Feature Article

Erectile dysfunction. Part 2: Management of ED unresponsive to PDE5 inhibitors



© sturti/istockphoto.com models used for illustrative purposes only
© sturti/istockphoto.com models used for illustrative purposes only


Although phosphodiesterase-5 (PDE5) inhibitors are regarded as first-line treatment for most men with erectile dysfunction (ED), they are not effective in about a third of cases. GPs have a pivotal role in management of this group, with a range of strategies and therapeutic options, including sex therapy, alternative medications, devices and surgery.

Key Points

  • About a third of men with erectile dysfunction (ED) fail to respond to a phosphodiesterase-5 (PDE5) inhibitor.
  • The most common cause of initial PDE5 inhibitor failure is inadequate patient education or a failure to optimise dosage.
  • Severe penile vascular disease, unrecognised hypogonadism, uncorrected comorbid disease, vascular risk factors or psychosocial factors are also associated with initial PDE5 inhibitor failure.
  • Initial PDE5 inhibitor failure is almost universal after a radical prostatectomy.
  • Treatment with self-administered intracavernous injection therapy, a vacuum constriction device, combination therapy or a penile prosthesis is likely to help men with ED unresponsive to PDE5 inhibitors.