Urological Science 24 (2013) 35e40

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Urological Science
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Mini review
CME
q Credits
Contemporary management of erectile dysfunction
Jian-Kang Chao a, b, Thomas I-Sheng Hwang c, d, e, *
a
Department of Psychiatry, Yuli Veterans Hospital, Hualien, Taiwan
b
Department of Health Administration, Tuz Chi College of Technology, Hualien, Taiwan
c
Division of Urology, Shin Kong Memorial Hospital, Taipei, Taiwan
d
School of Medicine, Fu Jen Catholic University, Taipei, Taiwan
e
School of Medicine, Taipei Medical University, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Erectile dysfunction (ED) is one of the most common sexual disorders in men, and the existence of an
Received 14 January 2011 underlying cause should always be considered. It is also commonly and closely associated with age and
Received in revised form risk factors for cardiovascular disease. Therefore, all men with ED should be screened for medical
6 May 2011
problems. Treatment of ED can enhance self-esteem, reduce psychological morbidity, and increase the
Accepted 14 February 2012
emotional well-being of both partners. Today, unless contraindicated, user-friendly, effective, and safe
Available online 10 June 2013
therapies offered for the treatment of ED are lifestyle and risk factor modification (e.g., exercise and
weight loss) and the use of oral phosphodiesterase type 5 inhibitors, such as sildenafil, tadalafil, or
Keywords:
erectile dysfunction
vardenafil. Vacuum erection devices, intracavernous injection therapy, and penile prostheses are other
management options options of treatment when oral medication fails. The following minireview provides a practical approach
prevalence for the management of ED in outpatient departments.
Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC.
Open access under CC BY-NC-ND license.

1. Introduction association with CV disease (CVD) mortality. ED is a common

Erectile dysfunction (ED) is a common, persistent inability to
achieve or maintain an erection of sufficient quality for sexual in-
tercourse.1,2 It is a risk factor for other diseases and conditions, and
it is a secondary condition brought about by other primary causes,
such as certain lifestyles, side effects of drugs, aging, systemic
diseases, and neurovascular and psychological disorders.3e12 ED
commonly occurs, and the incidence increases with age.13 ED is
classified as psychogenic, organic, or mixed psychogenic and
organic. The increased amount of study devoted to ED has provided
more pathophysiological evidence to support the association of ED
with organic causes; hence, 80% of cases are now considered to be
organic in origin.14 Chew et al’s study15 also showed that ED is not
only significantly associated withdbut is also strongly predictive
ofdsubsequent atherosclerotic cardiovascular (CV) events. Mon-
torsi et al16 pointed out that sexual dysfunction in men represents a
group of common medical conditions that needs to be managed
from a multidisciplinary perspective.
Araujo et al’s17 findings demonstrated that ED is significantly
associated with increased all-cause mortality, primarily through its
* Corresponding author. Division of Urology, Shin Kong Memorial Hospital, 95,
Wen Chang Road, Shihlin District, Taipei City, Taiwan.
E-mail address: M001009@ms.skh.org.tw (T.I.-S. Hwang).
q There are 4 CME questions based on this article.
problem among aging men. The factors that increase the risk of ED
include older age, depression, diabetes, and CVD risk factors.13,18,19
There are a number of risk factors associated with ED that can be
modified: obesity, hypertension, unfavorable lipid levels, alcohol
abuse, physical activity, tobacco addiction, diabetes mellitus (DM),
depression, anxiety disorders, hypothyroidism, prostate carcinoma,
testosterone deficiency, renal, hepatic, and neurologic diseases, and
a number of medications.5e8,20 ED may also act as a sentinel
symptom for other important underlying diseases, primarily coro-
nary heart disease and depression.21e24
2. Prevalence
ED is currently one of the most common sexual dysfunctions in
men worldwide, including Taiwan. Among 15 large-scale preva-
lence studies undertaken between 1994 and 2004, the prevalence
of ED ranged from 10% to 64%.25 Fatusi et al26 reported an overall ED
prevalence of 43.8% among 355 married men aged 30e70 years.
Parazzini et al’s study27 on more than 2000 individuals aged
18
years showed a prevalence of ED of 12.8%, and up to 48.3% for men
over 70 years. ED prevalences in the United States, the United
Kingdom, Australia, Japan, and Korea were reported to be 52%, 32%,
43%, 26%, and 37%, respectively.28e30 The prevalence rate of ED in
Taiwan, as defined by the International Index of Erectile Function
(IIEF)-5, was 27% among all respondents and 29% among those aged

