Treatment

The main aim of treatment is enable the individual or couple to enjoy a satisfactory sexual experience. This involves:

• identifying and treating any curable causes of ED
  • hormonal
    • androgen deficiency – treat with testosterone (cause of hypogonadism should always be sought before treatment with testosterone is initiated)
      • men with a total serum testosterone that is consistently <12 nmol/l might benefit from up to a 6 months trial of testosterone replacement therapy for ED
      • long-acting (three-monthly) testosterone injection or daily application of a transdermal testosterone gel are acceptable to most men
    • hyper/hypothyroidism, hyperprolactinaemia - effective treatment of the underlying cause
  • post-traumatic arteriogenic ED in young patients - penile revascularization
  • drug-induced ED - withdrawing or changing a drug suspected of causing sexual dysfunction may reduce ED (it is important not to compromise the effective management of another important condition)
  • partner sexual problems – identify and address co-existing sexual problems in the partner
  • radical prostatectomy - early introduction of pharmacotherapy
• initiating lifestyle change and risk factor modification
  • should accompany any specific pharmacotherapy or psychological therapy (however, pharmacotherapy should not be withheld on the basis that lifestyle changes have not been made)
  • beneficial especially in those with psychogenic ED, but patients with serious medical illnesses such as diabetes may also benefit from these changes, e.g. weight loss
  • simple lifestyle measures such as regular exercise, smoking cessation, and weight loss can be recommended for men with these risk factors who have mild erectile dysfunction
• providing psychosexual/ relationship therapy, counselling to patients and their partners
  • group or individual cognitive behavior therapy; psychosexual therapy, including sensate focus technique; and therapy aimed at improving relationship difficulties may help to improve sexual dysfunction in men (3)

Treatments options available in ED include:

• first line treatment
  • PDE5 inhibitors (e.g. sildenafil, tadalafil, vardenafil)
    • sildenafil and vardenafil are relatively short-acting drugs while tadalafil has a significantly longer half life of 17.5 hours
    • are not initiators of erection but require sexual stimulation in order to facilitate an erection
    • contraindicated in patients who are receiving nitrate preparations
    • it is currently recommended that patients should receive eight doses of a PDE5 inhibitor with sexual stimulation at maximum dose before classifying a patient as a non-responder
  • vacuum erection devices:
    • are highly effective in inducing erections regardless of the aetiology of the ED
    • reported satisfaction rates vary considerably from 35% to 84%
    • adverse effects include bruising, local pain, and failure to ejaculate. Partners sometimes report the penis feels cold
• second line treatment - available in secondary care
  • intracavernous Alprostadil (synthetic prostaglandin E1 analogue) injection
  • intraurethral Alprostadil
• third line treatment
  • penile prostheses

Other therapies available for treatment of ED (unlicensed products)

• yohombine
• delaquamine
• trazodone
• L-arginine
• red Korea
• ginseng
• oral limaprost
• oral phentolamine and nitroglycerine
• papaverine
• minoxidil topically (4)

Reference:

• (1) Hackett G et al. British Society for Sexual Medicine guidelines on the management of erectile dysfunction. J Sex Med. 2008;5(8):1841-65.
• (2) Muneer A et al. Erectile dysfunction. BMJ. 2014;348:g129
• (3) Heidelbaugh JJ. Management of erectile dysfunction. Am Fam Physician. 2010;81(3):305-12
• (4) Clinical Evidence. BMJ March 2006.