Reemphasize Optimal Use Strategies and Repeat 100 mg Sildenafil
The next step is to reemphasize strategies for optimal sildenafil use and recommend repeat attempts at the 100 mg dose (Option A). 1 This patient has not had an adequate trial because he is taking the medication immediately after dinner (which delays absorption) and with minimal foreplay (sexual stimulation is mandatory for PDE5 inhibitors to work). 1
Why This Patient Has Not Failed Sildenafil
Before declaring treatment failure, an adequate trial requires at least 5 separate attempts at maximum dose with proper technique—this patient has only tried the 100 mg dose once. 1 The American Urological Association emphasizes that many apparent "treatment failures" result from modifiable factors rather than true medication inefficacy. 1
Critical Modifiable Factors in This Case
Timing with meals: Taking sildenafil immediately after dinner significantly impairs absorption and delays onset of action. 1 The medication should be taken on an empty stomach or with a light meal, approximately 1 hour before sexual activity. 1, 2
Inadequate sexual stimulation: The patient reports "minimal subsequent foreplay." Sexual stimulation is absolutely required for PDE5 inhibitors to work—they enhance the natural erectile response to arousal but do not create erections independently. 1, 3 This is one of the most common reasons for apparent treatment failure. 1
Insufficient number of attempts: The patient tried 50 mg twice and 100 mg once. An adequate trial at maximum dose requires at least 5 separate attempts with proper technique before concluding the medication is ineffective. 1
Why Not Testosterone Replacement (Option B)
While this patient has low-normal testosterone (345 ng/dL), testosterone replacement is not the next step for several reasons:
Testosterone alone is ineffective for ED: Low-quality evidence shows testosterone monotherapy does not reliably improve erectile function or successful intercourse frequency compared to placebo. 4 Testosterone therapy alone is not an effective monotherapy for ED. 3
Combination therapy is premature: The National Comprehensive Cancer Network recommends adding testosterone to PDE5 inhibitors only for patients with testosterone levels <300 ng/dL who have already failed an adequate trial of a PDE5 inhibitor alone. 1 This patient's level of 345 ng/dL is low-normal but above the threshold, and he has not yet had an adequate sildenafil trial. 1
Response to PDE5 inhibitors indicates intact erectile tissue: Men with purely hormonal ED typically do not respond to PDE5 inhibitors at all because of inadequate sexual desire and impaired nitric oxide pathway function. 3 The fact that this patient is attempting intercourse suggests his testosterone level is sufficient for libido, and the issue is primarily technique-related. 1
Why Not Penile Prosthesis (Option C)
Penile prosthesis implantation is considered only after failure of at least two different PDE5 inhibitors at maximum dose with proper technique, plus failure of second-line therapies (vacuum devices, intraurethral alprostadil, or intracavernosal injections). 3, 5 This patient has not even completed an adequate trial of his first PDE5 inhibitor. 1
Why Not Intracavernosal Injections (Option D)
Intracavernosal injection therapy with papaverine and phentolamine is a second-line treatment reserved for patients who have failed at least two different PDE5 inhibitors at maximum dose after addressing all modifiable factors. 3 This patient should not proceed to second-line therapy when he has not had an adequate trial of first-line oral therapy. 1
Specific Counseling Points for This Patient
Timing: Take sildenafil 100 mg on an empty stomach or after a light meal, approximately 1 hour before anticipated sexual activity—not immediately after a large dinner. 1, 2
Sexual stimulation: Emphasize that adequate foreplay and sexual arousal are mandatory for the medication to work. 1 The drug enhances the natural erectile response but does not create erections without stimulation. 1
Number of attempts: Complete at least 5 separate attempts at the 100 mg dose with proper timing and adequate stimulation before concluding the medication is ineffective. 1
Alcohol: Limit alcohol consumption, as heavy alcohol use impairs erectile function independent of medication. 1
Follow-Up and Next Steps
Schedule follow-up in 4–6 weeks to reassess response after proper technique has been implemented. 1 At that visit, if the patient has completed at least 5 attempts with proper technique and remains unsuccessful, then consider:
- Checking testosterone levels more thoroughly (total, free, and SHBG) to quantify any hormonal contribution 3
- Switching to a different PDE5 inhibitor (tadalafil or vardenafil), as some men respond better to one agent than another 1, 3
- Evaluating for other modifiable factors such as relationship issues, depression, or medications that worsen ED 1, 3
Special Considerations for This Patient
Diabetes: Men with diabetes have more severe baseline ED and may respond less robustly to PDE5 inhibitors, but sildenafil remains effective in this population with proper use. 1, 6, 7 His well-controlled diabetes (HbA1c 6.9%) is favorable. 7
Cardiovascular safety: This patient has controlled hypertension and takes amlodipine and lisinopril. He falls into the low-risk cardiovascular category and can safely use sildenafil. 6 His medications do not contraindicate PDE5 inhibitor use. 6