Guideline of guidelines: a scoping review on comparison of major clinical guidelines for erectile dysfunction

Introduction

Erectile dysfunction (ED) is the persistent inability to maintain an erection sufficient to permit satisfactory sexual performance (1). ED is highly prevalent, becoming more common as men age and develop medical comorbidities (2), with significant impacts on the quality of life of patients and their partners (3-5). The incidence is likely under-reported due to various factors such as embarrassment to seek treatment, social stigma or lack of awareness and education, even among healthcare providers (6), and the estimated ED rates are greater than 320 million in 2025 (7). The dichotomy between physiological and psychological factors can be unclear since ED is often multifactorial and includes anatomical, vasculogenic, neurological, and hormonal factors, as well as stress, anxiety, depression and relationship stressors (8).

There are numerous published societal guidelines for the management of men with ED, often with specific nuances and some variations in diagnostic and treatment strategies based on relevant locoregional factors such as sociocultural barriers and differences in emphasis between urological organisations versus sexual medicine societies. Presently, there is limited comparison between these published recommendations and guidelines. Clinicians need to be mindful of existing discrepancies (and similarities) among these major ED guidelines and adapt specific nuances and tailor critical aspects of guidelines based on locoregional factors and personalize the care in the ED model specifically to the individual patient.

This scoping review aims to compare established ED guidelines from major organisations and societies and identify areas of consensus and variations across diagnostic and therapeutic domains. This “guideline of guidelines” narrative format will enable clinicians to identify best clinical practices, standardize the delivery of healthcare and address inconsistencies so that future research can be undertaken to improve ED care pathways. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0168/rc).

Methods

Guideline identification and eligibility

The review was conducted as a scoping review with a structured comparison of international clinical practice guidelines for the assessment and management of ED. Guidelines were identified through searches of official websites of major urological organisations and sexual medicine societies and published literature, with further review of references within each guideline.

The inclusion criteria for eligible guidelines are (I) issued and endorsed by a major national or international urologic or sexual medicine society; (II) specifically addressing the diagnosis and/or management of ED in adult men; and (III) an updated printed or electronic version at the time of manuscript preparation.

Available grading systems and the level of evidence (LoE) from these guidelines were recorded. Guidelines lacking grading systems were included if consensus-based recommendations, evidence summaries, or position statements intended to guide clinical practice were provided. Narrative reviews, expert opinion and consensus statements not formally endorsed by national or international organisations as guidelines were excluded.

Extraction and grading of guidelines

A total of eleven national and international ED guidelines were selected for inclusion in this study (Table 1). The American Urological Association (AUA) guidelines were published in 2018 (9). LoE is classified as grade A [high certainty from robust randomised controlled trials (RCTs) or strong observational studies], grade B (moderate certainty) and grade C (low certainty with notable limitations) (10). Recommendation strength aligns with this evidence, ranging from strong (clear benefit or harm) to moderate or conditional (unclear balance of benefits and risks). The European Association of Urology (EAU) published updated ED guidelines in 2025 (11). LoE is modified from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology (12). Recommendations are classified as strong or weak, considering the quality of evidence, balance between desirable and undesirable effects, values and preferences and cost.

National ED guidelines, such as the British Society for Sexual Medicine (BSSM), were published in 2018 (13) and the Urological Society of Australia and New Zealand (USANZ) in 2022 (14) do not outline a specific grading system; provide grade A to C recommendations and associated LoE 1–4. In contrast, the Canadian Urologic Association (CUA) in 2015 (15), Korean Society for Sexual Medicine and Andrology (KSSMAA) in 2013 (16), Japanese Society for Sexual Medicine (JSSM) in 2008 (17) and Process of Care Model (PCM) in 2018 (18,19) provide comprehensive assessment and management of ED, but they do not specify the strength of recommendation or associated LoE in their publications.

The International Consultation for Sexual Medicine (ICSM), which is endorsed by the International Society of Sexual Medicine (ISSM), provides specific recommendations split over multiple publications from 2015 to 2025 regarding ED management (20-22), while the SOP by experts from ISSM was published in 2013 (23) and covered both medical and mechanical treatment of men with ED. Other major guidelines, such as the Princeton IV Consensus (24) provides specific guidelines for the clinical management of men with ED with emphasis on cardiovascular disease (CVD) management.

