Comparing erectile dysfunction treatments

Erectile Dysfunction (ED) – the problem

ED is a very common problem indeed. In fact around 50% of men aged 40-70 suffer with ED at some point in their lives. Most men will occasionally fail to get or maintain an erection and this is usually due to stress, tiredness, anxiety, or excessive alcohol, and not a serious problem. But if it keeps happening you should see a GP as it could be a sign of an underlying health condition.

Why is ED so common?

This is a good question. ED seems to be a feature of living in modern society in the Western world. There are numerous possible causes and contributory factors.

To get a good erection you need:

• A good arterial blood supply to the penis.
• Effective dilatation of penile blood vessels – this requires a high level of nitric oxide (NO).
• Sexual stimulation.
• Effective nerve stimulation and functioning nerve pathways from erogenous zones to the brain and back again – these pass through the spinal cord.
• A suitable hormonal environment with adequate testosterone levels.
• A relaxed psychological state of mind.

The vast majority of ED does not have a serious medical underlying cause. It is usually due to a combination of psychological/psychosocial factors. However, it is important to note that ED can be the first sign of atherosclerosis.

Atherosclerosis is the name for fatty deposits of cholesterol which are laid down inside your artery walls. These fatty plaques obstruct the flow of blood through the artery. If they happen in your heart, this can directly cause a heart attack because the heart muscle is starved of oxygen. If these deposits are laid down in the penile artery, they restrict blood flow to the penis.

Atherosclerosis is a common occurrence as we age. However lifestyle factors such as obesity, smoking, inactivity, and alcohol can all increase the rate of development of atherosclerosis. In addition, some medical conditions may accelerate atherosclerosis such as diabetes. Diabetes is linked to obesity.

Stress is also a major factor in ED. This may be linked to anxiety and depression. Stress may be due to a variety of issues – relationship problems, marital breakdown, or financial difficulties. Whatever the cause, the outcome may be the same – this can affect sexual function.

To improve erectile function, there are many issues about your general health and lifestyle which you need to consider for the best long term outcome.

What are the treatment options for ED?

There are a range of different treatment options for ED. These are listed below. However, do bear in mind that it's easy to reach for a tablet to help resolve your issue. It's a lot harder to change your lifestyle, but this may be necessary for sustainable long term benefits, both for your general health and for your sexual function.

For non-prescription alternatives for ED see link.

Treatment options for ED

• Drug treatments
  • PDE5 inhibitors, e.g. Viagra/sildenafil
  • Alprostadil – cream (Vitaros), intraurethral pessary (MUSE), or injection (Caverject)
• Vacuum constriction pumps
• Penile implants – prostheses

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How do I choose between the different treatment options for ED?

Step 1: Have a medical assessment with your doctor/practice nurse

This is important. Try not to be embarrassed. These are trained health professionals who are there to help you. They will not judge you. Your consultation will be kept confidential.

At the consultation you will have an opportunity to discuss the problem. You will also be asked a lot of questions about your medical history and lifestyle.

The following checks are likely:

• Height and weight measured, and your Body Mass Index (BMI) calculated.
• Blood Pressure taken.
• Urine tested for any abnormalities e.g. glucose, protein.
• A cholesterol test may be arranged.

You will be given some general health advice, such as advice and help to lose weight, eat healthily, and give up smoking.

If you do not have a medical consultation with your doctor, important underlying issues may be missed. Initial treatment may fail.

Even if you purchase ED tablets online, you will still need to have a consultation by filling in a questionnaire with the online pharmacy.

For more information (Add link - See Erectile Dysfunction and Lifestyle brief 09F)

Step 2: You will agree a plan of action with your doctor/practice nurse

This may include trying some medication for ED. The most common first choice is Viagra. This can be prescribed for you by your doctor, and you will collect the prescription from your pharmacy in the usual way.

Viagra is now also available to purchase from a pharmacy without a prescription - as Viagra Connect.

It can also be prescribed in the generic form - sildenafil. Other PDE5 inhibitors can also be purchased online. Many men find an online service, such as Dr Fox Online Doctor and Pharmacy a highly convenient way to obtain treatments for ED. You still need a medical assessment, which is done by filling in an online medical questionnaire.

