Erectile Dysfunction Treatment: A Doctor’s Guide

INTRODUCTON

Erectile dysfunction (ED) is a symptom defined by the persistent or recurrent inability to obtain or maintain an erection permitting satisfactory sexual intercourse. A minimum duration of 6 months is necessary to confirm the diagnosis, according to the DSM-5. It is a common disorder whose prevalence increases with age and which can occur in young men (up to 10% of men under 40 years old) (2).

Beyond the pharmacological aspect, therapeutic care requires attention to the patient’s comorbidities and their lifestyle, to question the personal and psychological context in which their sexuality problems occur and to verify the absence of underlying pathology. This process will often involve several stakeholders (treating doctor, urologist, sexologist, specialist doctor, partner, etc.).

MANAGEMENT OF “CHANGEABLE” FACTORS

> Situations comorbides

• The following comorbidities should be looked for and their optimized management to improve erectile function:

– diabetes (prevalence of ED in diabetic patients > 50%) ➝ optimization of glycemic balance;

– obesity (IMC > 30 kg/m²) ➝ weight loss recommended;

– sleep apnea ➝ optimization of processing;

– anxiety-depressive syndrome (bidirectional association between depression and erectile dysfunction) ➝ screen and treat;

– testosterone deficiency ➝ In patients with ED and testosterone deficiency, testosterone supplementation improves erectile function. Note that testosterone supplementation carries a risk of stopping spermatogenesis and is therefore not recommended in cases of desire for paternity.

• Some common medications are also associated with an increased risk of impaired erectile function, including:

– antidepressants (all classes combined)

– antihypertensives (effect varies depending on the class, ARA2 and nebivolol being the classes least likely to provide ED)

➝ If a drug etiology is suspected, discuss possible modification of treatment with the prescriber.

> Lifestyle and hygienic-dietary rules

Hygiene and diet rules are an integral part of the management of ED:

– crecommend at least 30 minutes of physical activity dynamic per day, ideally 150 to 180 minutes of weekly aerobic exercise.

– ssmoking cessation

– detect excessive alcohol consumption > 3 glasses/day (non-linear relationship between alcohol and erectile function, with a “benefit” below 3 units/day and 8 units/week, and a strong increase in the risk of ED for greater consumption);

– Search for cannabis use and provide cessation advice ;

– Food balancing : stopping sodas, healthy diet, particularly “Mediterranean” type;

– look for sleep disordersdetect an unknown sleep apnea syndrome;

TREATMENTS

> Les IPDE-5

• Oral IPDE-5 constitutes the first treatment ligne in the absence of contraindications

• Their prescription is contraindicated in cases of unstable angina, decompensated heart disease or untreated symptomatic rhythm disturbance, or in combination with nitrates (trinitrin, poppers, etc.)

However, it is possible to prescribe an IPDE-5 after treatment of heart disease, a heart attack or stroke treated with cardiac function stabilized for more than 6 weeks (3).

• Gradually increase the doses IPDE-5 and prescribe the minimum effective dose in order to limit unwanted effects.

• Several molecules are available : sildenafil, vardenafil, avanafil and tadalafil. The literature does not find any difference in terms of effectiveness and tolerance between them (4).

• Specify the mode of action (erection facilitator and not trigger), time of action, possible side effects.

• In the event of poor tolerance or a non-optimal response, several alternatives are possible.

> Topical prostaglandins (PGE1)

• Two methods of use are possible : intracavernous injections (IIC) or topical intraurethral administration (IU). In both cases, the only molecule available in France is alprostadil.

• PGE1 (IU or IC) can be offered in 2nd line or 1st line as an alternative to IPDE-5. It constitutes an effective treatment, with little morbidity and good satisfaction rates (74% intraurethral and > 85% intracavernosal) (5).

• For IICs, gradually increase doses and prescribe the minimum effective dose in order to limit adverse effects.

• Any prescription of prostaglandins (IIC or IU) must be accompanied by therapeutic education: learning the procedure, progressive management of doses, information on the risk of priapism (how to avoid it, how to manage it, low frequency around 1%).

