of synthetic formulations of alprostadil is effective in 70–80% of patients with ED, but discontinuation rates are high because of the invasive nature of administration.
Surgery: A less frequently used form of therapy for ED involves the surgical implantation of a semirigid or inflatable penile prosthesis. These surgical treatments are invasive, associated with potential complications, and generally reserved for treatment of refractory ED. Despite their high cost and invasiveness, penile prostheses are associated with high rates of patient and partner
satisfaction.
7. Sex therapy : A course of sex therapy may be useful for addressing specific interpersonal factors that may affect sexual functioning. Sex therapy generally consists of in-session discussion and at-home exercises specific to the person and the relationship. It is preferable if therapy includes both partners, provided the patient is involved in an ongoing relationship.