Erectile Dysfunction Management

1. See Also
   1. Erectile Dysfunction (Impotence)
   2. Erectile Dysfunction Causes
2. Management: General Measures
   1. Psychological Support: Sex Therapy Indications
      1. Relationship Problems
      2. Performance Anxiety
      3. Situational Stress
   2. Alternative Sexual Techniques
      1. Closeness, fondling or foreplay
      2. Mutual masturbation
   3. Modifications
      1. Tobacco Cessation
      2. Reduce Alcohol intake
      3. Eliminate Medication Causes of Impotence
   4. Devices
      1. Constriction rings (for early detumescence)
      2. Vacuum Suction Device
3. Management: First-line Medications
   1. Phosphodiesterase-5 Inhibitor
      1. Viagra or Revatio (Sildenafil)
         1. Dose: 25-100 mg orally 30 minutes before intercourse (duration 4 hours)
         2. Revatio 20 mg will be generic in 2013 (but may still be expensive if 2 tabs need to be taken)
      2. Levitra or Staxyn (vardenafil)
         1. Dose: 5-20 mg orally 30 minutes before intercourse (duration 4 hours)
         2. Staxyn may be lower cost than Viagra 50-100 mg
      3. Cialis (Tadalafil)
         1. Dose: 5-20 mg orally 30-45 minutes before intercourse (duration 36-48 hours)
         2. Cialis 5 mg taken at 2 tabs per dose may be less expensive than Cialis 10 mg tabs or Viagra 50-100 mg
   2. Testosterone Supplementation
      1. Indicated for morning Total Testosterone <300 ng/dl
4. Management: Other Medications
   1. Apomorphine (Uprima) - new agent
   2. Korean Red Ginseng (Panax ginseng) 900 mg three times daily
      1. Hong (2002) J Urol 168(5): 2070-3
   3. Yohimbine 5.4 mg PO qid
      1. Not recommended due to lack of safety data and standardization of products
   4. Vitamin E
   5. Trazodone (Desyrel) 50 to 100 mg PO qhs
      1. May be combined with Yohimbine
      2. Priapism may occur (See Priapism Management)
5. Management: Experimental Agents
   1. Apomorphine hydrochloride (Zydis, sublingual)
      1. Central Dopamine Stimulant
      2. Nausea and Vomiting may occur
   2. Phentolamine (oral)
      1. Alpha Adrenergic Antagonist
6. Management: Local Pharmacologic Therapy
   1. Intracorporal Injection (Caverject)
   2. Intraurethral Alprostadil (MUSE)
7. Management: Surgery
   1. Penile Prosthesis
      1. Malleable device ($10,000)
      2. Inflatable prosthesis ($25,000)
   2. Penile Revascularization
8. References
   1. Heidelbaugh (2010) Am Fam Physician 81(3): 305-12
   2. McVary (2007) N Engl J Med 357(24): 2472-81