treatment

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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:

Last reviewed 01/2018

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