McMahon et al discussed how to evaluate a man with erectile dysfunction who has failed therapy with a PDE5 (phosphodiesterase type 5) inhibitor such as sildenafil. Often a man who has initially failed therapy can be successfully managed by selection of an appropriate intervention. The authors are from St. Vincent's and Princess Alexandra Hospitals in Australia and Columbia University in New York City.
Reason for Failure
Management
incorrect use of drug
educate patient on how to use drug
non-compliance
encourage compliance and monitor use
incorrect dosage
optimize dose
new or worsening comorbidity
identify and try to correct underlying conditions
psychological component
provide psychological counseling
hypogonadism
add testerosterone replacement
tachyphylaxis (drug tolerance)
switch to an alternative agent
Options if the above measures fail:
(1) referral to a specialist.
(2) penile prosthesis.
(3) intracavernosal injection.
(4) vacuum constriction device.
(5) combination therapy (PDE5 inhibitor plus doxazosin, apomorphine or intraurethral alprostadil).
(6) daily dosing of the PDE5 inhibitor (rather than intermittent, on demand dosing)
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