The evidence regarding a correlation between statin medications and ED risk is conflicting. Some studies suggest that statins have sexual side effects, while others propose that the overall cardiovascular benefit of these medications contributes to improved erectile function.7 No large-scale randomized controlled trials have established a link between statins and testosterone levels, and cessation of statin therapy or lowering of statin regimens as a means of improving ED is not recommended.
Rather, we suggest optimizing well-established contributing factors such as cardiovascular fitness and testosterone levels.
| Product | Dosage | Quantity + Bonus | Price | |
|---|---|---|---|---|
| Cialis Generic | 20mg | 120 + 8 Pills | 188.15€ 179.19€ | |
| Cialis Generic | 20mg | 180 + 10 Pills | 254.09€ 241.99€ | |
| Cialis Generic | 10mg | 270 + 10 Pills | 308.71€ 294.01€ | |
| Cialis Professional | 40mg | 30 Pills | 148.94€ 141.85€ | |
| Cialis Generic | 40mg | 60 + 6 Pills | 130.98€ 124.74€ | |
| Cialis Professional | 40mg | 90 + 2 Pills | 348.59€ 331.99€ | |
| Cialis Generic | 20mg | 90 + 6 Pills | 154.71€ 147.34€ | |
| Cialis Black | 80mg | 360 + 20 Pills | 639.78€ 609.31€ | |
| Cialis Original | 20mg | 48 + 4 Pills | 224.69€ 213.99€ | |
| Cialis Generic | 2.5mg | 90 + 6 Pills | 112.43€ 107.08€ | |
| Cialis Generic | 60mg | 10 Pills | 41.22€ 39.26€ |
Despite making lifestyle changes, many patients with ED require PDE5 inhibitors such as sildenafil or tadalafil to improve erectile function.
These agents promote erections by increasing nitric oxide levels and blocking the decomposition of cyclic guanosine monophosphate, thereby relaxing the smooth muscle within the corpora cavernosa and increasing blood flow.1 However, PDE5 inhibitors are efficacious in only 60% to 70% of patients.2 When starting PDE5 inhibitors, proper administration should be ensured, as a large proportion of treatment failures with these agents is attributed to incorrect use.2 Sildenafil should be taken 30 to 60 minutes before intercourse on an empty stomach. The recommended window for taking on-demand tadalafil, which is not impacted by food intake, is 30 to 120 minutes before intercourse, but for optimal effectiveness, it should be taken 60 to 120 minutes before intercourse.8 Daily low-dose tadalafil (5 mg) may be considered for men who also experience voiding dysfunction due to prostate enlargement or men with mild ED. Patients taking 5-alpha-reductase inhibitors for benign prostatic hyperplasia who also experience ED and low libido should be referred to a urologist for alternative management strategies such as daily low-dose tadalafil, alpha-blockers, or minimally invasive surgical therapies.
The evidence regarding a correlation between statin medications and ED risk is conflicting. Some studies suggest that statins have sexual side effects, while others propose that the overall cardiovascular benefit of these medications contributes to improved erectile function.7 No large-scale randomized controlled trials have established a link between statins and testosterone levels, and cessation of statin therapy or lowering of statin regimens as a means of improving ED is not recommended. Rather, we suggest optimizing well-established contributing factors such as cardiovascular fitness and testosterone levels. Despite making lifestyle changes, many patients with ED require PDE5 inhibitors such as sildenafil or tadalafil to improve erectile function. These agents promote erections by increasing nitric oxide levels and blocking the decomposition of cyclic guanosine monophosphate, thereby relaxing the smooth muscle within the corpora cavernosa and increasing blood flow.1 However, PDE5 inhibitors are efficacious in only 60% to 70% of patients.2 When starting PDE5 inhibitors, proper administration should be ensured, as a large proportion of treatment failures with these agents is attributed to incorrect use.2 Sildenafil should be taken 30 to 60 minutes before intercourse on an empty stomach.
