What is the treatment for sudden erectile dysfunction?

Treatment of Sudden Erectile Dysfunction

Start oral phosphodiesterase type 5 inhibitors (PDE5i) immediately as first-line therapy, regardless of whether the sudden onset suggests psychological or organic etiology. 1

Initial Diagnostic Evaluation

When evaluating sudden-onset ED, obtain the following to identify contraindications and comorbidities:

• Sexual history: Sudden onset with early collapse during intercourse and preserved morning/spontaneous erections suggests psychological causes, while gradual onset with complete loss of tumescence indicates organic pathology 2, 1
• Medical history: Screen for cardiovascular disease, diabetes, hypertension, neurological conditions, pelvic trauma/surgery, and medications that cause ED (antihypertensives, antidepressants, antipsychotics) 2
• Laboratory testing: Fasting glucose, lipid profile, and morning total testosterone (especially if hypogonadism suspected or if patient fails PDE5i trial) 2, 1
• Cardiovascular risk stratification: Critical before initiating treatment, as ED often signals underlying cardiovascular disease 2

First-Line Treatment: PDE5 Inhibitors

Initiate PDE5i therapy immediately with lifestyle modifications, not sequentially. 1

Medication Options and Dosing Strategy

• Available agents: Sildenafil, tadalafil, vardenafil, or avanafil 2, 1
• Dosing approach: Start conservatively and titrate to maximum dose; an adequate trial requires at least 5-8 separate attempts at maximum dose before declaring treatment failure 1, 3
• Timing: Take approximately 60 minutes before sexual activity (varies by agent) 4
• Success rate: 60-65% of men achieve successful intercourse, including those with diabetes, hypertension, and spinal cord injury 1, 5

Absolute Contraindications to PDE5i

• Concurrent nitrate use (any formulation) 1, 4
• Guanylate cyclase stimulators (riociguat) 1
• Class IA or III antiarrhythmic medications 4
• Congenital QT prolongation 4

Relative Contraindications and Dose Adjustments

• Alpha-blocker use: Start PDE5i at lowest dose due to hypotension risk 4
• Moderate hepatic impairment: Start vardenafil at 5 mg maximum 10 mg; avoid in severe hepatic impairment 4
• Moderate-to-severe renal impairment: Expect 20-30% higher drug levels 4

Concurrent Interventions

Lifestyle Modifications (Initiate Simultaneously)

• Smoking cessation: Mandatory recommendation 1
• Weight loss: If BMI >30 kg/m² 1
• Increased physical activity 1
• Reduced alcohol consumption 1
• Optimize glycemic control: In diabetics, though evidence for direct ED improvement is limited 2
• Blood pressure and lipid optimization 1

Psychological ED Management

For sudden-onset ED with psychological features, refer to sex therapy or couples counseling concurrently with PDE5i initiation, not after medication failure. 1

• Address specific psychiatric conditions: generalized anxiety, depression, substance use disorders 1
• Include partner in discussions whenever possible 2

Medication Optimization

• Switch causative medications: Replace antihypertensives with agents having lower ED risk (ACE inhibitors, calcium channel blockers, loop diuretics instead of thiazides/beta-blockers) 2
• Testosterone replacement: Only if documented low testosterone; contraindicated in men desiring fertility 1

Second-Line Therapies (After PDE5i Failure)

If two different PDE5i agents at maximum dose fail after adequate trials, refer to urology for second-line options. 1, 3

Available Second-Line Options

• Intracavernosal injection therapy: Alprostadil or other vasoactive drugs 2, 1, 6
• Intraurethral alprostadil suppositories 2, 1
• Vacuum erection devices (VEDs) 2, 1
• Combination therapy: PDE5i with VED may enhance results 3

Third-Line Therapy

Penile prosthesis implantation is reserved for patients who fail all medical therapies and is associated with high satisfaction rates. 1, 5

Critical Safety Warnings

• Priapism risk: If erection persists >6 hours, seek emergency care immediately to prevent permanent penile damage 6
• Cardiovascular events: High-risk cardiac patients should be stabilized before initiating ED treatment or resuming sexual activity 2
• Vision/hearing loss: Stop PDE5i immediately if sudden vision loss (NAION) or hearing loss occurs 4
• No protection against STIs: PDE5i and injection therapies do not prevent HIV or other sexually transmitted infections 6

Common Pitfalls to Avoid

• Declaring PDE5i failure prematurely: Ensure patient has attempted maximum dose at least 5-8 times with proper timing and sexual stimulation before switching agents 1, 3
• Sequential rather than concurrent approach: Always initiate lifestyle modifications, psychological counseling (when indicated), and PDE5i simultaneously 1
• Inadequate patient education: Proper instruction on timing, dosing, and need for sexual stimulation is essential for PDE5i effectiveness 1, 4
• Missing testosterone deficiency: Check testosterone in non-responders to PDE5i, as replacement may improve response 2, 1, 3