What are the treatment options for erectile dysfunction (ED) caused by medications?

Treatment of Medication-Induced Erectile Dysfunction

The first step in managing medication-induced ED is to identify and discontinue or substitute the offending medication whenever clinically feasible, as drug therapy accounts for approximately 25% of ED cases and is typically readily reversible when the causative agent is stopped. 1

Immediate Management Strategy

Step 1: Identify the Causative Medication

• Antihypertensives (particularly thiazide diuretics and beta-blockers) and SSRI antidepressants are the most commonly implicated drug classes causing ED 1
• Other frequent culprits include antipsychotics, antiandrogens, and substances like tobacco and alcohol 1, 2
• Drug-induced ED is typically dose-related and predictable from the medication's pharmacology 1

Step 2: Modify or Substitute the Offending Agent

• Discontinue the causative medication if medically appropriate, as this often results in complete resolution 1
• Switch to alternative agents within the same therapeutic class that have lower ED risk profiles 1
• For SSRI-induced ED specifically, consider switching to bupropion, which has selectivity for dopamine reuptake inhibition and can alleviate sexual symptoms caused by other antidepressants 3
• Ensure adequate control of underlying conditions (diabetes, hypertension, hyperlipidemia) through alternative medications, as poor disease control independently worsens ED 2

Pharmacological Treatment When Medication Cannot Be Changed

First-Line: PDE5 Inhibitors

If the causative medication cannot be discontinued, initiate PDE5 inhibitor therapy as first-line treatment, as these agents demonstrate 73-88% improvement in erections compared to 26-32% with placebo. 4, 5

Sildenafil

• Dosing: Start at 50 mg taken 1 hour before sexual activity; titrate between 25-100 mg based on response 6, 5
• Success rate: 69% (range 52-85%) versus 35.5% placebo 6
• Duration: 4-5 hours 6
• Nitrate washout: At least 24 hours required 6, 5

Tadalafil

• Dosing: 10-20 mg as needed, or 2.5-5 mg daily 7, 8
• Success rate: 69% (range 50-85%) versus 33% placebo 6
• Duration: Up to 36 hours 6
• Nitrate washout: At least 24-48 hours required due to longer half-life 6
• Key advantage: No significant dose-response difference between 5 mg, 10 mg, and 20 mg for on-demand dosing 4

Critical PDE5 Inhibitor Considerations

• Absolute contraindication: Never use with nitrates or guanylate cyclase stimulators (riociguat) due to severe hypotension risk 6, 8
• Common adverse effects: Headache, flushing, dyspepsia, nasal congestion (dose-dependent) 4, 5, 7
• Serious adverse events: Less than 2% incidence, no difference from placebo 4, 5
• Adequate trial: Ensure 4-8 attempts at proper dosing before declaring treatment failure 6
• Sexual stimulation is necessary for medication efficacy 5, 7

Testosterone Supplementation

• For men with concurrent testosterone deficiency: Combination therapy with PDE5 inhibitors plus testosterone is more effective than PDE5 inhibitors alone 4, 7
• Testosterone monotherapy is not effective for ED treatment 4

Second-Line Options When PDE5 Inhibitors Fail or Are Contraindicated

Intraurethral Alprostadil

• Efficacy: 64.9% achieve at least one episode of intercourse, with success rates ranging 29.5-78.1% 4
• Requirement: In-office test and dose titration mandatory before home use 4
• Appropriate for men with PDE5i contraindications or those preferring to avoid oral medication 4

Intracavernosal Injection (ICI) Therapy

• Agents: Alprostadil (FDA-approved), or combinations of papaverine, phentolamine, and/or atropine 4
• Efficacy: Success rates up to 90% 9
• Requirement: In-office injection test mandatory before home use 4
• Caution: Risk of priapism; patients must be counseled on seeking emergency care if erection lasts >4 hours 4

Vacuum Erection Device (VED)

• Only use devices with vacuum limiters 4
• Available over-the-counter or by prescription 4
• Minor adverse effects: Transient petechiae, bruising, discomfort, difficulty with ejaculation (all resolve without intervention) 4
• Use with caution: In men on anticoagulants, with bleeding disorders, or history of priapism 4

Third-Line: Surgical Options

Penile Prosthesis Implantation

• Indication: When all other treatments have failed 4, 10
• Modern infection rates: 1-2% with infection-inhibiting coated models 4
• Contraindications: Systemic, cutaneous, or urinary tract infection 4
• Essentially irreversible; requires thorough counseling regarding post-operative expectations 4
• High patient and partner satisfaction rates when appropriately selected 4

Common Pitfalls to Avoid

• Do not assume PDE5i failure without ensuring adequate trial: Verify proper dosing, timing, sexual stimulation, and at least 4-8 attempts 6, 5
• Do not overlook testosterone deficiency: Check testosterone levels in men with poor PDE5i response, as combination therapy significantly improves outcomes 4, 7
• Do not prescribe IU alprostadil or ICI therapy without in-office testing: This is a clinical principle requirement 4
• Do not ignore cardiovascular risk assessment: ED diagnosis provides opportunity to evaluate cardiovascular risk factors 6