What are the treatment options for erectile dysfunction in men?

Treatment of Erectile Dysfunction in Men

Start with an oral PDE5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil) as first-line therapy for all men with erectile dysfunction who do not have contraindications, particularly nitrate use. 1

First-Line Treatment: PDE5 Inhibitors

Efficacy and Evidence

• PDE5 inhibitors demonstrate 73-88% improvement in erectile function compared to 26-32% with placebo, representing high-quality evidence for their use 2
• These medications work effectively regardless of ED etiology, including diabetes, depression, cardiovascular disease, and post-prostatectomy status 2, 3
• First-time response rates are approximately 60-70%, with treatment success rates reaching 89% when patients are prescribed all available options 4

Choosing Between PDE5 Inhibitors

Select the specific PDE5 inhibitor based on patient preference regarding onset time, duration of action, cost, and side effect profile, as head-to-head trials show similar efficacy. 1

• Sildenafil: Standard option with 50mg starting dose (can titrate to 100mg); onset 30-60 minutes; duration 4-6 hours; higher rates of visual disturbances 1, 2, 4
• Tadalafil: Longest half-life; available as daily (5mg) or on-demand (10-20mg) dosing; onset 30 minutes; duration up to 36 hours; associated with back pain/myalgia 5, 4
• Vardenafil: Rapid onset; similar to sildenafil but associated with QT prolongation; avoid in patients with congenital QT prolongation or taking Class IA/III antiarrhythmics 6, 4
• Avanafil: Fastest onset with lowest rates of dyspepsia and flushing 1, 4

Critical Prescribing Instructions

Provide explicit instructions to maximize efficacy, as inadequate use is a common cause of treatment failure. 1, 2

• Sexual stimulation is required for the medication to work 2
• Take sildenafil/vardenafil 60 minutes before sexual activity; tadalafil can be taken 30 minutes prior 2, 5
• Higher doses (sildenafil 50mg vs 25mg; vardenafil dose escalation) improve erectile function but increase adverse effects 1, 2
• Food, excessive alcohol, hormonal abnormalities, and relationship factors can affect response 2
• If initial trial fails, assess whether the medication was used correctly before switching therapy 2

Absolute Contraindications

• Nitrate use (any form): PDE5 inhibitors cause severe hypotension when combined with nitrates; at least 24 hours must pass after sildenafil before nitrates can be safely administered 1, 2
• Congenital or acquired QT prolongation (particularly for vardenafil) 6

Common Adverse Effects

• Headache, flushing, rhinitis, dyspepsia, visual disturbances, myalgia, dizziness 1, 2
• Serious adverse events occur in less than 2% of patients, with no significant difference from placebo 2

Special Populations

Cardiovascular Disease and Hypertension

Perform cardiovascular risk assessment before initiating ED treatment; stabilize high-risk patients with cardiology consultation before prescribing PDE5 inhibitors. 3

• ED is a significant independent risk marker for cardiovascular disease, as strong as smoking or family history of MI 1
• Communicate this cardiovascular risk to the patient, partner, and primary care provider for appropriate interventions 1
• PDE5 inhibitors do not increase cardiovascular adverse events in meta-analyses 3

Alpha-Blocker Use

Start with the lowest PDE5 inhibitor dose (e.g., tadalafil 5mg, vardenafil 5mg) in patients taking alpha-blockers due to risk of symptomatic hypotension. 6

• Combined use can cause significant blood pressure drops leading to dizziness or syncope 6
• Review all antihypertensive medications as some (diuretics, beta-blockers) may contribute to ED 3

Diabetes

• PDE5 inhibitors remain first-line therapy with efficacy independent of diabetes duration, glycemic control, or microvascular complications 3
• Diabetic men have more severe baseline ED and respond less robustly than the general population 1
• Improving glycemic control can reduce ED severity 3

Post-Prostatectomy

• Men post-radical prostatectomy have more severe ED and lower response rates to PDE5 inhibitors 1
• PDE5 inhibitors remain appropriate first-line therapy despite reduced efficacy 1

Dose Optimization and Follow-Up

Titrate the PDE5 inhibitor dose to provide optimal efficacy before declaring treatment failure. 1

• Conduct periodic follow-up to evaluate efficacy, side effects, and changes in health status 2
• For sildenafil, dose-response exists from 25mg to 50mg, with less additional benefit from 50mg to 100mg 2
• Tadalafil daily dosing (5mg) produces similar efficacy to on-demand dosing and may improve erectile function over time 1, 4

Hormonal Testing

Do not routinely measure testosterone or other hormones unless clinical presentation suggests hormonal abnormality (decreased libido, premature ejaculation, fatigue, testicular atrophy, muscle atrophy). 1

• Evidence is insufficient regarding effectiveness of hormonal treatment even in hypogonadal men with ED 1
• Testosterone prevalence in ED patients ranges from 12.5-36%, but treatment effects are inconsistent 1

Second-Line Therapy

Intracavernosal Injection (Alprostadil)

For men who fail PDE5 inhibitors, offer intracavernosal alprostadil injection therapy, which produces erections in 5-20 minutes lasting up to one hour. 7, 8

• Effective in men unresponsive to oral agents 8
• Maximum frequency: 3 times per week with at least 24 hours between injections 7
• Critical warning: Erections lasting more than 6 hours require immediate medical attention to prevent permanent damage 7
• Common side effect is mild to moderate injection pain 7
• Contraindicated in men with sickle cell disease, leukemia, multiple myeloma, or penile implants 7

Adjunctive Therapy

Psychosexual Counseling

• For men with predominantly psychogenic ED, offer referral to psychotherapy as alternative or adjunct to medical treatment 1
• Combination therapy (PDE5 inhibitor plus psychotherapy) may provide greater improvement than medication alone 2
• Address performance anxiety, relationship issues, and strategies for integrating ED treatments into sexual relationships 1

Lifestyle Modifications

• Weight loss for obese patients 3
• Smoking cessation (smoking accentuates vascular disease effects) 7
• Optimize cardiovascular risk factors 3

Common Pitfalls to Avoid

• Inadequate patient education: Failure to explain that sexual stimulation is required and proper timing of medication leads to perceived treatment failure 2
• Premature treatment switching: Assess whether medication was used correctly before changing therapy 2
• Missing cardiovascular risk: ED diagnosis is an opportunity to identify and manage cardiovascular disease 1
• Ignoring medication interactions: Review all medications, particularly nitrates, alpha-blockers, and antihypertensives 3, 6
• Routine hormonal testing: Only measure testosterone when clinical features suggest hypogonadism 1