Guidelines for treatment have changed considerably over the past decade, and will continue to do so as new drugs and treatment options become available and are evaluated. Treatment can be subdivided into first, second and third line therapies, and includes drug therapies as well as psychotherapies and surgery. All patients should be provided with some general information about erectile dysfunction, which will include normalizing the condition, which can be reassuring for the man and his partner. The role of organic and psychological factors should be described and unbiased information provided on all suitable treatment options.

Pharmacotherapy For Men With Erectile Dysfunction

Few licensed drugs are currently available for the treatment of men with erectile dysfunction. Those that are available elicit their effect by one of two mechanisms. The agent boosts either the neuronal control mechanism or the local control mechanism. As we shall see, oral therapies can have their effect on either system, whereas the intracavernosal and intraurethral systems act locally to produce an erection.

First Line (Oral) Therapies

Oral agents used to treat erectile dysfunction should be reliable, have minimal side effects, and be simple to use. The oral therapies currently licensed for erectile dysfunction are the phosphodiesterase 5 inhibitors (PDE5 inhibitors), which have a peripheral mechanism of action, and apomorphine, which acts centrally. These agents require sexual stimulation to initiate the neuronal activation required to start the hemodynamic erectile response. This is in contrast to the PGE mediated response initiated by intracavernosal and intraurethral alprostadil administration that "forces" an erection. Yohimbine is another oral agent that has been shown to have some efficacy, but this is currently unlicensed in the UK although available on prescription in the UK and US. There are several advantages of the oral agents. Because they are administered orally, they are noninvasive, unlike intracavernosal and intraurethral medications and surgery. Taking a tablet is also more discreet, which is an important characteristic because it restores some of the spontaneity of sexual activity and removes the need for interruptions. In addition, oral methods of drug delivery are not associated with fibrosis (a potential adverse effect when using intracavernosal injections), neither is there any penile or urethral pain that can occur with alprostadil use when given by injection or as the intraurethral pellet. As a consequence, oral therapies are now considered to be first line therapy.