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