The “Guidelines for Male Sexual Dysfunction” published by the European Society of Urology provide diagnostic and treatment bases for patients with erectile dysfunction (ED) and premature ejaculation. It has been updated seven times since its first release in 2000.

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Drug therapy has fundamentally changed the diagnosis and treatment of ED. The "Guide" recommends the first treatment of ED patients: oral drug therapy (PDE5i), vacuum device therapy and shock wave therapy. Among these, PDE5i is popular with doctors and patients because of its rapid onset of action and its convenient administration. It is widely used in clinical practice. However, the problems that must be taken into account in the application and in the application process also affect doctors and patients. Therefore, the interpretation of PDE5i in the “Guide” aims to help general practitioners to use PDE5i more sensibly.

PDE5 hydrolyzes cGMP in the corpus cavernosum tissue. Inhibiting PDE5 can relax smooth muscles, increase arterial blood flow, and cause compression of the venous subalbumin plexus and penile erection. Such drugs cannot trigger an erection, but require sexual stimulation to promote an erection. The effect is that the hardness of the penile erection is enough to get into the vagina. Four effective and selective PDE5I have been approved by the European Medicines Agency (EMA) for the treatment of ED.

Sildenafil

It was first launched in 1998 and was the first PDE5i on the market with prescription doses of 25, 50 and 100 mg. The "Guide" recommends an initial dose of 50 mg, which is adapted to the effectiveness and side effects of the patient. After the patient has taken sildenafil for 30 to 60 minutes, the drug can have a therapeutic effect and the healing effect can be maintained for 12 hours. Patients who eat a high-fat diet may decrease the effectiveness of the drug due to prolonged drug intake. A dose-response study showed that after 24 weeks of taking the drug, the erection improvement rate of the placebo group was 25% and the erection improvement rate of the sildenafil 25, 50 and 100 mg groups was 56%, 77% and 84%, respectively .

Tadalafil

It was approved for the treatment of ED in February 2003 and works 30 minutes after taking the medicine. The best effect is 2 hours after taking the drug. The effect can be maintained for 36 hours without being affected by the diet. The prescribed doses are 10 mg and 20 mg, as required, or 5 mg daily. The "Guide" recommends an initial dose of 10 mg, which is adapted to the effectiveness and side effects of the patient. A dose-response study showed that after 12 weeks of taking the drug, the erection improvement rate of the placebo group was 35% and the erection improvement rate of the tadalafil 10 and 20 mg group was 67% and 81%, respectively. Tadalafil is effective in the treatment of patients with ED, including refractory ED (such as diabetes).

Vardenafil

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It was approved for the treatment of ED in March 2003 and came into effect 30 minutes after taking the drug. If the fat content in the diet is more than 57%, the effectiveness of the drug may be reduced. The prescribed doses are 5, 10 and 20 mg, as needed. The "Guide" recommends an initial dose of 10 mg, which should be adjusted to the efficacy and side effects of the patient. A dose-response study showed that after 12 weeks of taking the drug, the erection improvement rate of the placebo group was 30% and the erection improvement rate of the vardenafil 5, 10 and 20 mg groups was 66%, 76% and 80%, respectively. Valderafil is effective in the treatment of patients with ED, including refractory ED (such as diabetes).

Avanafil

Highly selective PDE5I, which was approved by the EMA for the treatment of ED in June 2013. The prescribed doses are 50, 100 and 200 mg, as needed. The "Guide" recommends an initial dose of 100 mg, which is taken orally if necessary and taken 30 minutes before sex. The dosage should be adjusted according to the effectiveness and side effects of the patient. After taking the drug, the success rate of intercourse in the placebo group was 28% and the success rate of intercourse in the Avanafil 50, 100 and 200 mg groups was 47%, 58% and 59%, respectively. In a sexual study within 15 minutes of administration, the strength of avanafil 50, 100 and 200 mg was 64%, 67% and 71%, respectively. The maximum recommended dose rate is once a day and the dose adjustment does not depend on kidney function, liver function, age or gender. Compared to fasting, eating can delay the effects of avanafil, and this medicine can be taken on an empty stomach or after eating. Avanafil is effective in the treatment of patients with ED, including refractory ED (such as diabetes).

Choose medicine

To date, there are no data on the efficacy of the four drugs and patient preference when using a multicentre double-blind or triple-blind method. Patients must understand the properties of each drug (short or long) and possible side effects, and decide which PDE5i to use based on the frequency of sex life and the patient's experience.

On-demand or long-term use

Age, diabetes and surgical damage can cause structural changes in the cavernous sinus. Animal studies have shown that long-term use of PDE5i can improve and prevent these changes, but human research data are still lacking.

Several studies have shown that long-term use of tadalafil significantly improves erectile function and is well tolerated. In 2007, the EMA approved 2.5 and 5 mg of tadalafil daily for the treatment of ED. Tadalafil 5 mg daily offers an alternative therapy of on-demand administration for couples who prefer natural traffic to planned traffic or who expect frequent traffic. The advantage of this therapy is that medication and sexual activity are no longer closely related. The drug can also be used for long-term treatment of patients with ED who are complicated by lower urinary tract symptoms.

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