What are the treatment options for erectile dysfunction?

Treatment Options for Erectile Dysfunction

The first-line treatment for erectile dysfunction should be oral phosphodiesterase type 5 (PDE5) inhibitors, unless contraindicated, with treatment options applied in a stepwise fashion balancing invasiveness and risk against efficacy. 1, 2

Initial Assessment and Risk Factors

Before initiating treatment, consider:

• Cardiovascular risk assessment (especially important as ED may be an early marker of cardiovascular disease)
• Medication review (many drugs can cause ED, including antihypertensives and psychotherapeutic drugs) 3
• Hormonal evaluation in select cases (testosterone levels)
• Lifestyle factors (obesity, smoking, alcohol consumption, physical inactivity)

Treatment Algorithm

First-Line Therapy: PDE5 Inhibitors

PDE5 inhibitors have success rates of 60-65% across various patient populations 2:

• Sildenafil: Take 60 minutes before sexual activity
• Tadalafil: Available as needed or daily dosing (2.5-5mg); effective for up to 24 hours 4
• Vardenafil: Higher selectivity compared to sildenafil
• Avanafil: Newer agent with similar efficacy profile

Important precautions:

• Absolute contraindication: Concurrent use of nitrates due to risk of severe hypotension 2, 4
• Cardiovascular risk stratification required before initiating therapy
• Sexual activity represents moderate physical exertion (2.0-5.4 METs)

Second-Line Therapies

If PDE5 inhibitors fail or are contraindicated:

1. Intraurethral alprostadil suppositories:

   • Effective alternative when oral therapy fails

2. Intracavernous injection therapy:

   • Using vasodilator drugs like alprostadil
   • Success rates up to 90%, but higher attrition due to personal inconvenience 5
   • Requires proper training for self-administration

3. Vacuum constriction devices:

   • Non-invasive mechanical option
   • Effective but may reduce spontaneity 2

Third-Line Therapy

Penile prosthesis implantation:

• Reserved for patients who fail or cannot use other therapies
• High satisfaction rates but invasive surgical procedure 6
• Modern implants have reduced infection rates and mechanical failures 5

Adjunctive Approaches

1. Lifestyle modifications:

   • Smoking cessation
   • Limiting alcohol consumption
   • Regular physical activity
   • Weight loss
   • These can improve both ED and cardiovascular health 2

2. Psychosexual therapy:

   • Useful in combination with medical treatments
   • Particularly valuable for ED with psychological components
   • Cognitive-behavioral therapy has 50-80% success rates for predominantly psychogenic ED 2

3. Medication adjustments:

   • Consider alternative medications with lower risk of causing ED
   • Common culprits include thiazide diuretics, beta-blockers, and SSRI antidepressants 3

Special Populations

• Diabetic patients: PDE5 inhibitors effective but may require more aggressive dosing 2
• Post-prostate cancer treatment: ED is common; validated tools like SHIM should monitor erectile function 2
• Testosterone deficiency: Consider replacement therapy only if confirmed (<300 ng/dL with symptoms) 2

Treatment Monitoring

• Follow-up evaluation to assess treatment efficacy
• Consider switching between different PDE5 inhibitors if initial response is suboptimal
• For daily tadalafil, start with 2.5mg, potentially increasing to 5mg if tolerated 2
• Ensure availability of treatment for priapism when initiating medical therapies 2

Emerging Therapies

Newer approaches showing promise include:

• Low-intensity extracorporeal shock wave therapy
• Stem cell injection therapy
• These aim to repair organic damage to the corpora cavernosa 7

The choice of treatment should be made jointly by the physician, patient, and when possible, the partner, considering patient preferences, expectations, and the physician's judgment 1.