Your doctor will then ask you to try this and go back for a review usually in three months. You must take the tablets as directed. It may take several attempts at having sexual intercourse to achieve success. Any side effects should be reported to your doctor/practice nurse.

For some men, a different PDE5 to sildenafil (Viagra & Viagra Connect) may be preferable. This may be because:

• You are on medication which means sildenafil might interact.
• You have something in your medical history which precludes the use of sildenafil.
• You have had side effects from sildenafil.
• Sildenafil did not seem to work for you.
• You prefer to use an ED treatment which is not a form of oral medication, such as alprostadil intraurethral cream, pessary or penile injection.

Your doctor/ practice nurse will suggest a suitable alternative.

If there are psychological issues these will be discussed. You may be recommended to see a specialist Psychosexual Therapist – as well or instead.

Step 3: Continuing treatment for ED

Once you know which ED treatment works best for you, you can continue to take this, either on repeat prescription from the doctor, or as an alternative if you prefer, some of these treatments are available online for example at Dr Fox Online Doctor and Pharmacy.

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What's the difference between the two main ED treatments - Phosphodiesterase inhibitors (PDE5 inhibitors ) e.g. Viagra, and Prostaglandin (PGE1) e.g. alprostadil?

Both of these types of medication are effective in the treatment of ED. They are however, different products and work differently as described below.

Phosphodiesterase inhibitors - PDE5 inhibitors e.g. Viagra

Phosphodiesterase is an enzyme present within the penile tissues.

To achieve an erection, large quantities of nitric oxide lead to the production of cyclic guanosine phosphate (cGMP). It is cGMP which causes the smooth muscle relaxation within the penis resulting in an erection. The enzyme phosphodiesterase breaks down cGMP.

PDE5 inhibitors such as sildenafil, inhibit cGMP breakdown. They therefore lead to higher concentrations of cGMP in the penis and facilitate the production and ability to maintain an erection.

Sildenafil and the other PDE5 inhibitors are tablets taken by mouth.

How effective are PDE5 inhibitors e.g. sildenafil and PGE1 alprostadil?

How effective is sildenafil at treating ED?

From clinic research trials, sildenafil has been shown to be highly effective in treating ED.

In studies of more than 8000 patients, the following percentages of men who took sildenafil experienced improved erections:

• sildenafil 25mg dose - 62%
• sildenafil 50mg dose - 74%
• sildenafil 100mg dose - 82%

How effective is alprostadil in treating ED?

Alprostadil is prostaglandin E1 (PGE1). A prostaglandin is a substance found in the body which has a hormone-like effect. It has a powerful effect to cause blood vessels to dilate, and hence is very effective in producing an erection.

Alprostadil is administered for ED, via three different mechanisms:

• Vitaros - a cream applied to the tip of the penis through the urethra.
• Medicated Urethral System for Erection (MUSE) – an intraurethral stick. The stick is gently inserted into the urethra and a small pessary of alprostadil is deposited.
• Caverject - an injection, self injected into the penile tissue itself.

How effective is Vitaros?

In a 2016 urology review, Vitaros is quoted as having an 83% success rate in men with severe ED using the 300mcg dose. Moreover as it is a cream, and administered to the penis directly, only 3% of users reported generalised side effects.

How effective is MUSE?

A 1997 study randomised 1511 men with erectile dysfunction to use either MUSE or a placebo. 65.9% of men in the MUSE group were able to achieve an erection adequate for sexual intercourse compared to 18.6% who used the placebo. This was highly statistically significant. The most common side effect was mild penile pain occurring in 10.3%. Most men found using MUSE quite acceptable.

How effective is Caverject?

Men can be taught to self inject Caverject into the body of the penis at home. Although this sounds unpleasant, a very fine bore needle is used, and in fact this has been found to be safe, acceptable, and highly effective.

In one 2011 study, 122 men who had already been using Caverject for 6 months were followed up for 2 years. Although by the end of the study around 50% had discontinued treatment – in those who were still using Caverject, there were statistically significant improvements in sexual satisfaction, sexual performance, erectile function, and in the ability to produce a rigid erection.

