Treatment Options for Erectile Dysfunction
Oral phosphodiesterase type 5 (PDE5) inhibitors—sildenafil, tadalafil, vardenafil, or avanafil—are the first-line treatment for erectile dysfunction and should be offered to all patients unless contraindicated, with proper dose titration to maximize efficacy. 1, 2
Stepwise Treatment Algorithm
First-Line: Lifestyle Modifications + PDE5 Inhibitors
Lifestyle interventions should be initiated immediately as they directly improve erectile function 1, 2:
- Weight loss in obese patients 2, 3
- Regular physical activity (sedentary lifestyle significantly increases ED risk) 2, 4
- Smoking cessation (smoking accentuates vascular disease effects) 5, 3, 4
- Moderate alcohol consumption 2, 3
- Optimal control of diabetes, hypertension, and cardiovascular disease 1, 2, 4
PDE5 inhibitors are the most effective oral agents with 50-80% success rates across all etiologies 6, 7:
- Sildenafil: Take 60 minutes before sexual activity with sexual stimulation; requires titration for optimal efficacy 1, 6
- Tadalafil: Provides erectile function enhancement for up to 24 hours, allowing flexibility in timing of sexual activity 8, 6, 9
- Vardenafil and avanafil: Similar efficacy and adverse event profiles to sildenafil 6, 7, 9
Critical contraindication: Concurrent nitrate therapy is an absolute contraindication to all PDE5 inhibitors 6, 4
Cardiovascular risk stratification must be performed before initiating PDE5 inhibitors—assign patients to low, intermediate, or high-risk categories; high-risk patients should not receive ED treatment until cardiac condition stabilizes 1, 2
Second-Line: Invasive Pharmacological Options
When PDE5 inhibitors fail or are contraindicated 1, 2, 7:
Intracavernosal injection therapy using alprostadil, papaverine, or phentolamine achieves success rates up to 90% 1, 5, 6, 7
Intraurethral alprostadil suppositories are an alternative local therapy option 1, 2, 4
Vacuum erection devices are non-invasive mechanical options safe and effective for well-selected patients who cannot use or do not respond to pharmacological treatments 1, 2, 6, 4
Third-Line: Surgical Intervention
Penile prosthesis implantation is reserved for patients with refractory ED who fail all less invasive treatments 1, 2, 6:
- Multicomponent inflatable implants completely imitate physiologic erection with high patient and partner satisfaction rates 6, 7, 9
- Modern devices have minimized infection rates and mechanical failures 6
Adjunctive Treatments
Testosterone replacement therapy should be considered only in men with confirmed testosterone deficiency (total morning testosterone <300 ng/dL) and no contraindications 10, 2, 4:
- Improves ED and libido in hypogonadal men 2, 4
- Requires interval monitoring of hemoglobin, liver enzymes, and prostate-specific antigen due to prostate cancer risk 4
- Contraindicated in men seeking fertility 2
Psychosexual therapy is beneficial when combined with medical or surgical treatments, particularly for psychogenic ED or relationship issues 1, 2, 4:
- Reduces performance anxiety and improves communication about sexual concerns 1
- Cognitive behavioral therapy helps address psychological factors 4
- Partner involvement in treatment decisions is essential for optimal outcomes 1, 2
Critical Clinical Pitfalls to Avoid
- Failing to recognize ED as a cardiovascular disease marker: ED symptoms present on average 3 years before coronary artery disease symptoms—all ED patients require cardiovascular risk factor screening 1, 2, 4
- Not titrating PDE5 inhibitor doses: Many treatment failures result from inadequate dosing rather than true drug failure 1
- Ignoring psychosexual factors: Even organic ED has psychological components that benefit from counseling 1, 2
- Inadequate patient education: Proper instructions on PDE5 inhibitor use (timing, need for sexual stimulation, food interactions) are essential for efficacy 1