Most Effective Treatments for ED

Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.¹ It may significantly impact psychosocial health and quality of life for both patients and their partners.² The EAU Guidelines recommend a stepwise approach to ED treatment, beginning with lifestyle modifications and oral medications before progressing to more invasive options.³ First-line treatments include oral phosphodiesterase type 5 inhibitors (PDE5Is) such as sildenafil, tadalafil, vardenafil, and avanafil, which are effective in about 70% of men with ED.⁴ However, when these medications fail or are contraindicated, second-line treatments like vacuum erection devices, intracavernosal injections, or intraurethral alprostadil may be considered.⁵ These options have varying success rates but can be effective alternatives for many patients. For men who don’t respond to or cannot use first and second-line treatments, penile implants (penile prostheses) represent the most effective surgical solution.⁶ The EAU Guidelines recognize two main types of penile implants: malleable (semi-rigid) and inflatable (2-piece and 3-piece) prostheses.⁷ The 3-piece inflatable prosthesis most closely mimics the natural erection process and offers the best rigidity and flaccidity, though it requires more complex surgery and carries a slightly higher risk of mechanical failure.⁸ According to the guidelines, patient satisfaction rates with penile implants are exceptionally high, exceeding 90% in most studies.⁹ Partner satisfaction rates are similarly impressive, ranging from 82-94%.¹⁰ These high satisfaction rates are attributed to the reliable, on-demand erections that implants provide, allowing for spontaneous sexual activity without the need for pre-planning or medication.¹¹ The EAU Guidelines note that complications of penile implant surgery have decreased significantly with technological improvements and surgical refinements. Current five-year mechanical reliability rates exceed 90% for most devices.¹² The most serious complication is infection, occurring in 1-3% of primary implantations, though this rate has decreased with the introduction of antibiotic-coated implants and improved surgical techniques.¹³ Patients should be counseled about realistic expectations, including that the implant will not increase penile length beyond what was achieved during natural erections prior to ED.¹⁴ When considering treatment options for ED, the guidelines emphasize the importance of shared decision-making between the patient, their partner, and healthcare provider.¹⁵ While penile implants represent the most effective solution for severe ED, the choice of treatment should be individualized based on the patient’s specific situation, preferences, and goals.¹⁶