Although the penile prosthesis remains one of the most effective treatments for all types of ED, nonsurgical management has replaced prosthetic surgery as the preferred choice in the last decade. Both specific and nonspecific treatments are available. The former include psychotherapy, change of offending medications, and hormonal therapy; the latter include sildenafil, vacuum constriction device, transurethral therapy and intracavernous injection. Although nonspecific therapies appear to be more effective for most cases of ED, the patient should also be made aware of specific therapies.

Lifestyle Changes

It is well known that ED is intimately related to the atherosclerotic coronary and peripheral vascular diseases. Although it is difficult to prove its beneficial effect, a change of lifestyle should be encouraged (regular exercise, a healthy diet, smoking cessation, alcohol in moderation only). Long-distance bicycling is another risk factor that should be discussed. The detrimental effects of perineal compression on penile arteries may be lessened by changes in seat design and riding practices.

Changing Medications

When a patient complains of sexual dysfunction after taking a particular medication, it is important to determine whether the problem is related to loss of sexual drive, impaired erection, or rapid/delayed ejaculation. In many situations, changing the medication to a different class of agents is a feasible first step. Antihypertension agents therapeutically lower blood pressure; this primary effect has long been thought the mechanism of their adverse actions on erection. Switching patients to newer agents such as alpha-adrenoceptor antagonists, calcium channel blockers, and angiotensin-converting enzyme inhibitors may reverse ED in some patients. Patients complaining of sexual dysfunction while taking antidepressants may benefit from changing to trazodone or bupropion.

Psychosexual Therapy

Therapies such as a sildenafil, vacuum constriction device, or intracavernous injection may provide a faster relief for patients than a prolonged course of psychosexual therapy. However, in patients with obvious psychologic problems, a referral to a psychologist or sex therapist is highly recommended because elimination of the specific underlying cause may result in a cure. Moreover, in some patients with mixed psychogenic and organic ED, psychosexual therapy may help relieve the anxiety and remove unrealistic expectations associated with medical or surgical therapy.