Which erectile dysfunction treatment works best?
Guidelines do not name a single best treatment for erectile dysfunction. The European guideline tailors the choice to invasiveness, efficacy, safety, cost and the man's preference, with PDE5 inhibitor tablets as first-line therapy. Penile implants have one of the highest satisfaction rates of any option, at 92% to 100% of patients, and are recommended when other treatments fail or by preference.
How do guidelines decide on an erectile dysfunction treatment?
The European guideline replaced the older fixed sequence of first, second and third-line treatment with a personalised approach.
"The treatment algorithm was developed as an alternative to the traditional three-tier concept to support personalised treatment tailored to individual patients according to invasiveness, tolerability and effectiveness of the different therapeutic options and patients' expectations." Source 1, p. 47
Patients are fully counselled on every available treatment, and dialogue between doctor and patient is treated as essential throughout. A systematic review found that men stop every type of treatment for erectile dysfunction over time, with treatment costs among the most common reasons. The American guideline states that every man should be told about all options that are medically safe for him. Many men begin with the least invasive one, but a man may reasonably start with any treatment or choose none.
What are the main treatment options?
PDE5 inhibitor tablets are the first-line treatment. They improve erectile function significantly with a good safety profile, and no difference in effectiveness has been shown between the different PDE5 inhibitors. Injections into the penis are an alternative first-line or second-line option and work well, although many men stop using them.
Alprostadil applied to the tip of the penis or placed in the urethra is an alternative for men who do not want tablets or injections, but it is less effective than injections. Vacuum devices suit men who want treatment without medicines, and satisfaction with them varies widely.
Why do tablets sometimes seem not to work?
Before a tablet is judged ineffective, the prescription, the way it is taken and whether it is a licensed medicine are checked. High-fat meals can delay the absorption of sildenafil, vardenafil and avanafil, and men may wait too short or too long after a tablet before sex.
When the importance of the dose, the timing and sexual stimulation is explained, erections can often be restored on the same tablet. In men with low testosterone who do not respond, testosterone treatment may improve the response, and the American guideline recommends adjusting the dose for the best effect.
What about shockwave therapy and platelet-rich plasma?
The two guidelines differ on low-intensity shockwave therapy. The European guideline accepts it as an option for mild erectile dysfunction caused by blood vessel problems, where it can produce a mild improvement, while the American guideline considers it investigational.
Injections of platelet-rich plasma have produced a mild improvement in some studies, but the European guideline finds the evidence insufficient and limits them to clinical trials. Larger trials are needed to confirm whether they work and are safe. The American guideline calls them experimental and considers stem cell treatment investigational.
Where does a penile implant fit?
A penile implant is recommended when other treatments fail or when the patient prefers it. It has one of the highest satisfaction rates of any treatment for erectile dysfunction, at 92% to 100% in patients and 91% to 95% in partners, with appropriate counselling.
An implant is best regarded as irreversible, because the penis is unlikely to respond reliably to other treatments if the device is removed. Satisfaction is generally higher with inflatable implants, while a malleable implant can suit men with limited hand dexterity or cost concerns. Counselling before surgery covers these points and the realistic results of surgery.