Erectile Dysfunction Treatments

Recreational use is common–most often to shorten the refractory period between erections–and the side effects are the same as when the drugs are used by men with ED. The One Medical blog is published by One Medical, a national, modern primary care practice pairing 24/7 virtual care services with inviting and convenient in-person care at over 100 locations across the U.S. One Medical is on a mission to transform health care for all through a human-centered, technology-powered approach to caring for people at every stage of life. Any general advice posted on our blog, website, or app is for informational purposes only and is not intended to replace or substitute for any medical or other advice.

• Hormonal therapy may be necessary if low testosterone is diagnosed.
• Testosterone replacement therapy can improve libido and function.
• Blood tests are needed to confirm hormone levels.
• This therapy may come with side effects like acne or sleep apnea.
• Not suitable for men with certain prostate conditions.
• Always seek professional guidance before hormone treatment.

1Life Healthcare, Inc. and the One Medical entities make no representations or warranties and expressly disclaim any and all liability concerning any treatment, action by, or effect on any person following the general information offered or provided within or through the blog, website, or app. If you have specific concerns or a situation arises in which you require medical advice, you should consult with an appropriately trained and qualified medical services provider. Erectile dysfunction (ED) is the most common sexual problem in men. The incidence increases with age and affects up to one third of men throughout their lives. It causes a substantial negative impact on intimate relationships, quality of life, and self-esteem.

How is ED diagnosed?

Recreational use is common–most often to shorten the refractory period between erections–and the side effects are the same as when the drugs are used by men with ED. The One Medical blog is published by One Medical, a national, modern primary care practice pairing 24/7 virtual care services with inviting and convenient in-person care at over 100 locations across the U.S. One Medical is on a mission to transform health care for all through a human-centered, technology-powered approach to caring for people at every stage of life. Any general advice posted on our blog, website, or app is for informational purposes only and is not intended to replace or substitute for any medical or other advice. 1Life Healthcare, Inc.

Study of Flexible Dose Escalation, Efficacy, and Safety with a Long-Term, Open-Label Extension

and the One Medical entities make no representations or warranties and expressly disclaim any and all liability concerning any treatment, action by, or effect on any person following the general information offered or provided within or through the blog, website, or app. If you have specific concerns or a situation arises in which you require medical advice, you should consult with an appropriately trained and qualified medical services provider. Erectile dysfunction (ED) is the most common sexual problem in men. The incidence increases with age and affects up to one third of men throughout their lives. It causes a substantial negative impact on intimate relationships, quality of life, and self-esteem.

Lifestyle factors that can contribute to ED

History and physical examination are sufficient to make a diagnosis of ED in most cases, because there is no preferred, first-line diagnostic test. Initial diagnostic workup should usually be limited to a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test, and morning total testosterone level. First-line therapy for ED consists of lifestyle changes, modifying drug therapy that may cause ED, and pharmacotherapy with phosphodiesterase type 5 inhibitors. Obesity, sedentary lifestyle, and smoking greatly increase the risk of ED. Phosphodiesterase type vardenafil premature ejaculation 5 inhibitors are the most effective oral drugs for treatment of ED, including ED associated with diabetes mellitus, spinal cord injury, and antidepressants. History and physical examination are sufficient to make a diagnosis of ED in most cases, because there is no preferred, first-line diagnostic test. Initial diagnostic workup should usually be limited to a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test, and morning total testosterone level.

• PDE5 inhibitors require sexual arousal to work effectively.
• They are contraindicated with nitrates for chest pain.
• Possible side effects include headaches and flushing.
• These medications do not cause an erection without stimulation.
• Effectiveness varies among individuals tested during clinical trials.
• Consult a doctor before starting any ED medication.

First-line therapy for ED consists of lifestyle changes, modifying drug therapy that may cause ED, and pharmacotherapy with phosphodiesterase type 5 inhibitors. Obesity, sedentary lifestyle, and smoking greatly increase the risk of ED. Phosphodiesterase type vardenafil premature ejaculation 5 inhibitors are the most effective oral drugs for treatment of ED, including ED associated with diabetes mellitus, spinal cord injury, and antidepressants.

