Erectile Dysfunction (clinical workup)

Erectile dysfunction is the kind of complaint that gets undertreated because people are embarrassed and overtreated because they go straight to the…

Sections

1. It’s the cardio canary, which is the part nobody opens with
2. Psychogenic vs organic, and the dichotomy is messier than the textbook
3. The PDE5 ladder, which is the medication category that did most of the work in the 2000s
4. Testosterone’s role, which the wellness internet is wrong about
5. What’s nice to hear, since this whole post leans on the bad-news cardio angle
6. A typical pattern, no demographic detail because the pattern is the lesson
7. What you should know if you’ve been quietly self-medicating
8. Where this lands
9. Sources

Erectile dysfunction is the kind of complaint that gets undertreated because people are embarrassed and overtreated because they go straight to the internet and buy generic Viagra from a sketchy website. Both moves skip the part of the visit that actually matters, which is that ED in a guy over 40 is frequently the early warning sign of something bigger, and the workup is the cheap part of the visit. The pill is the easy part. The workup is the part the wellness clinics skip and the part the sketchy mail-order setups don’t do at all.

It’s the cardio canary, which is the part nobody opens with

The single most important thing to understand about new-onset ED in a man over 40 is that it’s frequently the first symptom of cardiovascular disease. The blood vessels in the penis are smaller and more sensitive than the ones in your heart, which means they get clogged earlier and start having trouble before your coronary arteries do. Guys with new ED have a meaningfully elevated risk of a cardiac event in the following five years, and this is well-documented in the cardiology literature, not some fringe theory.

What that means practically: if you’re 45 and your erections have softened and the morning wood has gone quiet, the first thing your doctor should do isn’t write you a Cialis script and send you home. It’s screen your lipids, your blood pressure, your A1C (the three-month average blood sugar test that catches diabetes and prediabetes), ask about your family history, and ask about your exercise tolerance. Sometimes the ED is the cheap early warning the body sent so you’d catch the cardio problem before the cardio problem caught you. It’s a useful symptom in the same way a check-engine light is useful… it’s annoying, you’d rather it weren’t on, and it’s also doing its job.

There’s a pattern of patients who come in for ED and walk out with a statin and a referral to cardiology and end up having a stent placed within six months. They are not happy about it at the time. They are extremely happy about it five years later when they haven’t had a heart attack. The ED visit ended up being the most important medical encounter of their decade. Which is not the framing anybody walks in expecting.

Psychogenic vs organic, and the dichotomy is messier than the textbook

The classic teaching is that you can sort psychogenic from organic ED by whether the guy is still getting nocturnal or morning erections. If you’re getting reliable morning wood, the plumbing works, and the problem is happening upstairs. If you’ve stopped getting morning erections too, the issue is more likely physiological. That’s mostly still true. Mostly. The clean dichotomy is messier in real life because a lot of patients have some of both, performance anxiety stacked on top of mildly diminished vascular function is the common combo, and the ED is real on both axes.

Treating only the medication side and ignoring the anxiety leaves the guy frustrated. Treating only the anxiety and ignoring the vascular contribution leaves him frustrated in a different way. The right move is usually to treat both at once, the way you’d treat any condition with two contributing causes… fix what’s fixable on each side, see where it lands, adjust from there.

Psychogenic ED skews younger and tends to be situational. He’s fine with masturbation but not with a partner. He’s fine with a new partner but not with his wife of fifteen years. He’s fine when nothing’s on the line and falls apart when there’s any pressure attached. The pattern itself is the diagnosis, the context-sensitivity is the tell.

Organic ED is more consistent across contexts. It doesn’t care who’s in the room or whether you’re alone. It just doesn’t fully work. Diabetes, vascular disease, low testosterone, post-prostate-surgery, certain medications (SSRIs are big offenders, beta blockers too, lots of common ones), and aging itself all contribute, sometimes simultaneously.

The PDE5 ladder, which is the medication category that did most of the work in the 2000s

The PDE5 inhibitors (Viagra, Cialis, Levitra, Stendra… a class of drugs that block an enzyme called phosphodiesterase-5, which in plain language means they let the blood vessels in the penis stay relaxed longer when they’re supposed to be relaxed) are the first-line medications for most ED that has any vascular contribution. They don’t create erections out of nothing. They potentiate the body’s normal mechanism, so you still need the desire and the stimulation, the pill just helps the plumbing actually respond to what’s coming in.

Sildenafil (Viagra) works fast (30 to 60 minutes), lasts four to six hours, on-demand dosing, food affects absorption so don’t take it right after a heavy steak dinner unless you want it not to work.

