A review on pharmacological options for the treatment of erectile dysfunction: state of the art and new strategies

ABSTRACT

Introduction

Erectile dysfunction (ED) affects between 12.9% and 28.1% of men worldwide, presenting a strong aged-correlated prevalence. Several pharmacological treatments are currently available for ED, which can be classified into oral, injection, and topical/intraurethral therapies.

Areas covered

Extensive research on PubMed/MEDLINE until February 2023 was performed. For each of the aforementioned drug classes, available molecules, and formulations, their efficacy and most common adverse events as well as general guidelines on prescription were investigated and extensively described. A glimpse into future directions regarding ED pharmacotherapy is also present.

Expert opinion

In recent years, there have been significant developments in pharmacological treatments for ED. It is essential for physicians to identify the best treatment option for patients based on their preferences and sexual habits. The treatment approach for ED has shifted from a sequential to a parallel paradigm, where all treatment options are available as first-line therapies. While there are promising regenerative therapies for ED, such as shockwaves and platelet-rich plasma injections, pharmacological treatment is still the most effective option for most patients.

KEYWORDS:

• erectile dysfunction
• pharmacotherapy
• PDE5 inhibitors
• prostaglandin
• intracavernous injections

Article highlights

• Current pharmacological strategies to the treatment of erectile dysfunction (ED) are based on three classes of drugs: oral, injections and intraurethral/topical therapy.

• Four oral inhibitors of PDE5 (PDE5Is) are currently available. Whereas no differences in terms of efficacy have been found, higher PDE5-selectivity is correlated with less systemic side effects.

• To date, only alprostadil is approved for intraurethral/topical therapy. This formulation permits the desired erection avoiding the most common systemic effects of oral PDE5Is.

• Intracavernous injections (ICIs) consists of prostaglandin E1 (alprostadil), which can also be used in different ‘mixtures’ containing papaverine, phentolamine and atropine in order to reduce the risk of priapism and penile fibrosis.

• Oral, intracarnosal and intraurethral/topical therapy may be used simultaneously in patients non-responders to monotherapy.

• Emerging pharmacological approaches consists of soluble guanylate cyclase (sGC) stimulators and activators, maxi-potassium channel activators, NO donors, melanocortin agonist, botulinum toxin and topical PDE5Is.

• As most recent guidelines suggest, the therapeutic choice should rely on patient’s characteristics and comorbidities as well as specific needs.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.