Recommended Treatments for Erectile Dysfunction

PDE5 inhibitors should be offered as first-line therapy for erectile dysfunction due to their established efficacy and safety profile. 1, 2

First-Line Treatment: PDE5 Inhibitors

FDA-approved oral phosphodiesterase type 5 inhibitors (PDE5i) available in the US include sildenafil, tadalafil, vardenafil, and avanafil 1, 2
PDE5 inhibitors demonstrate superior efficacy compared to placebo with success rates of approximately 70-88% versus 26-35% for placebo 2, 3
These medications work by selectively inhibiting phosphodiesterase type 5, allowing corpus cavernosum smooth muscle to relax, potentiating erections during sexual stimulation 4
At this time, there is insufficient evidence to support the superiority of one PDE5i agent over the others 1

Start with recommended initial doses and titrate as needed for optimal efficacy 1, 2
Dose-response relationships exist for sildenafil (50mg vs. 25mg) and vardenafil (20mg vs. 10mg vs. 5mg) but not for tadalafil (20mg vs. 10mg vs. 5mg) 1
Instructions should be provided to maximize benefit/efficacy, including proper timing relative to meals and the need for sexual stimulation 1, 2

Most common adverse events include headache, flushing, dyspepsia, nasal congestion, back pain, myalgia, visual disturbance, and dizziness 1, 4
Most adverse events are transient, mild to moderate in severity, and follow a dose-response pattern 1
The incidence of serious adverse events is less than 2%, with no difference between PDE5 inhibitors and placebo 1

PDE5 inhibitors are contraindicated in patients taking nitrates due to risk of severe hypotension 1, 2
Cardiac risk factors should be evaluated in all erectile dysfunction patients before initiating treatment 1
Patients with unstable cardiovascular conditions should have their cardiac condition stabilized before treatment for erectile dysfunction 1

For patients who do not respond to or cannot take PDE5 inhibitors:

ED is a risk marker for systemic cardiovascular disease; diagnosis provides an opportunity to discuss cardiovascular risk 1
Men with diabetes and post-prostatectomy patients have more severe ED at baseline and may respond less robustly to PDE5i 1
For men with predominantly psychogenic ED, providers should offer a referral to a psychotherapist as either an alternative or adjunct to medical treatment 1
Lifestyle modification is associated with improvement in erectile dysfunction in obese men 1

Initial Assessment:
- Evaluate for cardiovascular risk factors and contraindications to PDE5i 1
- Check for medications that may cause ED (e.g., antihypertensives, antidepressants) 1
First-Line Treatment:
- Start with a PDE5 inhibitor (sildenafil 50mg, tadalafil 10mg, vardenafil 10mg, or avanafil 100mg) 1, 2
- If efficacy is prioritized, sildenafil 50mg appears to be the treatment of choice 3
- If tolerability is prioritized, tadalafil 10mg may be preferred 3
- Titrate dose as needed for optimal efficacy 1
If First-Line Treatment Fails:
- Try an alternative PDE5 inhibitor 6
- Consider specialized testing (nocturnal penile tumescence, intracavernosal injection, penile duplex ultrasound) 1
- Move to second-line treatments: intracavernous injections or intraurethral suppositories 1, 5
For Refractory Cases:
- Consider vacuum erection devices 2
- Penile prostheses may be considered for intractable ED in carefully selected patients 7

Incorrect use accounts for a large percentage of treatment failures; provide clear instructions on proper medication use 2
Communicate the increased risk of cardiovascular disease associated with erectile dysfunction to patients and their primary care providers 1, 2
PDE5 inhibitors should not be used more than once daily 4
Erections lasting more than 6 hours can cause serious damage to penile tissue and may result in permanent impotence; patients should seek immediate medical attention 5