Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)

1st line – treatment of underlying condition

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ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
1st line – 

treatment of underlying condition

Appropriate management of underlying medical conditions is the initial step in therapy, when they are present.​

Non-pharmacological intervention strategies for reducing weight, improving quality of diet, and increasing physical activity can improve erectile function in men at risk.[52][68][69]​​

Consider – psychosexual therapy (individual and/or couples)

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ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
Consider – 

psychosexual therapy (individual and/or couples)

Additional treatment recommended for SOME patients in selected patient group

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors.[16]​ Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

2nd line – phosphodiesterase-5 (PDE5) inhibitors

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ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
2nd line – 

phosphodiesterase-5 (PDE5) inhibitors

In most studies, PDE5 inhibitors have been shown to effectively and safely improve erectile function (when used on an 'as required' basis) regardless of cause, severity, or presence of comorbid conditions, including hypertension, diabetes mellitus, and hypogonadism.​​​[86]​​

Tadalafil has a substantially longer half-life compared with other PDE5 inhibitors. This longer half-life enables continuous daily dosing, as well as the ability to have improved erections for 36 hour (in contrast to 4-6 hours with the shorter acting agents).[76] Continuous daily therapy with tadalafil has been shown to be efficacious and well tolerated, and may be an alternative to 'as required' treatment with tadalafil or the other PDE5 inhibitors for some men.​​[72]​​ Daily dosing with tadalafil has a lower incidence of acute side effects compared with 'as required' dosing with tadalafil or the other PDE5 inhibitors, and allows for not having to plan sexual activity around taking a pill (i.e., increased spontaneity).​[75]​​

Treatment failure with >4 attempts with a PDE5 inhibitor is recommended before moving to a new agent. Continuous daily dosing regimens with tadalafil may be considered as salvage of on-demand PDE5 inhibitors for non-responders.[76]​​​​​

Contraindications include: use of organic nitrates, severe cardiovascular disease, and myocardial infarction within 90 days; cerebrovascular accident within 6 months; New York Heart Association class II or greater heart failure within 6 months; unstable or coital angina; uncontrolled arrhythmias; hypotension (BP <90/50 mmHg); uncontrolled hypertension (BP >170/100 mmHg); and known hereditary degenerative retinal disorders, including retinitis pigmentosa.

Caution is recommended when PDE5 inhibitors are used with alpha-blockers, as this combination can result in orthostatic hypotension.

Vardenafil has the potential for mild QT-interval prolongation.[87]

Primary options

sildenafil: 25-100 mg orally once daily when required one hour before anticipated sexual activity

OR

tadalafil: 5-20 mg orally once daily when required 45 minutes before anticipated sexual activity; or 2.5 to 5 mg orally once daily

OR

vardenafil: 5-20 mg orally once daily when required 45 minutes before anticipated sexual activity

OR

avanafil: 50-200 mg orally once daily when required 15 minutes before anticipated sexual activity

Consider – psychosexual therapy (individual and/or couples)

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
Consider – 

psychosexual therapy (individual and/or couples)

Additional treatment recommended for SOME patients in selected patient group

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors.[16]​ Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

3rd line – intracavernous injection

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
3rd line – 

intracavernous injection

Men who do not respond to phosphodiesterase-5 inhibitors or have contraindications to their use can be considered for locally delivered drug therapy by intracavernosal injection.[78]​ Local delivery improves drug delivery and minimises systemic toxicity.

The primary option in this situation is alprostadil (prostaglandin E1).[79]​ Alprostadil is the only agent that is US Food and Drug Administration-approved; however, it is associated with penile burning as it can activate sensory nerve fibres.

Secondary options include papaverine alone or in combination regimens such as BiMix (papaverine and phentolamine) or TriMix (papaverine and phentolamine and alprostadil).[79]​ The concept behind TriMix is to decrease the dose of alprostadil while maintaining efficacy. Papaverine is generally less effective than BiMix or TriMix. The initial test-dose of these regimens can be given in the clinic to ascertain the efficacy and to assess the risk of priapism.