Each guideline was reviewed in full and relevant recommendations extracted. Extraction was restricted to content presented within the guideline documents. Predefined domains of comparison were established a priori to ensure consistency across guidelines. Recommendations were synthesised descriptively and compared across various guidelines to identify areas of consensus, divergence, and omission. Given that many ED guidelines differed in methodological approach (for example, use or absence of formal grading for some or all recommendations), key recommendations were compared qualitatively without attempting to standardise strength or LoE across documents.

Formal appraisal of guideline quality, such as the AGREE II tool, was not undertaken, as the primary objective of this review was comparative synthesis rather than quality assessment. Discrepancies or uncertainties regarding guidelines content were verified by the senior author to ensure consistency and a structured, predefined domain for comparison.

Results

Initial assessment

History and physical examination

All ED guidelines highlight the importance of clinical assessment in incorporating a thorough medical, sexual, and psychological history (AUA/EAU strong, USANZ/BSSM grade B, KSSMA, JSSM, PCM). Uniformly endorsed aspects include onset of symptoms, degree of bother, presence of nocturnal and morning erections, and investigation of concomitant ejaculatory disorders, Peyronie’s disease or lower urinary tract symptoms. Notably, most guidelines recommended the presence and involvement of the patient’s partner during consultation (AUA, EAU, USANZ, CUA, JSSM, KUA).

Targeted physical exam is consistently endorsed across all guidelines. Core components included cardiovascular assessment (such as heart rate and blood pressure), waist circumference, body mass index, and focused genitalia examination, including palpation for penile plaques or deformity and evaluation of secondary sexual characteristics and testicular volume as markers of androgen status. EAU (strong), USANZ (grade B), CUA, KSSMA, JSSM recommend further vascular and neurologic assessment to identify associated conditions, while PCM classifies these as optional.

A routine digital rectal examination (DRE) is not widely recommended. The EAU acknowledges DRE as part of the assessment, while KSSMA and JSSM recommend DRE only if the men are over 50 years old. The AUA recommends DRE in patients who may proceed with testosterone therapy, while the PCM advocates DRE as optional. The well-established association between benign prostatic hypertrophy (BPH) and sexual dysfunction (25,26) may prompt DRE as part of routine evaluation for BPH.

Guidelines advocate screening for symptoms of hypogonadism such as low libido, decreased muscle mass, testicular atrophy and fatigue as part of the medical history and physical examination. Identification of these features should prompt biochemical assessment of testosterone deficiency (TD).

Approach to patients with CVD

ED is an independent predictor of major adverse cardiovascular events such as stroke, myocardial infarction and cardiac death (27). Hence, ED serves as a useful early marker of subclinical CVD, preceding clinically evident CVD by 2 to 5 years (28). As a result, special emphasis is placed on men with known risk factors presenting with concurrent ED and CVD. The Princeton Consensus provides an in-depth discussion regarding ED management in men with ED and CVD, and similarly, thorough CVD assessment in men with ED and known risk factors is widely endorsed by national guidelines (AUA EAU, KSSMA, JSSM, ISSM, USANZ, BSSM, PCM). The Princeton IV consensus differentiates patients with overt CVD from those with suspected vasculogenic ED. In overt CVD, low-risk patients may proceed to treatment, while high-risk patients warrant cardiologist referral. Intermediate-risk patients are recommended to be reclassified after undergoing exercise stress testing, like the Princeton III recommendations (29).

Most guidelines similarly recommend cardiovascular risk stratification before initiating ED treatment, deeming low-risk patients safe to proceed to treatment and high-risk patients requiring cardiology consultation. The approach differs regarding intermediate-risk patients. The AUA recommends cardiology consultation in these patients (clinical principal), while EAU (strong) and KSSMA recommend reclassification after cardiac stress testing. BSSM, JSSM and ISSM also recommend re-stratification of intermediate-risk patients but lack formal recommendations for additional testing. The USANZ recommends cardiac risk stratification and further investigation, with referral to the cardiology team at the clinician’s discretion (grade A).

A new component of Princeton IV, which is not yet adopted into other societal guidelines, is the use of coronary artery calcium (CAC) to aid in risk stratification of intermediate-risk patients. If vasculogenic ED is suspected, the American College of Cardiology CVD Risk Estimator is recommended to provide a 10-year estimated risk of cardiovascular event to stratify patients into low risk (<5%), borderline risk (5%–<7.5%), intermediate risk (≥7.5% to <20%) and high risk (≥20%). CAC scores can be used in borderline to intermediate risk patients for re-stratification.