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Which ED treatment is currently recommended as a first choice?

The International Society for Sexual Medicine produced recommendations on medication for ED in 2016. These recommendations stated:

• PDE5 inhibitors should be offered as a first choice for ED unless there are medical reasons why not to do so.
• PDE5 inhibitors are safe, well tolerated and effective treatments for ED.
• There are no significant differences in safety, tolerability or efficacy between the different types available.
• Self injected or intraurethral alprostadil cream should be offered as a second choice treatment option. These are effective treatments which are well tolerated.
• With PDE5 inhibitors the maximal tolerated dose should be used, because this increases satisfaction with the treatment.
• Other psychosocial aspects for each patient should be considered.
• The sexual partner should be involved in decision making.
• Beware purchasing drug treatments for ED over the internet. Counterfeit products may be dangerous. Always obtain medicine from reputable sites. The NHS website has sound advice on buying medicines online.

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If I choose a PDE5 inhibitor, how can I choose between them?

There are 4 different PDE5 inhibitors.

Brand name (generic name)

1. Viagra or Viagra Connect (sildenafil)
2. Cialis (tadalafil)
3. Levitra (vardenafil)
4. Spedra (avanafil)

These drugs are available as brand named products, or as their generic names. The generic name is the active ingredient of the drug. Both Viagra (sildenafil) and Cialis (tadalafil) are off-patent and many drug companies market generics of the original. See generic medicines FAQs for further information about generic drugs.

The brand name is the name given to the drug by the pharmaceutical company when it was first produced. After a period of time (usually around 20 years), a drug's patent expires, and other drug companies can market copies using the same active ingredient. The drug is then known by its medical or generic name.

Which PDE5 inhibitor is most effective for treatment of ED?

A 2005 comprehensive review of 35 randomised controlled trial of clinical experience with different PDE5 inhibitors for ED, concluded that all the PDE5 drugs studied were similar in their efficacy at improving erectile function.

The cumulative results of all these medical studies showed that 76% of men with ED had improved erections using sildenafil, 75% with tadalafil, and 71% with vardenafil - compared to 22%–24% with a placebo.

All three drugs also resulted in a significantly improved number of successful attempts at sexual intercourse: 65% for sildenafil, 62% for tadalafil, and 59% for vardenafil - compared to 23%–25% with a placebo.

The numbers of men discontinuing the trials for lack of response was slightly higher in the vardenafil group, and the lowest in the sildenafil group. There were the least number of adverse events in the sildenafil group.

Each PDE5 inhibitor has some similar and some different features of use.

PDE5 inhibitors: which features of use are similar?

• These are all taken by mouth, before sexual intercourse.
• You should not take any other treatments for ED at the same time.
• You do need sexual stimulation for the medication to be effective.
• The tablets should all be taken as directed – swallow the tablets whole, do not crush or chew them.
• Don't have too much alcohol – remember alcohol reduces sexual performance.
• Whichever PDE5 you take, it may not be successful the first time you take it. You may need to try it several times – up to 8 times – to achieve success.
• Don't take more than one tablet in 24 hours.
• Side effects are very similar with all the PDE5 inhibitors – (Add link to ‘Who is suitable for Viagra Connect?' and ‘Who is not suitable for Viagra Connect?' in brief 03F). The most common side effects are headache, flushing, indigestion, nasal congestion and visual disturbance.
• There is concern about using any PDE5 inhibitor if you have cardiovascular disease. This is because the PDE5 inhibitors work by causing blood vessels to dilate, and hence may lower your blood pressure. If you have a history of heart disease, or current symptoms or take any heart medication you must see a doctor for advice before taking at PDE5 inhibitor.
• The advice for what to do if you get side effects on PDE5 inhibitors is the same for all the different types - including serious side effects.
• There are some common precautions for use.
• The list of drug interactions is very similar.
• Do not take grapefruit juice within the 24 hours before taking any of the PDE5 inhibitors.

Individual PDE5 inhibitors: how do features of use differ?

The main differences between each PDE5 inhibitor are set out below. A summary is available in Table 1 below.

