After all the information regarding the patient's status has been gathered, the various options in
management can be discussed. This is best completed in the presence of the patient and his partner.
Enough options are available that every man who wants to be sexually active can do so. These
include sexual counseling if no organic causes can be found for the dysfunction, oral medications,
external vacuum devices, or some type of invasive therapy, including the use of intracavernosal
injection therapy or the Medicated Urethral System for Erections (MUSE), which is an intraurethral
suppository. One of the most difficult aspects is teaching men that sex entails more than simply
achieving an erection.

Erectile dysfunction. The Medicated Urethral System for Erections (MUSE) is a
small suppository placed into the urethra with this device. The suppository is very
small, and patients often question whether anything is in the device.

The most common form of management in current practice is the use of one of the oral PDE-5
inhibitors. If one agent does not work adequately at its maximum dosage, another agent should be
tried. Trying these medications 3-4 times is sometimes necessary before concluding that the therapy
is ineffective. Men who have a vascular-leak (venous leak) phenomenon may need a constriction
device placed at the base of the penis to maintain the erection, which may be effective by itself or in
combination with a PDE-5 inhibitor. In selected cases, combination therapy with one of the PDE-5
inhibitors plus Yohimbine, MUSE, or intracavernosal injections can be tried. Although some men
have taken two different PDE-5 inhibitors simultaneously, no evidence suggests any benefit and the
risk of significant adverse effects is greatly enhanced. However, the use of both a shorter-acting
agent and a longer-acting agent is not unreasonable at appropriate times and intervals as long as
they are not taken together.

Erectile dysfunction. This is one of many types of constricting devices placed at the
base of the penis to diminish venous outflow and improve the quality and duration
of the erection. This is particularly useful in men who have a venous leak and are
only able to obtain partial erections that they are unable to maintain. These
constricting devices may be used in conjunction with oral agents, injection therapy,
and vacuum devices.

Possible blindness due to nonarteritic anterior ischemic optic neuropathy and cilioretinal artery
occlusion caused by PDE-5 inhibitors has been a concern. This is an extremely rare event, with only
a handful of reported cases from the tens of millions of patients using PDE-5 inhibitor medications.
This risk may be increased if the PDE-5 medication is misused or overdosed.

If none of these nonsurgical therapies is satisfactory to the patient and his partner, a discussion
regarding the relative merits and adverse effects associated with penile implants can be introduced.
Some data indicate an additional benefit in some men who have an implant but also take a PDE-5
inhibitor. Sexual stimulation and sensation is enhanced.

Psychogenic impotence is relatively uncommon. It is characterized objectively by the presence of
good nocturnal and morning erections and negative findings from all other tests. During the
interview, a history of highly variable erections that can be totally absent one day but virtually
normal the next suggests a psychogenic cause. Virtually 100% of men with severe depression have
erectile dysfunction (ED). Sildenafil (Viagra) works well for psychogenic ED; other treatment
modalities are also effective because the tissues, nerves, hormone levels, and vasculature are
normal. The authors usually recommend a full psychological evaluation in these patients so that the
underlying etiology can be identified and treated appropriately rather than just treating the symptom
of ED. Therefore, the authors defer treatment of the patient's ED until he has begun psychological
testing and therapy for the underlying problem.

As a relatively inexpensive method for producing an erection, vacuum devices to draw blood into
the penis have been used for many years. These are plastic cylinders that are placed over the penis.
Air is pumped out, causing a partial vacuum. Releasing the vacuum after a few minutes and then
reapplying the vacuum sometimes gives a better result. After an erection is obtained, a constricting
band is placed at the base of the penis. This technique is effective in 60-90% of patients and
maintains the erection for up to 30 minutes. (The erection would last until the constricting band is
released, but longer than 30 min is not recommended.)

These devices are generally safe, but hematomas, petechia, and ecchymosis have been reported.
Other adverse effects include pain, lower penile temperature, numbness, absent or painful
ejaculation, and pulling of scrotal tissue into the cylinder, where it becomes trapped under the ring.
Many of these problems can be alleviated by proper selection of the tension rings and cylinders.
The devices are very reliable and seem to work better with increased use and practice. They can be
operated and used quickly with experience but still tend to be less romantic than other therapeutic
options.

One drawback to the use of these external vacuum devices is the need to assemble the equipment and the difficulty in transporting it. Many patients lose interest in using the device because of the preparations that are necessary, the lack of easy transportability, the inability to hide the tension ring, and the relative lack of spontaneity. Approximately half the men who use a vacuum device obtain very good erections, but only half of these men consistently use the device for a prolonged period.

Sildenafil is the first oral agent to be well documented as an effective form of treatment for men
experiencing ED. Since its introduction in March, 1998, no other therapy for ED has achieved such
prominent public recognition. Of the 250,000 American physicians who have written prescriptions
for sildenafil, 14% have been written by urologists and 82% by nonurologists.

Controlled clinical trials in selected populations of men with ED have demonstrated the efficacy of
sildenafil in helping men achieve and maintain erections. The efficacy of sildenafil was
demonstrated in 21 randomized, double-blind, placebo-controlled studies of up to 6 months'
duration involving more than 3000 male subjects aged 20-87 years.

Sildenafil is a potent inhibitor of PDE-5, the enzyme that acts in the corpora to break down cGMP.
This action is mediated by the secondary neurotransmitter NO, which is primarily responsible for
smooth muscle relaxation within the corpora cavernosa. The inhibition of PDE-5 slows the
degradation of NO, which enhances its effect. This permits the development of an improved and
sustainable erection.

Sildenafil has been demonstrated to improve erectile function in diabetic patients, hypertensive
patients, post–transurethral resection of the prostrate patients, radical prostatectomy patients
following radiation therapy for prostate cancer, geriatric patients, spinal cord injury patients, and
depression patients. As many as 66-90% of patients with ED secondary to brachytherapy or external
beam radiation therapy for prostate cancer have significant improvements in erectile function.