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A. Phosphodiesterase 5 inhibitors: Phosphodiesterase 5 inhibitors (PDE5Is) are a group of drugs used for the treatment of ED. These drugs relax smooth muscle in the vessels in the penis to increase blood flow. They do not cause an erection without sexual stimulation.
There are 4 approved types of PDE5Is:
PDE5Is are the most commonly prescribed treatment for ED. All types of PDE5Is can be equally effective. Which drug is best for you depends on how often you want to have sexual activity, and your personal experience.
Because of the success of PDE5Is in treating ED, there are many fake pills on the market. These drugs are not approved for sale, they may be toxic and may damage your health.
Always talk to your doctor or healthcare provider before using or buying medication for ED.
A. There are 4 approved types of PDE5Is:
Sildenafil: Sildenafil is the oldest available PDE5I and is available as a pill. It comes in doses of 25, 50, and 100 mg. The dosage can be adjusted according to your needs. You can feel the effects of the drug 30-60 minutes after taking it. They may last for up to 12 hours. If you eat a fatty meal right before taking sildenafil, the drug is less effective.
Tadalafil: Tadalafil is available as a pill. It comes in doses of 5, 10, and 20 mg. The dosage can be adjusted according to your needs. You will start to feel the effects of the drug 30 minutes after taking it. It is most effective after 2 hours. The effects may last for up to 36 hours. In contrast to other PDE5Is, food has no effects on the working of tadalafil.
Daily Tadalafil (5 mg) has also been licensed for the treatment of urinary symptoms related to benign prostatic enlargement with or without ED. Your doctor may recommend daily tadalafil if you have ED with BPE
Vardenafil: Vardenafil is available as a pill, or as a dissolvable tablet. It comes in doses of 5, 10, and 20 mg. The dosage can be adjusted according to your needs. You will start to feel the effects of the drug 30 minutes after taking it. If you eat a fatty meal right before taking vardenafil, the drug is less effective.
Avanafil: Avanafil is the most recent PDE5I to become available. It comes in doses of 50, 100, and 200 mg. The dosage can be adjusted according to your needs. You can feel the effect of the drug 15-30 minutes after taking it. Taking the pill with any food can delay its effects.
A. PDE5Is can cause headaches, flushing of the skin, heartburn, a stuffy nose, and dizziness.
Sildenafil and vardenafil can cause changes in vision, and tadalafil and avanafil can cause back and muscle pain. All these side effects stop when you stop taking the pill.
A. The use of PDE5Is is not recommended if you are taking medication with a nitrate basis, or if you take alpha blockers.
They could lead to a sudden decrease in blood pressure. If you have any concerns, discuss with your doctor.
A. If you believe that PDE5Is are not working for you, it is important to figure out the cause. For that, you need to answer the following questions:
If with the highest dose and correct use PDE5Is are still not effective, discuss other possible treatment options with your doctor.
A. Topical therapies means medications are applied to the skin. Two specific formulations of alprostadil have been approved for topical therapy. The first one is the urethral pellet medication inserted into the tip of the penis (intraurethral). The second one is a cream formulation applied to the external opening of the urethra at the tip of the penis.
A. Alprostadil is a well-known drug for the treatment of ED. Commonly they are considered as the second-line therapy but they can be a first-line treatment option also. The major advantage of alprostadil cream is that adverse events are very rare and there are no interactions with other drugs (e.g. blood pressure medications, blood thinners such as heparin or warfarin).
A. Alprostadil is absorbed from the urethra and relax smooth muscle in the vessels of the penis to increase blood flow. Alprostadil cream includes a permeation enhancer in order to facilitate absorption of alprostadil. The mechanism of action is similar to intraurethral alprostadil.
A. You should not use alprostadil if you are allergic to it, or if you have:
A. The most common adverse events of topical therapy are local pain and dizziness with possible hypotension. In some cases urethral bleeding and urinary tract infections occur while penile fibrosis and priapism are very rare. Topical alprostadil has the advantage of only topical side effects that include penile erythema, penile burning and pain. Systemic side effects are very rare.
To make sure alprostadil is safe for you, tell your doctor if you have:
or HIV).
Use a condom to prevent transfer of this medicine to your sexual partner.
A. The vacuum erection device (VED), is a cylinder-shaped device that comes with a rubber or silicon constrictive ring that tightens around the penis. A VED makes it possible to get and maintain an erection.