• Regular monitoring is recommended (re-evaluation of the technique, tolerance, effectiveness).

> Mechanical vacuum treatment

In the case of ED, vacuum can be offered to all patients and especially to those who are ineligible (contraindications), intolerant or non-responsive to pharmacological treatments.

> Treatment combinations

• Several treatment combinations can be proposed:

– IPDE-5 + IPDE-5, 2nd line or 1st line in case of severe ED

– IPDE-5 + PGE1 (IIC or IIU), in 2nd intention

– IPDE-5 + vacuum or IPDE-5 + PGE1 in case of moderate to severe ED

– IPDE-5 + shock waves in case of mild to moderate ED

> Surgical treatment

• The penile implant is indicated in patients refractory or intolerant to pharmacological or mechanical treatments or if the patient wishes permanent treatment.

Preoperative information is essential: types of implants, expected result, convalescence, use, risk of complications (increased in the case of comorbidity: diabetes, tobacco, obesity, spinal cord injury, in the case of fibrosis of the corpus cavernosum or previous penile surgery).

Medical preparation is important, with if possible smoking cessation 1 month before and optimization of diabetes control (HbA1c < 8.5%).

Penile implant satisfaction rates among patients and partners are above 80% (6).

• Place of vascular surgery : arterial revascularization surgery may be offered in very specific cases.

There is no standardized management of venous leak.

> Emerging therapeutics and alternative medicines

ED is the subject of numerous proposals for new treatments and alternative/complementary medicines.

• Among emerging treatments:

THE Low intensity extracorporeal shock waves can be offered, alone or combined with IPDE-5, to patients with mild or moderate ED (no evaluation beyond 6 months and absence of a single protocol).

There are insufficient data to routinely recommend or discourage intracavernosal injections of platelet-rich plasma and botulinum toxin A.

• Concerning “alternative or complementary” treatments (acupuncture, low frequency magnetic pulses, etc.) and herbal medicine, the available data were considered insufficient to recommend any of them.

SEXOLOGICAL ADVICE

•The sex therapy approach is an integral part of ED management and can be offered at each stage of treatment. Cognitive-behavioral therapies make it possible to optimize treatment.

•Appropriate information on the physiological and psychological processes involved in the individual’s sexual response can improve ED (7).

The recommendations provide a practical sheet of explanations and behavioral advice to be given to the patient and his/her partner (see below).

CONCLUSION

ED is common and also affects young men. Do not hesitate to ask the patient about his sexuality because many therapeutic options can be offered beyond the simple prescription of IPDE-5.

The care is multidisciplinary (treating doctor, urologist, sexologist, organ specialists, etc.) and customizable according to the needs and expectations of the patient.

Links of interest: Dr Nadja Stivalet-Schoentgen declares that she has no link of interest relating to the content of this article

Bibliography:

1. Laumann EO, et al. Sexual dysfunction in the United States: prevalence and predictors. Jama. 1999;281(6):537-544.
2. Huyghe Eet al. Therapeutic management of erectile dysfunction: The AFU/SFMS guidelines. Fr J Urol. 2025;35(3):102842.
3. Köhler TSet al. The Princeton IV Consensus Recommendations for the Management of Erectile Dysfunction and Cardiovascular Disease. Mayo Clin Proc. 2024;99(9):1500-1517.
4. Yuan J et al. Comparative effectiveness and safety of oral phosphodiesterase type 5 inhibitors for erectile dysfunction: a systematic review and network meta-analysis. Eur Urol. 2013;63(5):902-912.
5. Duncan C, et al. Erectile dysfunction: a global review of intracavernosal injectables. World J Urol. 2019;37(6):1007-1014.
6. Salonia A, et al. European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction. Eur Urol. 2021;80(3):333-357.
7. Berner M, Günzler C. Efficacy of psychosocial interventions in men and women with sexual dysfunctions – a systematic review of controlled clinical trials: part 1-the efficacy of psychosocial interventions for male sexual dysfunction. J Sex Med. 2012;9(12):3089-3107.