Safe Erectile Dysfunction Medications After Radical Prostatectomy

First-Line Treatment: PDE5 Inhibitors

The American Urological Association recommends that all FDA-approved oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil, and avanafil) are safe and effective first-line treatments for erectile dysfunction after radical prostatectomy, though response rates are lower than in the general ED population 1
PDE5 inhibitors should be offered to all post-prostatectomy patients with ED unless contraindicated by concurrent nitrate use, as recommended by the American Urological Association 1

Before prescribing any PDE5 inhibitor, you must verify the patient is not taking nitrates in any form—this is an absolute contraindication due to risk of potentially fatal hypotension, as stated by the American Heart Association 1, 2
Assess cardiovascular risk by determining if the patient can climb 2 flights of stairs in 20 seconds, as recommended by the American College of Cardiology 2

Post-prostatectomy patients have more severe ED at baseline and respond less robustly to PDE5 inhibitors compared to the general ED population, with a success rate of 54% for tadalafil 20 mg vs 32% placebo, as reported by the American Urological Association 1, 2, 4

An adequate trial requires at least 5 separate attempts at maximum tolerated dose before declaring treatment failure, as recommended by the European Association of Urology 2
Inadequate sexual stimulation (PDE5 inhibitors require arousal to work) is a common cause of apparent treatment failure, as stated by the American Urological Association 1, 4

Tadalafil has a 36-hour duration of action, allowing spontaneous sexual activity without precise timing, as reported by the American College of Cardiology 2
Avanafil has the lowest rates of dyspepsia among all PDE5 inhibitors, as stated by the European Association of Urology 3

In patients with mild to moderate hepatic or renal impairment, start with lower doses due to delayed drug metabolism, as recommended by the National Kidney Foundation 1, 4
Severe hepatic impairment is a contraindication for PDE5 inhibitors, as stated by the American Association for the Study of Liver Diseases 2

Early initiation of PDE5 inhibitors after prostatectomy may assist with penile rehabilitation, though evidence for improving unassisted erectile function is limited, as reported by the American Cancer Society 1, 5