Due to the risk of the patient developing priapism, intracavernosal injection is contraindicated in patients with sickle cell anaemia, patients taking medication for schizophrenia or other severe psychiatric disorders, patients with severe systemic disease, and patients with a history of priapism. Anticoagulant and aspirin use is not contraindicated, but injection-site compression for 7 to 10 minutes is recommended to prevent haematoma formation.

Men with prolonged erection, lasting >3 hours, should seek prompt medical evaluation.

Primary options

alprostadil intracavernous: 10-20 micrograms when required, titrate dose according to response, maximum 60 micrograms/dose, maximum 3 doses per week with at least 24 hours between each dose

Secondary options

papaverine: consult specialist for guidance on dose

OR

BiMix

papaverine: consult specialist for guidance on dose

and

phentolamine: consult specialist for guidance on dose

OR

TriMix

papaverine: consult specialist for guidance on dose

and

phentolamine: consult specialist for guidance on dose

and

alprostadil intracavernous: consult specialist for guidance on dose

Consider – psychosexual therapy (individual and/or couples)

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
Consider – 

psychosexual therapy (individual and/or couples)

Additional treatment recommended for SOME patients in selected patient group

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors.[16]​ Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

4th line – intraurethral suppository

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
4th line – 

intraurethral suppository

Intraurethral suppositories deliver the medication into the corpus spongiosum (not the corpus cavernosum). Delivery of locally active vasoactive agents improves drug delivery and minimises systemic toxicity.

Can be used in men who have a contraindication or demonstrated failure with phosphodiesterase-5 inhibitors or intracavernous injection, or men unwilling to self-inject using a needle; however, this treatment is rarely used clinically because of cost and inability to provide for consistently rigid erections.

Efficacy is moderate at 50%, and use of a penile elastic constriction band may augment the response.

Penile pain, bleeding, and partner discomfort are common. Syncope and hypotension has been reported in up to 5.8%.[88]

Primary options

alprostadil intraurethral: 125-250 micrograms when required, increase dose according to response, doses of up to 1000 micrograms/day have been reported

Consider – psychosexual therapy (individual and/or couples)

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
Consider – 

psychosexual therapy (individual and/or couples)

Additional treatment recommended for SOME patients in selected patient group

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors.[16]​ Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

4th line – vacuum erection device

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
4th line – 

vacuum erection device

The penis is inserted into the cylindrical pump and engorgement occurs secondary to negative pressure exerted by the vacuum. Application of a penile constriction device helps to contain the erection for no longer than 30 minutes.

Satisfactory results are reported in 68% to 83% of men.[79]

Caution is recommended in men on concurrent anticoagulation or aspirin therapy. An increased risk of haematoma formation is possible.[89]

Consider – psychosexual therapy (individual and/or couples)

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
Consider – 

psychosexual therapy (individual and/or couples)

Additional treatment recommended for SOME patients in selected patient group

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors.[16]​ Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

4th line – topical alprostadil

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
4th line – 

topical alprostadil

A topical formulation of alprostadil has been approved in Europe for the treatment of ED; however, it is not currently available in some countries including the US. It is delivered with a permeation enhancer to facilitate absorption into the systemic circulation. The onset of action is purportedly faster than that of orally absorbed agents, although its efficacy has not been compared with oral therapies to date.

Primary options

alprostadil topical: consult specialist for guidance on dose

Consider – psychosexual therapy (individual and/or couples)

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
Consider – 

psychosexual therapy (individual and/or couples)

Additional treatment recommended for SOME patients in selected patient group

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors.[16]​ Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

5th line – penile prosthesis

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
5th line – 

penile prosthesis

Referral to a urologist for consideration of surgical therapy, if the patient seeks further treatment.

The nature of the implant is contingent on the decision of the surgeon and the patient, and usually entails use of an inflatable penile prosthesis or a malleable prosthesis.

Men should be aware that surgical therapy is permanent, in that placement of a prosthesis removes the ability to achieve erections naturally at any time.

