What are the treatment options for erectile dysfunction?

Treatment for Erectile Dysfunction

First-Line Treatment: Start with PDE5 Inhibitors

Initiate treatment with oral PDE5 inhibitors (sildenafil, tadalafil, or vardenafil) as first-line therapy for erectile dysfunction unless contraindicated. 1, 2, 3

Why PDE5 Inhibitors Work Best

• PDE5 inhibitors demonstrate success rates of 69% compared to 35% with placebo, representing clinically meaningful improvements in erectile function 1, 2
• All three FDA-approved agents (sildenafil, tadalafil, vardenafil) have equivalent efficacy in the general ED population—no single drug works better than another 1, 3, 4
• These medications are well-tolerated with mild to moderate adverse events including headache, flushing, nasal congestion, dyspepsia, back pain, and myalgia 1, 3

Selecting the Right PDE5 Inhibitor

Choose between PDE5 inhibitors based on pharmacokinetic differences and patient lifestyle preferences, not efficacy, since all three work equally well. 1, 4

• Tadalafil is the preferred option for most patients due to its 17.5-hour half-life providing a 36-hour window of opportunity, making sexual activity more spontaneous 1, 4
• Tadalafil has lower rates of flushing compared to other PDE5 inhibitors 1
• Tadalafil is not affected by food intake, unlike sildenafil and vardenafil which have reduced absorption with fatty meals 4
• Sildenafil and vardenafil have shorter half-lives of approximately 4 hours, requiring more precise timing before sexual activity 4

Proper Dosing Strategy

• Start tadalafil at 10mg as needed, increase to 20mg if inadequate response 1, 5
• Trial the medication for at least 5 separate occasions at maximum tolerated dose before declaring treatment failure—this is critical as many "failures" are actually inadequate trials 1, 2
• Higher doses provide greater efficacy but increase adverse effects, requiring careful titration 1, 3
• Incorrect medication use accounts for a large percentage of treatment failures—emphasize to patients the need for sexual stimulation, multiple trials, and proper timing 3

Critical Safety Screening Before Prescribing

Absolute Contraindications

• Never prescribe PDE5 inhibitors to patients taking nitrates—this combination causes potentially fatal hypotension 1, 2, 6
• Avoid in patients with unstable or refractory angina, uncontrolled hypertension, recent MI or stroke (within 2 weeks), severe heart failure (NYHA class II or greater), high-risk arrhythmias, hypertrophic obstructive cardiomyopathy, or moderate-to-severe valvular disease 1, 2
• Patients with congenital QT prolongation or taking Class IA (quinidine, procainamide) or Class III (amiodarone, sotalol) antiarrhythmics should avoid vardenafil 6

Special Dosing Adjustments

• Moderate hepatic impairment (Child-Pugh B): Start vardenafil at 5mg, maximum 10mg 6
• Severe hepatic impairment (Child-Pugh C): Vardenafil has not been evaluated and should be avoided 6
• Moderate to severe renal impairment: Vardenafil AUC increases 20-30%, use caution 6
• Patients on alpha-blockers: Start with lowest PDE5 inhibitor dose due to additive hypotensive effects 3, 6

Essential Lifestyle Modifications

• Counsel all ED patients on risk factor modification regardless of pharmacologic treatment 1
• Recommend smoking cessation, weight loss if overweight, increasing physical activity, avoiding excess alcohol, and optimal management of diabetes, hypertension, and dyslipidemia 1
• Communicate to patients that ED is often the first manifestation of cardiovascular disease and warrants cardiovascular risk assessment 2, 3

Hormonal Testing: When to Check Testosterone

• Do not routinely measure testosterone in all ED patients—only test when clinically indicated 1
• Measure testosterone levels when patients present with decreased libido, premature ejaculation, fatigue, testicular atrophy, or muscle atrophy 1
• Consider measuring free testosterone in patients who do not respond to PDE5 inhibitors 1, 2
• Testosterone therapy is not indicated for ED treatment in patients with normal testosterone levels 3

Troubleshooting PDE5 Inhibitor Failure

Before switching therapies or escalating to second-line options, evaluate:

• Hormonal abnormalities (check testosterone if not already done) 1
• Food or drug interactions (especially fatty meals with sildenafil/vardenafil) 1, 4
• Timing and frequency of dosing (ensure at least 5 maximum-dose trials) 1, 2
• Adequacy of sexual stimulation (medication requires arousal to work) 1, 3
• Heavy alcohol use (impairs erectile function) 1
• Relationship issues with partner (consider couples counseling) 1

Second-Line Therapies

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

• Intraurethral alprostadil suppositories 1, 2
• Intracavernosal vasoactive drug injection 1, 2
• Vacuum constriction devices 1, 2, 3

Third-Line Therapy

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

Special Populations with Reduced Response

• Men with diabetes have more severe ED at baseline and respond less robustly to PDE5 inhibitors—may require higher doses or earlier escalation to second-line therapies 1
• Post-prostatectomy patients show reduced response to PDE5 inhibitors compared to the general population 1
• Men with spinal cord injury require lower initial doses due to potential delayed metabolism 1

Common Pitfalls to Avoid

• Declaring treatment failure before completing at least 5 maximum-dose trials 1, 2
• Failing to screen for cardiovascular risk factors and contraindications before prescribing 1, 2, 3
• Not educating patients that sexual stimulation is required for medication effectiveness 3
• Ignoring testosterone deficiency in patients with decreased libido 2, 3
• Prescribing PDE5 inhibitors to patients on nitrates 1, 2, 6