choices and exercise. After 2 years the mean international index of erectile function (IIEF) score improved in the intervention group from 13.9 to 17 points, but not in the control group. In multivariate analyses, changes in body-mass index, physical activity, and C-reactive protein were independently associated with changes in IIEF score. Thus, lifestyle changes are associated with improvement in sexual function in obese men with ED (36).

Even if the cause is organic, almost all men with ED will be affected psychologically. Sexual counseling is an important aspect of any treatment, and it is preferable to also involve the partner.

Oral Agents

Most men consider this to be the treatment of choice. The oral treatment options and their mechanisms of action are summarized in Table 3.

Central Initiators

Yohimbine. Yohimbine was the first drug officially listed for this indication. Yohimbine acts through central a-2-receptor blockade and thus, increases the centrally initiated efferences of the erectogenic axis. Although, its effectivity is often debated because of insufficient historic data, it showed a significant effect in a recent double blind prospective study compared with placebo. Its side effect profile is benign including palpitations, tremor, hypertension, and anxiety. The proerectile effect usually starts after about 2 weeks (37). In a meta-analysis yohimbine has been found to be more effective than placebo for all types of ED combined, but the effect was most prominent in nonorganic ED (38). Because of its marginal effect on organic ED, yohimbine cannot be generally recommended for treatment of ED in men with diabetes.

Treatment strategy of erectile dysfunction (algorithm)

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