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Intraurethral and intracavernosal alprostadil, vacuum pump devices, and surgically implanted penile prostheses are alternative therapeutic options when phosphodiesterase type 5 inhibitors fail. Testosterone supplementation in men with hypogonadism improves ED and libido, but requires interval monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels because of an increased risk of prostate adenocarcinoma. Cognitive behavior therapy and therapy aimed at improving relationships may help to improve ED. Screening for cardiovascular risk factors should be considered in men with ED, because symptoms of ED present on average three years earlier than symptoms of coronary artery disease.

• Nutritional diet can support vascular health critical for erections.
• Foods rich in antioxidants and omega-3s are beneficial.
• Avoid foods high in saturated fats and sugars.
• Proper hydration improves overall health.
• Supplements like L-arginine are explored for ED but lack strong evidence.
• Balanced nutrition enhances overall sexual function.

Men with ED are at increased risk of coronary, cerebrovascular, and peripheral vascular diseases. Erectile dysfunction (ED) is defined by the National Institutes of Health as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.1 ED is the most common sexual problem in men; it often causes serious distress, prompting men to seek medical attention they may not otherwise seek. It often has a profound effect on intimate relationships, quality of life, and overall self-esteem. ED may also be the presenting symptom or harbinger of undetected cardiovascular disease.2 The economic impact of ED is multifactorial, with direct costs that include physician evaluation, pharmacotherapy, and diagnostic testing, and indirect costs that include lost time at work, lost productivity, and effects on the man's partner, family, and coworkers. Many men associate advancing age with declining sexual function and an overall decreased quality of life.

Medication	Common Side Effects	Serious Risks	Contraindications
Sildenafil	Headache, flushing	Vision changes, priapism	Nitrate therapy, heart conditions
Tadalafil	Muscle pain, flushing	Sudden vision loss	Same as above
Vardenafil	Dizziness, nasal congestion	Priapism	Use with caution in cardiovascular disease
Avanafil	Flushing, back pain	Hypotension	Avoid with certain medications

ED affects up to one third of men throughout their lives, and the incidence increases with age. A population-based study of U.S.

Surgery & Shockwave Treatment for Erectile Dysfunction

History and physical examination are sufficient in making an accurate diagnosis of ED in most cases. Penile duplex ultrasonography is not a useful diagnostic test for ED.7 The American Urological Association (AUA) recommends that the initial evaluation of ED include a complete medical, sexual, and psychosocial history.8 The medical history may reveal comorbid conditions, risk factors related to ED (Table 1),9 or medications that contribute to ED (Table 2).6 Sexual history should focus on erection adequacy, altered libido, quality and timing of orgasm, volume and appearance of ejaculate, presence of sexually-induced genital pain or penile curvature (Peyronie disease), and partner sexual function. The five-item version of the International Index of Erectile Function Questionnaire is a validated survey instrument that can be used to assess the severity of ED symptoms (Table 3).10 The physical examination should assess blood pressure and heart rate; body habitus, for central obesity; and cardiovascular, neurologic, and genitourinary systems, including penile, testicular, and digital rectal examinations (Figure 1).8,9,11–14 The AUA and World Health Organization recommend limited diagnostic testing in men with ED. First-line therapy for ED is aimed at lifestyle changes and modifying pharmacotherapy that may contribute to ED8 (Table 26). Sedentary lifestyle, a significant risk factor for cardiovascular disease, may also be a modifiable risk factor for ED.15 Obesity nearly doubles the risk of ED3; one study determined that one third of men who were obese improved their ED with moderate weight loss and an increase in the amount and duration of regular exercise.14 The risk of moderate or total ED is almost double in men who smoke compared with nonsmokers.16 Patient education should be aimed at increasing exercise, losing weight to achieve a body mass index (BMI) less than 30 kg per m2, and stopping smoking.