Diagnostic evaluation

All guidelines recommend basic laboratory testing in men presenting with ED regardless of suspected aetiology. The EAU recommends fasting glucose or haemoglobin A1c (HbA1c) and lipid profile if not available within 12 months (strong). Similarly, BSSM, USANZ (grade A), KSSMA, JSSM and AUA endorse lipid panels and glycaemic indices. In contrast, PCM and CUA guidelines recommend fasting glucose testing, but lipid studies are listed as optional.

The recommendation of routine prostate specific antigen (PSA) testing in men with ED is variable in the guidelines. AUA, EAU and KSSMA indicate PSA testing may be appropriate in select patients, while JSSM recommends PSA testing if considering testosterone replacement. It is recommended that clinicians follow local early detection of prostate cancer guidelines in relation to PSA testing.

Routine total testosterone testing is controversial. Early morning measurement is recommended to account for normal circadian variation (30). AUA recommend routine testing (moderate), with repeat measurement if TD is suspected, and thyroid function testing (TFT) in select patients. EAU (strong) and USANZ (grade A) endorse routine testosterone measurement, with additional hormonal evaluation [prolactin, luteinizing hormone (LH), sex hormone binding globulin] guided by clinical context. BSSM (grade A), KSSMA and PCM endorse routine measurement, with KSSMA recommending further hormonal testing in suspected TD. The CUA and JSSM reserve testosterone measurement for men with features of TD. The CUA also references the 2013 Canadian Diabetes Association guidelines (31) and recommends morning testosterone in patients with diabetes, accounting for the increased prevalence of hypogonadism in diabetic men (32-34). A summary of guideline recommendations is provided in Table 2.

The use of validated questionnaires

Validated questionnaires are widely recommended by all major guidelines as an adjunct to history taking and physical examination (Table 3). These instruments can quantify symptom severity and treatment response.

The International Index of Erectile Function (IIEF) is the most popular validated questionnaire for ED, assessing five domains of sexual function (erectile function, orgasm, desire, intercourse satisfaction, overall satisfaction) across 15 items (35). It is applicable across various socio-cultural contexts and is linguistically validated in 32 languages. While robust, it is not routinely completed in primary practice and lacks validation in non-heterosexual populations (36,37).

To enhance clinical utility, a five-item abridged tool, the IIEF-5 or Sexual Health Inventory for Men (SHIM), was developed by selecting the five most clinically relevant items from the IIEF, based on patient rankings during sildenafil clinical trials (38). Similarly, the erectile function domain of the IIEF (IIEF-EF) can be used to streamline assessment with a specific focus on erectile function and to monitor treatment response.

The Male Sexual Health Questionnaire (MSHQ) addresses gaps in the IIEF, specifically around ejaculatory function (39). It is validated for both composite and individual domain use and is available in multiple languages. The application may be limited in time-constrained practices. By contrast, the Erection Hardness Score (EHS) is a single-item measure of penile rigidity validated across international cohorts (40).

The IIEF and SHIM are widely endorsed (AUA expert opinion, EAU strong, USANZ grade B, BSSM grade B, CUA, KSSMA, JSSM, ISSM, PCM). AUA recommends using SHIM or EHS in certain settings; in specialty clinical practice, IIEF or MSHQ may be more appropriate. CUA, KSSMA, and JSSM recommend SHIM in clinical practice, while KSSMA prefers SHIM over IIEF for practicality in time-limited clinical settings. The ISSM and PCM endorse the use of IIEF-EF. The ISSM publication specifically recommends its use to assess the efficacy of pharmacologic treatments.

Specialised testing

There is consensus that specialised testing is generally not required but may be indicated in specific patient cohorts such as early onset or lifelong ED, failure of prior therapy, pelvic trauma, Peyronie’s disease, for medicolegal purposes or when considering surgical intervention. A summary of guideline recommendations for specialised testing is displayed in Table 3.

