Treatment of erectile dysfunction with medicines

Treatment of erectile dysfunction (impotence) pursues the following goals: achieving the quality of erections, which is necessary for a full sexual intercourse. The patient should be informed about the possible methods, their effectiveness and negative properties.

Treatment should be etiological and pathogenetic. First of all, it concerns diabetes, arterial hypertension, metabolic syndrome. Persistent cure for erectile dysfunction (impotence) can be expected in cases of psychogenic erectile dysfunction (rational psychotherapy), posttraumatic arteriogenic impotence in young men, with hormonal disorders (hypogonadism, hyperprolactinaemia).

Operative interventions on the vessels are shown to patients with occlusive lesions of the arteries supplying the pelvic organs. The ligation of veins draining cavernous bodies is sometimes used in young patients with venous occlusion.

Treatment of impotence, which arose against the background of androgen deficiency, can be very effective due to the restoration of physiological concentrations of androgens in the serum by the appointment of testosterone preparations of the latest generation.

In situations where a comprehensive examination did not reveal the underlying disease, erectile dysfunction is treated according to certain standards, taking into account the effectiveness of the method, safety, invasiveness. Material costs, as well as the patient's satisfaction.

Before starting treatment, the patient is shown the need to exclude the factors that negatively affect erection (see above), as well as the normalization of the lifestyle and the regime of sexual activity. It is necessary to consider the possibility of canceling or replacing the medications received by the patient, which can adversely affect the erection.

Treatment of erectile dysfunction requires compliance with the principle of phased use of medical measures.

Hospitalization is indicated only for performing complex invasive examinations and / or surgical interventions.

Treatment of erectile dysfunction: the first line

Medicinal preparations for oral administration with impotence: inhibitors of phosphodiesterase type 5.

The creation and availability of type 5 phosphodiesterase inhibitors led to revolutionary changes in the treatment of erectile dysfunction. The mechanism of their action is the following: during sexual stimulation, nitric oxide is released from the nerve structures of the cavernous bodies (N0). Which activates the enzyme guanylate cyclase, which leads to an increase in the content of cyclic guanosine monophosphate in the cells of the cavernous bodies. The result is a decrease in the content of free calcium in smooth muscle cells, their relaxation, a sharp increase in blood flow and the expansion of cells of cavernous bodies. Blocking phosphodiesterase-5, involved in the cleavage of cyclic guanosine monophosphate, these drugs contribute to the emergence and maintenance of an erection during sexual activity.

Currently, three drugs of this group are used in the world: sildenafil, talalafil and vardenafil, produced in tablet form and in different doses. Their distinguishing feature is high efficiency in all forms of impotence and good tolerability. Inhibitors of phosphodiesterase-5 are used occasionally (if necessary) for a certain time before sexual intercourse, while for the onset of the effect, sexual activity is necessary. To the merits of sildenafil is, first of all, the greatest experience of its application. Vardenafil distinguish the rapid onset of action, as well as a lesser dependence on the intake of fatty foods and alcohol. The peculiarity of tadalafil is the duration of the action. Which is 36 hours.

The main parameters of pharmacokinetics of phosphodiesterase type 5 inhibitors (based on US Product Information)

Parameter	Sildenafil (Viagra)	Tadalafil (Cialis)	Vardenafil (Levitra)
Time to reach the maximum concentration of Tmax		2	1
The half life of T 1/2	4	17.5	4-5

Clinical efficacy of type 5 phosphodiesterase inhibitors (EU registration data for product characterization)

Index	Sildenafil	Tadalafil	Vardenafil
Start of action, min	25	Thirty	25
Duration of action, h	5	36	5
Positive effect %	66 (50-100 mg)	75 (20 mg)	65 (20 mg)
Range of doses, mg	25 100	20	5-20

In comparable studies 84% of patients noted an improvement in the ability to achieve an erection against the background of sildenafil therapy, against the background of therapy with vardenafil - 80%, against the background of therapy with tadalafilom - 81%.

Apomorphine is applied sublingually if necessary in a dose of 2-3 mg, the effect develops after 10-20 minutes against the background of sexual stimulation. The drug is relatively safe, but significantly inferior to the efficacy of phosphodiesterase-5 inhibitors.

Yohimbine hydrochloride is a blocker of a2-adrenergic receptors and has the ability to activate penile hemodynamics and erection. Possible as an episodic, and course reception. Single dose is 5 mg orally, daily - up to 15-20 mg.

Vacuum constriction method

The essence of the method is to create a negative pressure in the cavernous bodies of the penis with a vacuum device. An increase in the flow of blood causes an erection, for the preservation of which a special compression ring is imposed on the base of the penis, limiting the venous outflow. Approximately 30% of patients abandon the method in connection with the occurrence of pain, subcutaneous hemorrhage, difficult ejaculation and decreased sensitivity.

Psychosexual therapy

Whatever the cause of erectile dysfunction (impotence), psychosexual therapy should be an obligatory component of treatment. In all cases, the doctor must use his influence to normalize or improve the interpersonal relationships of the sexual partners. It is highly desirable that the sexual partner be involved in the medical process, optimally - as a therapist.

Treatment of impotence: second line

In the absence of the effect of the use of oral drugs and vacuum-constrictor devices, intracavernous injections of vasoactive drugs can be used. The effectiveness of this treatment is about 85%. For intracavernous administration, several drugs can be used as monotherapy or in combination (alprostadil, phentolamine, papaverine). The initial dose of alprostadil (prostaglandin E1) is 10 μg, injected into one of the cavernous bodies after dissolution in 1 ml of sodium chloride (sodium chloride isotonic solution for injection 0.9%). If necessary, the dose may be increased to 20 μg. Erection occurs 5-15 minutes after the administration of the drug; its duration depends on the dose, on average - about 90 minutes. After choosing the dose of the drug and appropriate training the patient is transferred to perform autoinjections at a frequency of no more than 2 times a week.

This treatment of erectile dysfunction (impotence) has a number of contraindications and side effects. The patient should be warned that if the erection persists for more than 4 hours, he needs to see a doctor. An erection should be allowed by puncturing cavernous bodies and aspiration of blood, and if necessary by administering minimal doses of adrenomimetic drugs.

Treatment of impotence: the third line (prosthetics of the penis)

In those cases when drug treatment of erectile dysfunction did not give an effect or the patient insists on cardinally solving the problem of this problem, phalloendoprosthetics are used with a semi-rigid prosthesis or devices simulating an erection.

Advantages and disadvantages of various methods of treatment of impotence

Method of treatment, drug	Benefits	Disadvantages
Inhibitors of phosphodiesterase-5	High efficiency, ease of use	Contraindicated in the reception of nitrate interaction with food and certain drugs, a relatively high price
Iitraavernous administration of PGE preparations	High efficacy (75-85%), minor systemic side effects	The need for autoinjection requires special training, causes pain in the penis
Vacuum-constrictor devices	The least expensive, there are no systemic side effects	Unnatural erection, causes small hemorrhages swelling of the skin of the penis ejaculatory disorder
Prosthetics	Highly efficient	Requires surgery, unnatural erection is possible infectious complications in the case of an unsuccessful operation outcome, the use of other methods of the flow of erectile dysfunction can not be the probability of the need to replace the prosthesis after 5-10 years