Erectile Dysfunction: A Comprehensive Review of Pathophysiology, Diagnosis and Contemporary Management

Narrative review synthesizes the full ED treatment ladder — prosthetics top 95% satisfaction; shockwave and PRP remain experimental.

Journal: Medicina (Kaunas, Lithuania) | Published: 2026-04-30 | Type: Narrative Review | PMID: 42195107 Authors: Crocetto F, Amicuzi U, Musone M, Imbimbo C, Tammaro S, Napolitano L, Reccia P, De Luca L, Del Giudice F, Stizzo M (Federico II University Naples; University of Campania; Monaldi Hospital; Sapienza Rome) Funding/COI: Not disclosed

Summary

Ten Italian urologists pooled the published evidence on erectile dysfunction from pathophysiology through to the operating room and wrote a narrative synthesis aimed at practitioners. The review covers lifestyle modification, PDE5 inhibitors, alprostadil, vacuum erection devices, penile prosthesis implantation, psychosexual therapy, and the regenerative fringe — shockwave and platelet-rich plasma — landing firmly in the camp that the last two are not ready for routine use. Nothing in the abstract is new; the value proposition is consolidation, not discovery.

Claims

• PDE5 inhibitors demonstrate "high efficacy and safety across diverse patient populations" (no pooled effect size or NNT cited in the abstract)
• Alprostadil (intracavernosal) carries approximately 70% success rates
• Penile prosthesis surgery achieves patient and partner satisfaction exceeding 95% — qualified to "experienced centers"
• Low-intensity extracorporeal shockwave therapy (Li-SWT) and platelet-rich plasma (PRP) injections are supported "only in experimental settings due to limited long-term data"
• ED prevalence is rising among younger men (no incidence figure provided in the abstract)
• Psychosexual therapy is designated an "integral adjunct," particularly for psychogenic or mixed etiologies

Study Quality

This is a narrative review, which sits near the bottom of the evidence hierarchy. The authors conducted "a comprehensive literature search" but provide no PRISMA flow, no inclusion/exclusion criteria, no quality appraisal of the synthesized studies, and no statement of how many papers were screened or included. Without those scaffolds, it is impossible to assess whether the evidence has been selected systematically or cherry-picked to support a preferred framework. The 70% alprostadil success figure and the 95% prosthesis satisfaction figure are repeated from prior literature without the authors specifying which trials or meta-analyses generated them, what the comparators were, or how "success" and "satisfaction" were defined across studies.

The multidisciplinary framing is reasonable and guideline-concordant, but the review does not appear to adjudicate between competing guidelines (EAU, AUA, ISSM) where they diverge — a missed opportunity given the stated aim of "critically distinguishing well-established evidence from ongoing clinical debates."

Red Flags

• Narrative design with no stated methodology: subject to selection bias and confirmation bias throughout
• Funding and conflicts of interest not disclosed — all ten authors are institutional urologists whose practice income may depend on the procedures being reviewed, including penile prosthesis implantation
• No pooled effect sizes, confidence intervals, or NNTs presented for any intervention — cited percentages (70%, 95%) are inherited figures of uncertain provenance
• "Comprehensive literature search" is asserted, not demonstrated — no date range, databases, or search strings reported
• Prosthesis satisfaction figure is restricted to "experienced centers," a caveat that limits real-world generalizability and is easy to miss
• Published in Medicina (Kaunas), an MDPI open-access journal with a broad scope and article-processing-charge model; not a specialist urology journal

Strengths

• Covers the full treatment continuum in a single document, useful as a clinical orientation piece
• Correctly positions Li-SWT and PRP as investigational rather than routine — a more cautious stance than some prior reviews
• Includes psychosexual therapy as a named component rather than an afterthought
• Ten co-authors span multiple Italian academic centers, which marginally reduces single-institution bias

Verdict

This review reads like a well-organized textbook chapter, not a research contribution. It synthesizes conventional wisdom competently, and the prosthesis satisfaction caveat ("experienced centers") and the shockwave/PRP skepticism are appropriate calls. But the absence of a systematic methodology, undisclosed conflicts of interest, and lack of effect-size data make it unsuitable as primary evidence for anything. Cite it if you need a readable map of the ED treatment landscape; don't cite it if you need to know whether any specific intervention actually works.