Nocturnal penile tumescence and rigidity (NPTR) testing

NPTR testing is a neurophysiological test measuring spontaneous erections during sleep. Typically, men experience 3–5 nocturnal erections to maintain cavernosal oxygenation and tissue integrity (41-43). The test’s reliability is influenced by factors affecting rapid eye movement (REM) sleep, which can diminish NPTR signals and mimic organic ED. These include advancing age, hypogonadism, anxiety, depression, sleep disorders (e.g. OSA, insomnia) and medication that disrupts REM sleep (SSRIs, benzodiazepines, alcohol) (41,42). Suboptimal testing conditions (unfamiliar or uncomfortable sleep lab environments) may also alter sleep patterns and distort results (43).

The use of the NPTR test and its parameters were different across ED guidelines. The EAU, CUA and KSSMA define a functional erectile mechanism as an event of 60% rigidity recorded at the tip of the penis lasting for 10 minutes. These societies also recommend testing over at least two nights. The number of nocturnal erections indicating a positive result is not provided. BSSM defines normal value as >70% rigidity and specifies that 3–4 erections lasting >10 minutes are required for a positive test, without recommendation on the number of nights of testing.

The AUA and EAU guidelines suggest that NPTR testing can be used to differentiate between psychogenic and organic aetiologies, noting that false negatives and confounding factors may limit routine use. BSSM notes NPTR use in patients to confirm neurogenic ED, for medico-legal cases, to confirm erectile potency, or to exclude false-positive results from other investigations. USANZ does not recommend the use of NPTR, citing a lack of consensus on acceptable parameters and approved devices. CUA suggests NPTR’s greatest utility is in medico-legal cases, while KSSMA notes utility in suspected psychogenic ED. PCM indicates NPTR testing plays a very small role in modern sexual medicine.

Dynamic penile duplex ultrasonography (DUS)

Dynamic penile DUS is a vascular imaging modality assessing penile arterial inflow, veno-occlusive competence and anatomical abnormalities. It is particularly useful in men with suspected vasculogenic ED, particularly those with diabetes, peripheral vascular disease and cardiovascular risk factors. DUS quantifies peak systolic velocity and end-diastolic velocity, which can be used to evaluate arteriogenic insufficiency and veno-occlusive dysfunction, respectively. DUS is optimally performed following intracavernosal injection (ICI) of a vasoactive agent (typically prostaglandin E1), and is preferred to oral agents for higher diagnostic accuracy (44).

Indications for DUS differ across guidelines. The AUA supports its use to differentiate organic and psychogenic ED in men with predominantly vascular ED, to identify severe veno-occlusive dysfunction and in revascularisation candidates. EAU supports use in patients with suspected vasculogenic aetiologies. PCM advises selective use in Peyronies disease, prior trauma, abnormality on physical exam, patients with previous unidentified cardiac risk factors, patients with primary psychogenic ED, or to confirm veno-occlusive dysfunction in patients failing to respond to medical treatment. USANZ, BSSM and CUA do not provide specific indications, with CUA noting limited routine use.

Dynamic infusion cavernosography and cavernosometry (DICC)

DICC combines anatomical imaging (cavernosography) and functional pressure measurement (cavernosometry) to assess veno-occlusive dysfunction. Important measurements include intracorporal pressure post-ICI, flow to maintain erection and pressure decay.

DICC is reserved for highly select cases across all guidelines, namely, revascularisation candidates (45), with no guideline recommending routine use. EAU, CUA and KSSMA support consideration in revascularisation candidates following abnormal DUS results. BSSM suggests use to confirm an arterial lesion diagnosed on DUS or when penile revascularisation is being considered. USANZ is the only guideline to suggest the use to identify location of cavernous venous leak. The AUA states DICC is seldom used in the modern era, given that surgery for veno-occlusive dysfunction is not recommended. The PCM acknowledges that the role of DICC is limited due to the diagnostic value of DUS.

Angiographic evaluation

Selective internal pudendal angiography is an invasive test used to provide visualisation of the pelvic and penile vasculature to assess for collateral circulation, stenosis, occlusion, disruption or anomalies of the internal pudendal artery and its branches. Guidelines are consistent that SIPA should be reserved for highly select cases of young men with a history of pelvic trauma and who are potential candidates for vascular reconstruction (AUA, EAU, USANZ, BSSM, CUA, KSSMA, PCM).

While there is emerging evidence supporting non-invasive angiographic assessment using computed tomography angiography and magnetic resonance arteriography, these modalities are not discussed in any guidelines (46-48).

