Treatment of Antipsychotic-Induced Erectile Dysfunction
Initiate oral PDE5 inhibitors (sildenafil, vardenafil, or tadalafil) as first-line therapy for erectile dysfunction caused by antipsychotic medications, with expected success rates of 65-70% for improving erections. 1
First-Line Pharmacologic Treatment
PDE5 inhibitors should be offered immediately as first-line therapy for antipsychotic-induced erectile dysfunction, demonstrating high-quality evidence with 69% successful intercourse attempts versus 33-36% with placebo 2, 1
All three major PDE5 inhibitors show equivalent efficacy: sildenafil (69% vs 35.5% placebo), vardenafil (68% vs 35% placebo), and tadalafil (69% vs 33% placebo) 2
Select between PDE5 inhibitors based on patient preference, cost, and side effect profiles rather than efficacy differences, as all demonstrate similar effectiveness 1
Tadalafil demonstrates sustained efficacy at 24 hours (61% success) and 36 hours (64% success) post-dosing, offering flexibility for patients 3
Provide explicit instructions on proper medication use, as inadequate patient education is a common cause of treatment failure 1, 4
Critical Evaluation Before Treatment
Measure morning serum total testosterone levels in all men with antipsychotic-induced erectile dysfunction, as 55-68% have low testosterone and 12.5-35% have clinically significant hypogonadism 5, 6
Assess cardiovascular risk factors before initiating PDE5 inhibitors, as erectile dysfunction may signal underlying cardiovascular disease 1
Recognize that hyperprolactinemia from antipsychotics (occurring in 68% of patients) suppresses testosterone through gonadotropin-releasing hormone inhibition, creating a dual hormonal mechanism for sexual dysfunction 6
Antipsychotic-Specific Considerations
Risperidone, haloperidol, and amisulpride are high-risk prolactin-elevating antipsychotics causing sexual dysfunction in 30-60% of patients, while aripiprazole, quetiapine, clozapine, and olanzapine are prolactin-sparing alternatives 7, 8, 9
If the clinical situation permits, consider switching to aripiprazole or other prolactin-sparing antipsychotics as primary prevention strategy 9
When prolactin-elevating antipsychotics cannot be discontinued, add aripiprazole 5-20 mg/day as adjunctive therapy to normalize prolactin levels and treat sexual dysfunction 9
Second-Line and Escalation Strategies
For patients failing PDE5 inhibitors, advance to intracavernous injection therapy with alprostadil as second-line treatment 2, 1
Alternative second-line options include intraurethral alprostadil suppositories and vacuum erection devices 2, 10
Penile prosthesis implantation remains the definitive third-line option for patients who fail all less invasive treatments 2, 1, 10
Adjunctive Interventions
Incorporate psychosexual therapy alongside pharmacologic treatment, particularly when psychological factors (anxiety, unrealistic expectations) contribute to dysfunction 2, 1, 4
Include the patient's partner in treatment discussions when possible, as partner involvement improves outcomes 2, 10
If testosterone deficiency is confirmed, initiate testosterone replacement therapy, as PDE5 inhibitors demonstrate enhanced efficacy when combined with testosterone therapy in hypogonadal men 5
Common Pitfalls to Avoid
Failing to recognize that antipsychotic-induced erectile dysfunction is potentially reversible through medication adjustment or switching 1
Not discussing treatment options and their risks/benefits with both patient and partner 1
Neglecting to provide proper instructions on PDE5 inhibitor use (timing, sexual stimulation requirement, food interactions), leading to perceived treatment failure 1, 4
Overlooking testosterone deficiency, which may persist even when PDE5 inhibitors provide partial improvement 5
Dismissing the 50% prevalence of gynecomastia and 73% prevalence of penile symptoms in men taking prolactin-elevating antipsychotics 6