Treatment Options for Male 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 no evidence supporting superiority of one agent over others 2
- Tadalafil has been shown to be effective in improving erectile function when taken as needed up to once per day, with efficacy demonstrated at 24 and 36 hours after dosing 3
- PDE5 inhibitors should be properly titrated to provide optimal efficacy, with clear instructions to patients 1
- These medications are effective in 60-65% of men with ED, including those with comorbidities such as hypertension and diabetes mellitus 4
Important Contraindications and Precautions
- PDE5 inhibitors are contraindicated in patients taking nitrates due to risk of severe hypotension 2
- For patients who have taken sildenafil, a suggested time interval for nitrate administration during a medical emergency is 24 hours; for tadalafil, it is 48 hours 2
- Patients should be categorized into cardiovascular risk levels (high, intermediate, low) before initiating treatment 2, 1
- High-risk patients should not receive treatment for sexual dysfunction until their cardiac condition has stabilized 2
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, 4
- Intra-urethral alprostadil suppositories are another option for those who cannot use or do not respond to oral medications 1, 5
- Vacuum constriction devices are a non-invasive mechanical option and particularly useful for patients with contraindications to pharmacological treatments 1, 5
Third-Line Treatment
- Penile prosthesis implantation is reserved for patients who fail less invasive treatments 1, 4
- Surgical implantation of multicomponent inflatable penile prostheses is associated with high satisfaction rates 4
- Penile arterial revascularization and venous ligation surgery generally show poor outcomes in men with atherosclerotic disease or corporal veno-occlusive dysfunction 4
Adjunctive Treatments
Lifestyle modifications can significantly improve erectile function 1, 6:
Psychosexual therapy is beneficial, particularly when combined with medical treatments 1:
Testosterone therapy should be considered in men with confirmed testosterone deficiency 1, 5
- Requires monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels due to increased risk of prostate adenocarcinoma 5
Special Considerations
- ED is a risk marker for cardiovascular disease, with symptoms presenting on average three years earlier than symptoms of coronary artery disease 5
- Patients with ED should be evaluated for cardiovascular risk factors 1, 5
- Patients with three or more cardiovascular risk factors (age, hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, sedentary lifestyle) are at increased risk for MI during sexual activity 2
- Treatment decisions should consider the patient's cardiovascular status and preferences 1, 8
Common Pitfalls to Avoid
- Failing to recognize ED as a potential marker of underlying cardiovascular disease 1
- Not titrating PDE5 inhibitor doses to achieve optimal efficacy 1
- Not considering psychosexual factors that may contribute to or exacerbate ED 1, 7
- Overlooking medication side effects as a potential cause of ED 7
- Not discussing treatment options and their risks/benefits with both the patient and partner 1, 8