What are the treatment options for erectile dysfunction?

Treatment Options for Erectile Dysfunction

Oral phosphodiesterase type 5 (PDE5) inhibitors should be offered as first-line therapy for erectile dysfunction unless contraindicated, followed by more invasive options in a stepwise approach based on efficacy and invasiveness. 1

First-Line Treatment

PDE5 Inhibitors

• Sildenafil, tadalafil, and vardenafil are effective first-line treatments with success rates of 60-65% across various patient populations including those with hypertension, diabetes mellitus, and other comorbidities 2
• These medications should be titrated to provide optimal efficacy 1
• Proper instructions should be provided to maximize benefit/efficacy 1
• Contraindicated in patients taking nitrates or nicorandil due to risk of synergistic hypotensive effect 3, 4
• Common side effects include headache, flushing, dyspepsia, and nasal congestion 3

Second-Line Treatments

Intrapenile Therapies

• Intracavernous injection therapy using vasodilator drugs such as alprostadil, papaverine, or phentolamine is effective for patients who fail to respond to oral agents 1, 2
• Intra-urethral alprostadil suppositories are another option 1
• Alprostadil injections should not be used more than 3 times per week with at least 24 hours between doses 5
• Risk of priapism (erections lasting >6 hours) which requires immediate medical attention 5

Vacuum Constriction Devices

• Non-invasive mechanical option for patients who cannot use or do not respond to pharmacological treatments 1, 6
• Can be effective but may be less preferred by some patients due to mechanical nature 6

Third-Line Treatment

Surgical Options

• Penile prosthesis implantation is reserved for patients who fail less invasive treatments 1, 2
• Associated with high satisfaction rates in properly selected patients 2
• Penile arterial revascularization and venous ligation surgery have relatively poor outcomes in men with atherosclerotic disease or veno-occlusive dysfunction 2

Adjunctive Treatments

Lifestyle Modifications

• Should be recommended alongside other treatments 7
• Include smoking cessation, weight reduction, dietary modification, physical activity, and psychological stress reduction 7
• Optimal management of comorbid conditions like diabetes, hypertension, and heart disease may help prevent or improve ED 1

Psychosexual Therapy

• Useful in combination with both medical and surgical treatments 1
• Particularly beneficial for patients with predominantly psychogenic ED 1
• Helps improve communication about sexual concerns and reduce anxiety 1

Hormonal Treatment

• Testosterone therapy should be considered in men with confirmed testosterone deficiency (total testosterone <300 ng/dL with symptoms) 1

Special Considerations

Cardiovascular Risk Assessment

• ED is a risk marker for cardiovascular disease 1
• Patients with ED should be evaluated for cardiovascular risk factors 1, 4
• The Princeton Consensus Panel guidelines recommend assigning patients to risk categories (low, intermediate, high) to guide ED treatment in the context of cardiovascular health 1
• High-risk patients should not receive treatment for sexual dysfunction until their cardiac condition has stabilized 1

Common Pitfalls to Avoid

• Failure to recognize ED as a potential marker of underlying cardiovascular disease 1, 4
• Not discussing treatment options and their risks/benefits with both the patient and partner when possible 1
• Prescribing PDE5 inhibitors to patients taking nitrates or with unstable cardiovascular conditions 3, 4
• Not titrating PDE5 inhibitor doses to achieve optimal efficacy 1
• Not considering psychosexual factors that may contribute to or exacerbate ED 1

Treatment should be applied in a stepwise fashion with increasing invasiveness and risk balanced against the likelihood of efficacy, always considering the patient's cardiovascular status and preferences 1.