Erectile%20dysfunction Treatment

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

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

• 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

• 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

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