Refractory erectile dysfunction: what to try next when pills fail

About 20–30% of men with erectile dysfunction don’t get the results they expect from first-line pills. If that’s you, it’s frustrating—and you’re not out of options. Refractory erectile dysfunction just means common treatments didn’t work. The goal now is to find WHY and then pick a different, often more effective, approach.

What counts as refractory ED and how doctors evaluate it

Refractory ED usually shows up when multiple attempts at oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil) produce little or no response. Your doctor will ask specific questions: medical history, surgery or radiation, medications (like SSRIs or some blood pressure drugs), alcohol use, and mental health. Expect simple tests: blood pressure, fasting glucose, lipid panel, and a morning testosterone level. If results are unclear, providers may order penile Doppler ultrasound, nocturnal penile tumescence testing, or refer you to a sexual medicine specialist.

Treatment options that actually help

If pills fail, there are proven next steps. Adjusting the pill dose or switching to a different PDE5 inhibitor helps some men. If that still misses the mark, consider these options:

- Injectable therapy. Intracavernosal injections (usually alprostadil or combinations) work quickly and reliably for many men who don’t respond to pills. Learning proper technique is key and most clinics teach you in one visit.

- Intraurethral suppositories. A small alprostadil pellet placed in the urethra can help when injections aren’t preferred.

- Vacuum erection devices. These are non-drug, affordable tools that create an erection by drawing blood into the penis and using a constriction ring to hold it.

- Penile prosthesis. For men wanting a permanent, reliable solution, implants (inflatable or malleable) have high satisfaction rates. Surgery is straightforward and many men return to sexual activity within weeks.

- Hormone and medical optimization. If low testosterone is identified, replacement can improve response to other treatments. Controlling diabetes, stopping smoking, losing weight, and reviewing interacting medications often makes a big difference.

- Psychological and pelvic-floor treatment. For men with performance anxiety or relationship strain, sex therapy and pelvic-floor exercises add real benefits, especially combined with medical treatments.

Safety matters. Never mix nitrates (for chest pain) with PDE5 inhibitors. Tell your doctor all meds and health conditions. If you try injections or devices, a trained provider should show you the correct use and risks.

Next steps: keep a simple log—what you tried, dose, timing, and results. Bring that to an appointment with a urologist or sexual health clinic. Ask about vascular testing and whether you’re a candidate for injections or an implant. With the right evaluation, most men move from “nothing works” to reliable solutions that fit their life.

Want help preparing for your visit? Write down your medication list, any past prostate or pelvic surgeries, and your sleep/mood changes. Those details speed diagnosis and get you to a treatment that actually works.