1879-5226 Copyright Ó 2013, Taiwan Urological Association. Published by Elsevier Taiwan LLC. Open access under CC BY-NC-ND license.
http://dx.doi.org/10.1016/j.urols.2013.04.008
36 J.-K. Chao, T.I.-S. Hwang / Urological Science 24 (2013) 35e40

40 years.31 Although ED is a common health problem in Taiwan
and the prevalence of ED increases with age, affected men lack
awareness regarding the presence of erectile problems and the
importance of initiating timely and effective treatment.32 Wu et al31
also found that the prevalence of ED among study participants was
17.7%, and the frequency increased with age. Patients with chronic
diseases were significantly associated with ED. A significant num-
ber of men now know that ED is not just a consequence of
advancing age, but also can be a result of chronic illness or radical
prostate cancer surgery. Because many chronic diseases are asso-
ciated with ED and because of its high prevalence, ED has been
given increasing attention in recent years.
indicated. Hypogonadism is a treatable cause of ED that may also
make men less responsive; therefore, all men with ED should have
serum testosterone measured with a blood sample taken in the
morning between 08:00 and 11:00.39,40 Serum prostate-specific
antigen should be considered if clinically indicated. It should
certainly be measured before commencing testosterone and at
regular intervals during testosterone therapy. ED in an otherwise
asymptomatic man may be a marker for underlying coronary artery
disease, so all men with unexplained ED should have a thorough
evaluation, and any risk factors for coronary artery disease that are
identified should be addressed.41

3. Initial evaluation of ED 3.5. Management options for ED

3.1. Initial assessment
The initial evaluation should include medical, sexual, and psy-
chosocial histories, as well as laboratory assays to identify possible
comorbidities for a well-organized management. The evaluation
process should include the patient’s partner, their relationship, and
the situation in which their sexual activity occurs or is attempted.
A few effective and most commonly used ED-related question-
naires include an abridged, five-item version of the IIEF-5 score,
Sexual Health Inventory for Men, and Erection Hardness Grading
Scale.33e35
3.2. Medical history
For most men, ED is a personal issue that is difficult and embar-
rassing to admit to their physicians. All treatments are individual-
ized, and it is important to identify the etiology in all cases. In
addition to patient difficulties in discussing their personal matters
with a specialist, the process of the care model for ED outlines a goal-
oriented approach for diagnosis and treatment of ED.
3.6. Objectives of treatment
The primary goal in managing ED is to enable the individual or
couple to enjoy a satisfactory sexual experience. This involves: (1)
identifying and treating any curable causes of ED; (2) initiating

For a well-organized evaluation, a complete medical history

Treatment of erectile dysfunction
should be collected. A detailed description of the problem,
including the duration of symptoms and original precipitants,
should be obtained.36 Concurrent medical (especially hypertension,
Identify and treat Lifestyle changes and Provide education and
DM, hyperlipidemia, ischemic heart disease, peripheral vascular
‘curable’ cause of ED risk factor modification counseling to patients and partners
disease, and cerebrovascular events), and psychiatric and surgical
histories (especially urogenital or spinal surgery and trauma)
should be asked about, as should the current relationship status
Identify patient needs and expectations
(single, married, in a long-term relationship, etc.) and history of
Share decision-making
previous sexual partners and relationships. Issues of sexual orien-
Offer conjoint psychosocial and medical treatment
tation and gender identity should also be noted. Finally, the pa-
tient’s use of social and illicit drugs (e.g., tobacco, alcohol,
marijuana, and heroin) should be recorded.
PDE5 inhibitors Other drug therapies:
1st- line Hormone replacement therapy Yohombine, Delaquamine,
3.3. Physical examination
treatment Trazodone, L-arginine, etc.