A. You should consider a VED if PDE5Is are not effective. A VED is also an alternative treatment option if you cannot use PDE5Is or if you do not want to take medication for ED.
A. By placing the cylinder over your penis, you create a vacuum with a manual or an electronic pump which removes the air from the cylinder. This process draws blood into the penis, so that it gets swollen and then erect (Fig. 2). After removing the pump you need to place the rubber or silicon ring around the base of the penis, to keep an erection. Never leave the ring on for more than 30 minutes. It is important to be aware that the blood drawn into the penis is dark in colour. As a result, your penis feels colder to the touch and looks slightly blue once the band is in place. Some people do not mind, but if this makes you or your partner uncomfortable, make sure to discuss your concern with each other, and your doctor.
It is very important to know that the ring should be removed after 30 minutes. The blood drawn into the penis is low in oxygen, and the lack of oxygen can damage the skin in the penis. If you choose to use a constrictive ring without a VED, make sure that it is made of flexible material like silicone or rubber. Never use rigid materials such as steel or hard plastic because they may be difficult to remove.
A. VEDs are not recommended if you take medication to prevent blood clotting, or if you have a bleeding disorder.
A. VEDs can cause some discomfort, difficulty with ejaculation during orgasm, bruising of the skin of the penis, and numbness. Leaving the constrictive ring for more than 30 minutes can cause severe skin damage to the penis.
A. Extracorporeal Shock-Wave Therapy (ESWT) is a therapy in which short pulses of shock waves with a very low intensity are directed at the penis to improve erectile function. It consists of several sessions, and it can be repeated if necessary.
ESWT is being researched as a new treatment option for ED. It is not a standard treatment option. Specific ESWT devices are necessary to treat ED. Discuss with your doctor if ESWT is the right treatment for you and if it is available in your hospital.
A. If you have mild ED and you cannot or do not want to take PDE5Is, your doctor may recommend ESWT. Keep in mind that ESWT is currently no standard option for the treatment of ED.
A. ESWT causes minor damage to penile tissue. During the healing process new blood vessels are formed, which increase the blood flow to the penis. This may result in improved ability to get and maintain an erection.
A. Intracavernous injections are a treatment option for ED where you inject drugs into the spongy tissue in the penis to open the blood vessels.
A. Intracavernous injections are a treatment option if previous treatments such as lifestyle changes or PDE5Is were unsuccessful. Although many men will be scared by the idea of placing a needle into their penis, most men who choose injection therapy quickly realize that the benefits of the injection far outweigh a little pinprick.
A. The drugs in intracavernous injections relax smooth muscle in the vessels in the penis to increase blood flow. This results in an erection 10-15 minutes after the injection, even without sexual stimulation. The most common drug used for intracavernous injections is alprostadil. In some cases your doctor may recommend a combination of drugs to improve the effect or reduce the side effects. Common drugs include: papaverine, phentolamine, vaso-active intestinal peptide, atropine and forskolin. Dosages may vary and can be adjusted as needed. Keep in mind that not all drugs are available in all countries.
A. You might receive an in-office training from your urologist to learn how to inject yourself. In some cases your partner may receive training as well. During the training the urologist will also discuss the correct dosage with you. The location of the injection is important. Make sure to inject at the base of the penis, and between 2 and 4 ‘o clock, or 8 to 10 ‘o clock positions in order not to damage the urethra or the nerves and blood vessels in the penis (Fig. 3). Then, gently apply pressure for 2-5 minutes at the injection site to prevent bruises. If the correct dosage is injected, you will have an erection within 10-15 minutes.
A. You should not use intracavernous injections when you are hypersensitive to any ingredients in the drug, when you are at risk for priapism, or when you take medications to prevent blood clotting. Your urologist can give your more in-depth information on these contraindications and discuss your individual situation.
A. The most common side effects of injections is pain in the penis during erection. This happens in about 1 out of 10 injections and the pain usually stops when the erection ends. Another minor side effect is bruising at the injection site. The most serious side effect is priapism. This means that an erection lasts longer than 4 hours, and is painful. Priapism may damage the smooth muscle cells in the penile vessels, and can worsen ED. It is very important to contact your doctor if you have an erection that lasts longer than 2-3 hours. Generally priapism can be treated effectively with the injection of an antidote.