In the years since the last Princeton Consensus Conference was held in 2010, significant advancements have been made in the biomedical knowledge and clinical experience surrounding phosphodiesterase type 5 inhibitor (PDE5i) therapy for erectile dysfunction (ED). In particular, new data have emerged particularly with respect to the safety and potential cardioprotective benefit of this therapy.

In this light, the next Princeton Conference was conceived: the Princeton IV Consensus Guidelines Conference. Held on March 10-11, 2023, at the Huntington Medical Research Institute in Pasadena, California, this meeting convened an interdisciplinary panel of scientists and clinical practitioners, representing cardiology, urology, internal medicine, family practice, psychology, and sexual medicine (see Figure). The panel addressed current clinical practice considerations surrounding cardiovascular health and sexual function in both men and women, with special attention given to the use of PDE5i.

Figure. The Princeton IV Consensus Conference panel members. Front row, left to right: Sharon Parish, MD; Tom Lue, MD, ScD; Kevin McVary, MD; Arthur Burnett, MD, MBA; Robert Kloner, MD, PhD; Raymond Rosen, PhD, Martin Miner, MD; Noel Kim, PhD; Ira Sharlip, MD; back row, left to right, Richard Sadovsky, MD; Peter Ganz, MD; Michael Blaha, MD; Mark Hirsh, MD; John Mulhall, MD, MSc; Irwin Goldstein, MD; Hossein Sadeghi-Nejad, MD; Tobias Kohler, MD.

The Conference involved a thorough review of the extant literature relevant to this subject matter and then generation of new recommendations for clinical management. Panel members delivered presentations as assigned on a host of topics, which were followed by group deliberation. The range of topic areas included: the psychological effect of ED and the benefits of including mental health care; phosphodiesterase type 5 regulatory biology in vasculature and mechanisms of action of PDE5i; drug-drug interactions with PDE5i, including the effects of nitrates; optimizing the use of PDE5i in the treatment of ED; adverse events and potential cardiovascular benefits of using PDE5i; adulteration of dietary supplements with PDE5i; proposals and concerns related to over-the-counter PDE5i administration; alternative non-PDE5i therapies for ED, including intracavernosal injection therapy and penile prostheses; novel restorative interventions proposed for treating ED, such as stem cells, platelet rich plasma, and low intensity shock waves; perspectives on PDE5i use in women; and recommendations for future studies using PDE5i in sexual medicine. A deliberate decision was made to defer the topic of testosterone therapy with cardiovascular outcomes, while awaiting the imminent completion of studies in this arena which may impact guideline recommendations.

The panel issued recommendations for managing and optimizing sexual health incorporating factors of cardiovascular fitness. A salient feature of this endeavor was the formulation of algorithms to assist in the clinical management of the patient presenting with ED. These algorithms were derived in part from recent recommendations of the American College of Cardiology and the American Heart Association, with additional reference to the utility of CT coronary artery calcium scoring.

The program content of the Conference is meant to offer a resource for practitioners of all professional backgrounds in caring for patients presenting with sexual dysfunction, particularly in the course of administering PDE5i therapy for ED. With this purpose in mind, the findings and recommendations of this Conference will be introduced as a state-of-the-art presentation at the 24th Annual Fall Scientific Meeting of the Sexual Medicine Society of North America, to be held November 16-19, 2023, in San Diego, California. All are welcomed to attend and discuss. The proceedings of the Conference will be communicated additionally as forthcoming journal publications for wider audience access.