Surgery For Erectile Dysfunction

Phosphodiesterase type 5 (PDE5) inhibitors are the most effective oral drugs in the treatment of ED,9,12 and should be considered first-line therapy.8,14,17 Retail sales of sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) approached $1.48 billion in 2007.18 Sildenafil has been found to be effective and safe in cases of ED associated with diabetes mellitus17,19 and spinal cord injury,20 and in men with sexual dysfunction secondary to antidepressant therapy.21 Compared with placebo, sildenafil has been shown to improve erections (74 versus 21 percent; number needed to treat [NNT] = 2)22 and results in more frequent intercourse attempts (57 versus 21 percent; NNT = 3).23 Approximately one third of men with ED do not respond to therapy with PDE5 inhibitors. These agents are not effective for improving libido.24 The three PDE5 inhibitors are considered to be relatively similar in effectiveness, but there are differences in dosing, onset of action, and duration of therapeutic effect (Table 6).25 There are no rigorous data to suggest that one PDE5 inhibitor is superior to another. An cenforce 200mg canada open-label trial found that patients preferred tadalafil and vardenafil over sildenafil,26 yet most evidence supports equal effectiveness between sildenafil and vardenafil.27 PDE5 inhibitors are generally well tolerated, with mild transient adverse effects of headache, flushing, dyspepsia, rhinitis, and abnormal vision. Headache is the most commonly reported adverse effect, occurring in approximately 10 percent of patients. Rare but important adverse effects include dizziness, syncope, and nonarteritic anterior optic neuropathy (predominantly from crossover phosphodiesterase type 6 inhibition).

The Connection Between Diabetes and Erectile Dysfunction

PDE5 inhibitors should not be taken concomitantly with nitrates because this may lead to a synergistic effect, resulting in a potentially serious, even fatal, decrease in blood pressure. PDE5 inhibitors are metabolized by the cytochrome P450 3A4 and may affect metabolism of protease inhibitors and antifungal medications. Intracavernosal pressure and PDE5 activity are androgen-dependent. The prevalence of hypogonadism (defined as a morning serum total testosterone level less than 300 ng per dL [10.41 nmol per L]) in men with ED is estimated to be 5 to 10 percent.13,28 In men with hypogonadism, testosterone supplementation is superior to placebo in improving erections and sexual function. Response rates are higher in primary versus secondary testicular failure, and with transdermal versus oral or intramuscular testosterone.13 Supplementation is also associated with improved satisfaction with erectile function and sexual desire.29 Men with hypogonadism who failed a trial of sildenafil were found to have significant improvement in erectile function with the addition of testosterone supplementation.30 Testosterone supplementation may result in erythrocytosis, elevated serum trans-aminase levels, exacerbation of untreated sleep apnea, benign prostatic hyperplasia, and an increased risk of adenocarcinoma of the prostate. health professionals found the prevalence of sexual dysfunction in men to be 12 cost of vardenafil percent in those younger than 59 years, 22 percent in those 60 to 69 years of age, and 30 percent in those older than 69 years.3 Persons with type 2 diabetes mellitus have a threefold greater risk of ED compared with the general population.4 Depression increases the risk of ED, but it is not clear if this relationship is causal.5 ED may result from organic causes (e.g., vascular, neurogenic, hormonal, anatomic, drug-induced), psychological causes, or a combination of both. A normal sexual erectile response results from the interaction between neurotransmitter, biochemical, and vascular smooth muscle responses initiated by parasympathetic and sympathetic neuronal triggers that integrate physiologic stimuli of the penis with sexual perception and desire. Nitric oxide produced from endothelial cells after parasympathetic stimuli triggers a molecular cascade that results in smooth muscle relaxation and arterial influx of blood into the corpus cavernosum. This is followed by compression of venous return, which produces an erection.6 There is no preferred, first-line diagnostic test for ED, and routine screening is not recommended. History and physical examination are sufficient in making an accurate diagnosis of ED in most cases. Penile duplex ultrasonography is not a useful diagnostic test for ED.7 The American Urological Association (AUA) recommends that the initial evaluation of ED include a complete medical, sexual, and psychosocial history.8 The medical history may reveal comorbid conditions, risk factors related to ED (Table 1),9 or medications that contribute to ED (Table 2).6 Sexual history should focus on erection adequacy, altered libido, quality and timing of orgasm, volume and appearance of ejaculate, presence of sexually-induced genital pain or penile curvature (Peyronie disease), and partner sexual function.

