Specific treatment regimens for erectile dysfunction (ED) include oral medications, transurethral suppositories, intracavernosal injection, vacuum devices, and surgery. First-line therapies include oral medications and vacuum constriction devices. The newest Food and Drug Administration approved oral treatments include sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra).

Yohimbine is another oral medication that has been available for many years. Its efficacy in improving ED has never been clearly proven, especially when the strong placebo effect of any oral medication for this problem is considered. Results are slightly better in men with primary psychogenic etiologies; men with primarily organic etiologies probably will not be helped by taking this medication. Adverse effects of hypertension and increased heart rate and its prescription with most antidepressants and in patients with vascular disease make Yohimbine significantly less useful than sildenafil. The American Urological Association does not recommend Yohimbine for ED.

Apomorphine, a dopamine agonist that causes central initiation of an erection through specific action in the brain, is available in Europe and offers another approach to managing ED.

Vacuum devices are a reasonable choice for many men who are in a stable relationship in which their partners are willing to accept the inconvenience. Pumps can be hand or battery powered. The band used at the base of the penis needs to be the right size to keep the blood trapped in the penis and permit painless sexual intercourse.

Testosterone augmentation (available as patches or injection) is best reserved for patients with documented hypogonadism based on the morning serum-free testosterone level. Generally, testosterone augmentation is associated with enhanced libido. This may improve erectile status by restoring interest and, perhaps, through other neurohormonal mechanisms, but relying solely on testosterone to restore erectile function in the dysfunctional male is inappropriate. Testosterone augmentation requires thorough evaluation and monitoring for prostate cancer.

Second-line therapies for ED include injectable prostaglandin preparations. Alprostadil (e.g., Muse) is a prostaglandin-E preparation in a pellet form that is inserted into the urethral opening with a plunger-like mechanism. Ideally, the first insertion of alprostadil should be performed in the doctor’s office to monitor technique, change in blood pressure, and the response (although this may be blunted in the office environment). Because venous drainage problems may thwart the erection caused by alprostadil insertion because of premature drainage, a ring at the base of the penis may be used to constrict venous outflow. Contraindications include use with a pregnant partner or a partner who is likely to get pregnant, hypersensitivity to prostaglandin, and sickle cell anemia (prone to developing priapism).

Intracavernosal injection therapy with alprostadil can be considered. This injection is administered directly into the corpus cavernosum through the side of the penis near the base. The success rate is high, but problems include pain, prolonged erections or priapism, and penile fibrosis and plaques. This therapy should be initiated in the physician’s office, and caution should be exercised in patients on anticoagulation.

The third-line treatment for ED is penile implant surgery. This is a successful therapy, but it should be reserved for patients who have considered or attempted several other treatments. The surgery is irreversible, and the normal function of the corpus cavernosa is obliterated. The surgery carries low morbidity and mortality and is relatively routine.

Some clinicians have advised that ED can be managed naturally, although no controlled trials exist. A dietary program rich in whole foods, including vegetables, fruits, whole grains, and legumes, has been suggested; key recommended nutrients include zinc, essential fatty acids, and vitamins A, B6, and E. Herbal supplements such as ginseng, gota kola, and saw palmetto have also been discussed. Spices reported to increase sexual desire include nutmeg, saffron, parsley, vanilla, avocado, carrot oil, and celery.