What are the treatment options for erectile dysfunction?

Treatment of Erectile Dysfunction

First-Line Treatment: PDE5 Inhibitors

Oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil) should be offered as first-line therapy for erectile dysfunction unless contraindicated. 1, 2

Why PDE5 Inhibitors Are First-Line

• PDE5 inhibitors demonstrate statistically significant and clinically relevant improvements in erectile function with success rates of 69% compared to 35% with placebo 2
• All three FDA-approved agents (sildenafil, tadalafil, vardenafil) have similar efficacy in the general ED population 2, 3, 4
• These medications are relatively well-tolerated with mild to moderate adverse events including headache, flushing, nasal congestion, dyspepsia, back pain, and myalgia 1, 3

Choosing Between PDE5 Inhibitors

Base your choice on pharmacokinetic differences and patient lifestyle preferences rather than efficacy, since all three work equally well. 1, 2

• Tadalafil has a significantly longer half-life (17.5 hours) providing a 36-hour window of opportunity, making it ideal for men who prefer spontaneity 5, 6
• Sildenafil and vardenafil have shorter half-lives (approximately 4 hours) and may be preferred by older men who want more predictable timing 6, 7
• Tadalafil has lower rates of flushing compared to other PDE5 inhibitors 3, 5
• Food (especially fatty meals) affects absorption of sildenafil and vardenafil but not tadalafil 6

Dosing Strategy

Start with standard dosing and titrate to maximum tolerated dose before declaring treatment failure. 2, 4

• Begin tadalafil at 10mg as needed, can increase to 20mg 5
• An adequate trial requires at least 5 separate occasions at the maximum dose before considering the medication ineffective 2
• Higher doses provide greater efficacy but also increased risk of adverse effects 1
• Dose titration significantly increases efficacy and patient satisfaction 4

Critical Contraindications and Safety

Never prescribe PDE5 inhibitors to patients taking nitrates—this combination causes potentially fatal hypotension. 1, 2, 5

Cardiovascular Risk Stratification

Assess cardiovascular risk before initiating ED treatment using the Princeton Consensus Panel criteria. 1

High-risk patients (defer treatment until stabilized): 1, 3

• Unstable or refractory angina
• Uncontrolled hypertension
• Left ventricular dysfunction/CHF (NYHA class II or greater)
• MI or stroke within previous 2 weeks
• High-risk arrhythmias
• Hypertrophic obstructive cardiomyopathies
• Moderate-to-severe valvular disease

Low-risk patients (safe for all first-line therapies): 1

• Asymptomatic coronary artery disease with fewer than 3 risk factors
• Controlled hypertension
• Mild, stable angina
• Successful coronary revascularization
• Uncomplicated past MI
• Mild valvular disease
• CHF (NYHA class I)

Practical screening test: Patients unable to walk 1 mile in 20 minutes or climb 2 flights of stairs in 20 seconds without symptoms should be referred to cardiology before treatment 2

Lifestyle Modifications

Counsel all ED patients on risk factor modification regardless of pharmacologic treatment. 1, 2

• Smoking cessation 2
• Weight loss if overweight 1, 2
• Increasing physical activity 1, 2
• Avoiding excess alcohol consumption 2
• Optimal management of diabetes, hypertension, and dyslipidemia 1

Hormonal Testing

Do not routinely measure testosterone in all ED patients—individualize based on clinical presentation. 1, 2

When to Check Testosterone

Measure testosterone levels when patients present with: 1, 2

• Decreased libido
• Premature ejaculation
• Fatigue
• Testicular atrophy
• Muscle atrophy

Note: Testosterone prevalence ranges from 12.5% to 36% in men with ED, but testosterone therapy is not indicated for ED in men with normal testosterone levels 1

Second-Line Therapies

If PDE5 inhibitors fail after adequate trial, proceed to second-line interventions. 1, 2

• Intraurethral alprostadil suppositories 1, 2, 4
• Intracavernous vasoactive drug injection (alprostadil, papaverine, phentolamine or combinations) 1, 4
• Vacuum constriction devices 1

Intracavernous alprostadil is effective and well-tolerated with strong evidence supporting its use as second-line therapy. 4

Third-Line Therapy

Penile prosthesis implantation is the definitive third-line intervention for refractory ED. 1, 2

Common Pitfalls to Avoid

Many treatment "failures" are actually due to incorrect medication use—provide explicit instructions. 2, 3

• Patients must understand that sexual stimulation is required for PDE5 inhibitors to work 5
• Timing relative to sexual activity matters (varies by agent) 5
• Inadequate dosing or insufficient number of attempts accounts for many perceived failures 2

Do not prescribe trazodone or yohimbine for ED—insufficient evidence supports their use. 1, 2

Avoid prescribing testosterone for ED in men with normal testosterone levels—it is not indicated. 1, 2

Patient and Partner Involvement

Inform both patient and partner of treatment options, risks, and benefits, making treatment decisions jointly. 1

• Psychosexual therapy may be useful in combination with medical treatment 1
• For some patients, brief education and reassurance may be sufficient 1
• Assessment of partner's sexual function may be helpful 1

Special Populations

Men with diabetes have more severe ED at baseline and respond less robustly to PDE5 inhibitors. 3

Post-prostatectomy patients show reduced response to PDE5 inhibitors compared to the general population. 3

Men with spinal cord injury require lower initial doses due to potential delayed metabolism. 3

Follow-Up

Periodically assess efficacy, side effects, and any significant changes in health status or medications. 3, 5