What are the recommended management options for erectile dysfunction?

Management of Erectile Dysfunction

The management of erectile dysfunction should follow a stepwise approach, beginning with oral phosphodiesterase type 5 (PDE5) inhibitors as first-line therapy, followed by intraurethral/intracavernous injections or vacuum devices as second-line options, and penile prosthesis implantation as third-line therapy when other treatments fail. 1, 2

Initial Assessment and Diagnostic Testing

• Comprehensive evaluation should include:

  • Medical, sexual, and psychosocial history
  • Targeted physical examination
  • Laboratory tests: fasting glucose, lipid panel, and morning total testosterone level 2
  • Cardiovascular risk assessment (all men with ED should have cardiovascular risk evaluated) 1, 2

• Validated questionnaires such as the International Index of Erectile Function (IIEF) or Sexual Health Inventory for Men (SHIM) help assess severity and measure treatment efficacy 2

• Testosterone measurement is routinely recommended, with replacement therapy considered when levels are <300 ng/dL 1, 2

Treatment Algorithm

First-Line Therapy: PDE5 Inhibitors

• PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are the first choice due to:

  • High efficacy (73-88% success rates compared to 26-32% with placebo) 2
  • Favorable safety profile
  • Ease of administration

• Tadalafil dosing options:

  • As needed: Start with 10mg (range 5-20mg) taken prior to sexual activity 3
  • Daily use: 2.5-5mg daily, regardless of timing of sexual activity 3
  • Daily tadalafil provides spontaneity rather than scheduled sexual activity 2

• Important considerations:

  • An adequate trial requires at least 5 attempts at maximum dose 2
  • If one PDE5 inhibitor fails, try another before moving to second-line therapy 2
  • Absolute contraindication: concurrent use of nitrates 2

Second-Line Therapies

When PDE5 inhibitors fail or are contraindicated:

• Intraurethral alprostadil suppositories 1, 2
• Intracavernous injection therapy with alprostadil 1, 2, 4
  • Should be administered just prior to foreplay
  • Should not be used more than 3 times weekly with injections at least 24 hours apart 4
  • Risk of priapism (erections lasting >6 hours) requiring immediate medical attention 4
• Vacuum constriction devices - noninvasive mechanical option 1, 2

Third-Line Therapy

• Penile prosthesis implantation - surgical option with high satisfaction rates when other treatments have failed 1, 2, 5

Risk Factor Modification

Lifestyle modifications are critical for both ED management and cardiovascular risk reduction:

• Smoking cessation - tobacco use significantly worsens erectile function 1, 2, 6
• Regular physical activity - improves vascular function 1, 2, 6
• Weight loss for overweight/obese patients 2, 6
• Healthy diet (e.g., Mediterranean diet) 1, 2
• Moderate alcohol consumption 1, 2
• Optimal management of comorbidities (diabetes, hypertension, hyperlipidemia) 1, 7

Special Considerations

Cardiovascular Risk

• ED often precedes cardiovascular disease by 3-5 years and shares common risk factors 8
• Sexual activity increases physical exertion (3-4 METS) and carries a small increased risk of MI in patients with cardiovascular disease 1
• The Princeton Consensus Panel recommends risk stratification (high, intermediate, low) for patients with cardiovascular disease 1

Testosterone Therapy

• Only indicated when testosterone levels are <300 ng/dL 2
• Supplementation without documented hypogonadism provides no benefit and carries risks 2
• Can improve response to PDE5 inhibitors in hypogonadal men 1

Psychosexual Therapy

• Consider referral to mental health professionals with expertise in sexual health 2
• Particularly valuable for patients with psychological factors contributing to ED 2
• Most effective when combined with medical treatments 2

Treatment Monitoring

• Regular assessment of treatment response using validated questionnaires 2
• Consider referral to a sexual health specialist if optimized therapy fails 2
• Monitor for adverse effects of medications

Common Pitfalls to Avoid

• Failing to assess cardiovascular risk in men with ED
• Not giving PDE5 inhibitors an adequate trial (minimum 5 attempts at maximum dose)
• Prescribing testosterone without documented hypogonadism
• Overlooking psychological factors that may contribute to ED
• Neglecting to address modifiable lifestyle factors
• Using PDE5 inhibitors in patients taking nitrates (absolute contraindication)