Erectile Dysfunction
Page updated Winter 2023.
Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to take or administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.
Oral Medication
Phosphodiesterase type 5 inhibitor (PDE5Is) are first line treatment for erectile dysfunction (ED).
Available Medications
Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), and Avanafil (Stendra)
Efficacy
All of above medications have shown equivalent efficacy and tolerability.
General Population: 70%
Diabetics: 40-50%
After Radical Prostatectomy: 40-50%
After bilateral nerve-sparing Radical Prostatectomy: 60-70%
Contraindications
Myocardial infarction, stroke, or life-threatening arrhythmia within the last six months
Angina with sexual intercourse
Hypotension (blood pressure < 90/50 mmHg
Hypertension (blood pressure > 170/100 mmHg
Unstable angina
Congestive heart failure class IV
Nitrates including Nitroglycerine, and Isosorbide use
Other Cautions
All PDE5Is may result in orthostatic hypotension with α-blockers.
Drugs that inhibit the CYP34A pathway, like ketoconazole will inhibit the metabolic breakdown of PDE5Is, thus increasing PDE5Is blood levels.
Drugs that induce CYP3A4 pathway, like phenobarbital, enhance the breakdown of PDE5Is, so higher doses of PDE5Is are required.
Most Frequent Adverse Effects
Headache, dizziness
Visual disturbance
Flushing, nasal congestion
Dyspepsia
Back pain, myalgia
Alprostadil + Papaverine + Phentolamine Injection- Trimix
Efficacy: 90%
Contraindications
History of hypersensitivity to ingredients
Risk of priapism
Bleeding disorders or anticoagulant therapy
Most Frequent Adverse Effects
Priapism
Pain in the penis during erection
Bruising at the injection site
Penile fibrosis or plaque formation and penile deformities
Prescribed Combination Dose
10 μg/mL + 30 mg/mL + 1.0 mg/mL
Test Dose
0.1 mL (10 units) intracavernosal injection
Dose Adjustment
Will increase subsequent dosage by no more than 5 units at a time to achieve a good erection.
We generally do not prescribe a dose above 50 units at a time.
Prolong Erection
If there is an erection at penetration hardness that lasts more than 2 hours, 4 tablets (each 30 mg) of Pseudoephedrine (Sudafed) should be taken.
If the erection lasts more than 3 hours, patient needs to go to the local emergency room immediately.
Alprostadil Injection-Caverject
Efficacy: 70%
Treatment dose: 5–40 μg/mL
Intraurethral Alprostadil- MUSE
Response Rate: 50%
Dose: Semisolid Intraurethral pellet (1 × 3 mm) 125-, 250-, 500-, and
1000-μg doses
Vacuum Erection Devices
First-line therapy in older patients with infrequent sexual intercourse and comorbidity
Contraindications
Bleeding disorders or anticoagulant therapy
Testosterone Supplementation
PDE5Is may be more effective if combined with testosterone therapy if there is a testosterone deficiency.
Contraindications
Untreated prostate cancer
Unstable cardiac disease
Cautions
PSA should be measured in men over 40 years of age prior to starting testosterone therapy.
Testosterone should not be started for a period of three to six months in patients with a history of a cardiovascular events.
Testosterone should not be given to men who are currently trying to conceive.
Intramuscular Testosterone Injections
Testosterone Cypionate
IM- 50- 200mg every 7 -14 days. Initial dose: 50-100 mg
Testosterone Enanthate
Same as above agent.
Injection Site
Gluteal muscle or lateral upper thigh
Most Frequent Adverse Effects
Local site reactions
Abnormally elevated hemoglobin
Transdermal Testosterone Gel
Androgel 1%
Dose:
50 to 100 mg daily to shoulders, and upper arms
Most Frequent Adverse Effects
Local site reactions
Transference
Penile Prostheses
Options:
Inflatable (2- and 3-piece) devices
Semi-rigid devices (malleable)
Complications:
Mechanical failure, Infection
Contraindications:
Urinary tract infection.
Cutaneous infection
Systemic infection