Focus on phosphodiesterase inhibitors for the treatment of erectile dysfunction in older men

Background: Phosphodiesterase type 5 inhibitors (PDEIs) are the drugs of choice for the medical management of erectile dysfunction independent of the etiology of the disorder.

Objective: This review focuses on specific aspects of clinical use of PDEIs in older men with erectile dysfunction.

Methods: An electronic search of MEDLINE was conducted for articles published between January 1990 and January 2011 using the terms erectile dysfunction and PDEIs and limited to articles in English, humans, and males aged ≥45 years. The search was also conducted in EMBASE using the same search criteria for literature indexed between 1990 and 2010.

Results: A total of 1341 articles were identified. Of these, ∼91 were selected for this review. Sildenafil, vardenafil, and tadalafil are considered equally effective for erectile dysfunction, but they differ in some ways. Tadalafil's 36-hour duration of action allows for repeated sexual intercourse without the need to take additional medication in some patients, which is distinctly different from the shorter-acting sildenafil and vardenafil. Unlike tadalafil, the rate and extent of oral absorption of sildenafil and vardenafil are reduced by consumption of high-fat meals. Although headache, flushing, and rhinitis occur with all 3 PDEIs, cyanopsia is more common with sildenafil and vardenafil, and back pain is more common with tadalafil. Approximately 40% to 50% of patients who initially fail to respond to PDEIs can be salvaged with education and up-titration of dosing. PDEIs can be used in addition to antihypertensive medications in patients with well-controlled essential hypertension without producing clinically significant hypotension. Use of PDEIs in patients with cardiovascular disease is guided by the recommendations of the Second Princeton Consensus Conference. For the management of lower urinary tract symptoms due to benign prostatic hyperplasia, PDEIs may reduce obstructive voiding symptoms, but they do not increase urinary flow rate.

Conclusion: PDEIs are effective for erectile dysfunction and well tolerated in older men.