Treating Erectile Dysfunction: Options Beyond Alprostadil

Oral phosphodiesterase type 5 inhibitors

DrugDosageStart of actionComments
50, 100, o 200 mg
30 minutesCan be taken 15 minutes before sexual intercourse
SildenafilInitial: 50 mg
Maintenance: 25-100 mg (most patients respond better to a dose of 100 mg).
60 minutesDuration of action: ≈ 4 hours; take on an empty stomach
Tadalafil10‒20 mg60 minutesDuration of action: 24-36 hours
Tadalafil standard dose
2,5-5 mg
60 minutesFor daily use, taken at approximately the same time every day, regardless of the time of sexual activity.
For daily use in patients who also need treatment of benign prostatic hyperplasia
10‒20 mg
60 minutesDuration of action: ≈ 4 hours
Vardenafil, orally disintegrating formulation10 mg30 minutesIt can be taken 30 minutes before sexual intercourse

Phosphodiesterase 5 inhibitors (PDE5I) are a group of drugs used to treat erectile dysfunction. These drugs relax the muscles of the penis to increase blood flow. They do not cause an erection without sexual stimulation.

There are 4 approved types of PDE5Is:

  • Sildenafil
  • Tadalafil
  • Vardenafil
  • Avanafil

Phosphodiesterase 5 inhibitors are the most common treatment prescribed for erectile dysfunction. All types of phosphodiesterase 5 inhibitors can be equally effective. Which drug is best for the patient depends on how often sexual activity is desired and personal experience.

Because of the success of phosphodiesterase 5 inhibitors in treating erectile dysfunction, there are many fake pills on the market. These drugs are not approved for sale, can be toxic, and can harm your health. Always talk to your doctor before using or buying erectile dysfunction drugs.

Vacuum erection devices

A vacuum erection device, also known as a vacuum constriction device or penis pump, is a device that is used to help men achieve and maintain an erection. The device consists of a plastic cylinder that is placed over the penis, a pump that is used to create a vacuum inside the cylinder, and an elastic band that is placed around the base of the penis to maintain the erection once it has been achieved.

A VED consists of the following:

  • A plastic tube
  • A mechanical, battery-operated, or electric pump
  • A constriction band, which fits on one end of the tube
  • The tube is placed over the penis, and the pump is used to create a vacuum, which draws blood into the penis so that it becomes erect. The band is placed at the base of the penis to help maintain the erection.

The vacuum created by the pump helps to draw blood into the penis, which causes it to become erect. Once the penis is erect, the elastic band is placed around the base of the penis to maintain the erection. Vacuum erection devices are often used as a non-invasive treatment option for men with erectile dysfunction (ED) who do not respond to other forms of treatment.

Penile injections

Penile injections, also known as intracavernous injections, are a form of treatment for erectile dysfunction (ED) that involve injecting a medication directly into the corpus cavernosum of the penis. This medication is usually a vasodilator, which means it relaxes the smooth muscle in the blood vessels of the penis, allowing for increased blood flow and an erection.

The most common medication used for penile injections is alprostadil, which is a synthetic form of prostaglandin E1. Other medications that can be used include papaverine and phentolamine. Penile injections are typically administered directly into the corpus cavernosum of the penis using a very fine needle and syringe. The medication takes effect in 5-20 minutes and the effect lasts for about 1 hour.

Penile injections are a safe and effective treatment for men with ED who do not respond to other forms of treatment, however it may have some side effects such as pain, priapism, and penile fibrosis. It’s important to consult with a urologist or a specialist in sexual medicine for proper evaluation and treatment.

Intraurethral suppositories

Intraurethral suppositories, also known as urethral suppositories, are small, medicated pellets that are inserted into the urethra (the tube that carries urine from the bladder out of the body) to treat erectile dysfunction (ED). The medication used in intraurethral suppositories is usually alprostadil, which is a synthetic form of prostaglandin E1.

The suppository is inserted into the urethra using a special applicator. Once it is in place, it dissolves and the medication is absorbed into the surrounding tissue. This causes the smooth muscle in the blood vessels of the penis to relax, allowing for increased blood flow and an erection.

Intraurethral suppositories take effect within 5-20 minutes and the effect lasts for about an hour. It is a safe and effective treatment option for men with ED who do not respond to other forms of treatment. However, it may have some side effects such as pain, burning and bleeding in the urethra. It’s important to consult with a urologist or a specialist in sexual medicine for proper evaluation and treatment.

The use of alprostadil in intraurethral suppositories (small tablets, about the size of half a grain of rice, to be inserted into the urethra with a special applicator), rather than by direct injection at the base of the penis, produces much less action than the injectable formulation, being effective in producing a satisfactory erection in only 30-40% of patients with erectile dysfunction (rather than 80% and more).

Testosterone replacement therapy

Testosterone replacement therapy (TRT) is a treatment used to address low levels of testosterone. Testosterone is responsible for the development of male physical characteristics and plays an important role in maintaining muscle mass and bone density, sperm production, and sexual function. Low levels of testosterone can lead to a variety of symptoms such as decreased sex drive, erectile dysfunction, fatigue, and muscle weakness..

Need to establish a proper etiologic framing before starting replacement treatment. Thus, pathological conditions of male hypogonadism that might also benefit from other treatments (e.g., pituitary lesions to be treated with dopamine agonists or surgery) should be excluded.

TRT is typically administered in the form of gels, creams, injections, pellets, or patches and it aims to restore the testosterone levels to normal range. The therapy is individualized and the dosage and frequency of administration are based on the patient’s testosterone levels, symptoms, and response to treatment.