It is important to identify the underlying disease that brought

about the sexual difficulty with ED symptoms or that may
contribute to the maintenance of the difficulty or influence its Assess therapeutic outcome: 1. Erectile response
treatment. Blood work should be based on the potential underlying 2. Side effects 3. Satisfaction with treatment
conditions listed above plus special concerns raised from the his-
tory and physical examination. Data such as weight, height, body Inadequate treatment outcome
mass index, and waist circumference should be recorded to identify
metabolic syndrome. A genital examination is recommended, and
is essential if there is a history of rapid onset of pain, deviation of Vacuum erection devices
the penis during tumescence, or symptoms of hypogonadism or 2nd- line Intravenous injection therapy
other urological symptoms (past or present). The blood pressure, treatment
heart rate, waist circumference, and weight should be measured.37
Inadequate treatment outcome

3.4. Laboratory examination

Consider penile prosthesis implantation

ED is an independent marker for CV risk and can be the pre- 3rd- line
Penile revascularization surgery
senting feature of diabetes, so serum lipids and fasting plasma treatment
glucose should be measured in all patients.38 Special examinations,
such as Doppler flow studies, nocturnal penile tumescence, and Fig. 1. Treatment algorithm for erectile dysfunction. ED ¼ erectile dysfunction;
angiography, rarely impact therapy and are therefore rarely PDE5 ¼ phosphodiesterase type 5.
 J.-K. Chao, T.I.-S. Hwang / Urological Science 24 (2013) 35e40
lifestyle changes and risk factor modification; and (3) providing
education and counseling to patients and their partners (Fig. 1).
3.7. Reversible causes of ED
3.7.1. Hormone deficiencies and ED
Endocrine disorders may have a significant effect on sexual
function.42 These conditions, including hypogonadism, hyperthy-
roidism, and hyperprolactinemia, are examples of relevant disor-
ders. The advice of an endocrinologist is necessary when there is
doubt about the cause and appropriate management of the disor-
der. Androgen deficiency in the adult male is more common with
increasing age, but its management remains controversial.43 In
addition to sexual dysfunction, androgen deficiency is associated
with osteoporosis, dyslipidemia, type 2 diabetes, metabolic syn-
drome, and depression.43e45 Hyperthyroidism may influence
erectile function by increasing sex hormone-binding globulin pro-
duction, thereby reducing free testosterone levels. Effective treat-
ment of hyperthyroidism may resolve the coexisting ED.
Hyperprolactinemia is associated with ED, loss of sexual inter-
est, and anorgasmia. It is frequently accompanied by an androgen
deficiency, because high prolactin levels suppress luteinizing hor-
mone production, consequently causing hypogonadism. Hyper-
prolactinemia should be ruled out by blood tests in all men with
reduced sexual interest. A moderate elevation of prolactin levels
(<1000 mU/L) is unlikely to cause ED.46
3.7.2. Drug-induced ED
Many drugs are implicated in ED. In many cases, the evidence for
drugs having a direct causal relationship with some form of sexual
dysfunction is relatively poor (but patients often blame the drugs).
Drugs may affect sexual response in a number of ways: (1) those
that cause sedation may affect sexual motivation and, indirectly,
cause ED; (2) those that affect CV function, such as antihypertensive
agents, may act centrally and may also affect penile hemodynamic;
(3) some drugs affect endocrine parameters (antiandrogens and
estrogens may affect both sexual desire and erection); and (4) drugs
that cause hyperprolactinemia, such as phenothiazines, may also
affect sexual desire and erection.
3.8. Irreversible causes of ED
3.8.1. Diabetes mellitus
Neuropathic ED develops in relation to other diabetic compli-
cations and is more likely to be present when there is evidence of
both somatic and autonomic neuropathies. It is hypothesized that
cavernosal artery insufficiency, corporal veno-occlusive dysfunc-
