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Santhosh Ramaraj

Editor | Updated On November 17, 2025 | News





Erectile Dysfunction — Clinical Pathways

Erectile Dysfunction — Clinical Pathways

This organizes the management of erectile dysfunction into three coordinated but separate pathways. Each pathway is intentionally limited to 2–3 levels of nesting to ensure mobile usability while preserving the decision-flow format of your original template.



Pathway 1 — Initial Evaluation & Foundational Management

This pathway guides the clinician through the initial assessment of erectile dysfunction, focusing on identifying
reversible causes, evaluating overall health, and ensuring that sexual activity is safe from a cardiovascular standpoint
before any pharmacologic treatment begins.

Erectile Dysfunction — Initial Evaluation Pathway
Initial Assessment
  • Identify and treat curable causes (organic & psychosexual)
  • Address lifestyle factors (weight, smoking, exercise)
  • Evaluate cardiac safety of sexual activity
Cardiac risk stratified?
Yes

  • Proceed to therapeutic decision-making

No

  • High risk → Refer to cardiology
  • Intermediate risk → Obtain stress test



Pathway 2 — First-Line Therapy (Oral PDE5 Inhibitors)

Once initial evaluation is complete and cardiac safety is established, most patients can begin oral PDE5 inhibitor
therapy as the first-line approach. This pathway helps determine candidacy, evaluate response, and decide when to move
to other treatment options.

Erectile Dysfunction — First-Line Therapy Pathway
Candidate for PDE5 Inhibitors?
Yes

  • Initiate oral PDE5 inhibitor therapy (first-line option)
  • Provide expectations and usage guidance
Improvement with PDE5 inhibitor?
Yes

  • Continue PDE5 inhibitor therapy
  • Maintain lifestyle optimization

No

  • Proceed to second-line therapy

No

  • Consider alternative or adjunctive therapies
Alternative/Adjunctive Options
  • Psychosexual therapy (psychogenic ED)
  • Testosterone replacement (hypogonadism)
  • Penile arterial reconstruction (focal arterial occlusion)



Pathway 3 — Second-Line & Third-Line Therapies

This pathway applies when first-line oral therapy is ineffective or contraindicated. It outlines the stepwise use of
local, mechanical, or surgical options, ensuring that escalation remains rational, evidence-based, and aligned with
patient preference.

Erectile Dysfunction — Second- & Third-Line Therapy Pathway
Second-Line Therapies
  • Intraurethral alprostadil
  • Topical alprostadil
  • Intracavernous injection therapy
  • Vacuum erection device
  • Eroxon topical gel
Improvement with second-line therapy?
Yes

  • Continue effective second-line therapy

No

  • Consider third-line therapy
Third-Line Therapy
  • Penile prosthesis implantation
Unresponsive or atypical?
  • Refer to urology or sexual medicine specialist


Disclaimer: This article is for educational purposes only and does not replace professional medical advice. Clinicians should use their judgment and adapt recommendations to each patient’s individual context. Patients should not replace a conversation with a qualified healthcare professional. It is not intended to provide medical advice, diagnosis, or treatment. Always consult your doctor or another licensed clinician for decisions about your health.