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 potent, reversible, competitive inhibitors of PDE5 with success rates of 65-70% for improving erections 2
• These medications should be titrated to provide optimal efficacy and proper instructions should be provided to maximize benefit 1
• PDE5 inhibitors are contraindicated in patients taking nitrates due to risk of dangerous hypotension 3
• Special considerations for PDE5 inhibitors:
  • Vardenafil dosage should be reduced to 5mg in patients with moderate hepatic impairment (Child-Pugh B) 4
  • Patients with moderate to severe renal impairment may have 20-30% higher drug exposure 4
  • Caution is advised when using PDE5 inhibitors with alpha-blockers due to potential for additive hypotensive effects 4

Second-Line Treatments

• Intracavernous injection therapy using vasodilator drugs such as alprostadil, papaverine, or phentolamine is effective for patients who fail to respond to oral agents 1, 5
• Alprostadil is indicated for erectile dysfunction due to neurogenic, vasculogenic, psychogenic, or mixed etiology 5
• Success rates with intracavernous injections can reach up to 90%, though attrition rates due to personal inconvenience remain significant 6
• Intra-urethral alprostadil suppositories are another option 1
• Vacuum constriction devices provide a non-invasive mechanical option for patients who cannot use or do not respond to pharmacological treatments 1, 6

Third-Line Treatment

• Penile prosthesis implantation is reserved for patients who fail less invasive treatments 1, 7
• Surgical implantation of multicomponent inflatable penile implants is associated with high satisfaction rates 7
• Penile arterial revascularization and venous ligation surgery show relatively poor outcomes in men with penile atherosclerotic disease or corporal veno-occlusive dysfunction 7

Adjunctive Treatments

• Optimal management of comorbid conditions like diabetes, hypertension, and heart disease may help prevent or improve ED 1
• Psychosexual therapy is useful in combination with both medical and surgical treatments, particularly for patients with predominantly psychogenic ED 1, 8
• Testosterone therapy should be considered in men with confirmed testosterone deficiency 1

Cardiovascular Risk Assessment

• ED is a risk marker for cardiovascular disease; patients should be evaluated for cardiovascular risk factors 1
• The Princeton Consensus Panel guidelines recommend assigning patients to risk categories (low, intermediate, high) to guide ED treatment in the context of cardiovascular health 3
• High-risk patients (unstable/refractory angina, uncontrolled hypertension, recent MI/stroke, etc.) should not receive treatment for sexual dysfunction until their cardiac condition has stabilized 3
• Low-risk patients may be considered for all first-line therapies 3

Common Pitfalls to Avoid

• Failing to recognize that ED may be drug-induced and potentially reversible in approximately 25% of cases 9
• Not discussing treatment options and their risks/benefits with both the patient and partner 2
• Not titrating PDE5 inhibitor doses to achieve optimal efficacy 1
• Not considering psychosexual factors that may contribute to or exacerbate ED 1
• Neglecting to consider cardiovascular status before initiating treatment 2
• Failing to recognize ED as a potential marker of underlying cardiovascular disease 1

Special Considerations

• Patients with anatomical deformation of the penis (angulation, cavernosal fibrosis, or Peyronie's disease) or conditions that predispose to priapism (sickle cell anemia, multiple myeloma, leukemia) require careful benefit-risk assessment 4, 5
• Erections lasting more than 6 hours can cause serious damage to penile tissue and may result in permanent impotence 5
• PDE5 inhibitors should be used with caution in patients with known QT prolongation or taking medications known to prolong the QT interval 4