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Guideline of Guidelines: a comparison of national guidelines on the management of erectile dysfunction

N. Gillman¹, E. Chung²

¹Gold Coast University Hospital, Gold Coast, Australia
²PA Hospital, Brisbane, Australia

Introduction:

Erectile dysfunction (ED) is a prevalent issue that can have substantial impacts on the quality of life of patients and their partners. Multiple national guidelines are available which provide recommendations for the assessment and management of men with ED, however variations exist in their approaches. This publication aims to summarise and compare key recommendations from major urologic society to highlight areas of consensus and divergence.

Material and methods:

Pubmed and Google Scholar were searched for erectile dysfunction guidelines published between 2000 and 2025. Major urologic and sexual health organisation websites were also investigated. Only the most recent publication from each society was included. Guidelines were only included if recommendations were presented with level of evidence and strength of recommendation. Four guidelines were accepted for inclusion which included the American Urological Association (AUA) guidelines published in 2018, European Urological Association (EUA) 2021, the British Society for Sexual Medicine (BSSM) in 2018 and The Urological Society of Australia and New Zealand (USANZ) in 2022. Key recommendations for the assessment and management of ED were synthesized and compared.

Results:

There was general consensus through all guidelines in the diagnosis and initial assessment of patients with ED. All guidelines emphasize the importance of thorough medical, sexual and psychologic history and targeted physical exam. All guidelines emphasize lifestyle modification and cardiovascular assessment, although there were variations in the workup of patients determined to be intermediate risk from a cardiovascular perspective. Variation also exists in the use of specialised testing such as nocturnal penile tumescence and rigidity testing. Available treatments were similar between guidelines, with all recommending phosphodiesterase-5 inhibitors, vacuum erection devices, intracavernosal injection and penile prothesis. A key difference between guidelines was the use of a graded, vs non-graded approach to management. Additionally, guidance on novel therapies including low-intensity shockwave therapy remains inconsistent.