The recommended window for taking on-demand tadalafil, which is not impacted by food intake, is 30 to 120 minutes before intercourse, but for optimal effectiveness, it should be taken 60 to 120 minutes before intercourse.8 Daily low-dose tadalafil (5 mg) may be considered for men who also experience voiding dysfunction due to prostate enlargement or men with mild ED. Patients taking 5-alpha-reductase inhibitors for benign prostatic hyperplasia who also experience ED and low libido should be referred to a urologist for alternative management strategies such as daily low-dose tadalafil, alpha-blockers, or minimally invasive surgical therapies. In fact, some selective alpha-blockers have been found to preserve or improve erectile function.9 Combination therapy with daily tadalafil plus on-demand higher-dose tadalafil or sildenafil may be considered.10 Before determining that the medication has failed to achieve the desired result, several trials of PDE5 inhibitors with at least 24 hours between doses should be attempted.11 Additionally, other reversible causes of ED, such as testosterone deficiency, should be assessed. An early morning testosterone level (before 11:00 am) can identify testosterone deficiency in the presence of symptoms or signs of low testosterone such as low libido, fatigue, and loss of body hair.10 Testosterone levels less than 300 ng/dL with these accompanying symptoms may warrant treatment with testosterone replacement therapy, which placebo-controlled randomized trials and meta-analyses have demonstrated may help improve erectile function and libido.10–12 However, patients with ED but no symptoms of testosterone deficiency are less likely to benefit from replacement therapy. Assessment of testosterone deficiency is most valuable in men with borderline response to PDE5 inhibitors and with other signs and symptoms of low testosterone. In fact, some selective alpha-blockers have been found to preserve or improve erectile function.9 Combination therapy with daily tadalafil plus on-demand higher-dose tadalafil or sildenafil may be considered.10 Before determining that the medication has failed to achieve the desired result, several trials of PDE5 inhibitors with at least 24 hours between doses should be attempted.11 Additionally, other reversible causes of ED, such as testosterone deficiency, should be assessed.
An early morning testosterone level (before 11:00 am) can identify testosterone deficiency in the presence of symptoms or signs of low testosterone such as low libido, fatigue, and loss of body hair.10 Testosterone levels less than 300 ng/dL with these accompanying symptoms may warrant treatment with testosterone replacement therapy, which placebo-controlled randomized trials and meta-analyses have demonstrated may help improve erectile function and libido.10–12 However, patients with ED but no symptoms of testosterone deficiency are less likely to benefit from replacement therapy. Assessment of testosterone deficiency is most valuable in men with borderline response to PDE5 inhibitors and with other signs and symptoms of low testosterone. Once these avenues have been exhausted, exploring alternative therapies that aid in restoring erectile function should be considered.
Therapeutic options beyond PDE5 inhibitors include intracavernosal injection therapy, vacuum erection devices, and penile prostheses.1,2,11 These alternatives are typically used when the patient does not respond to PDE5 inhibitors or experiences intolerable side effects (e.g., headache, flushing, dyspepsia, visual disturbances, backache) from them. Treatment should be based on patient and partner preferences, comorbidities, and current medications.2 The 2018 American Urological Association guideline on ED11 emphasizes the importance of shared decision-making between patient and physician. In this process, the physician presents the various treatment options to the patient, and the risks and benefits of each are discussed before the treatment most aligned with patient goals and expectations is determined. Intracavernosal injection is the direct injection of one or more vasoactive medications (e.g., alprostadil, papaverine, or phentolamine) into the corpora cavernosa of the penis to promote an erection through local dilation of penile vessels.11 Intracavernosal injection therapy is efficacious in providing erectile function adequate for sexual intercourse in 53.7% to 100% of patients.11,13 However, it has higher long-term dropout rates, and its side effects include priapism, ecchymoses, hematoma, penile fibrosis, and penile deformity due to Peyronie disease.14 Vacuum erection devices induce erection by generating negative pressure, which enhances blood flow into the corpora cavernosa, and the erection is maintained with a constricting ring at the base of the penis.15 Of note, despite initial use of vacuum erection devices for penile rehabilitation after prostatectomy, these devices have not been shown to definitively improve erectile function.16 Side buy cialis 2 5mg online effects of vacuum erection devices are quite mild but may include discomfort, bruising, numbness, skin irritation, and pain from the constricting ring.15 Vacuum erection devices are contraindicated in patients with coagulopathies or those taking anticoagulants.17 Furthermore, combination treatment with PDE5 inhibitors and other accepted therapies such as vacuum erection devices may have greater efficacy than either as monotherapy.18 Another option for patients with ED refractory to more conservative therapies is surgical implantation of an inflatable penile prosthesis.19 This option has the highest satisfaction rate, and is typically considered after failure of oral therapies in patients who do not desire injection or vacuum erection device therapy.20 Inflatable penile prosthesis implantation can address penile deformity, making it a particularly advantageous option for patients with ED secondary to Peyronie disease, in whom intracavernosal injection therapy is contraindicated due to the risk of progressive penile scarring and deformity.1 Several different prostheses are available, including two- or three-piece inflatable penile prostheses or a malleable device.21 Three-piece inflatable penile prostheses offer the most natural rigidity and flaccidity and are the most commonly implanted penile prostheses in the United States.1 Kucuk et al21 found that patients who underwent inflatable penile prosthesis implantation had greater improvements in their International Index of Erectile Function score than patients who received tadalafil or intracavernosal injection therapy. Partner satisfaction also improved, as both patient and partner Erectile Dysfunction Inventory of Treatment Satisfaction scores were significantly higher with penile prostheses than with other treatment modalities.
