With
phosphodiesterase inhibitors, a safe and effective oral
therapy has emerged for
erectile dysfunction. Increasing awareness, particularly through the media, is inducing more men to seek help for this condition.
Erectile dysfunction is defined as the persistent inability to achieve or maintain an erection adequate for satisfactory sexual activity. The prevalence increases with age. Basic and clinical research is identifying the neurovascular and humoral control of the mechanisms. The initial evaluation should differentiate
erectile dysfunction from
premature ejaculation and loss of libido. Myocardial insufficiency,
hypogonadism and
peripheral neuropathy should be looked for. Initial laboratory investigations should be restricted to identifying previously undetected medical illness that may directly contribute to
erectile dysfunction. Discussing the available options with the couple is an important aspect. If
erectile dysfunction is secondary to other treatable disorders these should be treated simultaneously. When other diseases that require intervention are ruled out and if there are no
contraindications,
therapy may be initiated with a
phosphodiesterase inhibitor. In selected cases, psychosexual
therapy may be beneficial. If
phosphodiesterase inhibitors are contraindicated, vacuum constriction devices may be tried. Further options include intracavemosal injection, intraurethral instillation, penile revascularization and
prosthesis. The availability of effective and well-tolerated oral medications has dramatically changed the clinical approach to
erectile dysfunction.
Pharmacotherapy is the preferred cost-effective first-line
therapy in the vast majority of patients. A stepped-care approach is followed in the primary care and family practice settings. Appropriate urological, endocrine and psychiatric referrals, and shared decision-making with the couple will enable effective treatment of men with
erectile dysfunction.