RISK FACTORS
β’ Prior pelvic surgery
β’ Medication use
β’ Risk factors for disorders listed in Causes
GENERAL MEASURES :
β’ Early use of penile implants is now discouraged because of success with vacuum erectile devices, sensate
focus therapy, injection therapy and oral therapy
β’ Improve partner communication
β’ Reduce performance pressure
β’ Use sensate focus therapy
β’ Try vacuum erectile device or oral therapy (and can be used in conjunction with intracavernous injections)
β’ Use of psychiatrists, psychologists, sex therapists, vascular surgeons, urologists, endocrinologists, neurologists, plastic surgeons, etc., often necessary for refractory cases
DRUG(S) OF CHOICE
. Erection induction: Prostaglandins
. Intracavernous injection (1/2", 30 gauge needle), starting with 0.1 mL
Compounded Intracavernousal solution
Drug Amt Conc/mL
----------------------------------------
PGE-1(500mcg/mL) 50mcg 6.6mcg
Papaverine(300mg/10mL) 150mg 20mg
Phentolamine 5mg 0.67mg
Bacteriostatic NaCl QS 7.5mL
or
. Alprostadil (Caverject) 10-20 mcg/mL; inject into the dorsolateral aspect of proximal third of the penis.
Do not exceed 60 mg dose. Do not use more than 3 times a week or more than once in 24 hours. Patient
to notify physician if erection lasts > 6 hours for immediate attention.
. Alprostadil (Muse) urethral suppository 125 mg, 250 mg, 500 mg, and 1000 mg pellets. Maximum of 2
uses in 24 hrs.
. Erection induction: Phosphodiesterase type 5 (PDE-5) inhibitors
. Sildenafil (Viagra) 25 mg, 50 mg, or 100 mg tablets. Usual dose, 50 mg 1 hr prior to sexual activity. Duration
up to 4 hrs.
. Vardenafil (Levitra) 2.5 mg, 5 mg, 10 mg, 20 mg tablets. Usual dose, 10 mg 1 hr prior to sexual activity.
Duration up to 4 hrs.
. Tadalafil (Cialis) 5mg, 10 mg, 20 mg tablets. Usual dose, 10 mg 1 hr prior to sexual activity. Duration up
to 36 hrs.
. Miscellaneous
. Testosterone cypionate 200 mg IM every two weeks when hypogonadism is present. Testosterone patch
or gel also available.
. Bromocriptine 2.5 mg bid up to 40 mg/day when hyperprolactinemia is present
Contraindications:
. Injections should be avoided in patients with bleeding disorders, patients with sickle cell disease or trait, and
in patients with penile deformities.
. Avoid use in patients with known allergies to constituents
. Nitroglycerin (or other nitrates) & phosphodiesterase inhibitors - potential for severe, potentially fatal, hypotension
PATIENT MONITORING : Meet with patient and, if possible, his partner, as required by cause,
therapy, and response
PREVENTION/AVOIDANCE : Since erectile dysfunction is multifactorial, referral to a sex therapist or couples therapist may help to speed recovery and prevent future problems
POSSIBLE COMPLICATIONS : Specific to therapy
EXPECTED COURSE/PROGNOSIS :
β’ Given that the majority of patients have unspecified causes of their erectile disorders, vacuum erection
device, injection or suppository therapy with alprostadil, oral sildenafi l and penile implant have improved the
outlook greatly
β’ Expect 20% failure rate of vacuum erection device, high drop-out rate from injection therapy, and a 10-30%
non-use rate for penile implants
β’ Spontaneous cure rate is about 15%
β’ Studies indicate a response rate of 40-60% for urethral alprostadil compared to 85-90% for the injection
β’ Sildenafil and other PDE-5 inhibitors are effective in 70% of men at maximum dose, but are less effective
in patients with diabetes and those who have had a prostatectomy for cancer