Editing Evaluation and Management of Erectile Dysfunction (section)

== Special scenarios ==

=== Erectile function recovery after radical treatment for prostate cancer ===
* '''Radical prostatectomy (RP)'''
** '''Erectile function may improve over time'''
*** '''The interval of spontaneous erectile function recovery usually occurs 12-24 months after RP, although recovery may still be possible as much as 36 months after surgery'''.
*** '''Relatively few men recover baseline erectile function, particularly those age > 60 at the time of surgery'''
** A meta-analysis of studies with >12 months follow-up post-RP reported that use of a '''bilateral nerve-sparing technique was associated with a 60% erectile function recovery rate compared to a rate of 47% for use of a unilateral nerve-sparing technique.'''
* '''Radiotherapy (RT)'''
** '''Erectile function may worsen over time'''
*** '''Onset of ED is delayed and may occur 24-36 months after treatment'''
* '''Penile rehabilitation'''
** Refers to the concept of using interventions to promote the natural recovery of erectile function after an insult to the erectile mechanism which occurs after radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy and other localized prostate cancer treatments.
*** Majority of studies focus on scheduled PDE5is for variable periods of time leading up to and following RP.
** Meta-analysis of 5 RCTs found that in every 1000 patients who receive penile rehabilitation with scheduled PDE5is, 28 more patients experienced ED resolution compared to placebo§
** '''2018 AUA: men who desire preservation of erectile function after treatment for prostate cancer (by RP or RT) should be informed that early use of PDE5i post-treatment may NOT improve spontaneous, unassisted erectile function'''
** '''2021 CUA'''
*** '''Conditionally recommends against penile rehabilitation with scheduled PDE5is following RP'''
*** '''Insufficient evidence to make any recommendation for penile rehabilitation following treatment with EBRT and brachytherapy for prostate cancer.'''
**** Limited evidence suggests that scheduled PDE5is taken around the time of radiation therapy (EBRT and/or brachytherapy) do not offer any long-term protective effects against future ED.

=== Hormonal therapy in patients with hypogonadism ===
* '''Testosterone monotherapy'''
** Unlikely leads to a clinically significant improvement in erectile function
*** Meta-analysis found that testosterone monotherapy increases IIEF-EF score by 2.65 compared to placebo§
** '''Not recommended for the purpose of treating ED in patients with hypogonadism and ED'''
* '''Dual PDE5i and testosterone therapy'''
** Some evidence to supports its use as a combination therapy to salvage patients who have failed PDE5is
** '''Should be considered in patients with hypogonadism and ED'''
*** '''Current recommendations suggest that a short (e.g. 3-month) therapeutic trial of testosterone is justified in men with hypogonadism, and in the absence of a response, testosterone administration should be discontinued'''
*** Once treatment with exogenous testosterone is initiated, ongoing follow-up is mandatory.
** Alternative hormonal replacement therapies have been suggested, but because of insufficient evidence they are not currently recommended for use