tion, and/or autonomic neuropathy are the major organic patho-
physiologic mechanisms leading to persistent erectile impairment
in men with DM. It was estimated that 10e19% of organic ED is
neurogenic.47 Once present, neuropathic ED is permanent and
irreversible. Its onset is always gradual and slowly progressive over
months and years.
3.8.2. Posttraumatic arteriogenic ED in young patients
Penile revascularization involves harvesting of the inferior
epigastric artery and anastomosing it to either the dorsal vein or
artery of the penis to increase arterial inflow to the corporal bodies.
Bicycle riding for more than 3 h/week was described as an in-
dependent risk factor for ED. The mechanism is postulated to be
related to the rider’s interaction with the saddle. This may produce
a neurapraxia, which is occasionally persistent, but usually
reversible or vascular endothelial injury and vasculogenic ED.
37
3.8.3. Postradical prostatectomy
The etiology of the development of corporal veno-occlusive
dysfunction in postprostatectomy patients has not been fully
elucidated, but it is thought to result from a combination of
denervation-induced cavernosal smooth muscle dysfunction and
collagen deposition resulting from relative ischemia of the corpo-
real tissues. However, in men who develop persistent ED after
surgery, the cavernosal smooth muscle is gradually replaced by
collagenous tissue.48 This change in the cavernosal structure may
be what leads to persistent ED in some men, even though they have
had nerve-sparing surgery. In these men, there is inadequate
healthy cavernosal smooth muscle to create an erection.
3.8.4. Venous leakage syndrome
A venous leak is a leak in the veins of the penis. Because leakage
allows blood to leave the penis during an erection, an erection
cannot be maintained. Venous leak can occur from damage to the
veins in the penis caused by injury or disease.
3.9. Partner sexual problems and ED
Patients with significant psychosocial problems and/or rela-
tionship difficulties should be offered sex and/or couple therapy as
appropriate. Therapeutic programs include sex education,
communication and sexual skills training, sensate focus, systematic
desensitization, and cognitiveebehavioral therapy.
4. Treatment of ED
4.1. First-line treatment
4.1.1. Oral pharmacotherapy: phosphodiesterase 5 inhibitors
Selective inhibitors of phosphodiesterase 5 (PDE5) are currently
the treatments of choice, owing to their general efficacy, safety,
convenience, and physiologic mechanism of action.49 First-line
therapy for the majority of patients today is the use of selective
PDE5 inhibitors, which are associated with a reasonable efficacy of
60e70%.50 They have proven efficacy and tolerability in improving
erectile function across a wide range of clinical conditions.
The PDEs comprise 11 distinct families of enzymes (PDE1e
PDE11). PDE5 is present in high concentrations in the smooth
muscles of the corpus cavernosum of the penis.51 Normally, sexual
stimuli result in the release of the vasodilator, nitric oxide, from
nonadrenergic noncholinergic nerve fibers in the penile cavernous
tissue and from endothelial cells of penile arterioles.52 In recent
years, the availability of effective oral pharmacological treatment
for ED has revolutionized its management, and these oral medi-
cations are successful ED treatment for many men. Three potent
selective PDE5 inhibitors were approved by the European Medi-
cines Agency and the US Food and Drug Administration: sildenafil
(Viagra), tadalafil (Cialis), and vardenafil (Levitra). All three medi-
cations work in much the same way. These drugs mainly have an
effect on nitric oxide, which is a natural chemical produced by the
body that relaxes muscles in the penis. Drugs that inhibit PDE5
increase arterial blood flow, which leads to smooth muscle relax-
ation, vasodilation, and penile erection; however, PDE5 inhibitors
are not initiators of erectiondsexual stimulation is still needed.53
Overall, the adverse effects of PDE5 inhibitors are mild, transient,
and dose-related.
These medications may not work or may be dangerous for a