In general, the devices are well tolerated, and common complications include mild penile length loss, pain, swelling, and infection.

Mechanical failure (6% to 16% at 5 years) occurs, as does prosthetic infection (1% to 2%). Infection is a devastating complication, for which removal, revision, or re-implantation/salvage of the device is indicated.[90]

Magnetic resonance imaging is safe in men with penile prostheses.

Consider – psychosexual therapy (individual and/or couples)

Back
ACUTE
|
all patients (except those with Peyronie's disease, psychogenic ED, and previous pelvic injury with arterial compromise)
Consider – 

psychosexual therapy (individual and/or couples)

Additional treatment recommended for SOME patients in selected patient group

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors. Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

Peyronie's disease

1st line – phosphodiesterase-5 (PDE5) inhibitor

Back
ACUTE
|
Peyronie's disease
1st line – 

phosphodiesterase-5 (PDE5) inhibitor

The presence of Peyronie's disease does not preclude PDE5 inhibitor therapy, but penile angulation that prohibits intromission or is uncomfortable for the partner may require surgical correction.

In most studies, PDE5 inhibitors have been shown to effectively and safely improve erectile function (when used on an 'as required' basis) regardless of cause, severity, or presence of comorbid conditions, including hypertension, diabetes mellitus, and hypogonadism.​​​[86]​​

Tadalafil has a substantially longer half-life compared with other PDE5 inhibitors. This longer half-life enables continuous daily dosing, as well as the ability to have improved erections for 36 hours (in contrast to 4-6 hours with the shorter acting agents).[76] Continuous daily therapy with tadalafil has been shown to be efficacious and well tolerated, and may be an alternative to 'as required' treatment with tadalafil or the other PDE5 inhibitors for some men.[91] Daily dosing with tadalafil has a lower incidence of acute side effects compared with 'as required' dosing with tadalafil or the other PDE5 inhibitors, and allows for not having to plan sexual activity around taking a pill (i.e., increased spontaneity).​[75]​​

Treatment failure with >4 attempts with a PDE5 inhibitor is recommended before moving on to a new agent. Continuous daily dosing regimens with tadalafil may be considered as salvage of on-demand PDE5 inhibitors for non-responders.[76]

Contraindications include: use of organic nitrates; severe cardiovascular disease; myocardial infarction within 90 days; cerebrovascular accident within 6 months; New York Heart Association class II or greater heart failure within 6 months; unstable or coital angina; uncontrolled arrhythmias; hypotension (BP <90/50 mmHg); uncontrolled hypertension (BP >170/100 mmHg); and known hereditary degenerative retinal disorders, including retinitis pigmentosa.

Caution is recommended when PDE5 inhibitors are used with alpha-blockers, as this combination can result in orthostatic hypotension. The US Food and Drug Administration recommends dose-spacing of >4 hours.

Vardenafil has the potential for mild QT-interval prolongation.[87]

Primary options

sildenafil: 25-100 mg orally once daily when required one hour before anticipated sexual activity

OR

tadalafil: 5-20 mg orally once daily when required 45 minutes before anticipated sexual activity; or 2.5 to 5 mg orally once daily

OR

vardenafil: 5-20 mg orally once daily when required 45 minutes before anticipated sexual activity

OR

avanafil: 50-200 mg orally once daily when required 15 minutes before anticipated sexual activity

Consider – intralesional collagenase injection into plaque

Back
ACUTE
|
Peyronie's disease
Consider – 

intralesional collagenase injection into plaque

Additional treatment recommended for SOME patients in selected patient group

Patients with Peyronie's disease should be referred to a urologist for consideration of intralesional injection into the plaque.

Intralesional collagenase Clostridium histolyticum injection is approved for the treatment of Peyronie's disease in several countries.

