Erectile Dysfunction: AUA Guideline (2018)
When certain medications such as antidepressants or antihypertensives are suspected of contributing to ED,3 the patient should be advised to talk with the prescribing physician to determine whether alternative medications with better side-effect profiles are available.
| Name | Active Ingredient | Onset Time | Duration | Brand Names | Common Side Effects |
|---|---|---|---|---|---|
| Viagra | Sildenafil | 30-60 min | 4-6 hours | Viagra, Kamagra | Headache, flushing, nasal congestion |
| Cialis | Tadalafil | 30 min | Up to 36 hours | Cialis, Adcirca | Muscle pain, indigestion |
| Levitra | Vardenafil | 25-60 min | 4-5 hours | Levitra, Staxyn | Dizziness, flushing |
| Stendra | Avanafil | 15-30 min | Up to 6 hours | Stendra | Flushing, back pain |
Beta-blockers are associated with ED, although the etiology is not well established.4 Patient awareness or anxiety regarding ED as a potential side effect of beta-blockers may itself contribute to dissatisfaction with erectile function after starting a beta-blocker. While further study is needed, trying an alternative medication for patients on first-generation (propranolol) or second-generation (metoprolol, atenolol) beta-blockers may be considered. In a review of several small studies, Sharp and Gales5 noted mildly improved or similar sexual function in patients after starting nebivolol, which was attributed to the beta-blocker’s ability to stimulate endothelial release of nitric oxide, producing vasoactive effects and potentiating penile erection.
- Vacuum erection devices create a vacuum to draw blood into the penis.
- They use a constriction ring to maintain the erection.
- Non-drug treatment options are effective for some men.
- Proper use is important for safety and effectiveness.
- They are drug-free, non-invasive alternatives.
- Can be used with other ED treatments.
If feasible for the patient, medications like calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers can also be explored, as their risk for causing ED is thought to be lower. Thiazide diuretics at high doses have been associated with adverse effects on erectile function compared with other antihypertensive drugs.6 However, treatment of hypertension should remain the priority, and it may not be clinically appropriate to adjust antihypertensive medications, particularly without strong evidence to support the use of 1 medication over another.
Clinical Trials
Assessment of testosterone deficiency is most valuable in men with borderline response to PDE5 inhibitors and with other signs and symptoms of low testosterone. Once these avenues have been exhausted, exploring alternative therapies that aid in restoring erectile function should be considered. Therapeutic options beyond PDE5 inhibitors include intracavernosal injection therapy, vacuum erection devices, and penile prostheses.1,2,11 These alternatives are typically used when the patient does not respond to PDE5 inhibitors or experiences intolerable side effects (eg, headache, flushing, dyspepsia, visual disturbances, backache) from them. Treatment should be based on patient and partner preferences, comorbidities, and current medications.2 The 2018 American Urological Association guideline on ED11 emphasizes the importance of shared decision-making between patient and physician. In this process, the physician presents the various treatment options to the patient, and the risks and benefits of each are discussed before the treatment most aligned with patient goals and expectations is determined.
