Erectile dysfunction (ED) is more than a matter of sexual health; it is a diagnostic puzzle, a therapeutic challenge, and often a mirror reflecting the underlying vascular and endocrine well-being of a man. Despite the wealth of guidelines published by international societies, the reality in clinics is strikingly different. Patients rarely present as textbook cases, physicians rarely have the luxury of unlimited time, and treatment often demands flexibility rather than rigid adherence to recommendations.
To understand how physicians actually navigate this complex field, a group of Italian andrology experts engaged in a Delphi consensus exercise. Their findings highlight not only the discrepancies between guideline recommendations and daily clinical practice but also the nuanced judgment required in treating men with ED. This article unpacks those findings and places them in a broader context, offering a detailed exploration of diagnostic priorities, therapeutic dilemmas, and the art of tailoring treatment to real patients rather than hypothetical standards.
The Diagnostic Labyrinth: When Tests Help and When They Do Not
At first glance, diagnosing ED might seem straightforward: the patient cannot achieve or maintain an erection, therefore the problem is defined. Yet the subtleties begin once one asks why. Is it vascular, hormonal, psychological, neurological, or iatrogenic? And, crucially, how much testing is really necessary?
The consensus panel broadly supported standard blood work—glucose, lipid profiles, and testosterone levels. This is unsurprising, since ED is tightly interwoven with cardiovascular risk factors and endocrine dysfunction. Indeed, the identification of hypogonadism or dyslipidemia not only guides sexual health interventions but also provides a window into long-term systemic risk. Failing to check testosterone or metabolic markers would be akin to ignoring chest pain in a man with hypertension.
By contrast, enthusiasm waned for more esoteric tests. Nocturnal penile tumescence, once a darling of academic studies, was rejected by most experts as cumbersome and clinically unhelpful. Similarly, routine testicular ultrasound and transrectal prostate scans failed to win consensus. Physicians, pressed for time and practicality, know that many patients do not require an arsenal of imaging to reach an actionable diagnosis.
Perhaps the most contested tool was penile Doppler ultrasound after intracavernous injection. While guidelines caution against its routine use, many clinicians still rely on it in practice. The rationale is easy to understand: Doppler offers a rapid and tangible assessment of vascular integrity, sparing months of uncertainty. Yet the consensus revealed no clear agreement—underscoring that sometimes guidelines and bedside pragmatism are at odds, and neither is entirely wrong.
Lifestyle Modifications: The Oldest Treatment, Still Undervalued
If medicine were a matter of textbooks alone, ED could often be reversed with weight loss, a Mediterranean diet, smoking cessation, and moderate alcohol use. The panel strongly supported these measures, echoing decades of research linking lifestyle to erectile capacity. Weight loss in overweight men, a shift towards fruits, vegetables, and fish, and the elimination of smoking received near-unanimous agreement.
Alcohol, however, proved a sticking point. Complete abstinence was endorsed in the first survey round but collapsed under scrutiny in the second. Physicians know that real life tolerates nuance: light drinking can alleviate anxiety and improve endothelial function, while heavy consumption predictably impairs erections and cardiovascular health. The experts, in essence, mirrored what patients already know but seldom hear from doctors—one glass of wine is not the end of virility, but a bottle might be.
The irony is clear: lifestyle advice is cheap, effective, and universally applicable, yet it is often given little space in hurried consultations. Patients want pills; physicians want efficiency. And thus, while lifestyle change remains the first-line recommendation in guidelines, it too often becomes the forgotten prescription.
The First-Line Therapy Debate: To Counsel or to Prescribe?
When faced with a young man with mild ED, what should a physician do? Guidelines suggest counseling, reserving medication for more severe cases. But the panel revealed a different truth: few clinicians actually rely on counseling alone.
The reasons are pragmatic. Psychological interventions require time, expertise, and multiple sessions. Patients, meanwhile, are often impatient, distressed, and expecting a pharmacological fix. Thus, the combination of counseling with phosphodiesterase type 5 inhibitors (PDE5i) often becomes the real-world default.
Interestingly, the consensus fractured on whether to begin PDE5i as on-demand or daily regimens. Guidelines generally advise starting low and titrating up, but in practice many clinicians prescribe high doses initially to avoid under-treatment and patient discouragement. Here lies a subtle irony: in theory, slow titration is cautious and scientific; in practice, an unimpressed patient may never return for follow-up if the first dose fails. Real medicine, unlike clinical trials, must keep the patient engaged.
When PDE5 Inhibitors Fail: Rehabilitation or Replacement?
Despite their success, PDE5 inhibitors are not a panacea. Roughly a third of patients fail to respond, whether due to comorbidities, inadequate use, or advanced vascular disease. What then?
The panel debated options ranging from switching agents to combining treatments. Some advocated intracavernous prostaglandin injections, penile prostheses, or rehabilitation with long-term daily PDE5i. Yet consensus was elusive. While rehabilitation with daily dosing sounds attractive, evidence remains thin, and the burden on patients is high. The concept of “rehabilitating” an erection may work in theory, but in practice, persistence with a drug that has already disappointed rarely inspires enthusiasm.
