Erectile dysfunction (ED, erectile dysfunction, erection problem) is one of the problems we encounter frequently today. In recent years, there has been a significant increase in the use of oral drugs used in the treatment of erectile dysfunction. These drugs are groundbreaking drugs in the treatment of erection. This group of drugs is generally known as phosphodiesterase type 5 inhibitors (phospho diestherase type 5 inhibitors, PDE5i). It is among the most used drugs in the world.

These drugs, which were produced by the leading big companies in the world, are now produced by many companies. In our country, local companies have started to produce this group of drugs and are offered for sale in pharmacies.

In this article, I will give general information about the PDE5i group drugs taken orally in the treatment of erection.

What drugs are used in the treatment of erectile dysfunction?

Drugs taken orally as pills in the treatment of erection are known as PDE5i group drugs (ED drugs). This group of drugs is in 4 groups and they are:

• Sildenafil (Viagra): It is taken about 1 hour before intercourse. It is preferable to take it on an empty stomach. Depending on the degree of the disease, the effect may last up to 4-5 hours. It is available in the market in the form of 25, 50 and 100 mg.
• Vardenafil (Levitra): It is taken 45 minutes to 1 hour after intercourse. It can be taken on an empty stomach or with food. This should be taken care of as fatty foods will prevent absorption. It is effective for 4-5 hours. It is available in pharmacies as 5.10 and 20 mg.
• Tadalafil (Cialis, Hardcis): It is taken 1-2 hours before intercourse. Taking it with food does not pose a problem in terms of absorption. These drugs, unlike others, are effective for 36 hours. They are long-acting drugs. Low doses of these are meant to be taken every day. It is prepared to take high-weight doses before intercourse. It is available in pharmacies as 5,10 and 20 mg.
• Avanafil: It can be taken with food or on an empty stomach. It is generally recommended to be taken 30 minutes before intercourse. Effects can last up to 6 hours. It is available as 50, 100 and 200 mg.

How do PDE5i group drugs work?

PDE5i group drugs do this by increasing the effect of nitric oxide (NO). NO is an important molecule in erection formation. By relaxing the cavernous smooth muscles in the inner part of the penis, it allows the penile vessels to expand and more blood to the penis. An erection occurs as a result of excessive arterial blood flow to the penis. Although there are differences between them in terms of structure and duration of action, the mechanisms of action of this group of drugs are similar.

How are ED medications used?

PDE5i group drugs (ED drugs) are the most frequently used first-line drugs in the world for the first-line oral treatment in patients with erectile dysfunction. ED drugs are used in two ways:

• Before intercourse: It is usually taken about 1 hour before intercourse. This method is suitable for patients whose erection problem is not very serious or who are normal and use it to increase performance.
• Long-term use: Low doses are generally preferred for long-term use. For this purpose, we prefer tadalafil 5mg/day. Studies have shown that night erections begin and the erection improves in those who use these drugs for 3 months. In this way, long-term and low-dose therapy is also used for therapeutic purposes. We recommend this treatment for those with serious erection problems and for penile rehabilitation, and our results are quite successful.

What are the side effects of drugs used in the treatment of erection?

These drugs do not have very serious side effects. Common side effects of PDE5I group drugs are as follows:

• Facial redness
• Headache
• Indigestion
• Nasal congestion
• Back pain
• Vision problems: Blurred, blue vision, hypersensitivity to light

Although PDE5i group drugs are extremely rare, sometimes serious complications can occur. These:

• Hearing loss: PDE5i drugs can have mild vision-related side effects. However, its side effects, up to serious loss of vision, are extremely rare. There is also the possibility that these are caused by pre-existing problems rather than directly by the side effects of the medication. In such cases, patients should definitely consult their doctor. In fact, it is best to use these drugs with the recommendation of a doctor.
• Vision loss: The effects on the hearing system are extremely small. Serious effects are likely the result of pre-existing ear conditions.
• Priapism: Priapism means a painful and prolonged erection. Although very rare, it can be seen in patients taking PDE5i. In such cases, these patients must be seen by a urologist within 4-5 hours. Priapism should be drained immediately. Otherwise, it will cause permanent damage to the penis and erection problem.

We have been prescribing this group of drugs to our patients for many years. Except for mild side effects, we have never encountered any serious side effects (complications).

Who should not be given PDE5i group drugs?

Drugs used in the treatment of oral erectile dysfunction are used extensively because they have non-serious side effects in normal people. Most of the time, these drugs can be bought directly from pharmacies without a doctor’s prescription. In some cases, the use of PDE5i drugs can cause very serious side effects. There are some situations in which oral ED medications should not be taken or are inconvenient to take. These:

• Those who take nitrite-nitrate-containing drugs: Nitrite, nitrate-containing drugs (nitroglycerin) are drugs used in patients with heart-related chest pain (angina). Care should be taken in this regard, as serious low blood pressure and fainting will occur when taken together.
• Blood pressure patients: Patients with very low or very high blood pressure should be careful while taking these drugs. It is best for these patients not to take these drugs without the advice of a doctor.
• People with severe liver disease
• Patients with kidney failure and therefore undergoing dialysis.

Do ED drugs work the same for every patient?

