Although the penile prosthesis remains one of the most effective treatments for all types of ED, nonsurgical management replaced prosthetic surgery as the preferred choice during the 1990s. Both specific and nonspecific treatments are available. The former includes psychotherapy, replacement of offending medications, and hormonal therapy; the latter includes the vacuum constriction device and ICI. Although nonspecific therapies appear to be more effective for most cases of ED, we believe that the patient should also be made aware of specific therapies to make an informed decision.
Although it is difficult to prove its beneficial effect, a change of lifestyle should be encouraged (regular exercise, a healthy diet, smoking cessation, alcohol in moderation only). In rabbit experiments, the deleterious effect of a high-cholesterol diet on the cavernous smooth muscle was reversed several weeks after cholesterol was removed from the diet (Kim et al, 1994). We found that the best time to discuss this with the patient is at the time of vascular evaluation. If he is made aware that penile vascular disease is part of a generalized vascular disease that may involve other organs, he will more likely accept the advice. The pathophysiology of ED is intimately related to the pathophysiology of atherosclerotic coronary and peripheral vascular diseases. Although the probability of complete ED was not statistically different between smokers and nonsmokers in the MMAS (11% vs. 9.3%), cigarette smoking significantly increased impotence associated with cardiovascular disease, hypertension, and medication usage.