Tadalafil (Cialis) works slower (one to two hours), lasts 24 to 36 hours, can be taken as needed or daily at a lower dose. The daily 2.5 or 5mg dose is the option a lot of patients end up preferring because it removes the planning element entirely, you take it every morning, sex happens when it happens, no countdown clocks. The downside is the cost, even now that it’s generic, the daily dosing adds up over a year.

If the first one you try doesn’t work well, try a second before giving up on the class. They aren’t interchangeable for every patient. Some guys respond beautifully to Cialis and barely respond to Viagra, or the other way around, and the reasons aren’t entirely clear from the pharmacology. The trial-and-error step is real, don’t conclude the class doesn’t work for you on one bad night.

Testosterone’s role, which the wellness internet is wrong about

Low testosterone can contribute to ED but it’s usually not the main driver, and adding testosterone to a guy with normal-ish T isn’t going to fix the ED. We check it because we should check it on any guy with ED, but a normal T level rules it out as the cause, and an actually-low T level means we need to address that separately, in parallel with the ED workup.

The TRT-as-ED-fix mythology is everywhere in the wellness internet and it’s mostly wrong. If your T is genuinely low and you start replacement, your ED might get better, but more often it modestly improves libido while leaving the actual erectile function unchanged. The plumbing still needs to work, and testosterone doesn’t fix the plumbing, it just turns the desire back up. Confusing the two is the kind of mistake that’s good for TRT clinic revenue and not particularly good for patients.

What’s nice to hear, since this whole post leans on the bad-news cardio angle

The thing worth saying out loud: ED is one of the most treatable problems in men’s health when patients actually do the workup and start on a real medication regimen. The pills work for most guys, and the daily low-dose Cialis option in particular has changed the experience for a lot of patients, sex stops being something you have to plan around and goes back to being something that just happens when it happens. The patients who get the cardiac workup done and put on the right combination of a PDE5 plus whatever’s needed for the underlying vascular stuff usually report better sex than they were having in their late thirties, because the workup also catches and corrects the metabolic stuff that was quietly worsening everything else. The fix is real, the timeline is short, and the embarrassment of bringing it up is by far the worst part of the process. The actual visit is fifteen minutes and surprisingly anticlimactic.

A typical pattern, no demographic detail because the pattern is the lesson

The common shape of an ED workup that ended up mattering goes like this. Say you’ve got a guy who comes in because he hasn’t been able to maintain an erection with his wife for about a year. He’s embarrassed enough that he’s been ordering generic sildenafil online for six months without telling either his primary care doc or his wife. It’s been partially working. The right move is to make him do the full workup before refilling anything. His A1C comes back in the diabetic range. His LDL is high enough that nobody had been catching it. His blood pressure has been creeping up at his last few primary care visits and nobody had medicated it. The ED was the canary, exactly as advertised.

Get him on metformin, a statin, and lisinopril (the diabetes drug, the cholesterol drug, the blood pressure drug, three of the most studied medications in clinical medicine). Add tadalafil 5mg daily for the symptomatic side. Three months later his diabetes is controlled, his lipids are down, his pressure is normal, and his erections are back to where they’d been in his mid-thirties. He’s annoyed that the original ED workup was the thing that found the metabolic stuff, and grateful it found it before something worse did. That’s the workup paying for itself.

Sometimes the ED is the cheap warning the body sent so you’d catch the cardio problem before the cardio problem caught you.

What you should know if you’ve been quietly self-medicating

Don’t just buy sildenafil from the internet and call it done. The pills are usually real, they often work, and they’re treating a symptom while skipping the workup that might catch the thing that’s actually killing you. Get the labs. Get the blood pressure. Get the cardio screen if there’s any indication for it. Then if you want the PDE5 on top of that, fine, that’s a legitimate move and the right way to do it. The sequence matters more than the medication does, and the sequence is the part the wellness sites are leaving out.

Where this lands

ED in a man over 40 is often the first sign of vascular disease, and the workup is the cheap part of the visit. The pills work for most patients and the daily Cialis is the option a lot of guys end up preferring because it removes the timing problem. The TRT-as-cure-all marketing is mostly wrong. The most important thing your ED is telling you might have nothing to do with sex… it might be a check-engine light for the rest of the system, and the patient who pays attention to it ends up substantially ahead of the one who orders online and never mentions it.

Sources

1. Vlachopoulos CV, Terentes-Printzios DG, Ioakeimidis NK, et al. Prediction of cardiovascular events and all-cause mortality with erectile dysfunction: a systematic review and meta-analysis of cohort studies. Circ Cardiovasc Qual Outcomes. 2013;6(1):99-109. PMID 23300267.
2. Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. J Urol. 2018;200(3):633-641. PMID 29746858.
3. Yafi FA, Jenkins L, Albersen M, et al. Erectile dysfunction. Nat Rev Dis Primers. 2016;2:16003. PMID 27188339.