Still, the experts agreed that treatment failure should not be declared hastily. At least six properly conducted attempts are required before labeling a drug ineffective. Education about proper timing, need for stimulation, and avoidance of counterfeit medications can rescue many so-called failures. Indeed, treatment “re-education” may be more valuable than switching drugs in certain cases.
The Patient’s Voice: Preferences, Partners, and the Internet
Guidelines rarely mention the patient’s partner, yet in practice, her opinion often carries decisive weight. The consensus revealed that many physicians do consider partner preference in drug selection—whether for the convenience of an orodispersible film or the duration of action. After all, an erection is seldom a solitary affair.
External influences, however, remain problematic. Patients arrive having read forums, consulted pharmacists, or even purchased drugs online. The panel admitted that black-market PDE5i use is not uncommon, though they unanimously opposed encouraging online purchasing. Generic drugs, too, sparked debate: while theoretically equivalent, many physicians expressed mistrust of minor manufacturers, preferring branded products despite higher cost. Here, medical caution collides with economic reality—patients often choose affordability, while physicians prefer reliability.
Adherence and Dropout: Why Patients Abandon Therapy
One of the most sobering insights from the consensus was the recognition that up to half of patients discontinue PDE5i within a year. Reasons are multiple: lack of efficacy, side effects, cost, or resolution of symptoms. For intracavernous injections and vacuum devices, dropout rates are even higher.
To counter this, experts emphasized education. Patients should be taught about the pharmacokinetics of different drugs, realistic expectations, and the need for repeated attempts. A man expecting spontaneous erections after a single tablet may abandon treatment prematurely if not counseled properly. Switching agents can also improve adherence, as some patients respond better to one PDE5i than another, even if the pharmacology appears similar.
The message is clear: drugs alone do not guarantee success; informed, engaged patients do. Failure to address misconceptions breeds frustration, and frustration breeds dropout.
Rehabilitation After Surgery: A Delicate Balance
Postoperative ED, particularly after prostatectomy, presents unique challenges. Here, the consensus supported early intervention, recognizing that prolonged erectile inactivity leads to structural damage. Yet enthusiasm for daily rehabilitation regimens was tempered by evidence showing no clear superiority over on-demand approaches.
PDE5i remained the first-line choice after nerve-sparing surgery, while intracavernous injections and vacuum devices provided options for non-responders. Penile prostheses were reserved as a last resort, though many acknowledged their effectiveness in restoring function when all else fails.
These findings reflect a broader theme: rehabilitation is valuable, but its precise regimen remains a matter of debate. Guidelines may prescribe daily use, but patients often prefer on-demand therapy—an area where evidence and preference diverge.
Clinical Case Scenarios: Where Theory Meets Reality
The Delphi consensus included illustrative cases that tested theoretical guidelines against practical judgment.
In one case, a diabetic man with cardiovascular disease and kidney impairment was judged best treated with on-demand sildenafil orodispersible film rather than daily regimens or prostaglandins. Despite his comorbidities, experts dismissed the need for mandatory cardiology referral, recognizing that not all “complex” patients require a parade of specialists before treatment can begin.
Another case involved a middle-aged man recovering from a failed marriage, on sotalol for arrhythmia, and engaged in casual relationships. Here, the consensus favored on-demand short-acting PDE5i, while rejecting long-term regimens. Psychological evaluation was considered ideal but impractical, reflecting once again the divide between recommendations and clinical realities.
A third case, involving an elderly diabetic smoker with vascular disease, highlighted the limits of pharmacology. Some experts supported retrying sildenafil after improving metabolic control, while others advocated prostaglandins or prosthesis. Consensus was elusive, underscoring that in advanced disease, there is no perfect solution—only compromise.
Closing the Gap: Guidelines vs. Clinical Reality
The overarching lesson from this consensus is that guidelines, while invaluable, cannot capture the messy complexity of real-world practice. Physicians balance evidence, patient expectations, comorbidities, costs, and cultural factors in ways that defy rigid algorithms.
This does not mean guidelines should be abandoned. Rather, they should be adapted with humility, recognizing their role as a compass rather than a map. The consensus process itself—bringing together diverse expert opinions—demonstrated that when evidence is strong, clinicians converge; when it is weak, they improvise.
For ED, as in much of medicine, the future lies in flexibility. International collaborations, broader consensus studies, and better integration of patient voices may help narrow the gap between recommendation and reality. But perhaps the most valuable lesson is that the art of medicine resides in tailoring science to the individual—something no guideline can fully dictate.
Frequently Asked Questions
1. Why do many men stop using PDE5 inhibitors after starting treatment?
Up to half of patients discontinue within a year due to unmet expectations, cost, side effects, or misunderstanding of proper use. Education, repeated attempts, and sometimes switching agents can greatly improve adherence.
2. Is lifestyle modification really effective for ED, or is it just theoretical advice?
Lifestyle changes—weight loss, Mediterranean diet, smoking cessation—are among the most effective interventions, particularly in patients with cardiovascular risk factors. They not only improve erections but also reduce long-term health risks.
3. Should every man with ED undergo extensive diagnostic testing?
No. Basic hormonal and metabolic assessments are essential, but many specialized tests are unnecessary in routine practice. Targeted diagnostics should be reserved for complex or refractory cases.