Approach to treatment

While most guidelines endorse a stepwise therapeutic approach from least to most invasive options, the AUA differs, and treatment is based on informed, shared decision-making regardless of invasiveness or reversibility. The EAU recommends a two-tiered approach, with PDE5 inhibitors (PDE5-I), vacuum erection device (VED), and ICI therapy as acceptable first-line therapies, reserving penile prosthesis as second line. USANZ and CUA advocate for a three-tiered model with PDE5-Is as first line, ICI and VED as second line and penile prosthesis as third line. Similarly, BSSM, KSSMA, JSSM and ISSM SOP propose a three-tiered algorithm with PDE5-I and VED accepted as first-line options, and progress to ICI and penile prosthesis in a stepwise manner. The PCM only discusses first-line oral pharmacotherapy; however cites prior recommendations advocating for stepwise management (49). Despite guideline structure variations, it is important to note that all guidelines emphasized individualised, shared, informed decision-making in ED management.

Lifestyle and chronic disease management

Lifestyle modifications and optimisation of chronic diseases will improve penile erections and are advocated in all major guidelines. Modifiable risk factors for ED overlap with cardiovascular risk factors due to shared common pathogenesis (50,51) such as smoking, sedentary lifestyle, obesity and excessive alcohol consumption (3,52,53).

The effect of increased physical activity and weight reduction on erectile function is well established, with the MMAS demonstrating obesity and level of physical activity as independent predictors of ED (54). One study found that lifestyle changes improved IIEF scores in one-third of obese men with baseline ED, with changes in body mass index and physical activity being independently associated with IIEF improvement in multivariate analysis (55). Aerobic exercise can increase the efficacy of PDE5Is (56). These results have been reinforced by other RCTs, suggesting structured lifestyle interventions are a cornerstone of ED management (57).

Cigarette smoking is a known modifiable risk factor for ED (58) with a dose-dependent relationship observed over cross-sectional and longitudinal studies (59-62). Although the data on the effect of smoking cessation and improvement in IIEF scores remains unclear, there is increasing evidence to suggest that early cessation in younger men may improve erectile function (63,64).

Men with type II diabetes mellitus have a 3.5-fold increased prevalence of ED than those without and may be refractory to treatment (65-67). Those with type-1 (insulin-dependent) diabetes are more likely to have earlier, more advanced and medically refractory ED (65). The exact pathophysiology of ED in diabetics is complex, involving the accumulation of advanced glycation end-products, leading to impaired endothelial function with ensuing macrovascular and microvascular remodelling, while neurogenic injury diminishes nitric oxide-mediated neurotransmission and hormonal dysregulation. Diabetics with poor glycaemic control show higher rates of and more severe ED than those with optimal glycaemic control (68,69).

Oral pharmacotherapy

The use of PDE5-Is is widely endorsed. Both AUA (LoE B) and EAU (LoE 1a) provide strong recommendations for use. Similarly, USANZ, BSSM, and ICSM provide grade A recommendations supported by level 1 evidence. The ISSM SOP cites level 1 evidence in support of PDE5-Is, with the CUA, JSSM, KSSMA and PCM also endorsing their use.

Guidelines consistently highlight the importance of adequate patient education, especially in those who have had a poor response to treatment. Incorrect use of PDE5-I can lead to a significant proportion of treatment failure (56–81%) (70,71). Common scenarios include lack of sexual stimulation, timing of medication, inadequate dosing and failure to complete an adequate therapeutic trial (at least four appropriately timed doses under optimal conditions). The AUA guidelines cite 23.6% to 58.5% of men deemed to be “non-responders” may be salvaged after re-education (9). The ISSM and ICSM deem these men as “pseudo-non-responders” (23).

No single agent or dosing regimen is recommended in any guideline due to a lack of robust comparative trials. It is generally accepted, however, that currently available PDE5-Is have reasonable safety and efficacy profiles. The ICSM guidelines cite level 1 evidence to this effect, and note patients report comparable perceptions of improvement following treatment (72).

Dosing strategies differ between the AUA and ICSM guidelines. The AUA suggests titrating dosage to the lowest dose to produce acceptable patient/partner-defined outcomes. Data collated and published in the AUA guidelines suggest dose-response effects across PDE5I medications and are non-linear and often not clinically significant, while stronger dose-response effects are present for the adverse effects of the medication (9). Conversely, ICSM strongly recommends dose titration to the maximum tolerated dose to increase efficacy and treatment satisfaction (73).