Viagra/Viagra Connect/sildenafil

• When to take it? 30-60 minutes before sexual intercourse.
• With/without food – at least one hour before food.
• With/without alcohol – alcohol in moderation.
• Duration of action – 4 hours.
• Dose – start with 50mg unless there are special reasons for a lower dose. If it's not working at 50mg, try the 100mg dose. This has been shown to work most effectively.

For more information, including side effects, precautions, and drug interactions with sildenafil see Viagra patient information leaflet (PDF).

Cialis/tadalafil

• When to take it? 30 minutes before sexual intercourse.
• With/without food – it doesn't matter.
• With/without alcohol – alcohol in moderation.
• Duration of action – 36 hours.
• Dose – start with 10mg unless there are special reasons for a lower dose. If it's not working at 10mg, try the 20mg dose. The higher dose has been shown to work most effectively.
• How else can I take Cialis/tadalafil? This can be taken 2.5mg/5mg per day regularly. This means sex can be more spontaneous.
• Can Cialis/tadalafil be used for any other medical conditions? Cialis/tadalafil is also the only PDE5 inhibitor licensed to treat benign prostatic hyperplasia, so it is a useful treatment for men with both conditions.

For more information including side effects, precautions, and drug interactions with tadalafil see the patient leaflets for Cialis 20mg and also Cialis 2.5mg.

Levitra/vardenafil (and Levitra orodispersible tablets)

• When to take it? 60 minutes before sexual intercourse.
• With/without food – it doesn't matter.
• With/without alcohol – alcohol in moderation.
• Duration of action – 4-5 hours.
• Dose - start with 10mg unless there are special reasons for a lower dose. If it's not working at 10mg, try the 20mg dose. The higher dose has been shown to work most effectively.
• How else can I take Levitra/vardenafil? This can be taken 5mg per day regularly. This means sex can be more spontaneous. This is the only PDE5 inhibitor which has this effect.
• Additional features? Levitra is also available as an orodispersible tablet and dissolves in your mouth without the need for a glass of water. This means it works more quickly and is effective within 20 minutes.

For more information including side effects, precautions, and drug interactions with vardenafil see the patient leaflets for Levitra 10mg tablets and Levitra 10mg orodispersible.

Spedra/avanafil

• When to take it? 30 minutes before sexual intercourse.
• With/without food – it doesn't matter – may take longer to work if taken with food.
• With/without alcohol – alcohol in moderation. Alcohol reduces all aspects of sexual performance.
• Duration of action – 4 hours.
• Dose – start with 100mg unless there are special reasons for a lower dose. If it's not working at 100mg, try the 200mg dose. The higher dose has been shown to work most effectively.

For more information including side effects, precautions, and drug interactions with avanafil see the Spedra patient information leaflet.

What are the differences between the available PDE5 inhibitors? – a summary

There are no direct comparative studies of the different PDE5 inhibitors. Evidence from the individual published studies on the effectiveness of the types of PDE5 inhibitors, is summarised in the table below – Table 1: Comparison of the clinical usage and effects of different PDE5 inhibitors.

Table 1: Comparison of the clinical usage and effects of different PDE5 inhibitors

Table 2: Common adverse events of PDE5 inhibitors

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Alprostadil

Alprostadil is an alternative to PDE5 inhibitors. This is a prostaglandin – a hormone like substance which causes blood vessels to dilate, and hence is effective in producing an erection.

Alprostadil is available in three different preparations:

• an injection which is injected into the body of the penis (Caverject),
• a pessary inserted via an intraurethral stick (MUSE) or
• a cream which is applied directly to the tip of the penis (Vitaros).

Each alprostadil product has some similar and some different features of use.

Alprostadil products for ED - Which features of use are similar?

