Impotence of organic origin
ICD-10 N48.4 · ICD-11 HA01.1Z

Treatment of Organic Impotence When Oral PDE5 Inhibitors Have Not Achieved Adequate Erections

Clinical scenario

This protocol applies to men with impotence of organic origin who were previously treated with an oral phosphodiesterase type 5 (PDE5) inhibitor and did not achieve erections sufficient for satisfactory sexual performance.

Why this protocol is reached

The prior treatment line — an FDA-approved oral PDE5 inhibitor (sildenafil, tadalafil, vardenafil, or avanafil), titrated to provide optimal efficacy — did not achieve the goal of a penile erection sufficient for satisfactory sexual performance. Failure to meet that target triggers escalation to this next structured protocol.

Next-step approach (partial overview)

The next clinical line involves locally-acting, non-oral interventions — encompassing both device-based therapy and locally-delivered pharmacological options — directed at achieving the treatment goal. The complete set of options, their clinical sequencing, and supporting evidence are available in the full protocol.

Goal: Erection sufficient for successful intercourse
Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.juro.2018.05.004

Men with ED should be informed regarding the treatment option of a vacuum erection device (VED), including discussion of benefits and risks/burdens.

Men with ED should be informed regarding the treatment option of intraurethral (IU) alprostadil, including discussion of benefits and risks/burdens.

Intraurethral (IU) medication involves the insertion of a delivery catheter into the meatus and depositing an alprostadil (prostaglandin E1) pellet in the urethra to induce an erection sufficient for intercourse.

Men with ED should be informed regarding the treatment option of intracavernosal injections (ICI), including discussion of benefits and risks/burdens.

ICI medications are administered by injecting alprostadil, papaverine, phentolamine, and/or atropine into the corpus cavernosum of the penis to produce an erection.

The most commonly used outcome measure in ICI studies is the percentage of men who reported achieving an erection sufficient for successful intercourse.

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