Once these avenues have been exhausted, exploring alternative therapies that aid in restoring erectile function should be considered. Therapeutic options beyond PDE5 inhibitors include intracavernosal injection therapy, vacuum erection devices, and penile prostheses.1,2,11 These alternatives are typically used when the patient does not respond to PDE5 inhibitors or experiences intolerable side effects (e.g., headache, flushing, dyspepsia, visual disturbances, backache) from them. Treatment should be based on patient and partner preferences, comorbidities, and current medications.2 The 2018 American Urological Association guideline on ED11 emphasizes the importance of shared decision-making between patient and physician. In this process, the physician presents the various treatment options to the patient, and the risks and benefits of each are discussed before the treatment most aligned with patient goals and expectations is determined. Intracavernosal injection is the direct injection of one or more vasoactive medications (e.g., alprostadil, papaverine, or phentolamine) into the corpora cavernosa of the penis to promote an erection through local dilation of penile vessels.11 Intracavernosal injection therapy is efficacious in providing erectile function adequate for sexual intercourse in 53.7% to 100% of patients.11,13 However, it has higher long-term dropout rates, and its side effects include priapism, ecchymoses, hematoma, penile fibrosis, and penile deformity due to Peyronie disease.14 Vacuum erection devices induce erection by generating negative pressure, which enhances blood flow into the corpora cavernosa, and the erection is maintained with a constricting ring at the base of the penis.15 Of note, despite initial use of vacuum erection devices for penile rehabilitation after prostatectomy, these devices have not been shown to definitively improve erectile function.16 Side buy cialis 2 5mg online effects of vacuum erection devices are quite mild but may include discomfort, bruising, numbness, skin irritation, and pain from the constricting ring.15 Vacuum erection devices are contraindicated in patients with coagulopathies or those taking anticoagulants.17 Furthermore, combination treatment with PDE5 inhibitors and other accepted therapies such as vacuum erection devices may have greater efficacy than either as monotherapy.18 Another option for patients with ED refractory to more conservative therapies is surgical implantation of an inflatable penile prosthesis.19 This option has the highest satisfaction rate, and is typically considered after failure of oral therapies in patients who do not desire injection or vacuum erection device therapy.20 Inflatable penile prosthesis implantation can address penile deformity, making it a particularly advantageous option for patients with ED secondary to Peyronie disease, in whom intracavernosal injection therapy is contraindicated due to the risk of progressive penile scarring and deformity.1 Several different prostheses are available, including two- or three-piece inflatable penile prostheses or a malleable device.21 Three-piece inflatable penile prostheses offer the most natural rigidity and flaccidity and are the most commonly implanted penile prostheses in the United States.1 Kucuk et al21 found that patients who underwent inflatable penile prosthesis implantation had greater improvements in their International Index of Erectile Function score than patients who received tadalafil or intracavernosal injection therapy.
Partner satisfaction also improved, as both patient and partner Erectile Dysfunction Inventory of Treatment Satisfaction scores were significantly higher with penile prostheses than with other treatment modalities. A multicenter study found that more than 90% of patients who received an inflatable penile prosthesis were able to engage in normal sexual activity following implantation.22 Potential complications of penile prosthesis implantation include bleeding, infection, erosion, mechanical failure, need for revision surgery, and automatic inflation.20 The mechanism of action of low-intensity extracorporeal shockwave therapy (Li-ESWT) in treating ED is unclear. It is hypothesized that extracorporeal shockwaves stimulate expression of endothelial nitric oxide synthase, vascular-endothelial growth factor, and other vascular growth factors, promoting vessel expansion and neovascularization that promote blood flow and erectile function.23 The Sexual Medicine Society of North America regards Li-ESWT as promising but does not endorse its use beyond research given its novelty.24 Since the release of this statement, further studies have demonstrated some efficacy of Li-ESWT in men with moderate ED, though an optimal protocol remains to be determined.25 It is important to differentiate between Li-ESWT and radial wave therapy, the latter of which uses low-pressure acoustic waves to deliver lower energy with less tissue penetrance compared with Li-ESWT.26 Direct-to-consumer marketing from men’s health clinics often use these two terms interchangeably even though a randomized controlled trial found no difference between radial wave therapy and sham therapy for treating ED.26 The Sexual Medicine Society of North America corroborates this, drawing a distinction between Li-ESWT and radial wave therapy.24 While regenerative therapies such as Li-ESWT in ED treatment require further investigation, patients should be informed regarding the lack of evidence to support radial wave therapy for ED treatment, particularly as radial wave therapy devices are often promoted as equivalent by health clinics for men. Stem cell therapy was initially proposed to improve erectile function by promoting angiogenesis and tissue healing and reducing scarring, inflammation, and apoptosis.27 Clinical trials have been limited, and its clinical application is still unknown. Similarly, platelet-rich plasma injections have been studied as an option for ED, but a recent randomized controlled trial found no difference in efficacy between platelet-rich plasma and placebo.28 Thus, the Sexual Medicine Society of North America’s position is that stem cell and platelet-rich plasma therapies should not be used in clinical practice.24 There are various effective treatment modalities for men who cannot tolerate PDE5 inhibitors or in whom these agents fail. A multicenter study found that more than 90% of patients who received an inflatable penile prosthesis were able to engage in normal sexual activity following implantation.22 Potential complications of penile prosthesis implantation include bleeding, infection, erosion, mechanical failure, need for revision surgery, and automatic inflation.20 The mechanism of action of low-intensity extracorporeal shockwave therapy (Li-ESWT) in treating ED is unclear.
