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This Month's Question:

Erectile dysfunction (ED) management involves restoring erectile function while reestablishing the couple’s intimate relationship. Resuming sexual activity after a period of abstinence is difficult for some couples. What psychosocial implications should be considered when managing ED in patients and prescribing a phosphodiesterase type 5 (PDE5) inhibitor?

Response by Marian E. Dunn, PhD, Posted 09/21/06:

ED can create stress and emotional distance in a relationship that may require both partners’ involvement to overcome, even with the best treatments. Psychosocial factors affecting the man with ED, his partner, and the couple may provide the rationale for selecting a particular pharmacotherapy.¹ One reason for partner involvement when deciding to initiate PDE5 inhibitor therapy is to help the partner to understand how treatments work and to feel that her needs are being considered as well.¹ Organic and psychological components are not mutually exclusive.²

When discussing which PDE5 inhibitor may work best for a patient, it is important to
delineate the pharmacokinetic differences between them because these nuances may
influence selection of therapy. Sildenafil and vardenafil, each with a half-life of about
4 hours, achieve maximum absorption within 30 to 120 minutes, and the rate of absorption is reduced when administered with a high-fat meal.^3-5 In contrast, tadalafil, with a mean half-life of 17.5 hours, is absorbed within 30 minutes to 6 hours and can be taken with or without food.^5,6

When a man takes a shorter-acting agent, the partner may be aware of the resulting time constraints and feel pressured to be available for sexual activity during the drug’s period of action, even if “the mood” changes.¹ Worry about “wasting the pill” exacerbates this anxiety.¹ With a longer-acting PDE5 inhibitor, the partner may feel freer about timing sexual intercourse.¹ The partner also may feel comfortable initiating sexual activity. The longer-acting agent may provide the capacity for multiple attempts at sexual intercourse over a longer period.¹

A recent study found that use of a longer-acting agent was preferred because it restored the man’s morning erections and thus his “confidence as a man.”⁷ Further, when the drug is administered long before sexual activity, it restores confidence to the partner, too, who may feel responsible for the erection rather than suspect it is artificial and drug-induced.^1,8

Men who opt for a shorter-acting agent may have serious chronic conditions or concerns about having a medication in their bodies for longer than they feel is necessary.¹ Couples whose sexual activity is planned and those with a customary sexual routine and good communication skills also may prefer a shorter-acting agent.¹

References

1. Dunn ME, Althof SE, Perelman MA. Phosphodiesterase type 5 inhibitors’ extended duration of response as a variable in the treatment of erectile dysfunction [review]. Int J Impot Res. 2006 Jun 1; [E-pub ahead of print].

2. Tiefer L, Schuetz-Mueller D. Psychological issues in diagnosis and treatment of erectile disorders. Urol Clin North Am. 1995;22:767-773.

3. Viagra^® (sildenafil) prescribing information. Pfizer Inc: New York, NY; 2005.

4. Levitra^® (vardenafil) prescribing information. Bayer Pharmaceuticals Corp: West Haven, Conn; 2005.

5. Hedelin H, Ströberg P. Treatment for erectile dysfunction based on patient-reported outcomes: to every man the PDE5 inhibitor that he finds superior. Drugs. 2005;65:2245-2251.

6. Cialis^® (tadalafil) prescribing information. Lilly ICOS LLC: Indianapolis, Ind and Bothell, Wash; 2005.

7. Kim SC. Regaining of morning erection and sexual confidence by patients with erectile dysfunction. Asian J Androl. 2006 Jul 11; [E-pub ahead of print].

8. Riley A. The role of the partner in erectile dysfunction and its treatment. Int J Impot Res. 2002;14(suppl 1):S105-S109.