What are the treatment options for erectile dysfunction?

Treatment Options for Erectile Dysfunction

Phosphodiesterase type 5 (PDE5) inhibitors should be offered as first-line therapy for erectile dysfunction in men without contraindications due to their high efficacy and favorable safety profile. 1, 2

First-Line Treatment: PDE5 Inhibitors

Efficacy and Selection

• High-quality evidence shows PDE5 inhibitors significantly improve erections (73-88%) compared to placebo (26-32%) 1
• All available PDE5 inhibitors (sildenafil, vardenafil, tadalafil, mirodenafil, and udenafil) have comparable efficacy 1
• Selection should be based on:
  • Individual patient preferences
  • Cost considerations
  • Side effect profiles
  • Dosing schedule requirements 1, 2

Dosing Guidelines

• Sildenafil: 25-100mg as needed, starting at 50mg approximately 1 hour before sexual activity 2
• Vardenafil: 5-20mg as needed, with dose adjustment based on efficacy and tolerability 3
• Tadalafil: 5-20mg as needed, or 2.5-5mg daily 2

Efficacy in Special Populations

PDE5 inhibitors remain effective in patients with various comorbidities:

• Diabetes
• Depression
• Cardiovascular disease
• Prostate cancer
• Multiple sclerosis
• Renal failure 1

Contraindications and Precautions

• Absolute contraindication: Concurrent use of nitrates due to risk of severe hypotension 2, 3
• Time restrictions if nitrates needed: Wait at least 24 hours after sildenafil/vardenafil and 48 hours after tadalafil 2, 3
• Caution with alpha-blockers: Start with lowest PDE5 inhibitor dose due to potential hypotension 3
• Hepatic impairment: Dose reduction recommended (e.g., vardenafil 5mg maximum for moderate impairment) 3
• Cardiovascular risk assessment: Categorize patients as low, intermediate, or high cardiovascular risk 1, 2
  • High-risk patients should have cardiac condition stabilized before ED treatment 2

Second-Line Treatments

When PDE5 inhibitors fail or are contraindicated:

Intracavernous Injection Therapy

• Alprostadil (prostaglandin E1) is the most commonly used agent 4
• Higher efficacy than oral agents but more invasive 2
• Should not be used in patients with conditions predisposing to priapism (sickle cell anemia, leukemia, multiple myeloma) 4
• Patients must be properly trained in injection technique 4
• Maximum usage: 3 times weekly with at least 24 hours between injections 4

Intraurethral Suppositories

• Alprostadil suppositories administered under healthcare supervision initially due to 3% risk of syncope 2
• May be combined with a penile constriction device for increased efficacy 2

Vacuum Erection Devices

• Non-pharmacological option with approximately 90% initial efficacy 2
• Good option for older patients with infrequent sexual activity 2
• Contraindicated in patients with bleeding disorders 2

Third-Line Treatment

Penile Prostheses

• Reserved for patients who have failed or cannot use less invasive treatments 2
• High satisfaction rates but irreversible 2

Combination Therapy

Sildenafil combined with other ED therapies (psychotherapy, dihydroergotamine, cabergoline, atorvastatin, quinapril, or alfuzosin) has shown greater improvements in erectile function than sildenafil alone 1

Hormonal Treatment

• Evidence for testosterone therapy in hypogonadal men with ED is inconclusive 1
• The American College of Physicians does not recommend for or against routine hormonal blood tests or treatment 1
• Consider individualized hormonal testing based on clinical presentation (decreased libido, premature ejaculation, fatigue) and physical findings (testicular atrophy, muscle atrophy) 1

Safety Considerations

Common Side Effects of PDE5 Inhibitors

• Headache, flushing, rhinitis, dyspepsia 1
• Less common: visual disturbances, myalgia, nausea, diarrhea, dizziness, chest pain 1

Serious Adverse Events

• Incidence less than 2%, with no difference between PDE5 inhibitors and placebo 1
• Patients should seek immediate medical attention for:
  • Erections lasting >6 hours (risk of permanent impotence) 4
  • Sudden vision or hearing loss 3
  • Chest pain, severe dizziness, or fainting 2

Important Clinical Considerations

• ED may be a marker for cardiovascular disease; appropriate cardiovascular assessment is warranted 2
• Regular follow-up is necessary to assess treatment efficacy and side effects 2
• PDE5 inhibitors offer no protection from sexually transmitted diseases 4
• Smoking adversely affects erectile function by exacerbating other risk factors like vascular disease 4