Shared Decision-Making in Erectile Dysfunction Care: Key Insights from the AUA Guideline

Men who consult a urologist about erectile dysfunction are often presented with a range of treatment options and asked which they would prefer, rather than being told which one to use. This reflects the approach set out in the 2018 American Urological Association (AUA) Erectile Dysfunction Guideline, which identifies shared decision-making as central to ED care.

This article is the third in our series on the AUA Erectile Dysfunction Guideline. The first explained what the guideline is and how urologists use it, and the second covered what it says about venous leak and surgery. This article covers shared decision-making: what the guideline asks of the clinician, what it asks of the patient, and how it applies when the underlying problem is venous leak.

Background: what the AUA Guideline is

The Erectile Dysfunction: AUA Guideline (2018) is the primary evidence-based document guiding how urologists in the United States evaluate and treat ED. It was produced by a multidisciplinary panel following a systematic review of the literature. Its recommendations carry designations such as Strong, Moderate, or Conditional Recommendation, alongside statements labeled Clinical Principle or Expert Opinion where the evidence base is thinner but professional consensus is clear. For a fuller overview, see our earlier article on the guideline itself.

The change from stepwise treatment

ED treatment has historically followed a stepwise sequence: oral medication first, then a vacuum device, then injections, with penile prosthesis considered only after the earlier options had been attempted and had failed.

The 2018 guideline does not follow this model. Its position is that men should be informed of all treatment options that are not medically contraindicated, regardless of invasiveness or reversibility, and that beginning with any of them is valid. A man who, after a full discussion, prefers to start with injections rather than oral medication is making a legitimate choice, as is a man who wants to try an external device before any pharmacological treatment.

The practical effect is that treatment selection is based on the mechanism involved and the patient's circumstances and preferences, rather than on a fixed sequence.

What the guideline asks of the clinician

Shared decision-making involves specific obligations rather than simply presenting a list of options.

Evaluation before discussion

Statement 1 is a Clinical Principle: men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychosocial history, a physical examination, and selective laboratory testing. Treatment selection depends on knowing the underlying mechanism. The evaluation is also relevant because ED is a recognized early marker of cardiovascular disease, and the appointment may be the first point at which that is identified.

Presenting the full range of options

The clinician is expected to set out all non-contraindicated treatments: oral medications, vacuum erection devices, intracavernosal injections, intraurethral therapy, external constriction devices that improve blood retention, penile prosthesis, and, in narrowly selected cases, vascular surgery. Omitting an option on the assumption that a patient would not want it, or because it is unfamiliar in a particular practice, does not meet the guideline's expectation.

Discussing benefits and burdens

For each option, the guideline expects the patient, and his partner where appropriate, to understand the benefits and the risks or burdens involved. This includes realistic success rates rather than best-case figures, what regular use involves, which treatments are reversible and which are not, and what the options are if the chosen approach does not work.

Psychological support

Statement 6 (Moderate Recommendation; Evidence Level: Grade C) advises that referral to a mental health professional should be considered, to promote treatment adherence and reduce performance anxiety. The guideline treats psychological support as a component of care rather than a separate matter.

Partner involvement

The guideline encourages inviting the patient's partner into the assessment and the decision where this is possible and clinically appropriate. A partner may hold relevant information, may have views on which treatments are acceptable, and is directly affected by the approach chosen. Adherence is a recognized problem in ED care, and a treatment that a couple does not use consistently does not produce results.

If your partner is able to attend, bringing them is worthwhile. If not, discussing the options with them beforehand allows their concerns to be raised during the appointment.

What shared decision-making asks of the patient

The approach depends on information from the patient as well as from the clinician.

Describing symptoms precisely is important. A general statement that erections are unsatisfactory provides limited diagnostic information. Whether you can achieve an erection but not maintain it, whether firmness is lost on changing position, whether morning erections still occur, and whether medication was previously effective each point toward a different mechanism. Our article on how to talk to your doctor about erectile dysfunction and venous leak covers this in more detail.

Stating your priorities is equally relevant. Frequency, spontaneity, comfort, discretion, cost, and how a treatment is experienced by a partner are all legitimate considerations, and a clinician can only weigh preferences that have been expressed.

Declining an option is also a decision the guideline supports, provided the decision is made with a clear understanding of what the option involves.

Application to venous leak

Venous leak illustrates the practical difference between the two approaches.

Under a stepwise model, a man whose primary problem is excessive venous outflow would begin with oral medication, since that was the first step. PDE5 inhibitors act primarily by increasing blood flow into the penis. For a man with significant veno-occlusive dysfunction, the result may be partial or absent, and under the stepwise model that outcome was a prerequisite for moving to the next option.

Under shared decision-making, the discussion begins with the mechanism. Where evaluation indicates that outflow rather than inflow is the dominant problem, approaches that improve blood retention can be discussed from the outset, alongside or instead of those that address inflow. As covered in the previous article in this series, the guideline does not recommend penile venous surgery, which leaves non-surgical approaches as the practical option. Combining a treatment that supports inflow with one that slows outflow is a legitimate approach.

If a constriction device forms part of your treatment, observe the standard safe-use limits: a maximum of 30 minutes of continuous wear, removal before sleeping, and immediate removal if numbness, coldness, discolouration, or pain occurs. Men taking anticoagulants, men with sickle cell disease, and men with reduced penile sensation should consult a physician before use.

For an explanation of the mechanism itself, see our guide to venous leak and erectile dysfunction.

Practical points

If you are preparing for an appointment:

• Ask what the evaluation indicated about mechanism: inflow, outflow, or both.
• Ask to hear every option that is not contraindicated for you, including those your clinician may assume you would not want.
• Ask for long-term rather than short-term success rates, and what the options are if the first choice does not work.
• State what matters to you: spontaneity, comfort, reversibility, cost, and how a treatment is experienced by your partner.
• Bring your partner if possible, or raise their perspective on their behalf.
• Note that decisions can be revisited. Choosing one approach does not preclude the others, with the exception of penile prosthesis, which is irreversible.

Summary

• The 2018 AUA Erectile Dysfunction Guideline identifies shared decision-making as central to ED care.
• The guideline does not follow a stepwise treatment model. Men should be informed of all non-contraindicated options and may begin with any of them, regardless of invasiveness or reversibility.
• Clinicians are expected to evaluate thoroughly first (Statement 1), present the full range of options, and discuss benefits and burdens.
• Referral for mental health support should be considered to support adherence and reduce performance anxiety (Statement 6).
• Partners should be invited into the process where possible and clinically appropriate.
• For men with venous leak, approaches that address blood retention can be discussed from the outset rather than only after inflow-focused therapies have been tried.

The next article in this series covers how the guideline distinguishes arterial from venous causes of vasculogenic ED, and what that distinction means for treatment selection.

References

• Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. Journal of Urology. 2018;200(3):633–641. https://www.auajournals.org/doi/10.1016/j.juro.2018.05.004
• American Urological Association. Erectile Dysfunction: AUA Guideline (2018) — unabridged version, including Statement 1 (evaluation), Statement 2 (validated questionnaires), Statement 6 (mental health referral), and the panel's discussion of shared decision-making and partner involvement. AUA Guidelines page