Treatment of Erectile Dysfunction
The management of erectile dysfunction should follow a stepwise approach, with PDE5 inhibitors as first-line therapy, followed by intraurethral alprostadil or intracavernous injections as second-line options, and penile prosthesis implantation as a third-line treatment for those who fail other therapies. 1
Initial Assessment and Cardiovascular Risk Evaluation
Before initiating treatment for erectile dysfunction (ED), it's crucial to:
- Perform cardiovascular risk assessment, as ED may be a marker for underlying cardiovascular disease 1
- Assess exercise tolerance: patients should be able to walk 1 mile in 20 minutes or climb 2 flights of stairs in 20 seconds without symptoms 1
- Screen for psychosocial factors contributing to ED: anxiety, depression, relationship issues, substance use 1
- Evaluate medications that may cause ED: antihypertensives, NSAIDs, antacids, psychiatric medications 1
Diagnostic Evaluation
- Complete medical, sexual, and psychosocial history
- Targeted physical examination including genital examination
- Laboratory tests:
- Morning total serum testosterone
- Fasting glucose or HbA1c
- Lipid profile
- Consider prolactin and thyroid hormones if endocrine disorders are suspected 1
Treatment Algorithm
First-Line Therapy: PDE5 Inhibitors
PDE5 inhibitors (sildenafil, vardenafil, tadalafil, avanafil) are the recommended first-line treatment 1, 2:
- Start with conservative dosing and titrate as needed
- Consider an adequate trial to be at least 5 separate occasions at maximum dose before declaring ineffective
- If the first PDE5 inhibitor fails, try a different one 1
Important considerations for PDE5 inhibitors:
- Contraindicated with nitrates due to risk of dangerous hypotension 3
- Use with caution in patients taking alpha-blockers; start with lowest dose 3
- Adjust dosing in hepatic impairment (Child-Pugh B): start with 5 mg vardenafil, maximum 10 mg 3
- Use caution in patients with QT prolongation or taking medications that prolong QT interval 3
Second-Line Therapy
If PDE5 inhibitors fail or are contraindicated, consider:
- Intraurethral alprostadil suppositories
- Intracavernous injection therapy (alprostadil)
- Vacuum constriction devices 2, 1
Third-Line Therapy
Penile prosthesis implantation for patients who fail or cannot use first and second-line therapies 2, 1
- Associated with high satisfaction rates 4
Lifestyle Modifications
Implement these modifications alongside pharmacological treatment:
- Smoking cessation
- Weight loss if overweight/obese
- Regular physical activity
- Limiting alcohol consumption
- Healthy diet (e.g., Mediterranean diet) 1
Special Considerations
Testosterone Therapy
- Consider in men with hypogonadism (low testosterone levels)
- May improve ED and libido when combined with PDE5 inhibitors in men with total testosterone <10-13 nmol/l 1
- Requires monitoring of hemoglobin, liver enzymes, and PSA due to increased risk of prostate adenocarcinoma 6
Medication-Induced ED
- Consider medication review and possible alternatives if ED is potentially medication-induced 7
- Common culprits: thiazide diuretics, beta-blockers, SSRIs 7
Complications and Follow-up
Priapism Warning
- Erections lasting >6 hours can cause permanent tissue damage and impotence
- Patients should seek immediate medical attention for erections lasting >6 hours 5
Follow-up
- Schedule follow-up visits to evaluate treatment response
- Consider referral to specialist if initial treatments fail 1
- Consider referral to mental health professional if psychological factors are significant 1
This comprehensive approach addresses both the physical and psychological aspects of erectile dysfunction, with treatment options that progress from least to most invasive based on patient response and preference.