| Medication | Active Substance | Onset of Action | Duration of Effect | Common Side Effects | Special Notes |
|---|---|---|---|---|---|
| Cialis (Tadalafil) | Tadalafil | 30–60 min | Up to 36 hours | Headache, flushing, back pain | Food does not affect absorption |
| Viagra (Sildenafil) | Sildenafil | 30–60 min | 4–6 hours | Visual disturbances, headache | Taken on an empty stomach |
| Levitra (Vardenafil) | Vardenafil | 30–60 min | 4–5 hours | Dizziness, flushing | More effective with high-fat meals |
It is hypothesized that extracorporeal shockwaves stimulate expression of endothelial nitric oxide synthase, vascular-endothelial growth factor, and other vascular growth factors, promoting vessel expansion and neovascularization that promote blood flow and erectile function.23 The Sexual Medicine Society of North America regards Li-ESWT as promising but does not endorse its use beyond research given its novelty.24 Since the release of this statement, further studies have demonstrated some efficacy of Li-ESWT in men with moderate ED, though an optimal protocol remains to be determined.25 It is important to differentiate between Li-ESWT and radial wave therapy, the latter of which uses low-pressure acoustic waves to deliver lower energy with less tissue penetrance compared with Li-ESWT.26 Direct-to-consumer marketing from men’s health clinics often use these two terms interchangeably even though a randomized controlled trial found no difference between radial wave therapy and sham therapy for treating ED.26 The Sexual Medicine Society of North America corroborates this, drawing a distinction between Li-ESWT and radial wave therapy.24 While regenerative therapies such as Li-ESWT in ED treatment require further investigation, patients should be informed regarding the lack of evidence to support radial wave therapy for ED treatment, particularly as radial wave therapy devices are often promoted as equivalent by health clinics for men. Stem cell therapy was initially proposed to improve erectile function by promoting angiogenesis and tissue healing and reducing scarring, inflammation, and apoptosis.27 Clinical trials have been limited, and its clinical application is still unknown. Similarly, platelet-rich plasma injections have been studied as an option for ED, but a recent randomized controlled trial found no difference in efficacy between platelet-rich plasma and placebo.28 Thus, the Sexual Medicine Society of North America’s position is that stem cell and platelet-rich plasma therapies should not be used in clinical practice.24 There are various effective treatment modalities for men who cannot tolerate PDE5 inhibitors or in whom these agents fail.
Treatment choice should take underlying comorbidities into account. Referral to a urologist experienced in sexual dysfunction can ensure that patients choose the option best aligned with their goals and expectations. Dr. Bajic has disclosed serving as an advisor or review panel participant for Endo Pharmaceuticals, Inc. The other authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
Treatment choice should take underlying comorbidities into account.
Referral to a urologist experienced in sexual dysfunction can ensure that patients choose the option best aligned with their goals and expectations. Dr. Bajic has disclosed serving as an advisor or review panel participant for Endo Pharmaceuticals, Inc.
| Lifestyle Factor | Recommended Action | Expected Benefit | Additional Notes |
|---|---|---|---|
| Physical Activity | Regular aerobic exercise | Better blood circulation | 30 minutes, 4 times/week |
| Diet | Consume heart-healthy foods | Improve vascular health | Fruits, vegetables, lean proteins |
| Alcohol Consumption | Limit or abstain | Reduces erectile dysfunction risk | Excess alcohol can impair function |
| Smoking | Quit smoking | Enhances blood vessel health | Various cessation programs |
The other authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.