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 the initial treatment for most patients with ED 2, 1
• These medications should be properly titrated to provide optimal efficacy with clear instructions to patients 1, 3
• At this time, there is insufficient evidence to support the superiority of one PDE5 inhibitor over the others 2
• PDE5 inhibitors are effective in 60-65% of men with ED, including those with hypertension, diabetes mellitus, and spinal cord injury 4
• Contraindications include concurrent use of nitrates, which can cause dangerous hypotension 2, 5
• Caution is needed in patients taking alpha-blockers; the lowest recommended starting dose should be used to prevent symptomatic hypotension 5

Second-Line Treatments

• For patients who fail to respond to oral PDE5 inhibitors, intracavernous injection therapy with vasodilator drugs is recommended 1, 4

  • Alprostadil, papaverine, or phentolamine (alone or in combination) are effective options 1, 6
  • These medications are injected directly into the penis and should produce an erection in 5-20 minutes lasting up to one hour 6
  • Should not be used more than 3 times per week with injections at least 24 hours apart 6

• Intraurethral alprostadil suppositories are another alternative second-line option 1, 7

• Vacuum constriction devices are a non-invasive mechanical option for patients who cannot use or do not respond to pharmacological treatments 1, 7

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

Adjunctive Treatments

• 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
• Psychosexual therapy is beneficial, particularly for patients with predominantly psychogenic ED, and can be useful in combination with both medical and surgical treatments 1, 8

Special Considerations

• ED is a risk marker for cardiovascular disease; patients should be evaluated for cardiovascular risk factors 1, 7
• The Princeton Consensus Panel guidelines recommend assigning patients to risk categories (low, intermediate, high) to guide ED treatment in the context of cardiovascular health 2, 1
• 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 2, 1
• Lifestyle modifications including weight loss, regular physical activity, smoking cessation, and moderate alcohol consumption can improve erectile function 8, 7
• Management of comorbidities such as diabetes, hypertension, and cardiovascular disease may help prevent or improve ED 1, 8

Common Pitfalls to Avoid

• Failure to recognize ED as a potential marker of underlying cardiovascular disease 1, 7
• Not providing proper instructions on PDE5 inhibitor use, which can lead to suboptimal efficacy 1, 3
• Not considering psychosexual factors that may contribute to or exacerbate ED 1, 8
• Not monitoring for prolonged erections with injection therapy, which can cause serious damage to penile tissue if lasting more than 6 hours 6
• Not considering drug interactions, particularly between PDE5 inhibitors and nitrates or alpha-blockers 2, 5