Optimum use of second line treatment options for erectile dysfunction

About 30 % of patients receiving PDE5-Inhibitors for the treatment of erectile dysfunction do not respond to oral drug. It could depend on lack of correct information for drug use, lack of appropriate follow-up, presence of comorbidities, unrealistic patient expectations, incorrect diagnosis, performance anxiety and problematic relationships. So, before prescribing to patients a second line therapy, it is mandatory to carefully check if patient is taking PDE5-inhibitors in the right way and with an adequate sexual stimulation, if the medication taken is a licensed one, if patient is affected by hypogonadism and therefore needs a testosterone replacement therapy or if patient could benefit from the treatment of comorbidities. In addition, switching to another PDE5- inhibitor or a combination therapy with long-acting and short-acting PDE5-inhibitors could be effective strategies in non-responders. If patients are still not-responders, a second line therapy could be suggested. Intracavernosal injections (ICI) with vasoactive agents (prostaglandins, papaverine, phentolamine, vasoactive intestinal polypeptide) are the most widely used second line therapy and their effectiveness is high (>70 %). Nevertheless, the drop-out rate of these therapy is still high due to willing of a definitive and permanent therapy, discomfort in self-injection, lack of spontaneity in sexual relationship and stop of sexual activity. Use of vacuum device is a valid treatment too for erectile dysfunction with a success rate of more than 90 % and could be an alternative method in older patients in a stable relationship. Treatment with alprostadil cream with a permeation enhancer in patients affected by erectile dysfunction of all etiology and physical therapy with low-intensity shockwave in patients affected by vasculogenic erectile dysfunction are very promising strategies but to date no specific recommendation could be given for their use. Combination of different second line therapies or combination between a second line treatment and a PDE5-inhibitor could be tried before proposing a penile prosthesis implant