ABSTRACT
The management of patients with erectile dysfunction has recently been grouped into three different levels1. Initially, patients should be advised to control every clinical abnormality or life-style factor associated with a higher risk of erectile dysfunction. Usually, this first step alone is not able to cause a significant improvement of the patient’s erectile function, and first-line therapy is considered. This includes oral pharmacotherapy, use of a vacuum device or psychosexual therapy. The majority of patients who are currently seen for erectile dysfunction are prescribed either sildenafil or apomorphine sublingual, the two drugs that are officially marketed. This happens because the efficacy and safety of the oral approach have been clearly established, and because most patients would rather undertake a therapy that is simple to use. Patients who do not respond to oral therapy are considered for second-line treatment, which includes intraurethral or intra-cavernosal administration of vasoactive drugs. To date, it has been rare to prescribe one of the second-line therapies when choosing treatment for the first time: this used to happen when sildenafil was the only oral drug on the market, as patients using nitrates had a definite contraindication to the use of sildenafil. A second patient category might be represented by those requesting a fast response that could not be obtained with sildenafil; however, apomorphine sublingual is characterized by a fast onset of action, and may represent an effective solution for these patients2. In conclusion, intraurethral and intracavernosal therapies are currently used almost exclusively in patients who fail to respond to oral therapy; however, when counselling the patient with erectile dysfunction on the treatment options available, every alternative should be extensively detailed at the first office visit.
