An In-Depth Review of Erectile Dysfunction and Ejaculation Disorders: Pathophysiology, Diagnostic Approaches, and Multimodal Therapeutic Strategies

Erectile dysfunction (ED) and ejaculation disorders (EjD), including premature ejaculation, delayed ejaculation, retrograde ejaculation, and anejaculation, are highly prevalent male sexual dysfunctions with multifactorial etiologies. These conditions exert profound effects on psychological well-being, interpersonal relationships, and overall quality of life. Despite advancements in diagnostics and therapeutics, management remains challenging due to the complex interplay of vascular, neurological, hormonal, psychogenic, and iatrogenic factors. This review aims to provide a comprehensive synthesis of current knowledge on the pathophysiology, diagnostic modalities, and therapeutic interventions for ED and EjD, with a particular focus on multimodal and individualized management strategies. An extensive literature search was conducted using PubMed, Scopus, and Web of Science databases up to August 2025. Studies addressing epidemiology, pathophysiological mechanisms, diagnostic tools, and management of ED and EjD were included. Emphasis was placed on clinical trials, meta-analyses, and consensus guidelines from leading sexual medicine societies. ED and EjD arise from diverse mechanisms, including endothelial dysfunction, central and peripheral neurogenic impairment, hormonal dysregulation, psychological stressors, and drug-induced causes. Diagnostic evaluation integrates validated questionnaires, physical and neurological assessment, laboratory profiling, and imaging modalities such as penile Doppler ultrasound. Therapeutic strategies range from lifestyle modification and psychological counseling to pharmacological interventions (PDE5 inhibitors, SSRIs, hormonal therapy), device-based treatments, and surgical options. Emerging approaches, such as regenerative medicine, stem cell therapy, low-intensity shockwave therapy, and AI-driven diagnostics, hold promise for precision sexual health management. Effective management of ED and EjD requires a patient-centered, multidisciplinary approach that integrates pharmacological, behavioral, and psychosocial strategies. Future directions emphasize precision medicine, biomarker development, and digital health innovations. Continued research and clinical translation of emerging therapies are critical to improving outcomes in men with sexual dysfunction.