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Sexual Medicine & Andrology Pharmacotherapy

Pharmacotherapy for erectile dysfunction (ED), Peyronie's disease (PD), priapism, male hypogonadism, and female hypoactive sexual desire disorder (HSDD). The toolkit spans oral first-line therapy (PDE5 inhibitors), second-line intracavernosal and intraurethral injectables, intralesional plaque-modifying agents (clostridial collagenase, interferon, verapamil), the testosterone-replacement framework recently reshaped by the TRAVERSE 2023 cardiovascular non-inferiority finding, and the female-HSDD agents (flibanserin, bremelanotide, off-label transdermal testosterone).

For surgical management of these conditions see the Sexual Dysfunction Treatment Atlas. For Peyronie's disease and hypogonadism / testosterone clinical articles see the linked pages.

  • PDE5 InhibitorsSildenafil, tadalafil, vardenafil, avanafil. FDA-approved ED + tadalafil-LUTS/BPH; post-RP rehab (Sari Motlagh network meta + REACTT + Jo 2018 immediate start); recurrent ischemic priapism (AUA/SMSNA 2022 + Hou 2021 4.4× ED-visit reduction); Peyronie's disease-modifying (Spirito 2024); MET (Sharma 2021 tadalafil + silodosin); transplant tacrolimus PK; nitrate Trolle Lagerros 2024 JACC mortality data.
  • Intracavernosal Injection AgentsAUA second-line ED. BiMix / TriMix / QuadMix / Invicorp (Al-Mitwalli 2025); ICI for Peyronie's (CCH REMS, IMPRESS, Ziegelmann 2023 incremental benefit per cycle, Goldstein 2020 5-yr durability, Zucker 2024 corporal rupture 0.7%); PDUS diagnostic; phenylephrine rescue for ICI-induced prolonged erection.
  • Intraurethral Alprostadil (MUSE)MUSE applicator technique; Padma-Nathan 1997 NEJM pivotal (65% vs 18%); real-world efficacy 35–78%; Shabsigh 2000 / Shokeir 1999 head-to-head vs ICI (efficacy vs acceptability trade-off); ACTIS band rescue; MUSE + PDE5i combination for salvage; McCullough 2010 post-RP rehab equivalent to sildenafil.
  • Testosterone ReplacementTRAVERSE 2023 resolving MACE non-inferiority; Snyder 2024 fracture paradox; 2025 NEJM reframing (libido yes, ED no); full formulation table including oral undecanoate (Jatenzo / Tlando / Kyzatrex) and nasal Natesto; T4DM vs TRAVERSE glycemic contrast; prostate-cancer safety (TRAVERSE substudy, Baik 2025 Medicare HR 0.84, García-Becerra 2026 41-RCT meta, saturation-model rationale); fertility-preservation alternatives.
  • Androgen AdjunctshCG (only FDA-approved adjunct), clomiphene, anastrozole, enclomiphene. Habous 2018 RCT clomiphene / hCG / combination equivalence; Muir 2025 meta for HH spermatogenesis induction; Helo 2015 head-to-head CC vs anastrozole RCT; Burnett-Bowie 2009 anastrozole bone-loss signal; combination strategies.
  • Peyronie's Disease AgentsCCH (only FDA-approved — IMPRESS 17°, Hellstrom 2019 real-world, Ziegelmann 2023 pooled incremental benefit, Goldstein 5-yr durability, Zucker 2024 0.7% rupture); IFN α-2b (Tulane / ventral plaques); verapamil Cochrane very-low-certainty + EAU recommends-against; explicit AUA do-NOT-offer list (vitamin E, tamoxifen, procarbazine, omega-3, E + carnitine); acute-phase tadalafil + pentoxifylline; emerging PRP (Ledesma Phase 2) and hyaluronic acid.
  • Priapism ManagementIntracavernosal phenylephrine protocol (standard + CV-risk dilutions); Scarberry 2022 / Sidhu 2018 / Ridyard 2016 / Muruve 1996; methylene blue Martínez Portillo CCIT-induced rescue; Lowe-Jarow 1993 terbutaline RCT; prevention with counterintuitive daily PDE5i (Burnett 2006/2014 RCT, Hou 2021 4.4× reduction, Pereira NO-resistance mechanism); Hoeh-Levine ketoconazole-prednisone 94% success; etilefrine, hormonal suppression with explicit fertility impact.
  • Flibanserin (Addyi)FDA-approved for acquired, generalized HSDD in premenopausal women only (2015). Daily 100 mg PO at bedtime; 5-HT1A agonist / 5-HT2A antagonist. Boxed warning — alcohol-related severe hypotension and syncope; CYP3A4 inhibitor + hepatic-impairment contraindications. Modest efficacy: meta-analysis of 8 RCTs / 5,914 pts shows +0.5 SSE/month over placebo.
  • Bremelanotide (Vyleesi)FDA-approved for acquired, generalized HSDD in premenopausal women only (2019). On-demand 1.75 mg SC ~45 min before activity; melanocortin-4 receptor agonist. RECONNECT phase 3 n=1,267 (Kingsberg 2019; Simon 2019 / 2022): FSFI-desire +0.35 vs placebo (p<0.001); 52-wk extension confirms sustained effect. Nausea ~40%, transient BP increase contraindicates uncontrolled HTN.
  • Female Testosterone for HSDDPostmenopausal HSDD only — the only evidence-based indication for testosterone in women per the 2019 Global Consensus Position Statement. Off-label in the US (no FDA-approved female formulation). Islam 2019 Lancet Diabetes Endocrinol meta of 36 RCTs / 8,480 pts: +0.85 SSE/month over placebo. Transdermal route only; aim for upper-female-reference-range; 3–6 month trial; discontinue at 6 mo if no response.