Management of Erectile Dysfunction After Failed Acoustic Radio Wave Therapy

Diagnostic Evaluation and Treatment Algorithm

The European Association of Urology recommends that a 45-year-old male who has failed to achieve benefit after six weeks of acoustic radio wave therapy for erectile dysfunction should initiate phosphodiesterase type 5 inhibitors (PDE5i) therapy 1
Before initiating PDE5i therapy, laboratory tests including glucose-lipid profile and morning total testosterone level should be performed to identify potential underlying causes, as recommended by the European Urology guidelines 1, 2
The European Urology guidelines suggest assessing for cardiovascular risk factors as ED can be a marker for underlying cardiovascular disease, with a strength of evidence level of high 1, 3
A review of medication history is necessary to identify potential drug-related causes of ED, according to the BMJ guidelines 4, 5
Consideration of psychological factors that may contribute to ED, including anxiety, depression, or relationship issues, is essential, as recommended by the European Urology guidelines 1, 3

PDE5 inhibitors are the most effective first-line oral treatment for ED after failed low-intensity shockwave therapy (LI-SWT), with a success rate of 70-80%, according to the European Urology guidelines 1, 2
Options for PDE5 inhibitors include sildenafil, tadalafil, vardenafil, and avanafil, with varying dosing regimens and side effect profiles, as recommended by the European Urology guidelines 1
Proper education about dosing and timing of PDE5i is essential for effectiveness, with a strength of evidence level of high, according to the European Urology guidelines 1

If PDE5i therapy is ineffective or contraindicated, second-line options include intracavernosal injection therapy with vasoactive drugs, vacuum erection devices (VEDs), and intraurethral prostaglandin suppositories, with varying success rates and side effect profiles, as recommended by the European Urology guidelines 1, 6
Combination therapy, such as PDE5i with VED, may be considered for enhanced results, with a strength of evidence level of moderate, according to the European Urology guidelines 1

Verification of appropriate use of acoustic wave therapy before declaring failure is necessary, as standardized protocols are still lacking, according to the European Urology guidelines 1
Consideration of testosterone therapy if hypogonadism is present may improve response to PDE5i, with a strength of evidence level of high, according to the European Urology guidelines 1, 3
Psychosexual counseling may be beneficial, especially if psychological factors are contributing to ED, with a strength of evidence level of moderate, according to the European Urology guidelines 1, 3

Reassessment of effectiveness of PDE5i after 4-8 weeks of proper use is recommended, with a strength of evidence level of high, according to the European Urology guidelines 1
If partial response, consideration of dose adjustment or switching to another PDE5i is necessary, with a strength of evidence level of moderate, according to the European Urology guidelines 1
For non-responders to optimized PDE5i therapy, proceeding to second-line treatments is recommended, with a strength of evidence level of high, according to the European Urology guidelines 1