Treatment of Erectile Dysfunction

A variety of medical and nonmedical options can be used to treat vascular ED. Lifestyle changes, such as weight loss, exercise, dietary changes, cessation of smoking, and reduced alcohol consumption, help treat ED and prevent the development of CVD. These modifiable behaviors should be the first interventions addressed with patients to improve their ED and their cardiovascular health.23

A longitudinal study found that men who initiated physical activity for the first time in midlife had a reduced risk for ED compared with those who remained sedentary (odds ratio, 0.3; 95% CI, 0.1-0.6). One-third of men with ED at baseline were able to improve sexual function through lifestyle changes alone.24

Younger men with vascular ED, in particular, should be counseled on their increased risk for atherosclerosis and educated about lifestyle changes that can lower the risk for CVD and mortality and improve quality of life. For example, the risk for death from CVD declines by half after 5 years of stopping smoking. Thus, smoking cessation should be encouraged in the younger population.25

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Phosphodiesterase type 5 (PDE5) inhibitors have been proven to be effective in improving ED in patients with cardiovascular risk factors or CVD. These medications allow for corporeal vascular relaxation and penile erection during sexual stimulation.26 This class of medications also has been shown to improve cardiovascular functioning by increasing the ischemic threshold.27 Three PDE5 inhibitors have been approved by the US Food and Drug Administration: sildenafil, tadalafil, and vardenafil. The drugs are the mainstay of the pharmacologic treatment for ED and have been shown to improve hypertension and endothelial changes in patients with CVD.19 These drugs do not increase the risk for cardiovascular events, such as ischemia, myocardial infarction, and myocardial hypertrophy, and can be safely coadministered with anti-hypertensive medications, statins, and most other medications. However, patients should avoid taking nitrates while taking PDE5 inhibitors because a severe drop in blood pressure may occur if these agents are used together.28

Aspirin, a medication known for its antiplatelet activity, also has been studied in patients with ED. In a study comparing aspirin and tadalafil, both medications were proven effective in the treatment of vascular ED; however, a combination of tadalafil and aspirin showed greater efficacy compared with aspirin or tadalafil alone.29 In addition, the analgesic and anti-inflammatory effects of aspirin decrease side effects of tadalafil, such as headache, back pain, extremity pain, flushing, and myalgia. Aspirin also may delay the onset of penile atherosclerosis by inhibiting platelet activity, reducing proinflammatory mediators, and decreasing vascular smooth muscle cell proliferation.29

Low intensity shock-wave therapy (LISWT) is a more invasive treatment option for men with vascular ED. While the mechanism of action of LISWT is unclear, it is believed that the compression and negative pressures created by this therapy lead to shear stress on cell membranes, causing an increased expression of vascular endothelial growth factor and resulting in neovascularization of penile arteries.30

For patients taking β-blockers for heart failure or hypertension who experience ED, practitioners should consider nebivolol, a β-blocker that is less likely to cause difficulty with obtaining and maintain an erection.19


Healthcare providers should discuss cardiovascular risk factors in all patients with ED. Men with any sexual dysfunction should be screened for CVD and educated promptly about lifestyle management. Early detection and comanagement of CVD risk factors in men with ED is beneficial to promote sexual well-being and prevent CVD.5

Melissa Long, PA-C, is a recently graduated physician assistant currently working at Doctors Urology and Pelvic Health Specialists in Augusta, Georgia. E. Rachel Fink, MPA, PA-C, is a physician assistant at Augusta Urology Associates and an assistant professor in the Physician Assistant Program at Augusta University.


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