What are the treatment options for erectile dysfunction (ED)?

Treatment Options for Erectile Dysfunction

Phosphodiesterase type 5 inhibitors (PDE5i) are the most effective first-line oral treatment for erectile dysfunction and should be offered as initial therapy for most patients. 1

First-Line Treatments

• PDE5 inhibitors (sildenafil, tadalafil, vardenafil) have demonstrated efficacy in 60-65% of men with ED, including those with comorbidities such as hypertension, diabetes mellitus, and spinal cord injury 2
• These medications work by enhancing the vasodilatory effects of nitric oxide, improving blood flow to the penis 3
• PDE5 inhibitors should be taken approximately 60 minutes before sexual activity, with effectiveness lasting between 4-36 hours depending on the specific medication 4, 5
• Common side effects include headache, flushing, dyspepsia, nasal congestion, and visual disturbances 4, 5
• PDE5 inhibitors are contraindicated in patients taking nitrates due to risk of severe hypotension 3, 4

Second-Line Treatments

• Intracavernosal injections (alprostadil) are effective for patients who fail to respond to oral agents 2
• Alprostadil is injected directly into the penis and should produce an erection within 5-20 minutes, lasting up to one hour 6
• Patients should be properly trained on injection technique and should not use more than 3 times per week with injections at least 24 hours apart 6
• Vacuum constriction devices are non-pharmacological options that create negative pressure to draw blood into the penis 3
• Only devices containing a vacuum limiter should be used to prevent injury to penile tissue 3

Third-Line Treatments

• Surgical implantation of penile prostheses is an option for patients who have failed other treatments 2
• These devices have high satisfaction rates but should be considered only after other options have been exhausted 2

Lifestyle Modifications

• Weight loss, increased physical activity, and smoking cessation can improve erectile function 1
• Dietary modifications and moderate alcohol consumption may help reduce cardiovascular risk factors associated with ED 1
• Addressing modifiable risk factors is essential as ED is often a marker for underlying cardiovascular disease 3, 1

Hormonal Therapy

• Testosterone replacement therapy should be considered only for men with documented low testosterone levels 1
• Men with testosterone levels between 231-346 ng/dL may benefit from a 4-6 month trial of TRT after discussing risks and benefits 1
• Testosterone therapy is not indicated for ED treatment in men with normal testosterone levels 3

Psychological Interventions

• Psychosexual therapy may be beneficial, particularly when psychological factors contribute to ED 3
• Success rates of 50-80% have been reported with psychosexual therapy 3
• This approach can be used alone or in conjunction with pharmacological treatments 3

Treatment Selection Algorithm

1. Assess cardiovascular risk and rule out contraindications to treatment 3
2. For most patients without contraindications, start with PDE5 inhibitors 1
3. If PDE5 inhibitors fail or are contraindicated, consider second-line options (intracavernosal injections or vacuum devices) 3, 6
4. For patients with low testosterone, consider testosterone replacement therapy 1
5. Consider surgical options only after failure of less invasive approaches 2

Important Considerations and Precautions

• ED may be the first sign of cardiovascular disease; consider cardiac assessment, especially with multiple risk factors 3, 1
• Patients taking alpha-blockers should start at the lowest recommended dose of PDE5 inhibitors to minimize risk of hypotension 4
• Priapism (erection lasting >4 hours) is a medical emergency requiring immediate attention 6
• Patients with hepatic impairment may require dose adjustments of PDE5 inhibitors 4
• Some medications commonly cause ED, including certain antihypertensives, antidepressants, and recreational drugs; consider medication changes when possible 7