without testosterone therapy. Optional hormone levels that also can be obtained include free (or bioavailable) testosterone, luteinizing hormone, estradiol, and prolactin levels. A screening hemoglobin A1c may be obtained in patients with clinical suspicion of pre-diabetes or diabetes.

In men with a known etiology for ED, empiric treatment with a PDE5-inhibitor (PDE5i) can be initiated [2]. However, if further evaluation of the vasculature of the penis is necessary, penile doppler ultrasound (PDUS) assessment can be performed in the clinic. The integrity of the penile vasculature is evaluated by measuring the change in the penile arterial diameter and fow velocity before and after an intracavernosal injection (ICI) of erectogenic medication. In patients with normal arterial infow, peak systolic velocity (PSV) after ICI should exceed 30 cm/s. End diastolic fow (EDF) should be less than 5 cm/s. Arterial diameter should increase by 50% after injection. The erection obtained during PDUS should estimate the intactness of the veno-occlusive mechanism within the penis, but cannot exclude subtle forms of venous insuf ciency, inhibited autonomic outfow, or totally psychogenic factors.

Treatment

Men with ED can have various etiologies. Diagnosis is key for appropriate counseling and treatment of the patient. Current non-experimental treatment modalities include lifestyle changes to minimize the risk of developing ED and oral medications, ICI, vacuum devices or intraurethral suppositories, and penile implant surgery. Finally, referral to a mental health professional can be considered to reduce anxiety around sexual performance.

Lifestyle Changes

Modi cation of various habits can result in decreased risk of developing ED. Various medical conditions, including obesity, diabetes, and cardiovascular disease, as well as lifestyle habits, including chronic alcohol use and tobacco use, can increase the risk of developing ED. In fact, the association of ED with cardiovascular disease is so strong that a diagnosis of ED in a young man with no comorbidities should be considered an indication for referral to a cardiologist for evaluation. Lifestyle modi-cations that have been linked with a decreased risk of developing ED include: an increase in physical activity along with weight loss and healthy diet, decreasing alcohol and tobacco use, improved glycemic control in diabetics, and minimizing stress, anxiety, and depression [3].

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