Treatment of erectile dysfunction with medications

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

Treatment should be etiological and pathogenetic. First of all, this concerns diabetes mellitus, arterial hypertension, metabolic syndrome. A stable cure for erectile dysfunction (impotence) can be expected in cases of psychogenic erectile dysfunction (rational psychotherapy), post-traumatic arteriogenic impotence in young men, and hormonal disorders (hypogonadism, hyperprolactinemia).

Vascular surgeries are indicated for patients with occlusive lesions of the arteries supplying the pelvic organs. Ligation of the veins draining the cavernous bodies is sometimes used in young patients with venous occlusion disorders.

Treatment of impotence that occurs due to androgen deficiency can be very effective due to the restoration of physiological concentrations of androgens in the blood serum by prescribing the latest generation of testosterone preparations.

In situations where a comprehensive examination has not revealed the underlying disease, treatment of erectile dysfunction is carried out according to certain standards that take into account the effectiveness of the method, safety, invasiveness, material costs, and patient satisfaction.

Before starting treatment, the patient is advised of the need to eliminate factors that negatively affect erection (see above), as well as normalize lifestyle and sexual activity. The possibility of canceling or replacing medications that the patient is receiving that can negatively affect erection should be considered.

Treatment of erectile dysfunction requires adherence to the principle of step-by-step use of therapeutic measures.

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

Treatment of erectile dysfunction: first line

Oral medications for impotence: phosphodiesterase type 5 inhibitors.

The development and availability of phosphodiesterase type 5 inhibitors have revolutionized the treatment of erectile dysfunction. Their mechanism of action is as follows: during sexual stimulation, nitric oxide (NO) is released from the nerve structures of the cavernous bodies. activating 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 expansion of the cells of the cavernous bodies. By blocking phosphodiesterase-5, which is involved in the breakdown of cyclic guanosine monophosphate, these drugs help to develop and maintain 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 different doses. Their distinctive feature is high efficiency in all forms of impotence and good tolerability. Phosphodiesterase-5 inhibitors are used episodically (as needed) for a certain time before sexual intercourse, while sexual activity is necessary for the effect to occur. The advantages of sildenafil include, first of all, the greatest experience of its use. Vardenafil is distinguished by a rapid onset of action, as well as less dependence on the intake of fatty foods and alcohol. A feature of tadalafil is the duration of action. 36 hours.

Key pharmacokinetic parameters of phosphodiesterase type 5 inhibitors (based on US Product Information)

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

Clinical efficacy of phosphodiesterase type 5 inhibitors (EU Summary of Product Characteristics)

Indicator	Sildenafil	Tadalafil	Vardenafil
Onset of action, min	25	30	25
Duration of action, h	5	36	5
Positive effect %	66 (50-100 mg)	75 (20 mg)	65 (20 mg)
Dose range, mg	25 100	20	5-20

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

Apomorphine is used sublingually as needed in a dose of 2-3 mg, the effect develops in 10-20 minutes against the background of sexual stimulation. The drug is relatively safe, but significantly inferior in effectiveness to phosphodiesterase-5 inhibitors.

Yohimbine hydrochloride is an a2-adrenoreceptor blocker and has the ability to activate penile hemodynamics and erection. Both episodic and course intake are possible. A single dose is 5 mg orally, daily - up to 15-20 mg.

Vacuum constrictor method

The essence of the method is to create negative pressure in the cavernous bodies of the penis using a vacuum device. Increased blood flow causes an erection, to maintain which a special compression ring is placed on the base of the penis, limiting venous outflow. Approximately 30% of patients refuse the method due to the occurrence of pain, subcutaneous hemorrhages, difficult ejaculation and decreased sensitivity.

Psychosexual therapy

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

Treatment of impotence: second line

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

This treatment for 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 should consult a doctor. The erection should be resolved by puncturing the cavernous bodies and aspirating blood, and if necessary, by administering minimal doses of adrenomimetic drugs.

Treatment of impotence: third line (penile prosthesis)

In cases where drug treatment of erectile dysfunction has not been effective or the patient insists on a radical solution to this problem, phalloendoprosthetics with a semi-rigid prosthesis or devices that simulate an erection are used.

Advantages and disadvantages of different methods of treating impotence

Treatment method, drug	Advantages	Flaws
Phosphodiesterase-5 inhibitors	High efficiency, easy to use	Contraindicated when taking nitrates interaction with food and some medications, relatively high price
Intra-avernosial administration of PGE preparations	High efficiency (75-85%), minor systemic side effects	The need for autoinjections requires special training, causes pain in the penis
Vacuum constrictor devices	Least expensive, no systemic side effects	Unnatural erection, causes small hemorrhages, swelling of the skin of the penis, ejaculation disorder
Prosthetics	Highly efficient	Requires surgery, unnatural erection, infectious complications are possible in case of unsuccessful outcome of surgery, the use of other methods of erectile dysfunction is impossible, the probability of the need to replace the prosthesis in 5-10 years