For You
Intracavernosal injection is the direct injection of 1 or more vasoactive medications (eg, alprostadil, papaverine, or phentolamine) into the corpora cavernosa of the penis to promote an erection through local dilation of penile vessels.11 Intracavernosal injection therapy is efficacious in providing erectile function adequate for sexual intercourse in 53.7% to 100% of patients.11,13 However, it has higher long-term dropout rates, and its side effects include priapism, ecchymoses, hematoma, penile fibrosis, and penile deformity due to Peyronie disease.14 Vacuum erection devices induce erection by generating negative pressure, which enhances blood flow into the corpora cavernosa, and the erection is maintained with a constricting ring at the base of the penis.15 Of note, despite initial use of vacuum erection devices for penile rehabilitation after prostatectomy, these devices have not been shown to definitively improve erectile function.16 Side effects of vacuum erection devices are quite mild but may include discomfort, bruising, numbness, skin irritation, and pain from the constricting ring.15 Vacuum erection devices are contraindicated in patients with coagulopathies or those taking anticoagulants.17 Furthermore, combination treatment with PDE5 inhibitors and other accepted therapies such as vacuum erection devices may have greater efficacy than either as monotherapy.18 Another option for patients with ED refractory to more conservative therapies is surgical implantation of an inflatable penile prosthesis.19 This option has the highest satisfaction rate, and is typically considered after failure of oral therapies in patients who do not desire injection or vacuum erection device therapy.20 Inflatable penile prosthesis implantation can address penile deformity, making it a particularly advantageous option for patients with ED secondary to Peyronie disease, in whom intracavernosal injection therapy is contraindicated due to the risk of progressive penile scarring and deformity.1 Several different prostheses are available, including 2- or 3-piece inflatable penile prostheses or a malleable device.21 Three-piece inflatable penile prostheses offer the most natural rigidity and flaccidity and are the most commonly implanted penile prostheses in the United States.1 Kucuk et al21 found that patients who underwent inflatable penile prosthesis implantation had greater improvements in their International Index of Erectile Function score than patients who received tadalafil or intracavernosal injection therapy. Partner satisfaction also improved, as both patient and partner Erectile Dysfunction Inventory of Treatment Satisfaction scores were significantly higher with penile prostheses than with other treatment modalities. A multicenter study found that more than 90% of patients who received an inflatable penile prosthesis were able to engage in normal sexual activity following implantation.22 Potential complications of penile prosthesis implantation include bleeding, infection, erosion, mechanical failure, need for revision surgery, and automatic inflation.20 The mechanism of action of low-intensity extracorporeal shockwave therapy (Li-ESWT) in treating ED is unclear. It is hypothesized that extracorporeal shockwaves stimulate expression of endothelial nitric oxide synthase, vascular-endothelial growth factor, and other vascular growth factors, promoting vessel expansion and neovascularization that promote blood flow and erectile function.23 The Sexual Medicine Society of North America regards Li-ESWT as promising but does not endorse its use beyond research given its novelty.24 Since the release of this statement, further studies have demonstrated some efficacy of Li-ESWT in men with moderate ED, though an optimal protocol remains to be determined.25 It is important to differentiate between Li-ESWT and radial wave therapy, the latter of which uses low-pressure acoustic waves to deliver lower energy with less tissue penetrance compared with Li-ESWT.26 Direct-to-consumer marketing from men’s health clinics often use these 2 terms interchangeably even though a randomized controlled trial found no difference between radial wave therapy and sham therapy for treating ED.26 The Sexual Medicine Society of North America corroborates this, drawing a distinction between Li-ESWT and radial wave therapy.24 While regenerative therapies such as Li-ESWT in ED treatment require further investigation, patients should be informed regarding the lack of evidence to support radial wave therapy for ED treatment, particularly as radial wave therapy devices are often promoted as equivalent by health clinics for men.
Vacuum erection devices
The evidence regarding a correlation between statin medications and ED risk is conflicting.
| Product | Dosage | Quantity + Bonus | Price | |
|---|---|---|---|---|
| Cialis Generic | 60mg | 30 + 2 Pills | 85.33€ 81.27€ | |
| Kamagra | 100mg | 60 + 4 Pills | 201.34€ 191.75€ | |
| Viagra Super Active | 100mg | 30 + 6 Pills | 64.09€ 61.04€ | |
| Kamagra Polo | 100 mg | 84 + 4 Pills | 244.49€ 232.85€ | |
| Kamagra 100 mg | 100 mg | 180 + 6 Pills | 436.79€ 415.99€ | |
| Viagra Professional | 100mg | 20 Pills | 71.14€ 67.75€ | |
| Apcalis SX Oral Jelly | 20mg | 50 + 6 Sachets | 146.39€ 139.42€ | |
| Kamagra Soft Tabs | 100 mg | 84 + 4 Pills | 233.05€ 221.95€ | |
| Cialis Generic | 5mg | 120 + 6 Pills | 132.92€ 126.59€ | |
| Viagra Generic | 100mg | 60 + 4 Pills | 96.36€ 91.77€ | |
| Cialis Professional | 20mg | 180 + 4 Pills | 423.11€ 402.96€ | |
| Cialis Generic | 20mg | 60 + 6 Pills | 117.76€ 112.15€ | |
| Tadalista Super Active | 20mg | 10 Pills | 55.64€ 52.99€ | |
| Kamagra | 100mg | 84 + 6 Pills | 264.44€ 251.85€ | |
| Tadalista Super Active | 20mg | 20 + 4 Pills | 92.35€ 87.95€ |
Some studies suggest that statins have sexual side effects, while others propose that the overall cardiovascular benefit of these medications contributes to improved erectile function.7 No large-scale randomized controlled trials have established a link between statins and testosterone levels, and cessation of statin therapy or lowering of statin regimens as a means of improving ED is not recommended. Rather, we suggest optimizing well-established contributing factors such as cardiovascular fitness and testosterone levels. Despite making lifestyle changes, many patients with ED require PDE5 inhibitors such as sildenafil or tadalafil to improve erectile function.