• All three products are effective in treating ED – success rates have been quoted between 50-83% in improved erectile function leading to successful intercourse.
• These are all local treatments – Vitaros - a cream, MUSE -a pessary and Caverject - an injection – all of which are applied directly to the penis itself. Because these are local treatments there are much less in the way of generalised side effects than there are for example with PDE5 inhibitors. Which are all swallowed by mouth.
• These are all administered before each episode of sexual intercourse.
• You should not take any other treatments for ED at the same time.
• You do need sexual stimulation for the medication to be effective.
• They are should all be administered as directed.
• Don't have too much alcohol – remember alcohol reduces sexual performance.
• Pass urine before you insert any alprostadil products – don't pee after insertion as you may literally - flush them out!
• Whichever alprostadil you use, it may not be successful the first time you take it. You may need to try it several times to achieve success.
• Don't use any more than one alprostadil in a 24 hour period, and not more than 3 times a week.
• Side effects are very similar with all the alprostadil products The most common side effects are a burning pain within the penis, itching, rash, redness and penile swelling – these may occur in more than 1 in 10 users. Female partners may complain of vaginal soreness and irritation. For more details about side effects click on the drug specific links below.
• There is also concern about using any alprostadil products if you have cardiovascular disease, for the same reasons as there is concern about using PDE5 inhibitors too. (Add link to the ‘cardiovascular disease' section in Brief 03F) This is because all the alprostadil products also work by causing blood vessels to dilate, and hence may lower your blood pressure.
• If you have a history of heart disease, or current symptoms or take any heart medication you must see a doctor for advice before using alprostadil. However, because these are local treatments and are not being taken by mouth, there are less in the way of generalised side effects. For men with cardiovascular disease alprostadil may be a preferable choice.
• The advice for what to do if you get side effects on alprostadil is the same for the three different products.
• This includes the advice about serious side effects such as acute allergy (anaphylaxis) - see the NHS pages for Anaphylaxis and Priapism.
• There are some common precautions for use. These products should not be used by men whose partners are pregnant or breast feeding.
• Alprostadil products may cause drowsiness so you should not drove or operate machinery within 1-2 hours of using them.
• The list of drug interactions for the three products is very similar.
• Alprostadil products do not damage latex condoms.

Individual alprostadil products - How do features of use differ?

Let's consider each of these in turn – Caverject, MUSE and Vitaros.

Caverject – alprostadil injection

How to use Caverject

There is a very specific technique required to use Caverject safely and effectively. If you choose this option, your doctor will give you one-to-one training on exactly how to do it.

This account covers the basics only.

1. Wash your hands – this has to be a clean procedure.
2. Draw up the alprostadil solution into the Caverject device. This is a syringe and a fine bore needle. There is a particular way to do this which your doctor will show you.
3. Hold your penis along the edge of your thigh. Identify an area to inject - not too near the head of the penis and not in a prominent vein. Clean this area with an alcohol swab.
4. Insert the needle into the injection site to the correct depth and depress the plunger so the whole dose is injected.
5. Remove the needle and press on the area for 5 minutes if needed to stop bleeding.
6. Dispose of the needle in a sharps bin.

For more information see the Caverject patient information leaflet (PDF).

• When to inject it? It takes around 15 minutes to become effective.
• With/without food – it doesn't matter.
• With/without alcohol – in moderation. Alcohol reduces all aspects of sexual performance.
• Duration of action – usually your erection will not last more than one hour.
• Dose – the starting dose is 1.25mcg. This is then increased according to response, the usual dose being 5–20mcg.

MUSE - Medicated Urethral System for Erections (MUSE) - alprostadil injection

How to use MUSE

There is a very specific technique required to use MUSE safely and effectively. If you choose this option, your doctor will give you one-to-one training on exactly how to do it.

This account covers the basics only.

1. Wash your hands – this is a clean procedure.
2. Pass urine before the insertion – any urine left inside the penis will help dissolve the suppository.
3. Take the alprostadil pessary - this is tiny - and insert it into the end of the MUSE stick.
4. You can use a little lubricant such as KY jelly on the tip of the applicator. Insert the applicator into the urethra – this is the tube which runs down the middle of your penis (this is where you pee from and ejaculate from).
5. Depress the plunger on the MUSE stick to fully deposit the pessary into the urethra.
6. Roll the penis between your two hands for a few moments to warm it and help dissolve the pessary.
7. If you sit or stand, or preferably walk around for a few minutes, this helps blood flow to the genital area.

For more information see the MUSE patient information leaflet (PDF).

