What is the best course for an 80-year-old male with erectile dysfunction who has unsuccessfully tried PDE5 (phosphodiesterase type 5) inhibitors?

Management of Erectile Dysfunction After PDE5 Inhibitor Failure in an 80-Year-Old Male

For an 80-year-old male with erectile dysfunction who has failed PDE5 inhibitor therapy, intracavernosal injection therapy with alprostadil is the most effective second-line treatment option. 1

Assessment of PDE5 Inhibitor Failure

Before moving to second-line therapy, verify proper use of PDE5 inhibitors:

• Ensure medication was taken on an empty stomach
• Confirm adequate sexual stimulation occurred
• Verify patient tried at least 5 separate occasions at maximum dose 1
• Check if patient tried different PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) 2

If testosterone deficiency is present:

• Consider combination therapy with testosterone plus PDE5 inhibitor, which is more effective than PDE5 inhibitor alone 2, 1

Second-Line Treatment Options

1. Intracavernosal Injection Therapy

• First choice for second-line therapy due to highest efficacy among non-surgical options 1
• Requires in-office test dose under healthcare provider supervision 2
• Meta-analyses show mean IIEF-EF improvement of 3.21 points versus placebo 2
• Appropriate for elderly patients with infrequent sexual activity 2

2. Vacuum Erection Device (VED)

• Non-pharmacological option with 90% initial efficacy, dropping to 50-64% after 2 years 2
• Benefits and risks should be discussed thoroughly 2
• Side effects include pain and bruising 2
• Contraindicated in patients with bleeding disorders 2, 1
• Only VEDs containing a vacuum limiter should be used 2

3. Intraurethral Alprostadil

• Less invasive than injections but generally less effective 1
• First dose should be administered under supervision due to risk of syncope 1
• Option for patients who prefer to avoid injections 2

Special Considerations for Elderly Patients

• Advanced age may affect treatment response and side effect profile
• Men with severe renal or liver disease should use caution with any medication 2
• Elderly patients often have comorbidities requiring medications that may interact with ED treatments 1
• VEDs may be particularly beneficial for older patients with infrequent sexual activity 2

Treatment Algorithm

1. Verify proper PDE5 inhibitor use and try alternative PDE5 inhibitors

   • Rule out incorrect administration, timing, or dosing
   • Consider testosterone testing and supplementation if deficient

2. If PDE5 inhibitors still fail, proceed to intracavernosal injection therapy

   • Perform in-office test dose
   • Provide proper training for self-administration

3. If injections are refused or contraindicated, consider:

   • Vacuum erection device
   • Intraurethral alprostadil

4. For patients who fail or cannot use all other options:

   • Consider penile prosthesis as final option 1

Monitoring and Follow-up

• Assess efficacy and side effects at regular intervals
• Monitor for changes in health status that might affect treatment
• Follow testosterone levels if hormonal therapy is used 1
• Reassess medication regimen periodically, especially if symptoms change 1

Remember that men with ED who are post-prostatectomy or have diabetes may have more severe ED at baseline and respond less robustly to treatments 2, 1.