Erectile Dysfunction

Page updated Winter 2021.
DisclaimerMedicine 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 resources. 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 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 resources. 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).


Sildenafil, tadalafil, vardenafil, and avanafil.


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 that higher doses of PDE5Is are required. 

Vacuum Erection Devices 

First-line therapy in older patients with infrequent sexual intercourse and comorbidity.


Bleeding disorders  or anticoagulant therapy

Intraurethral Alprostadil

An alternative to intracavernous injections.

Less-invasive but Less effective than injections.

Testosterone Supplementation 

PDE5Is may be more effective if combined with testosterone therapy if there is testosterone deficiency. 


Untreated prostate cancer 

Unstable cardiac disease


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.

Alprostadil Injection


History of hypersensitivity to alprostadil

Risk of priapism

Bleeding disorders. 

Papaverine, phentolamine and alprostadil triple injection

Fibrosis is more common because of papaverine and happens in 5-10% of patients.

Penile prostheses


Inflatable (2- and 3-piece) devices

Semi-rigid devices (malleable)


Mechanical failure 



Urinary tract infection. 

Cutaneous infection

Systemic  infection