Lifestyle Modifications

ED is correlated with several aspects of general health status; lifestyle modifications improve ED and slow the rate of decline that occurs with normal aging.  Former smokers one year after smoking cessation saw a 25% improvement in erection quality.23  Obesity is correlated with ED, and weight loss programs have been shown to improve ED.24  Heavy alcohol use is associated with ED. Alcohol cessation can also help improve several of the conditions associated with ED.3  Physical activity can improve many of the conditions associated with ED, including diabetes, dyslipidemia, and obesity, and is recommended for men with ED who do not have a contraindication to exercise.  Oxidative stress and inflammation are associated with ED, and nutritional strategies are part of a comprehensive treatment regimen to reduce oxidative stress and inflammation.  The Mediterranean diet is associated with an increase in erection quality, improved endothelial function, and decreased C-reactive protein.25

Medication Review

Several medications can contribute or even outright cause ED.  A thorough medication review by the pharmacist can help ascertain if medication is a contributing factor to ED.  Pharmacists can refer the patient back to their physician to discuss switching to a different medication and recommend possible therapeutic alternatives. Medications commonly associated with ED include:

  • Cytotoxic medications
  • Antihypertensives (diuretics, beta-blockers)
  • Antidepressants
  • Anticonvulsants
  • Opioid analgesics
  • Parkinson’s medication
  • Sedatives
  • Nicotine
  • Alcohol
  • Antihistamines
  • Amphetamines
  • Marijuana


Placebo effects occur reliably in ED medication trials, suggesting that psychosocial and relationship support needs drive some of the disability with ED.  Trials comparing medical support to psychotherapy and medical support alone show a greater improvement in ED with combined therapy over single treatment modalities.1   Pharmacists can refer patients with ED to local or online sources of psychotherapy and cognitive behavioral therapy.


Alprostadil (prostaglandin E1 or PGE1) is a known relaxer of smooth muscle. It is not first-line therapy, and patients should be referred to a physician to initiate this therapy. PGE1 works to increase the accumulation of intracellular cyclic adenosine monophosphate, decreasing calcium and causing relaxation of smooth muscle.  PGE1 can be delivered through an intraurethral suppository or direct injection into the corpus cavernosa.  The dosing varies by administration route with usual intraurethral dosing of 100 mcg to 1 mg compared to 2.5 mcg to 20 mcg if given by intracavernosal injection.  In-office testing is recommended to find the correct dose to minimize the risk of adverse effects, which increase with higher doses. Intracavernosal PGE1 has a higher success rate than intraurethral PGE1.  Side effects include fainting, dizziness, priapism, urethral injury, urethral bleeding (intraurethral), and partner dyspareunia (intraurethral), penile hematoma (intracavernosal), and penile contracture (intracavernosal).  Evidence using a primary endpoint of able to have intercourse with intraurethral PGE1 had an efficacy of 50%.26,27

Vacuum Erection Devices (VED)

Patients who have an incomplete or nonresponse to oral therapy or have financial constraints can be referred for VED therapy.  VED’s are an acrylic cylinder that is placed over the penis.  An erection occurs by creating a vacuum with the pump attached to the cylinder.  Once an erection occurs, a constriction band is placed on the base of the penis to maintain the erection.  The band should be removed in 30 minutes.  VED devices are a cost-effective option for ED and are effective for general ED and ED secondary to conditions such as diabetes, traumatic spinal cord injury, and post-prostatectomy.1   The rate of patient satisfaction with VED’s is high, with numerous trials indicating satisfaction rates of greater than 70%.  Efficacy is reported to be as high as 90% with proper instruction and support.

Complications of therapy are usually minor and include bruising, pivoting of the penis at its base, numbness or tingling of the penis, and trapping of ejaculated semen.  Men have also reported difficulty using the device.

Contraindications to VED therapy are conditions that predispose to priapism or penile injury and include sickle cell disease, anatomical deformities, polycythemia, and blood dyscrasias.  Patients on anticoagulants or at high risk for bleeding can use the device but should be counseled on the higher risk of bruising and bleeding.

Surgical Intervention

Penile prosthetics are an option for patients who fail more conservative measures.  Currently approved FDA devices are safe with MRI use.  Satisfaction rates with penile implants are 86.2%.1 Two different types of devices currently are available, a saline silicone device and a malleable device.  The silicone device has a more natural appearance but is more expensive and has a higher mechanical failure rate.  Mechanical failure rates range from 6% to 16%, depending on the device.31 Infection was a significant concern with previous devices, but the new coated devices combined with improved surgical technique have infection rates of less than 1%.31 Other adverse effects include a change in penis appearance, erosions, and post-operative pain and swelling.  AUA guidelines do not recommend routine venous ligation or penile revascularization procedures for ED treatment.1 

Oral Phosphodiesterase Type 5 inhibitors (PDE5i’s)

PDE5i blocks the phosphodiesterase type 5 enzyme from breaking down cGMP. This inhibition increases the concentration of penile cavernosal cGMP, which causes smooth muscle relaxation in the corpus cavernosum vasculature.  In men who have intact vasculature, this results in increased erection hardness and a longer duration of an erection.  PDE5i’s are ineffective in approximately 40% of men with ED.32 Also, tolerance may occur, and previous responders may become non-responders and require a different treatment modality.  Pooled data from a meta-analysis indicate that sildenafil, tadalafil, and vardenafil have similar efficacy.1 The medications do differ in their onset, half-life, and duration.  Dose responses are not linear, but side effects increase with dose; the lowest effective dose should be used.1 Daily dosing with tadalafil is associated with lower adverse effects compared to on-demand dosing.

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