Diagnosis and Tests
How do ED medications interact with other drugs or alcohol?
These agents promote erections by increasing nitric oxide levels and blocking the decomposition of cyclic guanosine monophosphate, thereby relaxing the smooth muscle within the corpora cavernosa and increasing blood flow.1 However, PDE5 inhibitors are efficacious in only 60% to 70% of patients.2 When starting PDE5 inhibitors, proper administration should be ensured, as a large proportion of treatment failures with these agents is attributed to incorrect use.2 Sildenafil should be taken 30 to 60 minutes before intercourse on an empty stomach.
General Considerations
When certain medications such as antidepressants or antihypertensives are suspected of contributing to ED,3 the patient should be advised to talk with the prescribing physician to determine whether alternative medications with better side-effect profiles are available. Beta-blockers are associated with ED, although the etiology is not well established.4 Patient awareness or anxiety regarding ED as a potential side effect of beta-blockers may itself contribute to dissatisfaction with erectile function after starting a beta-blocker. While further study is needed, trying an alternative medication for patients on first-generation (propranolol) or second-generation (metoprolol, atenolol) beta-blockers may be considered. In a review of several small studies, Sharp and Gales5 noted mildly improved or similar sexual function in patients after starting nebivolol, which was attributed to the beta-blocker’s ability to stimulate endothelial release of nitric oxide, producing vasoactive effects and potentiating penile erection. If feasible for the patient, medications like calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers can also be explored, as their risk for causing ED is thought to be lower.
Penile implants
Thiazide diuretics at high doses have been associated with adverse effects on erectile function compared with other antihypertensive drugs.6 However, treatment of hypertension should remain the priority, and it may not be clinically appropriate to adjust antihypertensive medications, particularly without strong evidence to support the use of 1 medication over another. The evidence regarding a correlation between statin medications and ED risk is conflicting. Some studies suggest that statins have sexual side effects, while others propose that the overall cardiovascular benefit of these medications contributes to improved erectile function.7 No large-scale randomized controlled trials have established a link between statins and testosterone levels, and cessation of statin therapy or lowering of statin regimens as a means of improving ED is not recommended. Rather, we suggest optimizing well-established contributing factors such as cardiovascular fitness and testosterone levels. Despite making lifestyle changes, many patients with ED require PDE5 inhibitors such as sildenafil or tadalafil to improve erectile function.