What is the treatment for ED?

Appendix B: Additional Tables and Plots

The five-item version of the International Index of Erectile Function Questionnaire is a validated survey instrument that can be used to assess the severity of ED symptoms (Table 3).10 The physical examination should assess blood pressure and heart rate; body habitus, for central obesity; and cardiovascular, neurologic, and genitourinary systems, including penile, testicular, and digital rectal examinations (Figure 1).8,9,11–14 The AUA and World Health Organization recommend limited diagnostic testing in men with ED.

SHOCKWAVE THERAPY

First-line therapy for ED is aimed at lifestyle changes and modifying pharmacotherapy that may contribute to ED8 (Table 26). Sedentary lifestyle, a significant risk factor for cardiovascular disease, may also be a modifiable risk factor for ED.15 Obesity nearly doubles the risk of ED3; one study determined that one third of men who were obese improved their ED with moderate weight loss and an increase in the amount and duration of regular exercise.14 The risk of moderate or total ED is almost double in men who smoke compared with nonsmokers.16 Patient education should be aimed at increasing exercise, losing weight to achieve a body mass index (BMI) less than 30 kg per m2, and stopping smoking.

• Natural supplements like ginseng are claimed to help ED.
• Evidence supporting supplements is limited and inconsistent.
• Some herbal remedies may interact with medications.
• Always consult a doctor before using supplements.
• Lifestyle changes are often more effective than herbal supplements.
• Beware of unregulated supplements and false claims.

Phosphodiesterase type 5 (PDE5) inhibitors are the most effective oral drugs in the treatment of ED,9,12 and should be considered first-line therapy.8,14,17 Retail sales of sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) approached $1.48 billion in 2007.18 Sildenafil has been found to be effective and safe in cases of ED associated with diabetes mellitus17,19 and spinal cord injury,20 and in men with sexual dysfunction secondary to antidepressant therapy.21 Compared with placebo, sildenafil has been shown to improve erections (74 versus 21 percent; number needed to treat [NNT] = 2)22 and results in more frequent intercourse attempts (57 versus 21 percent; NNT = 3).23 Approximately one third of men with ED do not respond to therapy with PDE5 inhibitors. These agents are not effective for improving libido.24 The three PDE5 inhibitors are considered to be relatively similar in effectiveness, but there are differences in dosing, onset of action, and duration of therapeutic effect (Table 6).25 There are no rigorous data to suggest that one PDE5 inhibitor is superior to another. An cenforce 200mg canada open-label trial found that patients preferred tadalafil and vardenafil over sildenafil,26 yet most evidence supports equal effectiveness between sildenafil and vardenafil.27 PDE5 inhibitors are generally well tolerated, with mild transient adverse effects of headache, flushing, dyspepsia, rhinitis, and abnormal vision. Headache is the most commonly reported adverse effect, occurring in approximately 10 percent of patients.

Can I Use Insurance?

Rare but important adverse effects include dizziness, syncope, and nonarteritic anterior optic neuropathy (predominantly from crossover phosphodiesterase type 6 inhibition). PDE5 inhibitors should not be taken concomitantly with nitrates because this may lead to a synergistic effect, resulting in a potentially serious, even fatal, decrease in blood pressure. PDE5 inhibitors are metabolized by the cytochrome P450 3A4 and may affect metabolism of protease inhibitors and antifungal medications. Intracavernosal pressure and PDE5 activity are androgen-dependent. The prevalence of hypogonadism (defined as a morning serum total testosterone level less than 300 ng per dL [10.41 nmol per L]) in men with ED is estimated to be 5 to 10 percent.13,28 In men with hypogonadism, testosterone supplementation is superior to placebo in improving erections and sexual function.

