Treatment Guideline Chart

Erectile dysfunction is the inability to attain and maintain an erection enough to have satisfactory sexual performance.

It is when the patient complains of partial erection that could not attain vaginal penetration.

Complete loss of penile rigidity is uncommon.

Initial penile erections can penetrate but early detumescence occurs without ejaculation.

Erectile%20dysfunction Treatment

Principles of Therapy

Goals of Therapy

  • Identify and treat any curable causes of ED
  • Initiate lifestyle and risk factor modifications
  • Provide education and counseling to patients and their partners
  • Correct any existing medical risk factors
    • Regulate glucose in poorly controlled DM
    • Optimize antihypertensive medications
    • Treat hyperlipidemia aggressively
    • Reduce/stop alcohol intake


Nonspecific Therapy for Erectile Dysfunction

Phosphodiesterase-5 (PDE5) Inhibitors

  • Eg Avanafil, Sildenafil, Tadalafil, Udenafil, Vardenafil
  • If there is no contraindication, oral PDE5 inhibitor should be offered as a first-line therapy
    • Highly effective, noninvasive but require sexual stimulation to facilitate erection
  • Have proven efficacy and safety in both non-selected populations of men with ED and in specific subgroups of patients (eg men with DM and those who have had a prostatectomy)
  • Works peripherally by inhibiting PDE5, which is found in the penile tissue
    • Increases smooth muscle relaxation in the corpora cavernosa and enhances penile rigidity in response to sexual stimulation
  • It is currently recommended that patients receive 8 doses of at least 2 PDE5 inhibitors, taken sequentially, with sexual stimulation at a maximum dose before classifying a patient as a non-responder
  • Testosterone replacement may be used with PDE5 inhibitors in men with ED and testosterone deficiency
  • Consider switching to other PDE5 inhibitors if one fails
  • Patients need to be counseled on the side effects and drug interactions

Alprostadil (topical)

  • Phase II clinical trials showed topical Alprostadil to be effective in patients with mild to severe ED symptoms
  • Topical administration eliminates the need of intraurethral or intracavernosal injection of Alprostadil
  • Seems to be safe in patients who are otherwise healthy, those undergoing treatment for CV disease and DM patients

Intracavernosal Injection Therapy
  • Drugs administered via this route are Alprostadil, Papaverine and Phentolamine
    • Single-agent Alprostadil has been shown to be highly effective and generally well-tolerated with up to 94% of patients being able to achieve an erection sufficient for intercourse
    • Combination of Papaverine, Phentolamine and Alprostadil may be more efficacious than Alprostadil monotherapy
  • Indicated in patients not responding to oral drugs
  • Rapid onset of action, highly effective
  • Direct action on the corporal smooth muscle
  • Most effective nonsurgical treatment for ED but has highest risk for priapism
  • Invasive therapy and therefore proper training of patient in intracavernosal injection is necessary
  • Initial trial dose must be given under the supervision of physician
  • Should be used only once within a 24-hour period
  • Inform patient of the potential event of prolonged erection
  • Physician must be prepared for urgent treatment of possible prolonged erections and inform patient of this treatment plan beforehand
    • Considered a medical emergency if erection lasts longer than 4 hours

Intraurethral Therapy

  • Drug administered via this route is Alprostadil
  • Less invasive alternative to intracavernosal injection therapy
  • Transfer of drug from urethra directly to the corpora cavernosa
  • Consider in patients who have unsatisfactory results with oral PDE5 inhibitors or are not candidates for the said drug
  • Initial trial dose must be given under the supervision of physician because of the risk of syncope
  • The combination of Alprostadil suppositories with either a penile constriction device or oral PDE5 inhibitor has been shown by some studies to be more efficacious over Alprostadil alone
  • Intraurethral Alprostadil has been shown to be effective in 60-70% of patients
ED Caused by Hypogonadism/Testosterone Deficiency
  • Not all hypogonadal males have ED
  • Patient usually has slow but steady increase in ED and progressive loss of libido over a few months
    • Patients who have a temporary decrease in hypothalamic-pituitary-gonadal axis functioning (eg after surgery or acute medical events, anxiety or alcohol) are unlikely to respond to androgen replacement
    Initiate androgen replacement
    • If prostate is normal (normal PSA, no BPH)
    • Reassess patient within 1-3 months then every 6-12 months
  • If no improvement in sexual function after 3 months
    • Hormone deficiency may not be the only cause for sexual dysfunction
    • Patient may wish to try other treatment options

Non-Pharmacological Therapy

Vacuum Constriction Device

  • Negative pressure is applied to the pendulous penis causing blood to be drawn into the penis
  • Blood is retained in penis by elastic band placed at the base
  • Highly effective in inducing erections regardless of ED etiology
  • Only devices with a vacuum limiter should be used
  • Preferred by patients who do not want to use pharmacological therapy or in whom medication is contraindicated
  • Contraindicated in patients with bleeding disorders or on anticoagulant therapy
  • Low-cost and effective
    • Up to 90% of patients can achieve a functional erection with adequate instruction and practice
  • May be used on an “on demand” basis
  • May be seen as cumbersome
  • Side effects include penile pain, numbness, petechiae, bruising, and slowed ejaculation
    • Serious adverse events are very rare but skin necrosis has been reported
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