What are the treatment options for erectile dysfunction?

Treatment Options for Erectile Dysfunction

First-Line Treatment: Oral PDE5 Inhibitors

Oral phosphodiesterase type 5 (PDE5) inhibitors—sildenafil, tadalafil, vardenafil, or avanafil—should be prescribed as first-line therapy for erectile dysfunction unless contraindicated. 1, 2

• All three FDA-approved agents (sildenafil, tadalafil, vardenafil) demonstrate equivalent efficacy in the general ED population with success rates of 69% compared to 35% with placebo. 2

• Start with standard dosing and titrate to the maximum tolerated dose before declaring treatment failure—an adequate trial requires at least 5 separate occasions at the maximum dose. 2

• For tadalafil, begin at 10mg as needed and increase to 20mg if needed. 2

• Choose between PDE5 inhibitors based on pharmacokinetic differences and patient lifestyle preferences rather than efficacy: 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 and has lower rates of flushing. 2

Critical Safety Considerations

Never prescribe PDE5 inhibitors to patients taking nitrates—this combination causes potentially fatal hypotension. 2, 3

• Assess cardiovascular risk before initiating treatment using the Princeton Consensus Panel criteria. 1, 2

• High-risk patients should not receive treatment for sexual dysfunction until their cardiac condition has stabilized, including those with 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, and moderate-to-severe valvular disease. 1, 2

• Patients taking Class 1A (quinidine, procainamide) or Class III (amiodarone, sotalol) antiarrhythmic medications or those with congenital QT prolongation should avoid vardenafil. 3

• For patients on alpha-blockers, start PDE5 inhibitors at the lowest recommended dose due to risk of symptomatic hypotension. 2, 3

• In moderate hepatic impairment (Child-Pugh B), start vardenafil at 5mg with a maximum dose of 10mg. 3

Common Adverse Effects

• Mild to moderate adverse events include headache, flushing, nasal congestion, dyspepsia, back pain, and myalgia. 2

• Advise patients to stop all PDE5 inhibitors and seek immediate medical attention for sudden loss of vision (potential non-arteritic anterior ischemic optic neuropathy) or sudden decrease/loss of hearing. 3

Adjunctive Lifestyle Modifications

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

• Recommend smoking cessation, weight loss if overweight, increasing physical activity, avoiding excess alcohol consumption, and optimal management of diabetes, hypertension, and dyslipidemia. 2, 4

• Obesity, sedentary lifestyle, and smoking greatly increase the risk of ED. 5

Hormonal Testing and Treatment

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

• Measure testosterone levels when patients present with decreased libido, premature ejaculation, fatigue, testicular atrophy, or muscle atrophy. 2

• The American College of Physicians does not recommend for or against routine use of hormonal blood tests or hormonal treatment in the management of patients with erectile dysfunction due to insufficient evidence. 6

• Testosterone therapy should be considered in men with confirmed testosterone deficiency. 1, 4

Second-Line Treatments (When PDE5 Inhibitors Fail)

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

Intracavernous Injection Therapy

• Intracavernous injection therapy using vasodilator drugs such as alprostadil, papaverine, or phentolamine is effective for patients who fail to respond to oral agents. 1, 7, 8

• Alprostadil is indicated for treatment of erectile dysfunction due to neurogenic, vasculogenic, psychogenic, or mixed etiology. 7

• Common side effect is mild to moderate pain during injection; patients should contact their physician if severe pain occurs. 7

• Erections lasting more than 6 hours require immediate medical attention to prevent permanent penile damage. 7

• Men with conditions that might result in long-lasting erections (sickle cell anemia or trait, leukemia, multiple myeloma) should not use alprostadil. 7

Intraurethral Alprostadil Suppositories

• Intraurethral alprostadil suppositories are another second-line option. 1, 4

Vacuum Constriction Devices

• Vacuum constriction devices are a non-invasive mechanical option for patients who cannot use or do not respond to pharmacological treatments. 1, 4

Third-Line Treatment: Penile Prosthesis

Penile prosthesis implantation is the definitive third-line intervention reserved for patients who fail less invasive treatments. 1, 2, 4

• Surgically implanted multicomponent inflatable penile implants are associated with high satisfaction rates. 8

Psychosexual Therapy

• Psychosexual therapy is useful in combination with both medical and surgical treatments, particularly beneficial for patients with predominantly psychogenic ED. 1, 4

• Helps improve communication about sexual concerns and reduce anxiety. 1

• Counseling is recommended for men with psychogenic ED. 9

Special Population Considerations

• Men with diabetes have more severe ED at baseline and respond less robustly to PDE5 inhibitors. 2

• Post-prostatectomy patients show reduced response to PDE5 inhibitors compared to the general population. 2

• Men with spinal cord injury require lower initial doses of PDE5 inhibitors due to potential delayed metabolism. 2

Cardiovascular Risk Assessment

ED is a risk marker for cardiovascular disease—patients with ED should be evaluated for cardiovascular risk factors. 1, 4

• Symptoms of ED present on average three years earlier than symptoms of coronary artery disease. 5

• Men with ED are at increased risk of coronary, cerebrovascular, and peripheral vascular diseases. 5

Common Pitfalls to Avoid

• Failure to recognize ED as a potential marker of underlying cardiovascular disease. 1

• Not titrating PDE5 inhibitor doses to achieve optimal efficacy before declaring treatment failure. 1, 2

• Not considering psychosexual factors that may contribute to or exacerbate ED. 1

• Not discussing treatment options and their risks/benefits with both the patient and partner when possible. 1