Treatment for erectile dysfunction (ED) has improved significantly over the past few years, and the arrival of new medications in 2003 has increased the choice.
However, older established treatments such as the vacuum pump remain useful for many men.
Deciding which treatment is best for an individual depends on many factors including:
the presence of other medical conditions
the possibility of interaction with other prescribed medication
the preferences of you and your partner.
For example, a man who takes blood-thinning drugs (anticoagulants) should avoid injections into the penis or a vacuum device, because they might lead to excessive bruising.
A man who takes nitrate medicines for angina cannot use Cialis (tadalafil), Levitra (vardenafil) or Viagra (sildenafil) because the combination can lead to a dangerous drop in blood pressure.
A simple scheme of how a doctor decides on the best treatment is presented below. This is a rough guide, because it is impossible to take into account every important detail in anything other than a one-to-one consultation with your doctor.
Step 1: Physical or psychological ED, or both?
This distinction is rarely clear cut – there is always a combination of both causes. However, if you regularly experience a firm morning erection yet have ED, it is much more likely that psychological factors contribute to your problem.
Where psychological factors and relationship difficulties are identified as the predominant causes of ED, it is important that they are addressed, preferably with a skilled sexual and relationship therapist.
If they aren’t, drugs are unlikely to restore enjoyable and satisfying sexual intimacy. Many therapists would now also consider recommending at least a trial of physical treatment to supplement the benefits of psychotherapy.
Step 2: Is there a potentially reversible cause of the ED?
The main ones are medications, for example some drugs used for depression. Sometimes it will be quite straightforward for the doctor to change to an alternative treatment that is less likely to cause ED.
Step 3: Can a ‘first-line’ treatment be used?
Cialis, Levitra, Viagra, vacuum devices and sex and relationship therapy can all be considered first-line therapies for ED.
Cialis, Levitra and Viagra are effective for all grades of ED, including men who never get an erection, as are vacuum devices.
All the medicines for ED have certain restrictions on who can safely use them, and this will play a part in which first line medicines you can try. For example, men who take nitrate drugs cannot take Cialis, Levitra or Viagra.
Men who have very low blood pressure may also not be able to tolerate these medicines.
If one of these medicines doesn’t work, it’s a good idea to consider trying the others before proceeding to more invasive treatment.
If these medicines are ineffective, unacceptable to yourself or your partner, or cannot be used for safety reasons, then the other treatments in step five should be considered.
Step 4: Trial of therapy Viagra
There are three strengths: 25mg, 50mg and 100mg. Most men should start at the 50mg dose.
If this dose is ineffective after four administrations and attempts, and is otherwise well-tolerated, the dose should be increased to 100mg. The maximum tolerated dose should be tried on at least eight separate occasions before deciding that it is ineffective.
It is essential that the drug is taken at least forty five minutes and preferably one hour before attempting intercourse, particularly if it is taken within two hours of food. Sexual stimulation is necessary for an erection to develop with this drug.
There are two strengths: 10mg and 20mg. The recommended dose is 10mg taken between 30 minutes and 12 hours before sexual activity. Its effectiveness is not altered by food.
If 10mg doesn’t work, the maximum dose of 20mg may be tried. This medicine may continue to work for up to 24 hours after the dose, so you shouldn’t take it more than once a day.
Cialis should be tried on numerous separate occasions before deciding that it is ineffective. Direct sexual stimulation of the penis is required for an erection to develop with this drug.
There are three strengths: 5mg, 10mg and 20mg. Most men should start at the 10mg dose.
If 10mg is ineffective, the dose may be increased to a maximum of 20mg. If 10mg is not tolerated, the dose should be decreased to 5mg.
Levitra should be taken about 25 minutes to one hour before attempting intercourse. It can be taken with or without food, but its effect may be delayed if it is taken with a meal that is high in fat.
It should be tried on multiple separate occasions before deciding that it is ineffective. Direct sexual stimulation of the penis is also required for an erection to develop with this drug.
Vacuum devices are effective for just about all men, but they do require some skill to use.
Both you and your partner need to be willing to use the device as a part of lovemaking. A positive attitude towards its use will make a difference to your satisfaction and decision to use it over the long term.
Couples should make sure that they understand how to use the device and to follow the manufacturer’s instructions carefully.
If you have difficulty in getting it to work, seek advice from the health professional who recommended it – and take the device with you. Poor technique of use is by far the commonest cause of not being able to get an erection with a pump.
Step 5: Other treatments
If the above therapies fail, or cannot be used, the next options are prostaglandin that you inject into the penis (Caverject, Viridal Duo) or insert into the tip of penis using an applicator (MUSE).
If these treatments prove ineffective, you should be referred to a specialist who may recommend use of an unlicensed injection therapy or a combination of drugs.
The specialist should carefully discuss the potential risks and benefits of such treatments before prescribing them.
Step 6: Inadequate response
All the above treatments might fail if:
the erectile tissue is severely damaged
there is a very poor blood supply to the penis (usually due to hardening of the arteries)
the penis is severely deformed
there has been a serious traumatic injury to the penis.
Effective treatment for ED is still possible, but this is specialised territory and needs the detailed advice that can only be given after assessment by an expert in ED (eg a urologist).
Surgery to the arteries and veins is rarely effective, except in men who have sustained penile or pelvic injuries.
At this stage, the decision will generally be whether to use insert bendable rods or inflatable tubes into the penis (penile prothesis).