• When to insert the pessary? It takes around 5- 10 minutes to become effective.
• With/without food – it doesn't matter.
• With/without alcohol – in moderation. Alcohol reduces all aspects of sexual performance.
• Duration of action – usually your erection will last 30–60 minutes.
• Dose – the starting dose is 125mcg. This is then increased according to response, to 250mcg, 500mcg, or 1000mcg.
• How to store – MUSE must be kept in the fridge. It may be taken out of the fridge for up to 14 days before use, but after this if not used, it should be discarded.

Vitaros – alprostadil cream

There is a very specific technique required to use alprostadil cream safely and effectively. If you choose this option, your doctor will give you one-to-one training on exactly how to do it.

This account covers the basics only.

• Wash your hands – this is a clean procedure.
• Vitaros cream is prepared in a single dose pipette called an AccuDose container. One pipette is one treatment.
• As Vitaros should be kept in the fridge, you can warm it up by rolling it between your hands for a few minutes.
• Twist the plunger, then take the cap off the device.
• Squeeze the tip of the penis slightly so the urethra is gaping. If you are not circumcised, roll the foreskin back first.
• Hold the plunger just above the urethral opening so it is just above it - do not insert it into the urethra directly. Depress the plunger so the cream fills the urethral opening. If some cream spills out gently replace it there with a finger.
• Hold the penis upright for 30 seconds to allow the cream to be absorbed.

For more information see the Vitaros patient information leaflet (PDF).

• When to insert the cream? It takes around 5- 30 minutes to become effective.
• With/without food – it doesn't matter.
• With/without alcohol – in moderation. Alcohol reduces all aspects of sexual performance.
• Duration of action – usually your erection will last 60 - 120 minutes.
• Dose – there are two doses available, 200mcg and 300 mcg. Each is contained within 100 ml of cream.
• How to store – Vitaros must be kept in the fridge. It may be taken out of the fridge for up to 3 days before use, but after this if not used, it should be discarded.

Alprostadil medical information

Listed below is medical information about the three ED products for ED which contain alprostadil: Caverject (injectable), MUSE (intraurethral pessary) and Vitaros (penile cream). Although the method of application differs for these three products, they are all delivering the same drug - alprostadil.

Who is suitable for alprostadil?

Alprostadil is suitable for:

• Men – alprostadil is not to be used in women.
• Aged 18 or over – it is not suitable for children/young people.
• Who have had erectile dysfunction as a recurring problem over a period not less than one year.
• It is not to be used by men who do not have ED.

Who is not suitable for alprostadil?

Men who have certain medical conditions/risk factors or who take medicines which may interact must not take alprostadil – see below.

• Allergy to alprostadil or any of its constituents
• Deformities of the penis e.g. Contractures of the penis such as Peyronie's Disease, or cavernosal fibrosis
• Any conditions which might predipose to priapism e.g. sickle cell anaemia or trait, multiple myeloma or leukaemia.

Are there any special precautions for use of alprostadil?

Any underlying cause for ED should be treated before starting treatment with alprostadil or other ED drugs.

Cardiovascular disease

In men with ED it is always important to consider any possible underlying cause/contributory medical conditions.

Cardiovascular disease - ED may be a presenting symptom of cardiovascular disease. Because of this, men with ED are strongly advised to see their doctor within 6 months of requesting alprostadil. Men with ED require an assessment to check for conditions such as raised cholesterol, high blood pressure, and diabetes.

If alprostadil is unsuccessful, or if ED seems to worsen while taking it, you should seek medical advice.

If you are already experiencing symptoms which suggest you might have impaired heart function, you should not take alprostadil. For example, if you get chest pain or breathlessness on minimal exertion such as walking briskly for 20 minutes or climbing two flights of stairs. If this is the case, you should see your doctor.

However, if you have had successful treatment to improve the blood supply to your heart, such as a stent, a coronary artery bypass or an angioplasty – alprostadil is a possible option for you.

If you have the following you may not be suitable for alprostadil:

• uncontrolled high blood pressure,
• moderate to severe valvular heart disease,
• heart failure - left ventricular failure,
• disease of the heart muscle - cardiomyopathies
• abnormal heart rhythms - arrhythmias

Priapism – this is a rare side effect from using alprostadil

Priapism is said to occur if an erection lasts more than 4 hours. The penis remains erect and will not become limp. It is very painful. Some medical conditions may predispose you to priapism such as leukaemia, multiple myeloma, and sickle cell anaemia.