No, this group of drugs does not show the same effect to every patient. Its effects differ from patient to patient. The effectiveness of PDE5i group drugs is less in patients who are obese, elderly, have a sedentary life, diabetics, hypertension patients, those who have undergone surgery for prostate cancer, those with cardiovascular disease, and those with neurogenic problems.

What should be considered for maximum effect from ED drugs?

There are some important issues that patients should pay attention to in order to get the maximum (best) degree from the drugs used in the treatment of erectile dysfunction (ED): These are:

• Regular exercise
• Obese (obese) patients to reach their ideal weight
• Hypertension (high blood pressure) if there is control
• Control if you have diabetes mellitus (diabetes mellitus, diabetes)
• To use at the appropriate dose and time
• If there is a testosterone deficiency, it should be treated.
• To use with doctor’s recommendation

What are the points to be considered while taking ED drugs?

Since the absorption of drugs is affected by food and drink, this must be taken into account during drug use:

• Sildenafil and Vardanafil interact with food and their absorption from the small intestine is prevented. Therefore, this group of drugs should be taken on an empty stomach. It is preferable not to take it with fatty foods.
• Since tadalafil and avanafil are not affected by food, they can be taken with food. But preferably these drugs are better not to be taken with excessive meals.

Which ED drug is the best?

The effects of this group of drugs are similar to each other. There is no best medicine for every patient. Factors such as the duration of action of the drug (short, long-acting), prices, ease of use are important in terms of patient preference.

Are ED drugs used to treat prostate enlargement?

ED drugs are also used in the drug treatment of benign prostate enlargement (BPH). It is widely used as a combination therapy with alpha blocker drugs. We also apply this treatment combination to our patients. For this purpose, most tdalafil group drugs are used at 5mg doses every day.

The use of PDE5i in the treatment of BPH has two main purposes:

• This group of drugs relaxes the smooth muscles in the bladder neck and prostate capsule, allowing patients to urinate comfortably.
• To treat if the patient has ED at the same time as BPH

Are ED drugs addictive?

PDE5i group drugs used in the treatment of ED do not cause addiction in patients. In particular, patients who use these drugs for a long time or for performance purposes think that they will have an erection problem when they stop taking the drug psychologically.

Are ED drugs used together with ESWT therapy?

ESWT, shock wave therapy to the penis is widely used in patients with erectile dysfunction. Studies have shown that ESWT treatment is effective in patients who do not respond to ED drugs. It is known that patients benefit from ED drugs after ESWT treatment. In addition, it has been shown that more positive results are obtained as a result of the co-administration of ESWT and PDE5i group drugs. We also apply ESWT and ED drugs together to our patients and our results are quite good.

Can ED drugs be used together with PRP and stem cell therapy?

ED drugs can be taken with PRP (P-shot), SVF and other stem cell applications applied to the penis. It has been shown that taking ED drugs together with these treatments, known as restorative or regenerative treatment methods, is more effective.

Do ED drugs harm sperm?

Ed drugs are also widely used among young people and men who want to have children. One of the questions frequently asked by our patients is whether these drugs will have negative effects on sperm or will they cause infertility. Scientific studies have shown that ED drugs have positive effects on sperm and do not cause infertility, on the contrary, they can be beneficial.

Can someone who uses one drug switch to another drug?

The effects and mechanisms of this group of drugs are very similar to each other. There is no problem in switching from one drug of the same group to another. It is better that these are under the control of the Urologist.

Are ED drugs effective in treating female sexual dysfunction?

ED drugs have been tried in the treatment of female sexual dysfunctions. However, it has been shown that they are not effective in this regard. There are scientific studies published in internationally respected Urology journals on this subject. We do not recommend these drugs to women.

Can ED drugs be taken for performance purposes by people who do not have erection problems?

One of the frequently asked questions is whether these drugs can only be used to increase performance in normal people. Yes, these drugs can also be used by normal people for performance purposes. If it is to be used for this purpose, we recommend the use of drugs only before intercourse, not for a long time.

Do ED drugs affect premature ejaculation?

PDE5i group drugs can also correct premature ejaculation. In the studies we conducted and presented in national and international congresses, we observed that ED drugs corrected this problem in patients with premature ejaculation problem. We published this study in international medical journals.

Can ED drugs be used with premature ejaculation drugs?

Yes it can be used. There is no harm in using ED drugs together with drugs used in the treatment of premature ejaculation. On the contrary, they are more effective when used together on premature ejaculation. We have shown this in our studies. We published this study in an international Urology journal.

Use of ED drugs in penile rehabilitation

PDE5i group drugs (ED drugs) are widely used in radical prostatectomy operations for prostate cancer (open, robotic, laparoscopic) to restore erection (penile rehabilitation). These drugs can be used alone or in combination with other methods used for penile rehabilitation. We also use this treatment method frequently for our patients. For this purpose, we prefer low dose tadalafil group 5 mg drugs.

In conclusion; PDE5i group drugs are the most commonly used drugs in the oral first-line treatment of erectile dysfunction all over the world. In order to obtain the expected result from these, it must be used under the control of a urologist. The urologist will prescribe the appropriate dose, duration and medication for the patient. Today, since these drugs are suitable for abuse, it is important to obtain the drug from a reliable source. In cases where there is no response to ED drugs and other treatment methods, penile prosthesis surgery is the last option.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul/ Turkey