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

From the Guidelines

Erectile dysfunction (ED) is best managed with oral phosphodiesterase type 5 (PDE5) inhibitors, such as sildenafil, tadalafil, vardenafil, or avanafil, as first-line treatment, according to the most recent and highest quality evidence. The management of ED begins with the identification of organic comorbidities and psychosexual dysfunctions, which should be appropriately treated or their care triaged 1. Lifestyle modifications, such as regular exercise, maintaining a healthy weight, quitting smoking, limiting alcohol, and managing stress, can also help improve ED symptoms.

For most men with ED, oral medications like sildenafil (Viagra, 25-100mg), tadalafil (Cialis, 5-20mg), vardenafil (Levitra, 5-20mg), or avanafil (Stendra, 50-200mg) taken before sexual activity are effective first-line treatments 1. These medications work by enhancing the effects of nitric oxide, which relaxes muscles in the penis and increases blood flow.

Some key points to consider when managing ED include:

• The choice of treatment should be made jointly by the physician, patient, and partner, when possible, taking into consideration patient preferences and expectations and the experience and judgment of the physician 1.
• 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.
• For those who don't respond to oral medications, alternatives include vacuum erection devices, penile injections (alprostadil), urethral suppositories, or penile implants 1.
• It's essential to consult a healthcare provider before starting any treatment, as ED can be a symptom of underlying health conditions like heart disease, diabetes, or hormonal imbalances that may require specific treatment 1.
• Psychological factors like anxiety, depression, or relationship issues can contribute to ED and may benefit from counseling alongside medical treatment 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.