Counseling for Erectile Dysfunction

Intraurethral and intracavernosal alprostadil, vacuum pump devices, and surgically implanted penile prostheses are alternative therapeutic options when phosphodiesterase type 5 inhibitors fail. Testosterone supplementation in men with hypogonadism improves ED and libido, but requires interval monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels because of an increased risk of prostate adenocarcinoma. Cognitive behavior therapy and therapy aimed at improving relationships may help to improve ED. Screening for cardiovascular risk factors should be considered in men with ED, because symptoms of ED present on average three years earlier than symptoms of coronary artery disease. Men with ED are at increased risk of coronary, cerebrovascular, and peripheral vascular diseases.

Anxiety and Depression

Erectile dysfunction (ED) is defined by the National Institutes of Health as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.1 ED is the most common sexual problem in men; it often causes serious distress, prompting men to seek medical attention they may not otherwise seek. It often has a profound effect on intimate relationships, quality of life, and overall self-esteem. ED may also be the presenting symptom or harbinger of undetected cardiovascular disease.2 The economic impact of ED is multifactorial, with direct costs that include physician evaluation, pharmacotherapy, and diagnostic testing, and indirect costs that include lost time at work, lost productivity, and effects on the man's partner, family, and coworkers. Many men associate advancing age with declining sexual function and an overall decreased quality of life. ED affects up to one third of men throughout their lives, and the incidence increases with age.

Figure 3.

A population-based study of U.S. health professionals found the prevalence of sexual dysfunction in men to be 12 cost of vardenafil percent in those younger than 59 years, 22 percent in those 60 to 69 years of age, and 30 percent in those older than 69 years.3 Persons with type 2 diabetes mellitus have a threefold greater risk of ED compared with the general population.4 Depression increases the risk of ED, but it is not clear if this relationship is causal.5 ED may result from organic causes (e.g., vascular, neurogenic, hormonal, anatomic, drug-induced), psychological causes, or a combination of both. A normal sexual erectile response results from the interaction between neurotransmitter, biochemical, and vascular smooth muscle responses initiated by parasympathetic and sympathetic neuronal triggers that integrate physiologic stimuli of the penis with sexual perception and desire. Nitric oxide produced from endothelial cells after parasympathetic stimuli triggers a molecular cascade that results in smooth muscle relaxation and arterial influx of blood into the corpus cavernosum. This is followed by compression of venous return, which produces an erection.6 There is no preferred, first-line diagnostic test for ED, and routine screening is not recommended. Response rates are higher in primary versus secondary testicular failure, and with transdermal versus oral or intramuscular testosterone.13 Supplementation is also associated with improved satisfaction with erectile function and sexual desire.29 Men with hypogonadism who failed a trial of sildenafil were found to have significant improvement in erectile function with the addition of testosterone supplementation.30 Testosterone supplementation may result in erythrocytosis, elevated serum trans-aminase levels, exacerbation of untreated sleep apnea, benign prostatic hyperplasia, and an increased risk of adenocarcinoma of the prostate.

Drug Type	Mechanism of Action	Target Enzyme/Pathway	Typical Use Cases
PDE5 Inhibitors	Inhibit phosphodiesterase type 5 enzyme	PDE5 enzyme	Relaxation of penile arteries
Testosterone Replacement	Increase testosterone levels	Hormonal pathway	Hormonal deficiency cases
Vasodilators	Directly relax smooth muscle	Nitric oxide pathway	Severe cases of ED
Melanocortin Agonists	Stimulate melanocortin receptors	Central nervous system	Experimental, limited availability