Non-responders to phosphodiesterase type 5 inhibitors: is there a second chance?

Phosphodiesterase type 5 (PDE5) inhibitors are, today, the first treatment option for erectile dysfunction (ED). However, efficacy does not exceed 70%, while the drop-out rate is high. Therefore, salvage strategies and second/third line treatment options are necessary to restore erectile response in such patients. This literature review of the currently available data on non-responders to PDE5 inhibitors aims to discuss key issues that physicians address in everyday clinical practice. These issues include the definition of treatment failure, the identification of factors that affect treatment outcome and the management strategy for non-responders to PDE5 inhibitors. Medication, clinical and patient/partner related issues have been identified as factors related to treatment failure. Treatment outcome assessment is based not only on quality of erectile response, but also on side effect profiles and patient satisfaction. Proper instructions for PDE5 inhibitor administration and psychosexual counselling may convert a substantial number of non-responders to responders. Inappropriate use of PDE5 inhibitors is a major issue in clinical practice. Non-responders may be converted to responders after careful assessment of the proper use of a PDE5 inhibitor. Treatment options for true non-responders are under investigation and include chronic administration of PDE5 inhibitors (everyday, low dose use), switchover from one drug to another or combination treatments. Management strategies must identify patient and partner needs and expectations and involve them in the decision-making.