Lifestyle changes
These agents promote erections by increasing nitric oxide levels and blocking the decomposition of cyclic guanosine monophosphate, thereby relaxing the smooth muscle within the corpora cavernosa and increasing blood flow.1 However, PDE5 inhibitors are efficacious in only 60% to 70% of patients.2 When starting PDE5 inhibitors, proper administration should be ensured, as a large proportion of treatment failures with these agents is attributed to incorrect use.2 Sildenafil should be taken 30 to 60 minutes before intercourse on an empty stomach. The recommended window for taking libido gummies female uk on-demand tadalafil, which is not impacted by food intake, is 30 to 120 minutes before intercourse, but for optimal effectiveness, it should be taken 60 to 120 minutes before intercourse.8 Daily low-dose tadalafil (5 mg) may be considered for men who also experience voiding dysfunction due to prostate enlargement or men with mild ED. Patients taking 5-alpha-reductase inhibitors for benign prostatic hyperplasia who also experience ED and low libido should be referred to a urologist for alternative management strategies such as daily low-dose tadalafil, alpha-blockers, or minimally invasive surgical therapies. In fact, some selective alpha-blockers have been found to preserve or improve erectile function.9 Combination therapy with daily tadalafil plus on-demand higher-dose tadalafil or sildenafil may be considered.10 Before determining that the medication has failed to achieve the desired result, several trials of PDE5 inhibitors with at least 24 hours between doses should be attempted.11 Additionally, other reversible causes of ED, such as testosterone deficiency, should be assessed. An early morning testosterone level (before 11:00 am) can identify testosterone deficiency in the presence of symptoms or signs of low testosterone such as low libido, fatigue, and loss of body hair.10 Testosterone levels less than 300 ng/dL with these accompanying symptoms may warrant treatment with testosterone replacement therapy, which placebo-controlled randomized trials and meta-analyses have demonstrated may help improve erectile function and libido.10–12 However, patients with ED but no symptoms of testosterone deficiency are less likely to benefit from replacement therapy. The recommended window for taking libido gummies female uk on-demand tadalafil, which is not impacted by food intake, is 30 to 120 minutes before intercourse, but for optimal effectiveness, it should be taken 60 to 120 minutes before intercourse.8 Daily low-dose tadalafil (5 mg) may be considered for men who also experience voiding dysfunction due to prostate enlargement or men with mild ED. Patients taking 5-alpha-reductase inhibitors for benign prostatic hyperplasia who also experience ED and low libido should be referred to a urologist for alternative management strategies such as daily low-dose tadalafil, alpha-blockers, or minimally invasive surgical therapies. In fact, some selective alpha-blockers have been found to preserve or improve erectile function.9 Combination therapy with daily tadalafil plus on-demand higher-dose tadalafil or sildenafil may be considered.10 Before determining that the medication has failed to achieve the desired result, several trials of PDE5 inhibitors with at least 24 hours between doses should be attempted.11 Additionally, other reversible causes of ED, such as testosterone deficiency, should be assessed. An early morning testosterone level (before 11:00 am) can identify testosterone deficiency in the presence of symptoms or signs of low testosterone such as low libido, fatigue, and loss of body hair.10 Testosterone levels less than 300 ng/dL with these accompanying symptoms may warrant treatment with testosterone replacement therapy, which placebo-controlled randomized trials and meta-analyses have demonstrated may help improve erectile function and libido.10–12 However, patients with ED but no symptoms of testosterone deficiency are less likely to benefit from replacement therapy.
What Lifestyle Changes Can Help With Erectile Dysfunction?
Assessment of testosterone deficiency is most valuable in men with borderline response to PDE5 inhibitors and with other signs and symptoms of low testosterone. Once these avenues have been exhausted, exploring alternative therapies that aid in restoring erectile function should be considered.
- ED is often a sign of underlying health problems.
- Cardiovascular health directly affects erectile function.
- Managing chronic illnesses can prevent or improve ED.
- Proactive lifestyle and medical management are essential.
- Emotional well-being is also a key factor.
- Addressing root causes offers the best long-term solution.
