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

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, unless contraindicated. 1, 2

First-Line Treatment: PDE5 Inhibitors

• FDA-approved PDE5 inhibitors (sildenafil, tadalafil, vardenafil, and avanafil) have similar efficacy in the general ED population, with success rates of approximately 70-88% compared to 26-35% for placebo 2, 3
• PDE5 inhibitors work by enhancing the vasodilatory effects of nitric oxide, improving blood flow to the penis during sexual stimulation 4
• The American College of Physicians recommends basing the choice of specific PDE5 inhibitor on individual preferences, ease of use, cost, and adverse effect profile 1
• Proper patient education is essential as incorrect use accounts for many treatment failures 5

Comparative Characteristics of PDE5 Inhibitors

• Sildenafil and vardenafil have half-lives of approximately 4 hours, while tadalafil has a longer half-life of 17.5 hours 6
• Food, especially fatty food, affects the absorption of sildenafil and vardenafil but not tadalafil 6
• Common side effects include headache, flushing, dyspepsia, nasal congestion, back pain, myalgia, visual disturbance, and dizziness 5
• Avanafil has the lowest rates of dyspepsia among PDE5 inhibitors 7
• Tadalafil has the lowest rates of flushing 5

Important Contraindications and Precautions

• PDE5 inhibitors are absolutely contraindicated in patients taking nitrates due to the risk of potentially dangerous hypotension 5, 8
• High-risk cardiac patients should not receive treatment for sexual dysfunction until their cardiac condition has stabilized 1, 5
• Patients with three or more cardiovascular risk factors are considered at increased risk for MI during sexual activity 1
• Dose adjustment is necessary for patients with moderate hepatic or renal impairment 8

Second-Line Treatment Options

When PDE5 inhibitors fail or are contraindicated, the following options can be considered:

Intracavernous Injections

• Alprostadil (prostaglandin E1) is administered via direct injection into the corpus cavernosum 9
• Should produce an erection in 5-20 minutes, lasting up to one hour 9
• Should not be used more than 3 times per week, with injections at least 24 hours apart 9
• Risk of prolonged erection (priapism) requiring medical attention if lasting more than 6 hours 9

Intraurethral Suppositories

• Alprostadil can also be administered as an intraurethral suppository 1
• Less invasive than injections but generally less effective 10

Vacuum Constriction Devices

• Non-pharmacological option that creates negative pressure to draw blood into the penis 2
• Effective regardless of the etiology of ED 1

Special Considerations for Specific Populations

• Men with diabetes have more severe ED at baseline and respond less robustly to PDE5 inhibitors 5
• Post-prostatectomy patients have more severe ED and show reduced response to PDE5 inhibitors compared to the general population 5
• For men with spinal cord injury, lower initial doses of PDE5 inhibitors are recommended due to potential delayed metabolism 5
• For men with predominantly psychogenic ED, PDE5 inhibitors are still effective as first-line therapy 5

Optimizing Treatment Success

• Dose titration should be performed to provide optimal efficacy while minimizing side effects 5, 7
• Patients should be advised that sexual stimulation is required for PDE5 inhibitors to work 8
• Multiple trials (at least 4-8) should be attempted before declaring treatment failure 5
• Periodic follow-up is necessary to assess efficacy, side effects, and any significant changes in health status or medications 5

Clinical Pearls and Pitfalls

• Erectile dysfunction may be an early marker of cardiovascular disease, and this risk should be communicated to patients 2
• Testosterone therapy is not indicated for ED treatment in patients with normal testosterone levels 2
• Herbal therapies, including yohimbine, have insufficient evidence to support their use 1
• Combination therapies (e.g., PDE5 inhibitors with vacuum devices) may be considered but have limited evidence 1