What is the best initial treatment for erectile dysfunction?

Best Initial Treatment for Erectile Dysfunction

Phosphodiesterase type 5 (PDE5) inhibitors are the first-line treatment for erectile dysfunction due to their high efficacy and favorable safety profile. 1, 2

Diagnostic Approach

Before initiating treatment, a focused evaluation should include:

• Sexual history using validated questionnaires like the International Index of Erectile Function (IIEF) or Sexual Health Inventory for Men (SHIM) 2
• Assessment of cardiovascular risk factors (diabetes, hypertension, dyslipidemia)
• Focused physical examination of abdomen, genitalia, and secondary sexual characteristics 1
• Limited laboratory testing:
  • Fasting glucose and lipid panel
  • Morning total testosterone level 1, 2

Treatment Algorithm

First-Line: PDE5 Inhibitors

PDE5 inhibitors have demonstrated significant efficacy with success rates of 73-88% compared to 26-32% with placebo 1. Options include:

• Sildenafil: Take 50-100mg approximately 1 hour before sexual activity
• Vardenafil: Take 10-20mg approximately 1 hour before sexual activity
• Tadalafil: Take 10-20mg as needed or 2.5-5mg daily 1, 3

High-quality evidence shows PDE5 inhibitors significantly improve successful sexual intercourse rates:

• Sildenafil: 69% success vs. 35.5% with placebo
• Vardenafil: 68% success vs. 35% with placebo
• Tadalafil: 69% success vs. 33% with placebo 1

Daily tadalafil (2.5-5mg) provides an alternative for couples preferring spontaneous rather than scheduled sexual activity 1.

Second-Line Options (if PDE5 inhibitors fail or are contraindicated)

• Intraurethral alprostadil suppositories
• Intracavernous injection therapy (alprostadil) 1, 2, 4
• Vacuum constriction devices 1, 2

Third-Line Option

• Penile prosthesis implantation 1, 2

Important Considerations and Cautions

Cardiovascular Assessment

• Evaluate cardiac risk factors in all ED patients 1
• Absolute contraindication: Concurrent use of nitrates with PDE5 inhibitors 1
• ED can be an early warning sign of cardiovascular disease, appearing approximately 3 years before coronary symptoms 5

Lifestyle Modifications

Concurrent lifestyle changes should be recommended:

• Smoking cessation
• Weight loss if obese
• Regular physical activity
• Limited alcohol consumption 2, 5

Treatment Failure

If the first PDE5 inhibitor fails:

• Try a different PDE5 inhibitor
• Consider an adequate trial as at least 5 separate occasions at maximum dose before declaring ineffective 2

Special Populations

PDE5 inhibitors remain effective in patients with specific medical conditions:

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

Follow-up

• Schedule follow-up visits to assess treatment efficacy and adjust therapy as needed
• Consider referral to specialists if initial treatments fail 2
• Monitor for side effects of PDE5 inhibitors, which may include headache, flushing, dyspepsia, and nasal congestion

The stepwise approach to ED treatment balances increasing invasiveness and risk against efficacy, with PDE5 inhibitors offering the best initial combination of effectiveness, safety, and convenience for most patients.