Primary options

collagenase clostridium histolyticum: 0.58 mg injected into plaque as a single dose, repeat in 1-3 days; consult specialist for further guidance on dose

Consider – surgical correction

Back
ACUTE
|
Peyronie's disease
Consider – 

surgical correction

Additional treatment recommended for SOME patients in selected patient group

These men should be referred to a urologist for consideration of specialised imaging and vascular evaluation, before considering surgical correction of the penile curvature.

Consider – penile prosthesis

Back
ACUTE
|
Peyronie's disease
Consider – 

penile prosthesis

Additional treatment recommended for SOME patients in selected patient group

A penile prosthesis may be placed.

The nature of the implant is contingent on the decision of the surgeon and the patient, and usually entails use of an inflatable penile prosthesis or a malleable prosthesis.

Men should be aware that surgical therapy is permanent, in that placement of a prosthesis removes the ability to achieve erections naturally at any time.

In general, the devices are well tolerated, and common complications include mild penile length loss, pain, and swelling.

Mechanical failure (6% to 16% at 5 years) occurs, as does prosthetic infection (1% to 2%). Infection is a devastating complication, for which removal, revision, or reimplantation/salvage of the device is indicated.[90]

Magnetic resonance imaging is safe in men with penile prostheses.

Consider – psychosexual therapy (individual and/or couples)

Back
ACUTE
|
Peyronie's disease
Consider – 

psychosexual therapy (individual and/or couples)

Additional treatment recommended for SOME patients in selected patient group

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors.[16]​ Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

previous pelvic injury with arterial compromise

1st line – penile revascularisation

Back
ACUTE
|
previous pelvic injury with arterial compromise
1st line – 

penile revascularisation

In the setting of pelvic crush injuries or penile trauma with vascular compromise, early urological consultation may allow for specialised vascular evaluations. In some cases, microsurgical revascularisation of the penis may be indicated.[82]

In young, healthy patients with focal endothelial thickening or narrowing after a traumatic insult, penile arterial reconstruction should be strongly considered.​[51]​ However, thorough workup of these patients to rule out other causes is required prior to intervention.​

Consider – penile prosthesis

Back
ACUTE
|
previous pelvic injury with arterial compromise
Consider – 

penile prosthesis

Additional treatment recommended for SOME patients in selected patient group

A penile prosthesis may be placed.

The nature of the implant is contingent on the decision of the surgeon and the patient, and usually entails use of an inflatable penile prosthesis or a malleable prosthesis.

Men should be aware that surgical therapy is permanent, in that placement of a prosthesis removes the ability to achieve erections naturally at any time.

In general, the devices are well tolerated and common complications include mild penile length loss, pain, and swelling.

Mechanical failure (6% to 16% at 5 years) occurs, as does prosthetic infection (1% to 2%). Infection is a devastating complication, for which removal, revision, or reimplantation/salvage of the device is indicated.[90]

Magnetic resonance imaging is safe in men with penile prostheses.

Consider – psychosexual therapy (individual and/or couples)

Back
ACUTE
|
previous pelvic injury with arterial compromise
Consider – 

psychosexual therapy (individual and/or couples)

Additional treatment recommended for SOME patients in selected patient group

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors.[16]​ Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

psychogenic ED

1st line – psychosexual therapy (individual and/or couples)

Back
ACUTE
|
psychogenic ED
1st line – 

psychosexual therapy (individual and/or couples)

Patients with psychogenic ED should be referred to a specialist for psychosexual therapy which can be given alone or with another therapeutic approach.[67]​ It should be noted that the efficacy of psychosexual therapy is varied and, when effective, therapy may take time.​

Psychosocial interventions such as individual and/or couples psychotherapy may improve erectile function.[84]​ The aetiology of ED is multi-factorial and can include psychological stressors.[16]​ Similarly, having ED can be a source of stress, anxiety, and concern, which, in turn, can further exacerbate a man's sexual dysfunction. Additionally, if men are not responding to the different treatment options, they may become discouraged and even depressed about their condition.

Sexual therapy and psychological counselling for these patients and their partners should be considered as part of ongoing treatment of ED based on the patient's history and symptoms, as well as their response to other therapies.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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