What are the causes and treatments of erectile dysfunction (ED)?

From the Guidelines

Erectile dysfunction (ED) is a common condition where a man has difficulty achieving or maintaining an erection sufficient for sexual activity, and the most effective first-line treatment is oral medications like sildenafil (Viagra, 25-100mg), tadalafil (Cialis, 5-20mg), vardenafil (Levitra, 5-20mg), or avanafil (Stendra, 50-200mg) taken 30-60 minutes before sexual activity, as recommended by the American College of Physicians 1.

Treatment Options

The treatment of ED involves a stepwise approach, starting with lifestyle modifications and oral medications, and progressing to more invasive options if necessary. The choice of treatment should be made jointly by the physician, patient, and partner, taking into consideration patient preferences and expectations, and the experience and judgment of the physician 1.

• Lifestyle changes that can help include regular exercise, maintaining healthy weight, quitting smoking, limiting alcohol, and managing stress.
• Oral medications like sildenafil, tadalafil, vardenafil, or avanafil are effective first-line treatments, and work by enhancing the effects of nitric oxide, which relaxes muscles in the penis and increases blood flow.
• Underlying conditions like diabetes, high blood pressure, or heart disease should be addressed as they often contribute to ED.
• If medications aren't effective, alternatives include vacuum erection devices, penile injections, urethral suppositories, or surgical penile implants.
• Psychological causes like anxiety, depression, or relationship issues may require counseling alongside physical treatments.

Important Considerations

It's essential to consult a healthcare provider for proper diagnosis and personalized treatment, as ED can sometimes indicate more serious health problems. The American College of Physicians recommends that clinicians initiate therapy with a PDE-5 inhibitor in men who seek treatment for erectile dysfunction and who do not have a contraindication to PDE-5 inhibitor use 1.

• The use of PDE5-Is together with oral nitrates is contraindicated.
• The efficacy of PDE5-Is is independent of the duration of diabetes, glycaemic control, and microvascular complications.
• Daily use of tadalafil provides an alternative to on-demand dosing for couples who prefer spontaneous rather than scheduled sexual activity 1.

From the FDA Drug Label

The efficacy and safety of tadalafil in the treatment of erectile dysfunction has been evaluated in 22 clinical trials of up to 24-weeks duration, involving over 4000 patients. Tadalafil, when taken as needed up to once per day, was shown to be effective in improving erectile function in men with erectile dysfunction (ED) Tadalafil was studied in the general ED population in 7 randomized, multicenter, double-blinded, placebo-controlled, parallel-arm design, primary efficacy and safety studies of 12-weeks duration. Results in ED Population in US Trials — The 2 primary US efficacy and safety trials included a total of 402 men with erectile dysfunction, with a mean age of 59 years (range 27 to 87 years) The treatment effect of tadalafil did not diminish over time Table 11: Mean Endpoint and Change from Baseline for the Primary Efficacy Variables in the Two Primary US Trials Study A Study B Placebo Tadalafil 20 mg Placebo Tadalafil 20 mg (N=49) (N=146) p-value (N=48) (N=159) p-value EF Domain Score Endpoint 13.5 19.5 13.6 22.5 Change from baseline -0.2 6.9 <.001 0.3 9.3 <.001 Insertion of Penis (SEP2) Endpoint 39% 62% 43% 77% Change from baseline 2% 26% <. 001 2% 32% <.001 Maintenance of Erection (SEP3) Endpoint 25% 50% 23% 64% Change from baseline 5% 34% <.001 4% 44% <.001

Tadalafil is effective in treating erectile dysfunction (ED).

• The drug has been evaluated in 22 clinical trials with over 4000 patients.
• Tadalafil improved erectile function in men with ED, with significant improvements in EF domain score, insertion of penis, and maintenance of erection.
• The treatment effect of tadalafil did not diminish over time 2. Key considerations for use:
• Patients should be evaluated for underlying cardiovascular disease before prescribing tadalafil.
• Tadalafil is not recommended for patients with certain cardiovascular conditions, such as myocardial infarction within the last 90 days or unstable angina 2.

From the Research

Treatment Options for Erectile Dysfunction

• Oral phosphodiesterase type 5 (PDE5) inhibitors are the recommended first-line treatment for erectile dysfunction, with similar efficacy and toxicity profiles among the three currently licensed PDE5 inhibitors: sildenafil citrate, vardenafil HCl, and tadalafil 3.
• The choice of PDE5 inhibitor may depend on patient preference, with factors such as onset of action, half-life, and food effects influencing this decision 3, 4.
• Sildenafil and vardenafil have similar molecular structures and half-lives, while tadalafil has a longer half-life and is less affected by food 3.

Lifestyle Modifications and Erectile Dysfunction

• Lifestyle modifications such as smoking cessation, weight reduction, dietary modification, physical activity, and psychological stress reduction may improve erectile function in men with erectile dysfunction 5, 6.
• Modifiable risk factors for erectile dysfunction include smoking, lack of physical activity, wrong diets, overweight or obesity, metabolic syndrome, and excessive alcohol consumption 6.
• Promoting healthful lifestyles may yield great benefits in reducing the burden of sexual dysfunction, and efforts should be made to implement educative strategies for healthy lifestyle 6.

Choosing the Right Treatment for Erectile Dysfunction

• The choice of PDE5 inhibitor should be individualized, taking into account the patient's profile, clinical, demographic, and relational factors 7.
• A systematic literature search and current treatment guidelines can help identify the main factors influencing the choice of PDE5 inhibitor 7.
• Simple algorithms can be used to help choose the right treatment for each patient affected by erectile dysfunction 7.