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TREATMENT OF ED
• Multiple effective therapeutic options are
available (see next slide)
• Treatment should be individualized
• Choice should be based on:
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Cause
Personal preference
Partner issues
Cost and practicality
Interventions
Life style
Regular
erections for
prevention
Non
pharm.
Vacuum constrictive
devices
medications
• Diet (a low-fat, low-cholesterol, plant-based diet)
• weight management, regular cardiovascular exercise, and smoking cessation.
Life style
• Stop or modify drugs increasing ED as possible
• Beneficial drugs for ED eg: ACEI , CCBlockers and doxazocin
medications
• For prevention of ED
• The risk of ED was inversely related to intercourse frequency.
• Further research is needed in this area.
Regular
erection
ED TREATMENT OPTIONS
• Phosphodiesterase-5 (PDE-5) inhibitor
• Vacuum tumescence device (external)
• Vasoactive drug (injected)
• MUSE (intraurethral)
• Testosterone (injected or topical)
• Surgery
ORAL PDE-5 INHIBITORS
• Potentiate the penile response to sexual
stimulation
• Improve the rigidity and duration of erection
• Effective for neurogenic conditions
• Taken 1 hr prior to sexual activity; last 4–36 hr
• No effect until sexual stimulation occurs
ORAL PDE-5 INHIBITORS
Sildenafil
Vardenafil
Tadalafil
Onset of
action
60 min
45 min
45–60 min
Duration of
action
4 hours
4 hours
24–36
hours
CAUTIONS WITH PDE-5 INHIBITORS
• Potential side effects
 Rhinitis
 Headache
 Flushing
 Dyspepsia
 Transient visual disturbance (sildenafil)
• Contraindicated for concomitant use with nitrate drugs,
since the combination can produce profound and fatal
hypotension
• Also contraindicated with α-blocker use
Failure of response WITH PDE-5
INHIBITORS
• Arteriogenic or venogenic cause
• Inadequate dose of vasoactive agent
Penile brachial pressure index to assess
arteriogenic ED
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hormonal abnormalities,
food or drug interactions,
timing and frequency of dosing,
lack of adequate sexual stimulation,
heavy alcohol use,
the patient's relationship with his partner
VACUUM TUMESCENCE DEVICES
• External device to create negative pressure
• Constriction ring placed at base of penis
• Effective for neurogenic, venogenic, and
psychogenic dysfunction
• Requires manual dexterity
• Can cause local pain, swelling, bruising, painful
ejaculation
• Must remove constriction ring after 30 min
Vacuum Constriction Devices.
INTRACAVERNOUS INJECTION OF
VASOACTIVE DRUGS
• Alprostadil
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FDA-approved
Erections last 40 to 60 minutes
• Phentolamine: used in combination with alprostadil
or papaverine, or both
• Potential adverse events: bruising, hematoma, local
pain, fibrosis, and priapism
Alprostadil Intraurethral Suppositories
and Intracavernosal Injections.
MUSE
(Medicated Urethral System for
Erection)
• Small pellet of alprostadil placed within urethra
• Produces erection in 10 to 15 minutes
• Possible side effects:
 Penile pain
 Urethral burning
 Throbbing sensation in perineum
TESTOSTERONE
• Increases libido and may improve ED in men
with true hypogonadism
• Available as IM injection; transdermal patch, gel
• Possible side effects:
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Polycythemia
Increased prostate size
Gynecomastia
Fluid retention
CAUTIONS WITH TESTOSTERONE
• Before starting therapy, perform digital
rectal exam to assess prostate size and
measure baseline prostate-specific antigen
(PSA)
• Check PSA and hematocrit every 3 months
during first year, then every 12 months
SURGICAL TREATMENTS FOR ED
• Implanted penile prosthesis
 For neurogenic, arteriogenic, and venogenic
erectile failure
 May result in infection, device erosion,
fibrosis
• Penile revascularization surgery has had
limited success
Managing ED in the Presence of
Cardiovascular Disease
• Guidelines for managing ED in patients with cardiovascular disease
developed by the Princeton Consensus Panel recommend assigning
patients to one of three risk levels (high, intermediate, and low)
based on their cardiovascular risk factors.
– High-risk patients are defined as those with unstable or refractory
angina; uncontrolled hypertension; congestive heart failure (CHF; New
York Heart Association class III, IV); MI or a cardiovascular accident
within the previous 2 weeks; high-risk arrhythmias; hypertrophic
obstructive and other cardiomyopathies; or moderate-to-severe
valvular disease. The document states that patients at high risk should
not receive treatment for sexual dysfunction until their cardiac
condition has stabilized.
– Patients at low risk may be considered for all first-line therapies. The
majority of patients treated for ED are in the low-risk category defined
as those who have asymptomatic coronary artery disease and less than
three risk factors for coronary artery disease (excluding gender);
controlled hypertension; mild, stable angina; a successful coronary
revascularization; uncomplicated past MI; mild valvular disease; or CHF
(left ventricular dysfunction and/or New York Heart Association class I).
– Patients whose risk is indeterminate should undergo further evaluation
by a cardiologist before receiving therapies for sexual dysfunction.
Post Radical Prostatectomy ED
• PDE5Is are the first-line choice of oral
pharmacotherapy for post-RP ED in patients who
have undergone nerve-sparing (NS) surgery. The
choice of PDE5Is as first-line treatment is
controversial because the experience (surgical
volume) of the surgeon is a key factor in preserving
postoperative erectile function, in addition to
patient age and NS technique. In fact, PDE5Is are
most effective in patients who have undergone a
rigorous NS procedure
√ Early use of high-dose sildenafil after RP has been
suggested
Definition
The penile erection
Phases of erection
Erectile function in elderly
Causes of erectile dysfunction
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Organic –
Psychological –
Mixed –
Diagnosis of ED •
History
Questionaire
Examination
Laboratory tests
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ED intervention •
Non pharmacological –
pharmacological –