ICD-11HA01.1	MALE ERECTILE DYSFUNCTION (ED) Male erectile dysfunction
ICD-10F52.2	Failure of genital response
DSM-5-TRF52.21	Erectile Disorder

1. Definition and nosology

Erectile Dysfunction (ED; ICD-11: HA01.1 Erectile Dysfunction; DSM-5-TR: F52.21) — persistent difficulty in obtaining or maintaining an erection sufficient for sexual intercourse. Duration ≥ 6 months, in most attempts.

2. History

• 1998 — FDA approval of sildenafil (Viagra) — revolution in ED treatment.
• AUA (American Urological Association) Guideline (Burnett 2018, 2024 update).
• EAU (European Association of Urology) Guidelines.

3. Epidemiology

• 5–10% at age 40, 50%+ at age 70.
• Risk factors: diabetes, cardiovascular disease (ED as cardiovascular early marker), hypertension, hyperlipidemia, smoking, obesity, depression, antidepressants.

4. Aetiology and pathogenesis

• Organic (~70%) — vascular, neurogenic, endocrine (hypogonadism), medication-related.
• Psychogenic (~10%) — performance anxiety, relationship problems, depression.
• Mixed (~20%).
• Princeton III Consensus (Nehra 2012) — ED an early cardiovascular marker, cardiac risk assessment important.

5. Clinical features

• Difficulty obtaining or maintaining erection.
• Presence or absence of morning or nighttime erections (for psychogenic vs organic differentiation)
• Relationship and emotional burden.

6. Diagnosis

6.1 Unified diagnostic criteria (AUA 2018 · EAU)

A. Persistent difficulty obtaining and/or maintaining erection.

B. Duration ≥ 6 months, in most attempts.

C. Distress or relationship impairment.

6.2 Source-specific clarifications

• AUA 2018/2024 and EAU — stepwise approach.

6.3 Diagnostic algorithm

1. Clinical interview (sexual and medical history, relationships).
2. IIEF (International Index of Erectile Function) / SHIM.
3. Laboratory — morning testosterone, glucose, HbA1c, lipid, prolactin, thyroid.
4. Cardiovascular evaluation.
5. Penile ultrasound (vascular suspicion) — selective.

6.4 Differential diagnosis

7. Examination and assessment

• IIEF.
• Medical and laboratory (above).
• Cardiac evaluation (EKG, stress test if needed).

8. Treatment

8.1 General principles (AUA 2018/2024 · EAU stepwise)

1. 1st line:
   • Lifestyle — smoking cessation, weight, physical activity, cardiovascular management;
   • PDE5 inhibitors — sildenafil (25–100 mg), tadalafil (5–20 mg as needed or 2.5–5 mg daily), vardenafil, avanafil; Never co-administered with nitrate; caution with α-blockers.
2. 1st line (in hypogonadism): Testosterone replacement therapy (TRT) — only for confirmed hypogonadism (≥ 2 morning measurements low + symptoms); monitoring PSA and hematocrit.
3. Second-line:
   • Intracavernosal alprostadil (PGE1);
   • Transurethral alprostadil (MUSE);
   • Vacuum erectile device.
4. Third-line: penile prosthesis (semirigid or inflatable); high satisfaction.
5. Psychotherapy — in performance anxiety; couple therapy.
6. Antidepressant-induced ED — bupropion, mirtazapine, vortioxetine alternative; sildenafil adjunct (Nurnberg JAMA 2003).

8.2 Source-specific clarifications

• Burnett A.L. et al. AUA Guideline. J Urol 2018, 2024 update.
• Salonia A. et al. EAU Guidelines 2023.

Treatment methods

1. PDE5 Inhibitors — Phosphodiesterase 5 inhibitor; absolutely contraindicated with nitrates.
2. Intracavernosal Alprostadil — PGE1; if PDE5 fails.
3. Vacuum Device — Non-invasive; can be used with anticoagulant.
4. Penile Prosthesis — Refractory ED; high satisfaction.
5. International Index of Erectile Function (IIEF) — Severity scale.

9. Prognosis

PDE5 with 70% efficacy; refractory cases 2nd–3rd line; cardiovascular risk management reduces mortality.

10. Myths and misconceptions

Myth 1: “ED is a normal part of aging, requires no treatment”

Evidence: ED is an early cardiovascular marker; active intervention is essential.

Myth 2: “Over-the-counter ‘natural’ potency enhancers are safe”

Evidence: FDA warnings — many “natural” products contain undeclared sildenafil/tadalafil — interaction with nitrates, risk of death.

Myth 3: “Testosterone replacement therapy is needed for every ED patient”

Evidence: AUA — only in confirmed hypogonadism; routine TRT not recommended.

Myth 4: “Shock wave therapy (Li-ESWT) is standard treatment”

Evidence: AUA 2024 — under investigation; not standard first-line.

Myth 5: “Yohimbine is an effective natural alternative”

Evidence: Ernst E., Pittler M.H. J Urol 1998;159(2):433–436 — small effect, side effects of anxiety and hypertension; PDE5 superior.

11. Sources

1. WHO. ICD-11. HA01.1 Male erectile dysfunction. 2024.
2. APA. DSM-5-TR. 2022.
3. Burnett A.L. et al. Erectile Dysfunction: AUA Guideline. J Urol 2018;200(3):633–641.
4. Salonia A. et al. EAU Guidelines on Sexual and Reproductive Health 2023.
5. Nehra A. et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc 2012;87(8):766–778.
6. Yuan J. et al. Comparative effectiveness and safety of oral phosphodiesterase type 5 inhibitors for erectile dysfunction: a systematic review and network meta-analysis. Eur Urol 2013;63(5):902–912.