person if that person: (1) takes nitrate drugs for angina, such as
nitroglycerin (Nitro-Bid and others), isosorbide mononitrate
(Imdur), and isosorbide dinitrate (Isordil); (2) takes a blood-
thinning (anticoagulant) medication, alpha blockers for an
enlarged prostate (benign prostatic hyperplasia), or high-blood-
38 J.-K. Chao, T.I.-S. Hwang / Urological Science 24 (2013) 35e40
pressure medications; (3) has heart disease or heart failure; (4) has
had a stroke (5) has very low blood pressure (hypotension) or un-
controlled high blood pressure (hypertension); or (6) has uncon-
trolled diabetes.
Most men who take Viagra, Levitra, and Cialis are not bothered
by the side effects. When side effects do occur, they can include
headaches, flushing, indigestion, stuffy or runny nose, back pain
and muscle aches (with Levitra), and temporary vision changes,
including “blue vision” (with Viagra). In a small number of cases,
men taking Viagra, Levitra, or Cialis have reported more serious
side effects, such as hearing or vision loss and priapism. Taking
Viagra, Levitra, or Cialis without treating the original problem
may improve sexual performance, but the patient should not
ignore an underlying health issue by just taking pills to treat the
symptom.
4.2. Hormone replacement therapy
For the small number of men who have a testosterone defi-
ciency, testosterone replacement therapy may be an option to
treat ED.
4.3. Other drug therapies
Other drug therapies include the following: Yohombine, Dela-
quamine, Trazodone, L-arginine, red Korean ginseng, oral limaprost,
oral phentolamine, and nitroglycerine; Papaverine and Minoxidil
are applied topically, but their effects are limited.
4.3.1. Psychosexual/relationship therapy
Psychosexual causes normally addressed in Taiwanese men with
ED include an uncaring partner, which leads to psychological
trauma, anger resulting from marital discord, depression, and
performance anxiety that may lead to a loss of self-confidence.
This option focuses on the patient’s interpersonal difficulties.
Psychosexual techniques, including the setting up of realistic goals
for a couple, periodic psychosexual therapy follow-up, continual
utilization of nonintercourse pleasuring sessions, and initiation of
intimacy dates, are advocated as prevention strategies.54 Some
studies showed the benefits of combining pharmacotherapy with
sexual counseling or brief sex therapy.55,56
4.3.2. Physiotherapy
The pelvic floor muscles have a role in erection. Contraction of
the ischiocavernosus muscle facilitates erection.57 A study showed
the benefit of treating ED via pelvic floor exercises.57 Kegel exer-
cises for men can help prevent or control urinary incontinence and
possibly improve sexual performance. Kegel exercises for men can
help prevent, treat, or delay some of the symptoms caused by weak
pelvic floor muscles, such as urine leakage.
4.4. Second-line treatment
4.4.1. Vacuum erection devices
The vacuum constriction device is a hollow tube with a hand-
powered or battery-powered pump, which creates a vacuum that
pulls blood into your penis. It is usually used in patients that who
do not want to use pharmacotherapy or for whom the drugs are
contraindicated. The vacuum constriction device has the following
features: (1) it is highly effective in inducing erections regardless of
the etiology of the ED58,59; (2) reported satisfaction rates vary
considerably at 35e84%60,61; (3) long-term usage of vacuum de-
vices also varies but is considerably higher than for self-injection
therapy; (4) most men who are satisfied with vacuum devices
continue to use them in the long term56; (5) adverse effects include
bruising, local pain, failure to ejaculate, and partners sometimes
report that the penis feels cold; and (6) serious adverse events are
very rare, but skin necrosis was reported.
4.4.2. Intracavernous injection therapy
With intracavernous injection treatment, the patient is taught to
inject his penis with a vasoactive drug in a private room. Intra-
cavernous injection therapy is the most effective form of pharma-
cotherapy for ED and has been used for more than 20 years.61
