II. Precautions

  1. Comorbid Diabetes Mellitus (and Metabolic Syndrome) and cardiovascular disease are common in Erectile Dysfunction
    1. See Erectile Dysfunction for recommended labs (includes serum Fasting Glucose or Hemoglobin A1C)
    2. Consider cardiac stress testing or other cardiovascular screening

III. Management: General Measures

  1. Psychological Support: Sex Therapy Indications (esp. in men age <40 years old)
    1. Relationship Problems
    2. Performance Anxiety
    3. Situational Stress
    4. Genital pain or Dyspareunia interfering with sexual arousal
    5. Normal Erections with masturbation, but not with intercourse
  2. Alternative Sexual Techniques
    1. Closeness, fondling or foreplay
    2. Mutual masturbation
  3. Lifestyle Modifications
    1. Regular Exercise
    2. Weight loss (if obese)
    3. Tobacco Cessation
    4. Reduce Alcohol intake
    5. Eliminate Medication Causes of Impotence
  4. Optimize comorbidity management
    1. Major Depression
    2. Cardiovascular disease
    3. Diabetes Mellitus, Metabolic Syndrome and Obesity
    4. Hypertension
    5. Hyperlipidemia
  5. Devices
    1. Constriction rings (for early detumescence)
    2. Vacuum Suction Device

IV. Management: First-line Medications

  1. Phosphodiesterase-5 Inhibitor
    1. Viagra or Revatio (Sildenafil)
      1. Dose: 25-100 mg orally 30 minutes before intercourse (duration 4 hours)
      2. Revatio 20 mg will be generic in 2013 (but may still be expensive if 2 tabs need to be taken)
    2. Levitra or Staxyn (vardenafil)
      1. Dose: 5-20 mg orally 30 minutes before intercourse (duration 4 hours)
      2. Staxyn may be lower cost than Viagra 50-100 mg
    3. Cialis (Tadalafil)
      1. Dose: 5-20 mg orally 30-45 minutes before intercourse (duration 36-48 hours)
      2. Cialis 5 mg taken at 2 tabs per dose may be less expensive than Cialis 10 mg tabs or Viagra 50-100 mg
  2. Testosterone Supplementation
    1. Indicated for morning Total Testosterone <300 ng/dl

V. Management: Other Medications

  1. Apomorphine (Uprima) - new agent
  2. Korean Red Ginseng (Panax ginseng) 900 mg three times daily
    1. Hong (2002) J Urol 168(5): 2070-3 [PubMed]
  3. Yohimbine 5.4 mg PO qid
    1. Not recommended due to lack of safety data and standardization of products
  4. Vitamin E
  5. Trazodone (Desyrel) 50 to 100 mg PO qhs
    1. May be combined with Yohimbine
    2. Priapism may occur (See Priapism Management)

VI. Management: Experimental Agents

  1. Apomorphine hydrochloride (Zydis, sublingual)
    1. Central Dopamine Stimulant
    2. Nausea and Vomiting may occur
  2. Phentolamine (oral)
    1. Alpha Adrenergic Antagonist

VII. Management: Local Pharmacologic Therapy

  1. Intracorporal Injection (Caverject)
  2. Intraurethral Alprostadil (MUSE)

VIII. Management: Surgery

  1. Penile Prosthesis
    1. Malleable device ($10,000)
    2. Inflatable prosthesis ($25,000)
  2. Penile Revascularization

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