Non-invasive Management Options for Erectile Dysfunction When a Phosphodiesterase Type 5 Inhibitor Fails
Phosphodiesterase type 5 inhibitors (PDE5Is) are the drug of choice for medical management of erectile dysfunction (ED). On-demand PDE5Is have an overall efficacy of 60–70% for ED; 30–35% of patients fail to respond to a PDE5I, and 30–50% of non-responders can be salvaged with detailed counseling on proper use and physician follow-up to ensure that the patient has been prescribed an appropriate and full PDE5I clinical trial. True non-responders may be offered intracavernosal injections of erectogenic drugs, intraurethral alprostadil, or surgical insertion of a penile prosthesis. Such options are not discreet and are associated with more adverse effects than PDE5Is. Thus patients may request additional non-invasive medical management options. This review describes published literature on patients who failed to respond to an on-demand PDE5I regimen and were treated with a non-invasive PDEI-based regimen, including switching from one PDE5I to another; increasing the dose of PDE5I above the labeled dosage range; using two PDE5Is concurrently; using a daily PDE5I regimen; or combining a PDE5I with a testosterone supplement, α-adrenergic antagonist, intraurethral or intracavernosal alprostadil, vacuum erection device, or low-intensity shock wave therapy. The limitations of published clinical trials do not allow for sufficient evidence to recommend one option over another. Therefore, in PDE5I-refractory patients, the choice of a specific next step should be individualized based on the preference of the patient and his sexual partner, the advantages and disadvantages of the various options, the concurrent medical illnesses and medications of the patient, and the patient’s response to treatment.
The authors received no research grants from funding agencies, honoraria for speaking at symposia, financial support for attending symposia, financial support for educational programs, employment or consultation, support from a project sponsor, position on advisory board or board of directors, multiple affiliations, financial relationships, intellectual property rights, or holdings of spouse and/or children that may have financial interest in the work.
Compliance with ethical standards
This is a review of published literature, therefore, compliance with ethical standards for research involving human participants and/or animals or informed consent are not applicable.
Conflict of interest
Dr. Mary Lee and Dr. Roohollah Sharifi declare that they have no conflict of interest.
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