What are the treatment options for erectile dysfunction?

Treatment Options for Erectile Dysfunction

Oral phosphodiesterase type 5 (PDE5) inhibitors—sildenafil, tadalafil, vardenafil, or avanafil—should be offered as first-line therapy for erectile dysfunction unless contraindicated, with treatment escalating in a stepwise fashion to more invasive options only if oral medications fail. 1, 2

First-Line Treatment: PDE5 Inhibitors

• PDE5 inhibitors are the standard first-line pharmacological treatment and should be offered to all men with ED unless specific contraindications exist 1, 2, 3
• These medications achieve successful intercourse in 60-65% of men with ED, including those with hypertension, diabetes, spinal cord injury, and other comorbidities 4
• The four available agents (sildenafil, tadalafil, vardenafil, avanafil) have comparable efficacy, and there is insufficient evidence to recommend one over another 1
• Doses must be titrated to optimal efficacy rather than using a single fixed dose 2
• Patients should receive proper instructions on timing and use to maximize benefit 2
• Tadalafil demonstrates efficacy for up to 36 hours after dosing, with 62-64% of patients achieving successful intercourse at this timepoint compared to 33-37% with placebo 5

Critical Contraindications

• Absolute contraindication: concurrent use with nitrates or guanylate cyclase stimulators (riociguat) due to potentially fatal hypotension 5
• After taking sildenafil, wait 24 hours before administering nitrates in an emergency; for tadalafil, wait 48 hours 1
• Recreational "poppers" (amyl nitrite, butyl nitrite) are also contraindicated 5

Cardiovascular Risk Stratification

• All men with ED require cardiovascular risk assessment before initiating PDE5 inhibitors 1, 2, 3
• High-risk patients (unstable angina, uncontrolled hypertension, recent MI or stroke within 2 weeks, severe heart failure, high-risk arrhythmias) should not receive ED treatment until cardiac condition stabilizes 1, 2
• Low-risk patients (asymptomatic coronary disease, <3 cardiac risk factors, controlled hypertension, mild stable angina, uncomplicated past MI) may receive all first-line therapies 1
• Intermediate-risk patients require cardiology evaluation before treatment 1

Adjunctive Measures with First-Line Treatment

• Lifestyle modifications improve erectile function and should be implemented alongside pharmacotherapy: smoking cessation, weight loss, regular physical activity, moderate alcohol consumption (<14 units/week for women, <21 units/week for men) 3, 6
• Optimal management of diabetes, hypertension, and cardiovascular disease enhances PDE5 inhibitor efficacy 2, 3
• Check testosterone levels in men who do not respond to PDE5 inhibitors, as adequate testosterone is required for full PDE5 inhibitor efficacy 3, 7
• Consider testosterone replacement in men with confirmed hypogonadism (testosterone <230 ng/dL) and symptoms, as this improves libido and may enhance PDE5 inhibitor response 3

Second-Line Treatment: Local Therapies

When oral medications fail or are contraindicated, escalate to:

• Intracavernous injection therapy using vasodilator drugs (alprostadil, papaverine, or phentolamine) is highly effective for PDE5 inhibitor non-responders 2, 3, 4
• Intraurethral alprostadil suppositories provide an alternative local therapy option 2, 3
• Vacuum constriction devices offer a non-invasive mechanical option for patients who cannot use or do not respond to pharmacological treatments 2, 3

Third-Line Treatment: Surgical Intervention

• Penile prosthesis implantation is reserved for patients with refractory ED who fail all less invasive treatments 2, 3
• Multicomponent inflatable penile implants achieve high patient satisfaction rates 4

Psychosexual Therapy

• Psychosexual therapy should be offered in combination with medical treatments, particularly for men with predominantly psychogenic ED 2, 3
• Partner involvement in treatment decisions improves outcomes 3
• Therapy helps improve communication about sexual concerns and reduces performance anxiety 2

Hormonal Evaluation

• The American College of Physicians does not recommend routine hormonal blood testing in all ED patients 1
• Obtain fasting glucose, lipid profile, and total testosterone levels in select cases: non-responders to PDE5 inhibitors, men with symptoms of hypogonadism (decreased libido, fatigue), or those with diabetes 3, 4, 7
• Additional hormonal evaluation (LH, prolactin, TSH, FT4) may be warranted in specific clinical scenarios 7

Critical Clinical Pitfalls

• ED is an early marker of cardiovascular disease, often preceding coronary symptoms by 2-5 years; screen all ED patients for diabetes, hypertension, hyperlipidemia, and metabolic syndrome 3, 4, 8
• Not titrating PDE5 inhibitor doses to achieve optimal efficacy leads to unnecessary treatment failures 2
• Failing to check testosterone in PDE5 inhibitor non-responders misses a treatable cause 3
• Not discussing treatment options with both patient and partner when possible reduces treatment success 3
• Certain antihypertensive agents (particularly non-selective beta-blockers and thiazide diuretics) can worsen ED; consider medication adjustment 6