What are the treatment options for erectile dysfunction?

Treatment Options for Erectile Dysfunction

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

Stepwise Treatment Algorithm

First-Line: PDE5 Inhibitors

• Start with a PDE5 inhibitor at standard dosing: tadalafil 10mg, sildenafil 50mg, or vardenafil 10mg 2
• Titrate to the maximum tolerated dose before declaring treatment failure—this requires at least 5 separate attempts at the maximum dose 2
• All three FDA-approved PDE5 inhibitors have equivalent efficacy (69% success rate vs 35% placebo), so choose based on pharmacokinetics and patient preference 2
• Tadalafil offers a 36-hour window due to its 17.5-hour half-life, making it ideal for men preferring spontaneity 2
• Provide explicit instructions: take approximately 60 minutes before sexual activity, and sexual stimulation is required for the medication to work 3, 2

Critical Safety Checks Before Prescribing:

• Never prescribe PDE5 inhibitors to patients taking nitrates—this combination causes potentially fatal hypotension 2, 3
• Assess cardiovascular risk using Princeton Consensus Panel criteria 1, 2
• Defer treatment in high-risk patients (unstable angina, uncontrolled hypertension, recent MI/stroke within 2 weeks, NYHA class II or greater heart failure, high-risk arrhythmias) until cardiac condition stabilizes 1, 2
• Use caution with alpha-blockers—start PDE5 inhibitors at the lowest dose due to additive hypotensive effects 3
• Reduce vardenafil dose to 5mg maximum 10mg in moderate hepatic impairment (Child-Pugh B); avoid in severe impairment 3

Lifestyle Modifications (Concurrent with Pharmacotherapy)

• Counsel on smoking cessation, weight loss if overweight, regular physical activity, and moderate alcohol consumption 1, 4, 2
• Optimize management of diabetes, hypertension, and dyslipidemia—these comorbidities both cause ED and predict cardiovascular mortality 4, 2

Hormonal Assessment (Selective, Not Routine)

• Do not routinely measure testosterone in all ED patients 5, 2
• Check total testosterone only in men with decreased libido, premature ejaculation, fatigue, testicular atrophy, or muscle atrophy 2
• Measure testosterone in patients who fail to respond to PDE5 inhibitors, as adequate testosterone levels are required for full PDE5 inhibitor efficacy 4, 2
• Consider testosterone replacement in men with confirmed hypogonadism (testosterone <230 ng/dL) and symptoms—this improves sexual function and may enhance PDE5 inhibitor response 4

Second-Line: Local Therapies

If PDE5 inhibitors fail after adequate trial (at least 5 attempts at maximum dose), proceed to:

• Intracavernosal injection therapy using vasodilator drugs (alprostadil, papaverine, or phentolamine) 1, 6, 7
• Intraurethral alprostadil suppositories 1, 4
• Vacuum constriction devices—a non-invasive mechanical option 1, 4

Third-Line: Surgical Intervention

• Penile prosthesis implantation is reserved for patients who fail all less invasive treatments 1, 4, 2
• Multicomponent inflatable penile implants are associated with high patient satisfaction rates 7

Adjunctive Psychosexual Therapy

• Psychosexual therapy is useful in combination with medical treatments, particularly for patients with predominantly psychogenic ED 1, 4
• This helps improve communication about sexual concerns, reduce performance anxiety, and address relationship issues 1, 4

Common Pitfalls to Avoid

• Failing to titrate PDE5 inhibitor doses to maximum before switching therapies—many treatment "failures" are actually inadequate dosing trials 2
• Not providing clear instructions on timing (60 minutes before activity) and the need for sexual stimulation 2, 3
• Missing the opportunity to screen for cardiovascular disease—ED symptoms typically precede coronary artery disease by 2-5 years 4, 8
• Prescribing testosterone without checking baseline levels or in men with normal testosterone (>350 ng/dL) 4
• Not evaluating for reversible causes: medication side effects, relationship issues, inadequate sexual stimulation, or heavy alcohol use 2

Special Population Considerations

• Men with diabetes have more severe ED and reduced PDE5 inhibitor response compared to the general population 2
• Post-prostatectomy patients show diminished response to oral agents 2
• Patients with spinal cord injury may require lower initial doses 2