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 and should be offered as first-line therapy 2
• These medications should be properly titrated to provide optimal efficacy with proper instructions to maximize benefit 1
• There is insufficient evidence to support the superiority of one PDE5 inhibitor over others 2
• PDE5 inhibitors enable 60-65% of men with ED, including those with hypertension, diabetes mellitus, and spinal cord injury, to successfully complete intercourse 3
• Important contraindications include concurrent use of nitrates, which can cause dangerous hypotension 4
• Patients taking alpha-blockers should be started on the lowest recommended dose of PDE5 inhibitors to avoid symptomatic hypotension 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 ED due to neurogenic, vasculogenic, psychogenic, or mixed etiology 5
• Patients should be fully trained on proper injection technique before home use 5
• Potential risks include prolonged erections (>6 hours), which can cause serious damage to penile tissue and may result in permanent impotence 5
• Intra-urethral alprostadil suppositories are another option for patients who fail oral therapy 1
• Vacuum constriction devices are 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
• Surgical treatment with multicomponent inflatable penile implants is associated with high satisfaction rates 3
• Penile arterial revascularization and venous ligation surgery show relatively poor outcomes in men with penile atherosclerotic disease or corporal veno-occlusive dysfunction 3

Adjunctive Treatments

• Optimal management of comorbid conditions like diabetes, hypertension, and heart disease may help prevent or improve ED 1, 7
• Lifestyle modifications including weight loss, regular physical activity, smoking cessation, and moderate alcohol consumption can improve erectile function 7, 6
• 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, 7
• The American College of Physicians does not recommend for or against routine use of hormonal blood tests or hormonal treatment in ED management due to insufficient evidence 2

Special Considerations

• ED may be a risk marker for cardiovascular disease, warranting evaluation of cardiovascular risk factors 1, 6
• The Princeton Consensus Panel recommends assigning patients to risk categories (low, intermediate, high) to guide ED treatment in the context of cardiovascular health 2, 1
• High-risk patients should not receive treatment for sexual dysfunction until their cardiac condition has stabilized 2, 1
• Patients at low risk may be considered for all first-line therapies 2
• Patients with three or more cardiovascular risk factors (age, hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, sedentary lifestyle) are considered to be at increased risk for MI during sexual activity 2

Common Pitfalls to Avoid

• Failure to recognize ED as a potential marker of underlying cardiovascular disease 1, 6
• Not discussing treatment options and their risks/benefits with both the patient and partner 1, 7
• Not titrating PDE5 inhibitor doses to achieve optimal efficacy 1, 8
• Not considering psychosexual factors that may contribute to or exacerbate ED 1, 7
• Overlooking the need for proper instructions when prescribing PDE5 inhibitors, which can significantly impact treatment success 8
• Not maintaining a safe time interval between nitrate administration and PDE5 inhibitor use (24 hours for sildenafil, 48 hours for tadalafil) 2