TRT has many benefits such as improvement in sexual function, muscle mass, bone density, mood, energy levels, and overall well-being. However, it’s important to note that TRT does not cure the underlying cause of low testosterone levels, and long-term use may also cause potential side effects such as acne, breast enlargement, and an increased risk of prostate cancer. Therefore, it’s important to consult with a specialist in endocrinology or urology for proper evaluation and treatment.

Penile implants

A penile prosthesis is a medical device that is implanted by surgical procedure in patients with organic erectile deficits of various origins that are not amenable to drug therapy.

Prostheses can also be used to correct congenital or acquired abnormalities of the penis, such as deviations or La Peyronie’s disease, and as support in gynoandroid conversion.
The implant does not change the state of glans turgor, penile sensitivity, or orgasm, which therefore remain unchanged by the surgery.

Devices can be divided, on the basis of construction and operation criteria, into two broad categories: non-hydraulic and hydraulic.

Non-hydraulic prostheses, also called semi-rigid, include soft, malleable, and mechanical (now little used) prostheses.
Hydraulic prostheses are divided according to the design and construction criterion of the inflation mechanism into single-component (no longer used), two-component and three-component models.

Malleable and mechanical prostheses both consist of a silicone body with a moldable support structure inside; the patient can position the penis in any direction by simply bending the prosthetic implant, thus simulating erection and detumescence.
The malleable model is made with a core of steel or silver wires woven or arranged in a spiral, which is extremely pliable.
The mechanical model, on the other hand, has within the silicone body a longitudinal structure consisting of polyethylene segments kept articulated with each other by a spring-loaded steel cable and covered with polytetrafluoroethylene.

The advantages of malleable prostheses are, in addition to easy handling by the patient, a very low failure rate, good penetrative capacity, and relatively low cost.
Disadvantages are imperfect simulation of detumescence and lack of subjective sensation of erection.

These devices find their ideal use in the surgery of induratio penis plastica associated with erectile dysfunction with removal of plaques, which are so large and extensive that the hydraulic prostheses cannot be used, and in patients with reduced manual dexterity thus unable to activate hydraulic implants.

Semi-rigid prostheses consist of a pair of malleable cylindrical “rods” that are implanted inside the two corpora cavernosa. The function of these implants is to provide central support to the corpora cavernosa to maintain their rigidity during erection; their use is advantageous because they simulate natural rigidity well, do not require activation, it is virtually impossible for them to rupture, and they have relatively low costs associated with extremely short operative times.
The only disadvantages are the lack of dissimulation; the penis always appears to be of maximum length and even in the absence of erection is semi-horizontal.

To overcome these inconveniences, it is preferred to implant hydraulic prostheses, by far the most widely used. They are distinguished into bi- and tri-components.
The former consist of two inflatable cylinders that fit inside the two corpora cavernosa and a pump-tank placed in the scrotum.

Tricomponents additionally have a larger reservoir that fits in the abdomen, in the pre-vesical space.
The latter are to be preferred because they offer the best result both aesthetically and functionally, offering perfect concealment with both erect and flaccid penis, also by virtue of the fact that implantation is through a small scrotal or suprapubic incision that is perfectly camouflaged.

In hydraulic prostheses, whether they are bi- or tri-component, mechanical erection occurs through activation of the pump, placed in the scrotum, which conveys the liquid (saline solution) from the reservoir into the cylinders placed in the two corpora cavernosa, which then stiffen and remain so until their detumescence is activated by squeezing a micro-valve placed on the pump itself.

The technically undemanding surgery is conducted under spinal or general anesthesia and requires an overnight stay. The next morning, the urinary catheter will be removed and dressing will be performed, which will be followed by discharge.
After three days of rest, it will be possible to resume daily activities, avoiding exertion of any magnitude for at least three weeks. Postoperative pain is contained, and in any case reduced by the help of drugs with antiphlogistic and antalgic action.
The main complications are prosthesis infection, mechanical failure, dysuria, malfunction, anejaculation, sensitivity disorders, postoperative pain, and dislocation of components.

Behavioral therapy

Behavior therapy is a psychotherapy that has as its main goal the modification of maladaptive behaviors of patients. It is the first form of psychotherapy that has been subjected to systematic experimental verification. It originated as an application to the clinical field of experimental principles of learning, evidenced in the laboratory, and has rapidly established itself since the 1950s, gradually replacing earlier modes of psychological intervention, which were widespread but lacked any experimental basis.


Acupuncture is an alternative medicine, unscientific and unverified, that makes use of the insertion of needles into specific points on the human body to promote the health and well-being of the individual: according to traditional Chinese medicine, stimulating these points can correct imbalances in the flow of qi through channels known as “meridians.”

The origin of acupuncture in China is uncertain. The earliest bibliographic references to the practice are found in the ancient Chinese text Huangdi Neijing, the legendary Emperor’s Canon of Internal Medicine, that was compiled between 305 and 204 BCE. Before that, it is conceivable that stone or bone instruments were used, and thus absolutely far removed from the view we have of the practice today.

The practice spread centuries ago to many parts of Asia; it is included in the theoretical-practical body of traditional Chinese medicine, of which it is one of its 5 components, along with diet, phytotherapy, massage therapy and the psychophysical gymnastics such as Qi Gong and Tai Chi; some of its forms are also described in the literature of traditional Korean medicine, where it is called yakchim as well as in India.