Erectile%20dysfunction Treatment

Goals of Therapy

• Identify & treat any curable causes of erectile dysfunction
• Initiate lifestyle & risk factor modifications
• Provide education & counselling to patients & their partners
• Correct any existing medical risk factors:
  • Regulate glucose in poorly controlled diabetes mellitus
  • Optimize antihypertensive medications
  • Treat hyperlipidemia aggressively
  • Reduce/stop alcohol intake

Phosphodiesterase-5 Inhibitors (oral)

• Eg Avanafil, Sildenafil, Tadalafil, Udenafil, Vardenafil
• If there is no contraindication, oral phosphodiesterase-5 (PDE5) inhibitors should be offered as a 1st-line therapy
  • Highly effective, noninvasive

• Have proven efficacy & safety in both non-selected populations of men w/ erectile dysfunction & in specific subgroups of patients (eg men w/ diabetes mellitus & those who have had a prostatectomy)
• Works peripherally; inhibits phosphodiesterase type 5, which is found in the penile tissue
• • Increases smooth muscle relaxation in the corpora cavernosa & enhances penile rigidity

• It is currently recommended that patients receive 8 doses of a PDE5 inhibitor w/ sexual stimulation at a maximum dose before classifying a patient as a non-responder
• Testosterone replacement may be used with PDE-5 inhibitors
• Consider switching to other PDE-5 inhibitors if one fails
• Patients need to be counseled on side effects & interactions

Alprostadil (topical)

• Phase II clinical trials showed topical Alprostadil to be effective in patients w/ mild to severe erectile dysfunction 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 cardiovascular disease & diabetes mellitus patients

Apomorphine (sublingual)

• No drug interaction w/ nitrates
  • May be an option for men who cannot take phosphodiesterase inhibitors due to nitrate use (however, manufacturers still advise to be cautious when used w/ nitrate)

• Sexual stimulation is still required
• Works at the central nervous system; agonist of the D₁ & D₂ postsynaptic receptors for dopamine
• Erectogenic effects are usually seen within 20 minutes of sublingual administration
  • Best efficacy was reported in patients w/ mild-moderate erectile dysfunction & may perhaps be better for men who have some residual erectile function & in younger patients

Yohimbine (oral)

• Alpha₂-adrenergic antagonist
• Has been shown to be more effective in psychologic erectile dysfunction than organic erectile dysfunction
  • Has been combined w/ Trazodone to increase responsiveness

• Drugs administered via this route are Alprostadil, Papaverine & Phentolamine
• Indicated in patients not responding to oral drugs
• Most effective nonsurgical treatment for erectile dysfunction but has highest risk for priapism
• Invasive therapy & 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 & inform patient of this treatment plan beforehand
• Direct action on the corporal smooth muscle
• Rapid onset of action, highly effective

Intraurethral Therapy

• Drug administered via this route is Alprostadil
• Alternative to intracavernosal injection therapy
  • Less invasive

• Transfer of drug from urethra directly to the corpora cavernosa
• Consider in patients who have unsatisfactory results w/ oral phosphodiesterase 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 w/ either a penile constriction device or oral phosphodiesterase inhibitors 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 erectile dysfunction
• Patient usually has slow but steady increase in erectile dysfunction & 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 prostate-specific antigen (PSA), no benign prostatic hyperplasia (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 erectile dysfunction etiology
• Only devices w/ 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 w/ bleeding disorders or on anticoagulant therapy
• Low-cost & effective; reported satisfaction rates vary from 35-84%
• May be used on an “on demand” basis
• May be seen as cumbersome
• Side effects include penile pain, numbness, petechiae, bruising & slowed ejaculation
  • Serious adverse events are very rare but skin necrosis has been reported