Priapism is a medical emergency and if this ever happens to you, you must get immediate help by dialling 999 or attending A&E (in the UK).

For more information see NHS – Priapism.

Do not use alprostadil products at the same time as you are using any other treatments for ED.

• Fibrosis may occur within the penis if you use Caverject regularly. Beware any fibrotic nodules or angulation of the penis. If this occurs you must stop treatment
• Anticoagulants - use Caverject with caution if you are anticoagulants. There may be increased bleeding at the injection site.
• Previous stroke/TIA - Caverject should be used with caution in patients who have previously had a stroke or a Transient Ischaemic Attack (TIA).
• Take care with the injection - Caverject involves the use of a fine bore needle. Take care not to bend or break the needle, and to dispose of this and the rest of the Caverject system correctly in a sharps bin.

Which drugs may interact with alprostadil?

Any drug which stimulates the sympathetic nervous system may interact with alprostadil. These include:

• Adrenaline
• Noradrenaline
• Salbutamol
• Amphetamines

Alprostadil may exaggerate the effects of drugs which lower your blood pressure, drugs which dilate blood vessels, as well as anti-clotting drugs.

What should I do if I experience side effects on alprostadil?

The following is a list of side effects which have been reported from clinical trials for the three alprostadil products: Caverject, MUSE, and Vitaros. It is not possible to be sure in all cases whether these side effects were really due to using alprostadil or may have been caused by another underlying cause. The list is not exhaustive so you are strongly recommended to have a medical consultation before deciding to use alprostadil, or any other drug to treat ED.

Studies suggest that generalised side effects seem to be less common with alprostadil products than with PDE5 inhibitors. This is probably because alprostadil products are local treatments being applied directly to the penis, and not being taken by mouth.

Vitaros is the least invasive alprostadil product as it is a cream applied to the tip of the penis, and does not require an injection or inserting anything inside the penile urethra. For example in clinical studies, most adverse events reported with Vitaros were localised to the penis – such as redness, tenderness, and genital pain – and more than 97% of these were described as mild.

Common side effects (reported in ≥1/100 to <1/10 users)

• Pain in the penis – this was a common side effect with all alprostadil products, and for example, was reported in around 30% of men self injecting with Caverject. Pain was described as mild or moderate and was an uncommon reason for discontinuing with Caverject.
• Penile fibrosis was reported in 3% of Caverject users. It was also reported in MUSE users but not specifically in those using Vitaros.
• Bleeding was reported in 3% of Caverject users, and bruises in 2%. Bleeding also occurred with MUSE users but was not reported with Vitaros.
• Vaginal burning/itching in sexual partners.

Uncommon side effects (reported in ≥1/1,000 to <1/100 users)

• Priapism was reported with all three different products but was said to be uncommon in each group.
• Feeling faint
• Heart arrhythmias
• Low blood pressure
• Venous bleeding, peripheral vascular disorders
• Nausea
• Dry mouth
• Excessive sweating
• Rash
• Itching
• Bleeding from the urethra
• Blood in the urine
• Pain passing urine
• Painful erection
• Balanitis (inflammation of the head of the penis)
• Swollen testicle
• Testicular pain
• Injection site, swelling, warmth
• Creatinine levels raised, or lowered

Unknown frequency

• Stroke
• Heart attack

When would taking alprostadil become an emergency?

If you have any symptoms or signs suggestive of an acute allergic reaction (anaphylaxis), you must get help immediately by phoning 999 (in the UK).

Symptoms/signs of an acute allergic reaction include:

• Difficulty breathing/ tight chest/ wheezing
• Swelling of the face, lips and tongue
• Skin rash – urticaria/hives
• Confusion/collapse/unconsciousness

For more information see NHS - Anaphylaxis.

Priapism is also a medical emergency (see above).