Clinicians need to understand the pharmacokinetic properties of each agent to tailor treatment to men/couples. For men who prioritise spontaneity, longer acting options may be preferred. The ISSM indicates couples may prefer tadalafil owing to increased sexual freedom and spontaneity due to the longer duration of action (74). EAU cites two meta-analyses, which demonstrated a preference for on-demand sildenafil in patients prioritising efficacy, while those wishing to optimise tolerability suggest patients should commence low-dose tadalafil (75,76). Daily vs on demand dosing should be discussed with patients. The AUA pooled data from a vast number of trials and published systematic reviews to support their recommendation that on-demand vs daily dosing of tadalafil appears to produce similar efficacy levels, which is supported by the EAU guidelines. EAU, BSSM, KSSMA and ISSM recommend that a switch to daily dosing may improve erectile function in men with partial response to on-demand dosing (77-79).

VED

VED provides a mechanical negative pressure to draw blood into the corpora, resulting in penile tumescence, and when used in combination with an occlusive ring at the base of the penis, VED can be applied to most men with ED regardless of aetiology.

National guidelines vary on the role and clinical evidence supporting the use of VEDs. The AUA provide a moderate recommendation for use with a low LoE and advocates that VED should be considered as a rescue tool in combination with PDE5-I (80,81). EAU issues a weak recommendation (LoE 2b), citing high dropout rates (50-64%) (82) and recommending use primarily in patients wishing for a non-invasive, medication-free treatment option. USANZ lists ICI as a viable second-line therapy (grade B, LoE 1), while the BSSM and KSSMA suggest alternative first-line use and highlight its potential role in salvage therapy post radical prostatectomy, including in combination with PDE5-I or ICI, which is further endorsed in the ISSM publication. ISSM similarly supports VED as a monotherapy or in combination with PDE5I or ICI. The ISSM cites level 2 evidence for the use of VED, while JSSM provides a grade B recommendation, and CUA supports use as a second-line therapy. The ICSM similarly supports the use of VED, including in complex ED.

ICI therapy

ED guidelines consistently advocate ICI therapy as an effective treatment option, especially in challenging patient cohorts such as those with diabetes, CVD, spinal cord injury, or following pelvic surgery, including radical prostatectomy (83-86).

The AUA provides a moderate recommendation and highlights the effectiveness of ICI across diverse patient groups. A low LoE (LoE C) is given since most studies analysed were observational and predate the era of validated questionnaires. The EAU provides a strong recommendation (LoE 1a) supporting ICI as an alternative first- or second-line therapy, acknowledging high dropout rates (41–68%), especially in the early treatment period (87).

ICSM (grade A, LoE 1), USANZ and BSSM (grade B, LoE1) recommend ICI as second-line therapy, while noting poor compliance and emphasising the need for patient education and support. The CUA and KSSMA similarly consider ICI as second-line therapy. JSSM provides a grade B recommendation, while ICSM assigns grade A (LoE1) evidence for safety and tolerability, supporting second-line use (grade C, LoE 3).

While most guidelines conclude that ICI therapy has high clinical efficacy and patient satisfaction, compliance, especially in the early treatment stages, is often low. The EAU cites a 41–68% dropout rate, disproportionately in the first two to three months after treatment initiation (87). USANZ, BSSM, KSSMA and ICSM guidelines echo similar findings. The ISSM highlights significant attrition, with 55% dropout after 18 months, 54% at two years, and 67% at four years in two key trials (83,88). One key aspect highlighted in guideline documents for high dropout rate is inadequate patient education, supporting AUA (clinical principle) and EAU recommendation for in-office testing when commencing men on ICI therapy.

Penile prostheses

Penile prosthesis implantation is an irreversible surgical procedure that can offer a definitive solution to men with ED regardless of the underlying aetiology. Penile prostheses can be largely divided into inflatable (more commonly the three-piece device) or malleable (semi-rigid), the latter generally considered in men with poor dexterity (89). Implantation involves structural alteration of corporal architecture, resulting in irreversible loss of spontaneous erections, and patients should be thoroughly counselled before consideration for surgery.

