What are the treatment options for erectile dysfunction?

Treatment Options for Erectile Dysfunction

PDE5 inhibitors should be offered as first-line therapy for erectile dysfunction due to their established efficacy and safety profile, with success rates of approximately 70-88% compared to 26-35% for placebo. 1

First-Line Treatment: PDE5 Inhibitors

• FDA-approved PDE5 inhibitors include sildenafil, tadalafil, vardenafil, and avanafil, all with similar efficacy in the general ED population 1, 2
• The American College of Physicians strongly recommends initiating therapy with a PDE5 inhibitor in men seeking treatment for erectile dysfunction who do not have contraindications 3
• PDE5 inhibitors significantly improve both erectile function and successful sexual intercourse rates across various patient populations 4
• The choice of specific PDE5 inhibitor should be based on individual preferences, ease of use, cost, and adverse effect profiles 3, 1

Dosing and Administration of PDE5 Inhibitors

• Start with recommended initial doses and titrate as needed for optimal efficacy 1
• A dose-response relationship exists for sildenafil and vardenafil (higher doses = greater efficacy), but not for tadalafil 1, 4
• Higher doses are associated with greater efficacy but also increased risk of adverse effects 1
• Proper medication use is crucial, as incorrect use accounts for many treatment failures 1, 2
• Patients should be instructed on:
  • The importance of sexual stimulation for medication effectiveness 1
  • Timing relative to meals (food affects absorption of sildenafil and vardenafil, but not tadalafil) 5
  • The need for multiple trials before determining efficacy 1

Common Adverse Effects of PDE5 Inhibitors

• Most frequently reported adverse events include headache, flushing, dyspepsia, nasal congestion, back pain, myalgia, visual disturbance, and dizziness 1, 2, 4
• Adverse effect profiles differ slightly between medications 1
• The incidence of serious adverse events is less than 2%, with no significant difference compared to placebo 4

Contraindications and Special Considerations

• PDE5 inhibitors are contraindicated in patients taking nitrates due to risk of severe hypotension 3, 1, 2, 6
• High-risk cardiac patients should not receive treatment until their cardiac condition has stabilized, including those with:
  • Unstable or refractory angina 3, 2
  • Uncontrolled hypertension 3, 2
  • Left ventricular dysfunction/CHF (NYHA class II or greater) 3, 2
  • MI or CVA within previous 2 weeks 3, 2
  • High-risk arrhythmias 3, 2
  • Hypertrophic obstructive cardiomyopathies 3, 2
  • Moderate-to-severe valvular disease 3, 2
• Use caution in patients with mild to moderate hepatic or renal impairment 1, 6
• For patients with moderate hepatic impairment (Child-Pugh B), a starting dose of 5 mg vardenafil is recommended with maximum dose not exceeding 10 mg 6

Second-Line Treatment Options

• For patients who fail PDE5 inhibitor therapy, alternative options include:
  • Intracavernous injection therapy with alprostadil 7
  • Intraurethral alprostadil 8
  • Vacuum erection devices (VEDs) 1

Special Patient Populations

• Men with diabetes have more severe ED at baseline and respond less robustly to PDE5 inhibitors 2
• Post-prostatectomy patients have more severe ED at baseline and show reduced response to PDE5 inhibitors compared to the general population 2
• For men with spinal cord injury, lower initial doses of PDE5 inhibitors are recommended due to potential delayed metabolism 2
• For men with predominantly psychogenic ED, PDE5 inhibitors are still effective as first-line therapy, but referral to a psychotherapist may be beneficial as either an alternative or adjunct to medical treatment 2

Important Clinical Considerations

• The American College of Physicians does not recommend routine hormonal blood tests or hormonal treatment in the management of ED 3
• Testosterone therapy is not indicated for ED treatment in patients with normal testosterone levels 1
• ED may be associated with increased risk of cardiovascular disease, which should be communicated to patients 1
• Patients should be warned about the risk of priapism (erections lasting >6 hours), which can cause serious damage to penile tissue and may result in permanent impotence 7
• Patients with anatomical deformation of the penis or conditions predisposing to priapism (sickle cell anemia, multiple myeloma, leukemia) should use ED treatments with caution 6