Therapeutic options beyond PDE5 inhibitors include intracavernosal injection therapy, vacuum erection devices, and penile prostheses.1,2,11 These alternatives are typically used when the patient does not respond to PDE5 inhibitors or experiences intolerable side effects (eg, headache, flushing, dyspepsia, visual disturbances, backache) from them. Treatment should be based on patient and partner preferences, comorbidities, and current medications.2 The 2018 American Urological Association guideline on ED11 emphasizes the importance of shared decision-making between patient and physician. In this process, the physician presents the various treatment options to the patient, and the risks and benefits of each are discussed before the treatment most aligned with patient goals and expectations is determined. Intracavernosal injection is the direct injection of 1 or more vasoactive medications (eg, alprostadil, papaverine, or phentolamine) into the corpora cavernosa of the penis to promote an erection through local dilation of penile vessels.11 Intracavernosal injection therapy is efficacious in providing erectile function adequate for sexual intercourse in 53.7% to 100% of patients.11,13 However, it has higher long-term dropout rates, and its side effects include priapism, ecchymoses, hematoma, penile fibrosis, and penile deformity due to Peyronie disease.14 Vacuum erection devices induce erection by generating negative pressure, which enhances blood flow into the corpora cavernosa, and the erection is maintained with a constricting ring at the base of the penis.15 Of note, despite initial use of vacuum erection devices for penile rehabilitation after prostatectomy, these devices have not been shown to definitively improve erectile function.16 Side effects of vacuum erection devices are quite mild but may include discomfort, bruising, numbness, skin irritation, and pain from the constricting ring.15 Vacuum erection devices are contraindicated in patients with coagulopathies or those taking anticoagulants.17 Furthermore, combination treatment with PDE5 inhibitors and other accepted therapies such as vacuum erection devices may have greater efficacy than either as monotherapy.18 Another option for patients with ED refractory to more conservative therapies is surgical implantation of an inflatable penile prosthesis.19 This option has the highest satisfaction rate, and is typically considered after failure of oral therapies in patients who do not desire injection or vacuum erection device therapy.20 Inflatable penile prosthesis implantation can address penile deformity, making it a particularly advantageous option for patients with ED secondary to Peyronie disease, in whom intracavernosal injection therapy is contraindicated due to the risk of progressive penile scarring and deformity.1 Several different prostheses are available, including 2- or 3-piece inflatable penile prostheses or a malleable device.21 Three-piece inflatable penile prostheses offer the most natural rigidity and flaccidity and are the most commonly implanted penile prostheses in the United States.1 Kucuk et al21 found that patients who underwent inflatable penile prosthesis implantation had greater improvements in their International Index of Erectile Function score than patients who received tadalafil or intracavernosal injection therapy. Partner satisfaction also improved, as both patient and partner Erectile Dysfunction Inventory of Treatment Satisfaction scores were significantly higher with penile prostheses than with other treatment modalities.
- Advances in regenerative medicine aim to restore erectile tissue.
- Stem cell therapy is being researched for ED.
- Platelet-rich plasma (PRP) injections are experimental.
- These treatments target tissue repair and blood vessel growth.
- Are still in early clinical trial phases.
- Consult specialists to explore emerging options.
A multicenter study found that more than 90% of patients who received an inflatable penile prosthesis were able to engage in normal sexual activity following implantation.22 Potential complications of penile prosthesis implantation include bleeding, infection, erosion, mechanical failure, need for revision surgery, and automatic inflation.20 The mechanism of action of low-intensity extracorporeal shockwave therapy (Li-ESWT) in treating ED is unclear. It is hypothesized that extracorporeal shockwaves stimulate expression of endothelial nitric oxide synthase, vascular-endothelial growth factor, and other vascular growth factors, promoting vessel expansion and neovascularization that promote blood flow and erectile function.23 The Sexual Medicine Society of North America regards Li-ESWT as promising but does not endorse its use beyond research given its novelty.24 Since the release of this statement, further studies have demonstrated some efficacy of Li-ESWT in men with moderate ED, though an optimal protocol remains to be determined.25 It is important to differentiate between Li-ESWT and radial wave therapy, the latter of which uses low-pressure acoustic waves to deliver lower energy with less tissue penetrance compared with Li-ESWT.26 Direct-to-consumer marketing from men’s health clinics often use these 2 terms interchangeably even though a randomized controlled trial found no difference between radial wave therapy and sham therapy for treating ED.26 The Sexual Medicine Society of North America corroborates this, drawing a distinction between Li-ESWT and radial wave therapy.24 While regenerative therapies such as Li-ESWT in ED treatment require further investigation, patients should be informed regarding the lack of evidence to support radial wave therapy for ED treatment, particularly as radial wave therapy devices are often promoted as equivalent by health clinics for men.