Guidelines adopting a stepwise management approach uniformly recommend penile prosthesis as a last-line treatment. AUA (LoE C) and EAU provide strong recommendations for use, with the latter suggesting consideration in refractory cases, those not suitable for less invasive treatment, or men preferring definitive therapy. USANZ (grade B), BSSM (grade C), JSSM (grade B), and KSSM support use as a third-line therapy after failure or intolerance of other treatments, highlighting high satisfaction rates but emphasizing invasiveness and irreversibility. The ISSM SOP similarly reserves prosthesis as a final line intervention. The ICSM recommends penile prosthesis implantation in motivated patients with ED unwilling to trial or report suboptimal erection with other treatments (strong recommendation).

Penile revascularization and venous surgery

Historically, venous ligation surgery was performed to address veno-occlusive dysfunction contributing to ED. In contemporary practice, venous surgery has largely become obsolete, with no guidelines advocating for its use.

On the other hand, penile revascularisation involving microsurgical bypass remains a valid treatment and is often considered in young patients with proven arteriogenic ED after trauma (typically pelvic fracture or perineal injury). The AUA provides a conditional recommendation (grade C) for revascularisation in this cohort with demonstrable focal pelvic or penile arterial occlusion in the absence of generalised vascular disease or veno-occlusive dysfunction. The EAU recommends preoperative evaluation with penile pharmaco-arteriography and DICC to confirm stenosis and exclude corporeal veno-occlusive dysfunction. National ED guidelines, such as the KSSM, recommend DUS, SIPA and DICC in this context; while BSSM supports SIPA as part of workup; and JSSM supports revascularisation in young patients with traumatic arterial damage (grade B).

Regenerative technology

Low-intensity extracorporeal shock wave therapy (LI-ESWT)

LI-ESWT is an emerging technology for the management of ED. Acoustic shockwaves induce micro-trauma to erectile tissue to stimulate the release of angiogenic factors, including nitric oxide synthase and vascular endothelial growth factor, promoting neovascularisation and endogenous tissue repair pathway activation (90-92). LI-ESWT is variably discussed across guidelines, with most considering its use investigational.

AUA provides a conditional recommendation (LoE C) for use in investigational settings, given that RCTs have yet to provide clear and replicable evidence that benefits reliably outweigh risks. AUA notes wide heterogeneity between available studies in parameters and treatment protocols, with RCTs demonstrating inconsistent outcomes (93-96). Concerns are raised in relation to decaying efficacy over time, which may necessitate adjunctive treatment (97,98).

EAU cites level 1a evidence that treatment can induce mild improvement in erectile function in men with mild vasculogenic ED (87). A weak recommendation is given for use with or without PDE5-I in this population, as well as an alternative therapy when oral vasoactive therapies are unsuitable or declined. Similar concerns regarding heterogeneity among available data and diminishing efficacy after an initial period of improvement (1–3 months) are raised. BSSM adopts a similar stance, indicating an emerging role in management of mild ED in those wishing to avoid pharmacologic therapy, though emphasising the need for further clinical studies before adoption.

USANZ regards LI-EWST as experimental (grade B, LoE 3), recognising emerging evidence in selected patient populations such as those with mild to moderate ED, younger patients, non-diabetic men with minimal cardiovascular risk factors, and those without a history of cavernous nerve injury (14). The Asia-Pacific Society of Sexual Medicine (APSSM) has released a specific guideline on LI-ESWT, highlighting the different shockwave machines and variations in treatment protocols, and that this treatment modality is effective in a highly select group of young men with mild to moderate ED and without cardiovascular risk factors (99).

Cellular-based treatment

Cellular-based treatment, including platelet-rich plasma (PRP) and stem cell therapy (SCT) is regarded as experimental across guidelines. The AUA provides a conditional recommendation (LoE C) that SCT should be considered investigational, highlighting that available evidence is observation with small sample sizes, heterogeneity in patient populations and protocols, and unclear safety outcomes. An expert opinion is provided that PRP should not be offered outside of clinical trials, with insufficient evidence for widespread use. EAU cites insufficient evidence to support SCT, with systematic reviews showing high heterogeneity insufficient to provide clinical recommendations. Although EAU does acknowledge emerging data for PRP for the treatment of primary organic ED (100), citing level 1b evidence that PRP may produce mild improvement in erectile function, guidelines maintain that current evidence base is insufficient to recommend PRP outside of the trial setting. USANZ states that pro-erectile regenerative therapies remain largely experimental at this stage (grade B, LoE 3).