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Vacuum Constriction Pumps

There are now a variety of penis pumps available which can literally pump up an erection! These are effective whatever the underlying cause of your ED. 9 out of 10 men with ED will be able to achieve an erection satisfactory for sexual intercourse after using a vacuum constriction pump.

Vacuum constriction pumps have the following advantages:

• They are used externally on the penis itself and there is no need to swallow a tablet or use any injections, pessaries or creams. They can be used therefore by just about anyone.
• As a purely mechanical device, they are very unlikely to cause generalised side effects elsewhere.
• Some vacuum pumps are battery operated or electric - so they can pump you up with minimal effort on your part!
• They work quickly – you can achieve a good erection in 2 and ½ minutes!

Vacuum constriction pumps have the following disadvantages:

• The penis is colder and has more blue veins on the surface.
• Because of the constriction ring at the base, you will may need to hold the penis in place for sexual activity.
• The erection will last around 30 minutes – drugs for ED are likely to give a longer lasting erection.
• Although some men find this acceptable, in clinical trial there was a 65% drop out rate for longer term use.

How to use a vacuum constriction pump

Each pump is slightly different but in general:

• Apply some gel to the pubic area – this helps make a seal for the pump.
• Apply a rubber constriction ring to the pump, with some gel.
• Slip the penis inside the plastic cylinder. Press the cylinder firmly against the pubic area.
• Activate the pump. This creates a negative pressure and results in expansion of the penis.
• When the penis is hard, slip a rubber ring over the pump and onto the base of the penis. This keeps the blood in the penis and helps maintain the erection.
• Remove the pump.

Can I get an ED pump on NHS prescription?

Erectile dysfunction pumps are only available by NHS prescription to patients who have ED with the following conditions:

• Diabetes mellitus
• Injury (spinal cord or pelvis)
• Multiple sclerosis
• Poliomyelitis
• Prostate cancer
• Psychological distress (severe)
• Renal failure
• Single-gene neurological disorders
• Spina bifida
• Surgery (prostatectomy & radical pelvic surgery)

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Penile implants – prostheses

Surgery for erectile dysfunction is a last resort option for when medical treatments have failed. Making a decision to have surgery – including penile surgery – is a very difficult decision.

Nevertheless, for some men, who find themselves in a very troubling physical condition, they may want to consider surgery as an option.

There are various different types of penile implant. One option are penile implants – two long rods – which can be inserted into the spongy tissue of the penis. These are permanently rigid enough to have sex.

With other types, there is a type of balloon placed within the penile shaft, and a reservoir of fluid placed within the scrotum. By activating a button, this will fill the penis and inflate it. Erections are good enough to have intercourse and you can ejaculate.

However surgery does come with risks – such as bleeding, infection, and scarring. If the implant has to be removed, it is unlikely you will ever be able to have a natural erection again.

The NHS will fund penile prostheses if all other treatments for ED have been tried and failed.

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Summing up – which treatment for ED?

Choosing your ED treatment depends on what is the best option for you. Each person is different and what suits one person may not suit another.

The good news is that all the treatments discussed in this section are very effective in helping you get good erections and improving your sexual function.

Do have a medical assessment. This is so important for your general health, and to exclude any underlying causes.

Do consider having some psychosexual counselling if this recommended to you. All the pills and potions in the world are unlikely to succeed unless you get your psychological problems sorted.

Viagra or one of the other PDE5 inhibitors is likely to be your first choice. Take is carefully exactly as directed. Don't be disheartened if it doesn't work first time – persevere! Cialis/tadalafil and Levitra/vardenafil can be taken every day if needed, meaning sex can be spontaneous. Cialis is also a good choice if you also have prostatic disease. Levitra can be obtained as an orodispersible tablet – a good choice if you can't swallow tablets!

If you have any risk factors and you and your doctor feel a local treatment is better, think about which alprostadil treatment might be best for you. These are very effective and tend to have less in the way of generalised side effects. Vitaros is particularly easy to use, as a cream applied to the tip of the penis.

Vacuum pumps may be the answer if these treatments fail. Many men have found these very effective.

And if all fails, you can always discuss surgery with your local specialist.

Really, it's time to take action! There is a treatment out there for every ED sufferer. Have a think about it.

Buy ED treatment

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