Treating Erectile Dysfunction

Talking about erectile dysfunction (ED) can be tough for any man, let alone discussing it with your doctor. Nonetheless, it’s important to take the leap to ensure a professional diagnosis is received and if necessary, treatment is administered to alleviate ED symptoms and improve sexual health.  

A simple questionnaire and if necessary, a physical examination are often all a doctor will need to diagnose ED. And the good news is that ED is a completely treatable condition and in some cases, reversible.¹  

ED Treatment options

There are many treatment options available for ED, each with their own unique properties that may be more suited for a particular patient depending on individual preference and clinical requirements. It’s a prerequisite that all doctors should discuss with you the benefits and risks of any ED treatment.  

What is the goal of ED treatment?

The primary goal of ED treatment is to allow the affected man (and their partner) to enjoy a satisfactory sexual life.¹ Improving sexual experience can have significant benefits as the burden of ED extends far beyond poor erectile function. The occurrence of depression and other mental health issues dramatically increases with ED exposure. In fact, in one analysis men with ED had a nearly 2-fold increased risk of depression.² ED treatment can successively reverse symptoms, improve erectile function, and intercourse.^1,3

First step: Identify and treat any curable causes of ED

It's recommended to identify and treat curable causes of ED as a first step in resolving the issue. Such causes can include cardiovascular disease or obesity which can both be improved and in some cases reversed with lifestyle interventions.¹ Unfortunately, long-term compliance with lifestyle interventions is poor and falls short of the impact needed to curb the epidemic of cardiovascular disease and obesity.⁴ Nonetheless, this should not be a reason to avoid recommending or attempting to make these lifestyle changes.

Further treatments such as therapy and medications should not be withheld on the basis that lifestyle changes have not been made, and should in fact accompany them to serve as a holistic treatment approach.¹  

Reversible causes of ED

Hormone deficiencies

Hormonal deficiencies are well known to impact sexual function. One of the most common examples is hypogonadism, a deficiency characterised by low testosterone. Low testosterone is reversible in the sense that levels can be ‘normalised’ through treatment which may resolve any associated symptoms of hypogonadism, like ED.¹  

Notably, a common concern with hypogonadism is it can impair the efficacy of a class of medications called phosphodiesterase-5 inhibitors (PDE5i), a first-line treatment for ED. Interestingly, restoring testosterone levels through testosterone treatment improves PDE5i response.¹

Learn more about hypogonadism

Drug-induced ED

There are many medications associated with ED. Though, high-quality evidence to support a causal relationship is in most cases, severely lacking. Assessing whether the underlying condition rather than the treatment causes ED is an important consideration for doctors.¹ An example of when such careful assessment is needed is in those who report ED after taking anti-depressants such as selective serotonin reuptake inhibitors (SSRIs). Depression is a well-established cause of ED, but there is also convincing data to suggest SSRIs increase ED risk too.⁵ Correctly identifying the cause in this scenario would avoid any unnecessary changes to depression treatment. Doctors should not compromise effective management of serious conditions in an attempt to resolve any suspected drug-induced ED.¹  

First line treatment for ED

PDE5i

PDE5i are the first line of treatment in ED pharmacotherapy. Taken orally, they work by relaxing the penile smooth muscle and dilating (opening) the blood vessels with the effect that an erection occurs. Approved PDE5i are backed by strong evidence supporting their efficacy and safety in men with ED.¹  

The onset of action can vary anywhere from 15 to 60 minutes and it’s estimated that up to 75% of sexual attempts result in sexual intercourse with PDE5i use. At maximum clinically indicated doses, they can improve ED by 7–10 points on the IIEF questionnaire compared to placebo treatment.⁶  

Best estimates however suggest between 25–50% of patients do not respond to PDE5i treatment within 12 months. These figures increase in comorbid patients like diabetics (>50%) and those with post-radical prostatectomies (70%). Additionally, PDE5i are contraindicated in patients on nitrates and in such patients, alternative treatment options should be explored.¹  

IIEF Score – What does it mean?

The IIEF questionnaire is a validated self-administered questionnaire that is used in studies to measure the severity of ED in patients. Typically, an improvement in IIEF score by 5 is considered clinically significant. You can download the IIEF questionnaire via the TRTed Toolkit here

Second line treatments

Intra-cavernous injection

For more than 20 years doctors have widely used intra-cavernous injection therapy in ED treatment and many consider them to be the most effective form of pharmacotherapy. On the assumption there is a good supply of blood to the penis, improvements in erectile function can be achieved in most men. The onset of an erection typically occurs between 5–15 minutes and can last up to 40 minutes. A single injection is performed on the side of the penile shaft close to the base of the penis to avoid the urethra and dorsal neurovascular bundle.¹  

Compliance is an issue

In one study of 100 patients with ED on intra-cavernous injection therapy, 50% of patients discontinued within the first 2–3 months. In a separate study of 720 men with ED using penile self-injection therapy, 31% dropped out.⁷ The main reasons included the cost of therapy and issues with the concept of penile injection. Long-term compliance remains a consistent observation in practice but it's not solely down to the self-injection method as other factors are also responsible.

