Is Buspar (buspirone) effective as an adjunct treatment for erectile dysfunction?

Buspirone as an Adjunct Treatment for Erectile Dysfunction

Buspirone is not recommended as an adjunct treatment for erectile dysfunction as there is insufficient evidence supporting its efficacy for this specific indication.

First-Line Treatment for Erectile Dysfunction

The American College of Physicians and European Association of Urology guidelines strongly recommend phosphodiesterase type 5 (PDE5) inhibitors as first-line therapy for erectile dysfunction (ED) 1. These medications have demonstrated significant clinical benefits with high-quality evidence supporting their use:

• PDE5 inhibitors improve successful sexual intercourse rates to approximately 69% compared to 35% with placebo 1
• They significantly improve erections in 73-88% of patients compared to 26-32% with placebo 1
• They are effective regardless of the underlying cause of ED (diabetes, depression, prostate cancer, etc.) 1

Role of Buspirone in Sexual Dysfunction

While buspirone has been mentioned in guidelines for certain types of sexual dysfunction, its role is primarily limited to:

1. Managing sexual dysfunction induced by SSRIs, particularly as an augmentation strategy 2, 3
2. Potentially addressing sexual performance anxiety, though evidence is limited 4

The NCCN guidelines mention bupropion (not buspirone) as an option for patients with low desire or libido 2, but do not specifically recommend buspirone for erectile dysfunction.

Evidence-Based Treatment Algorithm for ED

Step 1: First-Line Therapy

• PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) 1, 5
  • Titrate to maximum tolerated dose to increase efficacy 5
  • Tadalafil appears to be the most effective agent, followed by vardenafil 6

Step 2: For Non-Responders to PDE5 Inhibitors

• Verify appropriate medication use and timing 1
• Consider testosterone therapy if hypogonadism is present 1
• Consider second-line options:
  • Intracavernous injection therapy with alprostadil 5
  • Intraurethral or topical alprostadil 5
  • Vacuum erection devices (VEDs) 1

Step 3: Advanced Options

• Low-intensity shockwave therapy (LI-SWT) for mild vasculogenic ED 1
• Combination therapies (PDE5 inhibitors with other modalities) 1
• Surgical options for specific cases 1

Important Considerations

• Cardiovascular risk assessment: Patients should be evaluated for cardiovascular risk before initiating treatment 1
• Hormonal testing: Routine hormonal testing is not recommended unless specific signs of hormonal abnormalities are present 1
• Contraindications: PDE5 inhibitors are contraindicated with nitrate therapy due to dangerous blood pressure decreases 1

Why Buspirone Is Not Recommended

Despite buspirone's mention for sexual performance anxiety 4, there is a notable absence of high-quality evidence supporting its use specifically for erectile dysfunction. The most recent and highest quality guidelines from the American College of Physicians 1, European Association of Urology 1, and the International Consultation for Sexual Medicine 5 do not include buspirone in their recommended treatment algorithms for ED.

While buspirone may have theoretical benefits for anxiety-related sexual dysfunction, clinicians should rely on established first-line treatments with proven efficacy for erectile dysfunction rather than adjunct therapies with limited supporting evidence.