1, 2 and 3 Line Therapy of Erectile Dysfunction Treatment
Innovative erectile dysfunction treatment is a complex method. It is comprised of etiotropic meaning curing devoted to eliminating the causative factor effect of this condition and pathogenetic implying a restoration of the functional activity that participates in erection appearance. Modern treatment methods were created on the background of recent study related to the erection process, as well as the mechanisms of its violation.
The basic principles of therapy, applied by the andrologist, are based on the concepts of the recommendations of the European urological association together with Canadian Pharmacy Mall, which were developed in 2007. They include stepwise therapy of erectile dysfunction with 3 lines of basic treatment. The essence of this stepwise therapy is that usually after the diagnosis, the treatment includes the first line, in the absence of the necessary effect, the therapeutic measures of the 2nd line are applied, and then, if necessary, the third line, takes part in erectile dysfunction treatment.
The Main Headings of Etiotropic and Pathogenetic Therapy
Conventionally, there are 2 main groups of causes that lead to the development of erectile dysfunction, namely:
- psychogenic factors;
- organic penile changes.
To eliminate the psychogenic factors impact (stress, depression, men’s fear of insufficient erection during sex), various methods of psychotherapy are applied, in which usually married couple is taken part. With erectile dysfunction associated with depression (prolonged depressed mood), only some antidepressant drugs can be used.
When organic erectile dysfunction diagnosis is established, the appropriate and immediate ED treatment therapy is pathogenetic with drugs of the group phosphodiesterase-5 inhibitors (PDE-5) application. The main effect is comprised in blocking the enzyme preventing a concentration of nitric oxide (NO) increase in penile cavernous bodies. As a result, the penis is filled with blood which provokes erection appearance.
Table: The Difference between Organic and Psychogenic ED
|Exacerbation with time
|Constant dysfunction character
|Situational dysfunction character
|Caused by disorder or medications’ application
|Caused by stress and constant fatigue
|During sexual intercourse, the erection may be maintained
|During sexual intercourse the erection may disappear
|Addicted to a partner
|Not addicted to a partner
|Disappearance of morning/nocturnal erections
|Kept morning/nocturnal erections
The 1-Line Erectile Dysfunction Therapy
The 1-line erectile dysfunction therapy is comprised of PDE-5 inhibitors meds. The mechanism of these drugs onset is found on magnifying NO concentration in the penile cavernous bodies, achieved by means of their walls relaxation and an enhancement in blood filling, provoking an erection.
There are several basic mandatory conditions for appropriate PDE-5 medications effectiveness, which include:
- sexual desire presence;
- testosterone sufficient level;
- required sexual stimulation with a partner.
The pharmaceutical market is full of several major active components, which contain:
Sildenafil (Viagra) is the pioneer in erectile dysfunction treatment. The effect is achieved within 30 minutes after Viagra pill intake with a duration of up to 6 hours. Viagra oral medication is released in several dosages: 25, 50 and 100 mg. In form of severe sexual dysfunction, an initial recommended dosage is 100 mg, then it may be reduced as the effect is possible to be reached. The active substance bioavailability reduces in the case with conjoined consumption of food and alcohol. As a result, it is better to take generic Viagra on an empty stomach in.
Tadalafil Citrate (Cialis) is proved to be the most long-lasting effect up to 36 hours. Cialis from Canadian Health&Care Mall is released for an oral administration. The available dosage is 10 and 20 mg. Treatment by means of Cialis is recommended to start from 10 mg, then, if there is a necessity, to achieve a positive outcome, the dosage may be magnified.
Vardenafil (Levitra) is one more member in a PDE-5 inhibitors group with the effect lasting up to 12 hours. Nevertheless, 21% of men observe effect within 10 minutes after drug admission. The effect is achieved only in case of natural sexual stimulation, which is significant in the curing of psychogenic erectile dysfunction. Levitra has several dosages: 5, 10 and 20 mg. The average therapeutic recommended dose is 10 mg, if necessary, it may be changed.
Udenafil (Zidena) – a new drug with a rapid therapeutic effect onset with a long-lasting effect up to 1 day. Alcohol and fatty food practically do not affect the active substance absorption.
PDE-5 Inhibitors Effectiveness: Viagra, Cialis, Levitra and Zidena
|The Effect Onset, min
|The Effect Duration
|The Frequency of SuccessfulTreatment
|66 (50-100 mg)
|75 (20 mg)
|65 (20 mg)
|88 (100 mg)
2-Line Erectile Dysfunction Therapy
This 2-line is comprised of intracavernous and intraurethral injection of vasoactive medications in case if the 1-line ED treatment is considered to be ineffective.
The intracavernous injection approach is characterized as the injection of several subgroups of drugs directly into the penile cavernous bodies. It increases the treatment effectiveness up to 70%. The medications for intracavernous application are:
- Papaverine is a wide spectrum of an antispasmodic effect that advances the expansion of cavernous bodies and their better filling with blood.
- Phentolamine – a drug with alpha-adrenoblockers characteristics, which lead to a block of the corresponding receptors providing the relaxation of the cavernous bodies walls for greater blood filling.
- Prostaglandins are biologically active constituents that have a positive influence on the cavernous bodies functional condition.
For getting greater effectiveness, these ED drugs can be related in combination.
3-Line Erectile Dysfunction Therapy
The 3-Line erectile dysfunction therapy involves performing a surgical reconstruction of the penile arteries. In the case of the ineffectiveness of the first 2 lines of therapy for erectile dysfunction, the doctor can designate the 3rd line. The most effective such surgery can be in men of younger age with local occlusion (a violation of blood flow or blockage of the lumen) of one or more arteries of the penis, in particular as a result of the transferred trauma. In older men, against the background of systemic atherosclerotic arteries (cholesterol deposition in the walls of the vessels with the formation of atherosclerotic plaques that reduce or overlap their lumen), the effectiveness of this intervention is questionable, and a positive result with respect to erection is short-lived.
Performing reconstructive surgical interventions include dorsal bandaging of the penis veins, as well as ballooning of the arteries. According to the indications, an additional endoprosthesis of the penis can be performed with the implantation of a dense material or special air cylinders into cavernous bodies.
All 3 lines of therapy for erectile dysfunction represent a common tactic, the choice of specific drugs, their dosages, the methods of administration, and the use of additional mechanical techniques (LNP-therapy, special rigid condoms) is performed by the doctor individually.