Discussion

ED is a common sexual condition affecting males from their early 20s and beyond. Many older patients who exhibit cardiometabolic risk factors should be managed accordingly and risk-stratified for CVD. Published ED guidelines recommend referral for further cardiology review in patients at higher risk of CVD before commencing PDE5i therapy, while those taking nitrates should avoid PDE5-Is.

While the introduction and easy access of PDE5i have revolutionized ED therapy and raised awareness of good sexual health and practice, it is important to advise patients with medical comorbidities that their existing medical conditions and lifestyle factors should be addressed. The current evidence supports a multi-disciplinary approach with personalised medicine to tailor the management of ED.

While there is considerable interest and excitement in regenerative technology in the field of ED, since it can (potentially) reverse underlying pathophysiology, caution should be exercised given the vulnerable cohort. Longer-term safety concerns and the need for stricter regulation and clinical governance are required to ensure ethical practice and avoid over-commercialisation.

Patients (and partners) should be counselled regarding treatment efficacy, side effect profile, and durability of each treatment, taking into consideration patient preferences and expectations. Stepwise progression from the least invasive oral agents through to second- and third-line therapies should be offered in cases where better erection is desired and/or failure of oral medication is encountered as required. It is critical that ongoing monitoring and counselling should be provided by the clinician to maximize treatment success.

Clinical guidelines on ED will continue to evolve with advances in science as more knowledge is accrued on a specific therapy and new research and development of “cutting-edge” treatment options. While it is becoming harder for clinicians to keep up with the latest treatment in the era of digital consumerism and easier healthcare informatics, clinical guidelines play an important role in providing best-evidenced clinical practice and, importantly, “guide” clinicians on how to tailor treatment strategies for their patients.

SWOT analysis

• Strength: this “scoping” review provides a comparison among major international clinical practice guidelines. This paper highlights common areas of agreement, specifically regarding medical, sexual, and psychological history and targeted physical exam. The extent of endocrine assessment varies depending on specific organisations, while specialised (more invasive) diagnostic tests are reserved for selected cases. Some variations exist in therapeutic sequencing, with some guidelines advocating a less rigid framework of a tiered, stepwise escalation model. Areas of controversy continue to exist on emerging and regenerative therapies at this stage.
• Weakness: it is important to acknowledge that this review focuses specifically on published guideline-level recommendations, which would evolve (and change) as science advances and more evidence is accrued. Existing guideline documents vary concerning methodology, grade of evidence report and locoregional emphasis. Furthermore, this paper does not assess primary clinical evidence or real-world implementation.
• Opportunities: there is a need to standardise guideline structure and reporting to ensure general application and consistent translation of evidence into clinical care. This “guideline of guidelines” narrative format will enable clinicians to identify best clinical practices, standardize the delivery of healthcare and address any inconsistencies so that future research can be undertaken to improve ED care pathways.
• Threats: major organisations and relevant societies in the field of ED need to consolidate clinical practice and provide regular updates to ensure clinical guidelines remain contemporary and provide best-evidenced clinical care.

Conclusions

This review compares major international clinical practice guidelines addressing the evaluation and management of ED. Across guidelines, there is broad agreement regarding initial patient assessment, including highlighting the importance of a thorough medical, sexual, and psychological history and targeted physical exam. Selective use of laboratory testing is encouraged, with specialised investigations reserved for selected cases.

Greater variation exists in indications and thresholds for testosterone testing and broader endocrine evaluation, therapeutic sequencing, and whether management is framed as a tiered, stepwise escalation model or a shared decision model that de-emphasises treatment lines. Emerging technologies are discussed variably, but are generally positioned as investigational, reflecting ongoing uncertainty and heterogeneity in the evidence base.

This review is limited to guideline-level recommendations and does not assess primary clinical evidence or real-world implementation. Moreover, guideline documents differ substantially in methodology and reporting. Improved international alignment in guideline structure and reporting would facilitate clearer comparison, reduce practice variation and support more consistent translation of evidence into clinical care.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0168/rc

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Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0168/coif). E.C. serves as an unpaid Associate Editor-in-Chief of Translational Andrology and Urology from August 2024 to July 2026 and as the President-elect of the International Society of Sexual Medicine. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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