Erectile dysfunction is one of the most common male sexual disorders and a frequent reason for urological or andrological consultation. Yet ED is increasingly recognised not merely as an isolated sexual complaint but as a sentinel marker of endothelial dysfunction, metabolic impairment and cardiovascular risk. The 2025 EAU SRH guideline update marks an important evolution in the management of erectile dysfunction. The document moves clinicians toward a more holistic, integrated and personalised view of ED as both a sexual and systemic condition.
PDE5 inhibitors remain foundational, but hormonal assessment, testosterone therapy, comorbidity optimisation and shared decision-making play a far more prominent role. For clinicians managing male sexual health, the updated recommendations provide a more nuanced, evidence-based approach that addresses not only erectile function but also the broader health of the patient.
The EAU 2025 guidelines underscore that evaluation must start with a comprehensive clinical history. This includes the severity and duration of ED, situational vs generalized symptoms, libido assessment, relationship context, psychological contributors and a complete review of comorbidities. Particular attention is paid to cardiometabolic disease, as ED often precedes coronary artery disease by several years.
The physical exam remains standard (genital inspection, testicular volume, penile abnormalities, blood pressure, BMI/waist circumference) and digital rectal examination (DRE) is recommended when hypogonadism is suspected or when testosterone therapy is considered.
A major emphasis of the 2025 guideline is the structured assessment of testosterone. Morning total testosterone should be measured on two separate occasions. When results are borderline or SHBG abnormalities are suspected, clinicians should calculate free testosterone and measure LH/FSH to distinguish primary, secondary or compensated hypogonadism. This reflects stronger evidence linking low testosterone to reduced PDE5 inhibitor response and to cardiometabolic disease.
A key clinical message is that ED = CV risk evaluation. Patients should undergo glucose/HbA1c, lipid profile, renal function and blood pressure assessment. Identifying uncontrolled metabolic conditions is essential because treating them improves both general health and erectile function.
Specialised tests such as penile Doppler ultrasonography remain reserved for selected cases, not first-line.
PDE5 inhibitors continue as the cornerstone of ED treatment, but the guideline introduces several new clinical points:
One of the most clinically relevant 2025 updates is the repositioning of testosterone therapy in men with ED and proven low testosterone. Key changes include:
This integrated hormonal–vascular strategy aligns with newer data showing that testosterone deficiency is both a contributor to ED and a marker of broader metabolic dysfunction.
The traditional “stepwise” model (oral → injection → surgery) is replaced by a patient-centred modular pathway:
The guideline stresses shared decision-making, considering invasiveness, efficacy, patient expectations and couple dynamics.
The 2025 update places erectile dysfunction within a wider framework of male sexual health, recognising how closely it interacts with other conditions. Peyronie’s disease, for example, should always be assessed when men present with ED; documenting curvature, pain and functional impairment helps determine whether medical therapy, combined approaches or surgical correction are appropriate (particularly when the deformity compromises erectile function).
Premature ejaculation (PE) is another frequent companion of ED. The guidelines highlight the bidirectional relationship between the two: addressing anxiety, erection quality or ejaculatory control in one condition can lead to meaningful improvement in the other. For many patients, this means combining behavioural strategies with targeted pharmacological therapy.
Finally, hypogonadism remains central to the evaluation of any man with erectile difficulties. The updated diagnostic thresholds and clearer treatment indications in the 2025 guidelines reinforce the importance of routinely assessing testosterone. Correcting androgen deficiency not only improves general wellbeing but can also enhance responsiveness to PDE5 inhibitors, making hormonal evaluation a key step in a comprehensive ED work-up.