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Erectile Dysfunction: Monitoring Response to Treatment in Clinical Practice—Recommendations of an International Study Panel


John Mulhall, MD, Weill Medical College of Cornell University—Department of Urology, 525 East 68th Street, New York, NY 10021, USA. Tel: +1-212-746-5653; Fax: +1-212-746-0403; E-mail:


Introduction.  Clinical practice guidelines for management of erectile dysfunction (ED) provide limited direction in defining appropriate treatment goals with phosphodiesterase type 5 (PDE5) inhibitor therapy.

Aim.  To establish an evidence-based position on treatment goals in ED, including the role of erection hardness, with the potential to improve self-esteem, confidence, and overall sexual and relationship satisfaction.

Main Outcome Measure.  The target of ED therapy is optimization of a rigid erectile response, as assessed by the 4-point Erection Hardness Score (EHS).

Methods.  An international panel of experts in urology, psychology, and primary care convened to evaluate retrospective data from worldwide phase 2, 3, and 4 clinical trials, involving over 10,000 men with ED, as well as data from recent prospective studies, concerning the role of erection hardness in defining the response to treatment with PDE5 therapy.

Results.  Significant positive correlations were found between EHS and the Quality of Erection Questionnaire and the International Index of Erectile Function (IIEF) erectile function domain score and other IIEF measures. Significant positive correlations were also found between erection hardness and psychosocial measures such as self-esteem, confidence, and relationship satisfaction (assessed by the Self-Esteem And Relationship questionnaire), and satisfaction with medical treatment (assessed by the Erectile Dysfunction Inventory of Treatment Satisfaction). A shift in most frequent erection from EHS 3 (hard enough for penetration but not fully hard) at baseline to EHS 4 (completely hard and fully rigid) at the end of treatment was accompanied by significant improvements in intercourse and relationship satisfaction, psychosocial benefits, and satisfaction with ED treatment.

Conclusions.  Support is found for monitoring and treating patients with ED to their full erectile potential. Quantitative assessment of erection hardness in clinical practice will lead to improved outcomes in overall sexual experience and optimal treatment satisfaction. Mulhall J, Althof SE, Brock GB, Goldstein I, Jünemann K-P, and Kirby M. Erectile dysfunction: Monitoring response to treatment in clinical practice—Recommendations of an international study panel. J Sex Med 2007;4:448–464.