For many men, the journey with erectile dysfunction begins with a prescription for sildenafil (Viagra) or tadalafil (Cialis). At first, the medication works well. But over time — months or years later — something changes. The pill takes longer to kick in. The erection is not as firm. Eventually, it stops working altogether.
If this is happening to you, there are two things you should know: you are not alone, and you are not out of options.
Why ED medications stop working
Oral ED medications like sildenafil and tadalafil work by increasing blood flow to the penis. They need some degree of intact blood-vessel and nerve function to work. Over time, the underlying conditions that cause ED — diabetes, cardiovascular disease, ageing, nerve damage from surgery — can progress to the point where pills alone are no longer enough.
This is not a failure on your part. It is a natural progression of the condition. The good news is that there are well-established treatments beyond pills.
Your next options, explained
Option 1: penile injection therapy
Intracavernosal injection therapy (commonly called trimix or alprostadil injections) involves injecting a small amount of medication into the side of the penis before intercourse. The medication relaxes the blood vessels of the penis, producing an erection within minutes.
For men whose oral medications have stopped working, injections are often the next step. The needle is very small, and most men report that the injection is less uncomfortable than they expected. Dr. Robbins teaches every patient how to self-administer injections during an office training visit.
Option 2: low-intensity shockwave therapy
Low-intensity extracorporeal shockwave therapy (Li-ESWT) uses acoustic waves aimed at the blood vessels of the penis. It is a non-invasive, in-office treatment delivered over a series of sessions, and it can be combined with other treatments. It is not FDA approved or cleared for erectile dysfunction, and the American Urological Association classifies it as investigational; our erectile dysfunction page sets out what the evidence shows.
Option 3: vacuum erection device (VED)
A vacuum erection device uses negative pressure to draw blood into the penis, followed by a constriction ring placed at the base to maintain the erection. Many men find VEDs cumbersome and less spontaneous than other options. They are most useful as a bridge therapy or in combination with other treatments.
Option 4: the inflatable penile implant
For men who have tried pills, injections and other therapies without satisfactory results — or who want an always-available option — the inflatable penile prosthesis (IPP) is the established surgical treatment. Satisfaction is high: a 2021 review reports that patient satisfaction has been reported to be as high as 90 percent.1
The implant is completely internal and allows a man to have an erection on demand by squeezing a small pump in the scrotum. There is no need to plan around pill timing, no injections and no external devices. Modern implants are built for years of use; as mechanical devices, some eventually need revision or replacement, which is discussed before surgery. Our penile implant explainer covers how it works.
Some men tell us they wish they had learned about the penile implant earlier, rather than spending years cycling through treatments that were no longer working.
The most important step: seeing a urologist
If your ED medication has stopped working, the worst thing you can do is nothing. The underlying cause of your ED may be progressing, and a urologist can evaluate whether a different approach will work better. More importantly, ED that is worsening can be an early warning sign of cardiovascular disease or other conditions that deserve medical attention.
At Urological Consultants of Florida, Dr. Robbins offers the full range of ED treatments — from oral medications to injection therapy to penile implant surgery — and will help you decide on the next step based on your medical history, anatomy and goals.
Visit our penile implant page or our ED treatment options page, or call (305) 672-4222 to schedule a consultation.
