What are the treatment options for erectile dysfunction (ED)?

Updated: Oct 14, 2020
  • Author: Edward David Kim, MD, FACS; Chief Editor: Edward David Kim, MD, FACS  more...
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Treatment options for ED include the following:

  • Sexual counseling, if no organic causes can be found for the dysfunction

  • Oral medications

  • Injected, implanted, or topically applied medications

  • External vacuum and constriction devices

  • Surgery

Many patients with ED also have cardiovascular disease; thus, treatment of ED in these patients must take cardiovascular risks into account.

According to American Urological Association (AUA) guidelines, oral phosphodiesterase type 5 (PDE5) inhibitors are first-line therapy unless contraindicated. [1] Agents include the following:

  • Sildenafil

  • Vardenafil

  • Tadalafil

  • Avanafil

In patients with ED refractory to oral PDE5 inhibitors, one of these agents can be combined with an injection of PGE1. [3]

In a prospective, multicenter, single-armed study of ED patients who exhibited a suboptimal response to PDE5 inhibitors, the investigators found that percutaneous implantation of zotarolimus-eluting stents in focal atherosclerotic lesions was both safe and feasible and was associated with clinically meaningful improvement on subjective and objective measures of erectile function. [4]

Hormone replacement may benefit men with severe hypogonadism and may possibly be useful as adjunctive therapy when other treatments are unsuccessful. Replacement androgens are available in oral (rarely used), injectable, gel, and transdermal preparations.

Intracavernosal injection therapy may be considered and is almost always effective if the vasculature within the corpora cavernosa is healthy. Agents used include the following:

  • Alprostadil (most common)

  • Phentolamine

  • Papaverine

The Medicated Urethral System for Erections (MUSE) involves the formulation of alprostadil (PGE1) into a small intraurethral suppository that can be inserted into the urethra. This may be useful for men who do not want to use self-injections or those in whom oral medications have failed.

External devices that may be used include the following:

  • Vacuum devices to draw blood into the penis

  • Constriction devices placed at the base of the penis to maintain erection

Selected patients with ED are candidates for surgical treatment. Procedures to be considered include the following:

  • Revascularization (rarely indicated)

  • Surgical elimination of venous outflow (rarely indicated)

  • Placement of penile implant (semirigid or malleable rod implant, fully inflatable implant, or self-contained inflatable unitary implant) – Once the only effective therapy for men with organic ED, this is the last option considered in current practice

Suggested measures for preventing ED include the following:

  • Optimal management of diabetes, heart disease, and hypertension

  • Lifestyle modifications to improve vascular function (eg, not smoking, maintaining ideal body weight, and engaging in regular exercise)

See Treatment and Medication for more detail.

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