However, because of the invasive nature of the procedure, it is
unacceptable to some patients and their partners, and this may
result in poor long-term compliance among those who do try it.62,63
The most frequently used drug is alprostadil; other agents include
phentolamine, papaverine, and vasoactive intestinal polypeptide,
or a combination of agents. Alprostadil (Caverject, Viridal) was the
first and, until recently, the only licensed drug approved for intra-
cavernous ED treatment.
4.5. Third-line treatment
4.5.1. Penile prosthesis
This is a surgical treatment that involves emplacing devices into
the two sides of the penis. These implants consist of either inflat-
able or semirigid rods made from silicone or polyurethane. This
invasive treatment can be expensive and is usually not recom-
mended until other methods have been tried first. Penile prosthe-
ses are particularly suitable for those with severe organic ED,
especially if the cause is Peyronie’s disease or postpriapism.
Implanted inflatable penile prostheses have demonstrated the
capacity to produce suitable erections and good patient satisfaction
in long-term follow-up. The reliability of the implants is excellent,
and postoperative morbidity is low. However, infections associated
with inflatable penile prostheses are the most disastrous compli-
cation. As bacterial infection on the new penile prostheses is one of
the major problems, coating the prostheses with rifampin and
minocycline reduced bacterial growth; this method was developed
and approved in May 2001 by the US Food and Drug Administration.
With the InhibiZone (American Medical Systems, Minneapolis,
Minnesota, USA) prosthesis, tissue-contacting surfaces are
impregnated with quantifiable doses of rifampin and minocycline.
The reported incidence rates of infections after 60 days were
0.28% in the treated (InhibiZone) group and 1.59% in the control
group (p ¼ 0.0034). After 180 days, the respective infection rates in
the treated (InhibiZone) and control groups were 0.68% and 1.61%
(p ¼ 0.0047).64 The use of InhibiZone to target postoperative in-
fections resulted in a statistically significant decrease in penile
prosthesis infection rates in original implants.
4.5.2. Penile revascularization surgery
Penile revascularization surgery is microvascular arterial bypass
surgery for ED that is similar to a cardiac bypass, but in the penis.
The most common causes of ED that can be treated by penile
revascularization are blunt trauma to the perineum or bike riding.
The aim of penile arterial revascularization surgery is to increase
the cavernosal arterial blood supply to the penis in order to produce
a natural erection. Patients with systemic arterial disease or
atherosclerosis from conditions such as DM, hypertension, smok-
ing, dyslipidemia, and aging should not be considered for penile
arterial bypass surgery. This procedure is highly specialized and
requires extensive training in microvascular surgery as well as
special equipment in the operating room, so patients should be
referred only to centers of excellence that run strict protocols that
objectively measure success over long intervals.65
In conclusion, ED affects a significant proportion of the popula-
tion on a worldwide scale and is associated with a significant
 J.-K. Chao, T.I.-S. Hwang / Urological Science 24 (2013) 35e40
reduction in health-related quality of life, but clinicians must be
aware that ED is not a diagnosis, it is a symptom. It represents an
underlying cause that should always be considered. Treatment of
male ED is associated with enhanced self-esteem, reduced psycho-
logical morbidity, and increased emotional well-being for both
sexual partners. With the advent of highly effective and widely
available pharmacotherapy for ED, physicians are increasingly
involved in the diagnosis and treatment of this important quality-of-
life issue.
Conflicts of interest statement
The authors declare that they have no financial or non-financial
conflicts of interest related to the subject matter or materials dis-
cussed in the manuscript.
Source of Funding
none
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