What are the treatment options for erectile dysfunction?

Treatment Options for Erectile Dysfunction

First-line treatment for erectile dysfunction should be oral phosphodiesterase type 5 inhibitors (PDE5i), which are effective in 60-65% of men with ED regardless of comorbidities. 1

Initial Assessment

Before initiating treatment, a focused evaluation should include:

• Sexual, medical, and psychosocial history to identify:

  • Onset and duration (sudden vs. gradual)
  • Quality of spontaneous, morning, or self-stimulated erections
  • Cardiovascular risk factors (hypertension, diabetes, hyperlipidemia)
  • Current medications that may cause ED
  • Psychological factors (depression, anxiety, relationship issues)
  • Lifestyle factors (smoking, alcohol, recreational drugs)

• Focused physical examination:

  • Blood pressure measurement
  • Genital examination (testicular size, penile abnormalities)
  • Secondary sexual characteristics
  • Lower extremity pulses

• Basic laboratory tests:

  • Testosterone level (if hypogonadism is suspected)
  • Fasting glucose and lipid profile

Treatment Algorithm

First-Line: Oral PDE5 Inhibitors

PDE5 inhibitors available in the US include:

• Sildenafil
• Tadalafil
• Vardenafil
• Avanafil

Key considerations for PDE5i therapy:

• All have similar efficacy in general ED population 1
• Dose should be titrated for optimal efficacy 1
• Contraindicated in patients taking nitrates due to risk of severe hypotension 2
• Tadalafil offers both on-demand and daily dosing options 1
• Common side effects include headache, flushing, dyspepsia, nasal congestion 1

Second-Line: Intraurethral or Intracavernosal Therapy

For patients who fail to respond to PDE5i:

• Intracavernosal injection therapy using alprostadil 3
• Intraurethral alprostadil suppositories 3

Important considerations:

• Effective but more invasive than oral therapy
• Requires proper training on injection technique
• Should not be used more than 3 times per week with at least 24 hours between doses 3
• Risk of priapism (erections lasting >6 hours) requiring immediate medical attention 3

Third-Line: Vacuum Constriction Devices

• Non-invasive mechanical option
• Creates negative pressure to draw blood into the penis
• Constriction band maintains erection
• No drug interactions or systemic side effects

Fourth-Line: Penile Prosthesis Implantation

• Surgical option for patients who fail less invasive treatments
• High satisfaction rates reported 4
• Irreversible procedure with potential surgical complications

Adjunctive Treatments

Psychosexual Therapy

• Particularly beneficial for predominantly psychogenic ED 1
• Success rates of 50-80% reported 1
• Can be used alone or in combination with medical treatments
• Focuses on:
  • Improving communication about sexual concerns
  • Reducing performance anxiety
  • Integrating ED treatments into sexual relationship

Lifestyle Modifications

• Weight loss for obese patients
• Regular physical exercise
• Smoking cessation
• Moderation of alcohol consumption
• Management of cardiovascular risk factors

Testosterone Replacement

• Consider only if testosterone deficiency is confirmed (<300 ng/dL with symptoms) 1
• Requires PSA testing and digital rectal examination before initiation

Special Considerations

Cardiovascular Risk

• ED is a significant risk marker for cardiovascular disease 1
• Assess cardiovascular risk before initiating treatment
• Sexual activity represents moderate physical exertion (2.0-5.4 METs) 2
• Patients with unstable cardiovascular disease may need cardiac evaluation before ED treatment

Medication-Induced ED

Consider medication adjustment if current drugs contribute to ED:

• Antihypertensives (especially thiazides, beta-blockers)
• Antidepressants (particularly SSRIs)
• Antipsychotics
• Antiandrogens

Alternative medications with lower risk of ED include:

• ACE inhibitors
• Calcium channel blockers
• Loop diuretics
• Statins 1

Treatment Selection Based on Patient Factors

1. For most patients: Start with PDE5i (sildenafil, tadalafil, vardenafil, or avanafil)
2. For patients with cardiovascular disease: Ensure stable cardiac status; avoid PDE5i if taking nitrates
3. For patients with psychogenic ED: Consider combination of PDE5i and psychosexual therapy
4. For patients unresponsive to PDE5i: Progress to intracavernosal injections or intraurethral suppositories
5. For patients with severe ED unresponsive to other treatments: Consider penile prosthesis implantation

By following this structured approach to ED treatment, clinicians can effectively address this common condition that significantly impacts quality of life while considering individual patient factors and preferences.