Phosphodiesterase type 5 inhibitors (PDE5-i) have become first line therapy for the treatment of erectile dysfunction. Most initial prescriptions for PDE5-i are by primary care practitioners. Urologists must now routinely manage the patient who has failed initial therapy with PDE5-i. Lifestyle modifications can be of benefit to patients. Patient education and optimization of the PDE5-i can result in a successful response. Interestingly, there are reports of up to 60% salvage after changing the PDE5-i utilized. Daily PDE5-i have shown benefit, and treatment of hypogonadism can enhance response to PDE5-i. We review the management of PDE5-i failures with emphasis on noninvasive approaches to gaining improved erectile response to these medications. An algorithm based on the reviewed strategies is proposed to guide clinicians in the treatment of erectile dysfunction.
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