PSA Every 6–12 months >2.5 µg/L or a 25% rise from baseline triggers biopsy
Lipid panel Annually Monitor for changes due to testosterone therapy
Liver function tests Annually (if on HRT) ALT/AST within normal range
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4. Decision‑Tree Algorithm
START | |---Patient presents with erectile dysfunction | | | |---Take full history, perform physical exam, labs | | | |---Screen for cardiovascular risk factors | | | |---Assess psychosocial status | | | |---If organic cause suspected → Order Doppler ultrasound | |---Findings: Erectile dysfunction present? | |---Yes → Evaluate: | - Vascular (ultrasound) | - Hormonal | - Neurological | - Psychogenic | |---No → Reassess, consider other causes | |---Treatment decision | |---If organic cause confirmed → Initiate therapy | (PDE5 inhibitor, lifestyle changes) | Provide counseling on risks/benefits | |---If no clear cause or psychogenic → Consider psychotherapy | |---Follow-up | | - Monitor efficacy and side effects | - Adjust treatment as needed
7. Summary
No single "best" medication – the choice depends on patient‑specific factors (co‑morbidities, concurrent drugs, lifestyle).
Evidence base: All PDE5 inhibitors are similarly effective; newer agents offer modest advantages in certain subgroups.
Safety considerations: Avoid use with nitrates or strong CYP‑3A4 inhibitors; monitor for hypotension and visual disturbances.
Cost and adherence: Generic sildenafil is the most economical but may require twice‑daily dosing; tadalafil’s once‑daily regimen can improve compliance.
Future directions: Ongoing trials of non‑PDE5 treatments (guanylate cyclase stimulators, gene therapy) promise alternative options for patients who cannot tolerate current drugs.
By integrating these findings, clinicians can tailor erectile dysfunction therapy to individual patient profiles—balancing efficacy, safety, convenience, and cost—to achieve optimal outcomes.