Topical cream (Alprostadil cream)

Alprostadil cream is a much less invasive therapy compared to intra-cavernous injections and can be the preferred choice for many patients. In fact, the European Guidelines recommend alprostadil cream as an alternative choice for men who prefer a less-invasive treatment option to injections, although the drawback being they are a less effective therapy. ⁸  

Alprostadil cream is applied into the urethra of the penis with the onset of an erection between 5–30 minutes following application. The erection can last between one and two hours.⁹

In one study on 142 patients with severe ED, 83% observed improvements in erections compared to 26% in the placebo group.¹⁰ NICE evaluated two clinical trials randomising 1721 men with ED to receive either alprostadil cream or placebo for a duration of 12 weeks. Those who received alprostadil cream reported a 2.5-point increase in IIEF and a 15% increase in successful intercourse attempts. In a post-hoc analysis of the same trial nearly 40% of men treated on alprostadil cream reported clinically significant improvements in IIEF (>5 point increase). ^9,11  

Over the 12 week study duration, 2.7% of men withdrew from the trial. The most commonly reported side effects are localised to the application site, including but are not limited to, penile burning and erythema.¹¹

Low-intensity shockwave therapy

Low-intensity shock wave is a relatively new treatment for ED and uses targeted sound waves to help stimulate penile tissue and encourage blood flow. As it stands there is a lack of long-term data to support their use, although a small study suggested a 6.7 point improvement in IIEF score compared to 3.0 for placebo (between-group difference of 3.7 points).^1,12 However, all participants in this study were already successful responders to PDE5i treatment. Populations who respond well to PDE5i as discussed earlier, are not representative of the whole ED population as a high percentage discontinue treatment.¹² Nonetheless, further research is needed to explore this promising therapy.

Vacuum devices

External vacuum devices offer a non-surgical treatment for ED. The outer cylinder of the device should be placed over the penis and pressed to the body to create an airtight seal, then a small hand-operated vacuum pump is used to create a negative pressure around the penis, encouraging blood flow and creating an erection. The efficacy rates of vacuum devices are high with up to 94.6% of patients being able to successfully engage in sexual intercourse after 1-week of practising with the device.^1,13

Psychogenic ED

Psychosexual therapy is clinically indicated for men with ED, either alone or alongside the couple’s relationship counselling. As sexual intercourse is a subjective experience it’s no surprise to learn that all couples affected by ED have some psychological component to their ED.  

The psychosexual clinician should provide suggestions to help improve the sexual experience. Cognitive-behavioural therapy intervention is one method of therapy that can benefit those with a largely psychogenic component to ED. More holistic psychological methods such as integrative cognitive, behavioural, systemic, psychodynamic, and interpersonal approaches have shown early promising outcomes, but further research is needed in higher quality trials. Pharmacotherapy can accompany psychotherapy and may be more effective than using these interventions in isolation.¹

Take-home points:

• ED is a common condition in men, and there are plenty of treatment options available to alleviate symptoms and improve overall quality of life
• Treatment options each have their own benefits and drawbacks, and these should be discussed with a healthcare professional
• If you suspect you have ED, it's important to visit a healthcare professional to receive a professional diagnosis

‍TRTed Talking Guide for Sexual Health

Talking about sexual health can be challenging, but it’ is an important part of regular medical care. TRTed has developed a guide comprising a sample of questions and discussion points for healthcare professionals and patients to support men’s health patient care. You can find on the TRTed Toolkit here.

Join the conversation on the TRTed Community!

References

1. Hackett G, et al. J Seks Med 2018;15(4)430–457.  

2. Seagraves, RT. Postgrad Med 2000;107(6):24–7.

3. Catalano R, et al. Eur J Epi 2021;36:531–537.

4. Anderson JW, et al. Am J Clin Nutr 2001;74(5):579–84.

5. Stuart N, et al. Curr Psych Rep 2000;2:201–205.

6. Berner MM, et al. Int J Imp Res 2006;18:229–235.

7. Mulhall JP, et al. J Urol 1999;162(4):1291–4.  

8. Hatzimouratidis K, et al. Eur Urol 2019;57(5):804–14.

9. Erectile dysfunction: Alprostadil cream, 2014. NICE.  

10. Cuzin B, et al. The Adv Urol 2016 ;8(4) :249–256.

11. Padma H, et al. Urology 2006;68(2):386–391.

12. Bechara A, et al. Sex Med 2016;4:e225- e232.

13. Sooriyamoorthy T, Leslie SW. Erectile Dysfunction. [Updated 2022 May 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562253/?report=classic.