What are the management options for erectile dysfunction (ED)?

Management of Erectile Dysfunction

Oral phosphodiesterase type 5 (PDE5) inhibitors should be offered as first-line therapy for erectile dysfunction unless contraindicated, 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

Initial Evaluation

1. Cardiovascular Risk Assessment:

   • All men with ED should undergo cardiovascular risk assessment 2, 1
   • ED is a recognized index of cardiovascular risk and an independent predictor of coronary artery disease 1
   • Stratify patients into risk categories (high, intermediate, low) based on cardiovascular risk factors 2

2. Laboratory Testing:

   • Measure testosterone levels in all men with ED 2, 1
   • Obtain fasting glucose and lipid panel 1, 3
   • Consider thyroid-stimulating hormone test 3

Treatment Algorithm

Step 1: Lifestyle Modifications

• Smoking cessation 1
• Regular physical activity 1
• Weight loss for overweight/obese patients 1
• Healthy diet (e.g., Mediterranean diet) 2, 1
• Moderate alcohol consumption 2, 1

Step 2: First-Line Therapy - PDE5 Inhibitors

• Success rates of 73-88% compared to 26-32% with placebo 1

• Options include:

  • Sildenafil: Take 60 minutes before sexual activity 4
  • Vardenafil: Similar efficacy to sildenafil 2
  • Tadalafil: Available as daily dose (2.5-5mg) for couples preferring spontaneous sexual activity 1

• Important contraindications:

  • Concurrent use of nitrates (absolute contraindication) 1, 5
  • Use caution with alpha-blockers (start with lowest dose) 5
  • Avoid in patients with unstable cardiovascular disease 2

Step 3: Second-Line Therapies (if PDE5 inhibitors fail)

• Intraurethral alprostadil suppositories 2, 1
• Intracavernous injection therapy (alprostadil, papaverine, phentolamine) 2, 1, 6
  • Success rates up to 90%, but high attrition due to personal inconvenience 4
  • Warning: May cause prolonged erections (>6 hours) that require immediate medical attention 6
• Vacuum constriction devices 2, 1

Step 4: Third-Line Therapy

• Penile prosthesis implantation 2, 1
• Associated with high satisfaction rates 7

Special Considerations

Testosterone Replacement Therapy

• Consider testosterone replacement when levels are <230-300 ng/dL 2, 1
• Improves response to PDE5 inhibitors in hypogonadal men 2, 1
• Requires monitoring of hemoglobin, liver enzymes, and PSA due to increased risk of prostate adenocarcinoma 3

Cardiovascular Disease Management

• High-risk patients (unstable/refractory angina, uncontrolled hypertension, recent MI/stroke) should not receive ED treatment until cardiac condition stabilizes 2
• Low-risk patients may be considered for all first-line therapies 2
• Optimize management of comorbidities (diabetes, hypertension, hyperlipidemia) 1

Psychological Considerations

• Consider referral to mental health professional with expertise in sexual health 1
• Psychosexual therapy may be useful in combination with medical treatment 2

Monitoring and Follow-up

• Regularly assess treatment response using validated questionnaires 1
• Consider referral to sexual health specialist if therapy fails 1

Important Warnings

• PDE5 inhibitors with nitrates can cause dangerous hypotension 1, 5
• Erections lasting >6 hours can cause permanent tissue damage and impotence 6
• Report sudden vision or hearing loss immediately and discontinue PDE5 inhibitors 5
• Small risk of needle breakage with injection therapy 6

By following this stepwise approach to ED management, clinicians can effectively address this common condition while minimizing risks and optimizing outcomes for patients.