Most men remember the specific night. The tablet that had worked for years gets taken, the evening goes to plan, and nothing happens. A fortnight later it happens again.
If that is where you are, you have not run out of options. Tablets are the first rung on a ladder of erectile dysfunction treatments, not the whole ladder. Studies of men prescribed PDE5 inhibitors consistently find that around one in three do not get an adequate response, and for those men there is a well-established sequence of next steps.
This article sets out what that ladder looks like, why tablets stop working, and how a urologist decides which rung suits you. Dr Phillip Katelaris provides erectile dysfunction treatment in Sydney and across the North Shore from clinics at Hornsby, Castle Hill and St Leonards.
Why erectile dysfunction tablets stop working
Tablets usually stop working for one of four reasons: they were never taken properly, the underlying cause has progressed, something new has entered the picture, or the problem was never purely physical. Sorting out which one applies to you is the whole point of a specialist assessment.
The tablet was never taken correctly
A surprising number of men labelled “non-responders” were simply never given proper instructions. PDE5 inhibitors do not create an erection on their own; sexual stimulation is still required. Timing matters, a heavy meal or a few drinks can blunt the effect, and the dose may never have been optimised.
A fair trial means several attempts at an adequate dose, not one disappointing evening. A urologist checks this before concluding the medication has failed.
The underlying cause has progressed
Erectile function relies on healthy arteries and healthy nerves, and both can deteriorate. Vascular disease, poorly controlled diabetes and nerve injury after pelvic or prostate surgery all worsen over time. The tablet did not change. The blood vessels did. This is why a medication that worked reliably at 55 may be doing very little at 63.
Something else has entered the picture
New medications are a common culprit, particularly some blood pressure medications and antidepressants. So are weight gain, untreated sleep apnoea, falling testosterone, heavy drinking and a period of genuine stress. None of these makes ED untreatable, but they do change which treatment is likely to work, which is why a medication review is part of any proper assessment.
The ED was never purely physical
Performance anxiety builds quietly once a few attempts have gone badly, and it can undo an otherwise effective treatment. The physical and psychological sides feed each other in both directions. We cover this in more detail in our guide to the psychology behind erectile dysfunction.
The erectile dysfunction treatment ladder, step by step
There is an accepted order to this. A urologist starts with the least invasive option that has a reasonable chance of working for you, and moves up a step only if it does not deliver. Men often expect to pick from a list. In practice, each option is tried and reviewed before the next one is considered.
First line: oral medication (PDE5 inhibitors)
This is where nearly everyone starts. Sildenafil (Viagra) and tadalafil (Cialis) are PDE5 inhibitors. They relax the vessels feeding the erectile tissue so more blood can get in, and they do nothing at all until arousal has already begun.
What many men have never been offered is dose optimisation, or the choice between on-demand and low-dose daily use. Daily dosing suits men who dislike planning around a tablet. These medicines do not suit every man. Anyone taking nitrates cannot use them at all, and there are other interactions to check, so the prescription follows an assessment rather than the other way around.
The limitation is straightforward: if the arteries or nerves are badly affected, no amount of dose adjustment will produce a reliable result.
Second line: penile injection therapy
Intracavernosal injection therapy works for many men whose tablets have failed, including men with diabetes and men who have had prostate surgery. A very fine needle is used to deliver medication directly into the erectile tissue, which produces an erection within minutes.
Nearly every man objects to the needle first. It is a very fine one, close in gauge to an insulin needle, although how it feels varies from person to person. The first dose is given in the rooms, where the technique is taught and the dose is built up slowly under supervision. You are also told what to watch for afterwards. An erection that will not settle is a medical emergency and needs urgent care, not a wait and see approach.
Our post on penile injection therapy covers what to expect in detail.
Second line: vacuum erection devices
A vacuum erection device draws blood into the penis using negative pressure, with a constriction ring holding it there. No drugs are involved, which makes it an option for men who cannot take PDE5 inhibitors at all.
The drawbacks are practical ones. You have to stop and use the device, the erection can feel cool to the touch and tends to pivot at the base, and there is a learning curve before it works smoothly. Reactions are mixed. It suits some couples perfectly well, while other men give up after a few attempts.
Adjunct: linear shockwave therapy
Linear shockwave therapy aims to improve blood flow within the penis over time rather than produce an erection on demand, and it is best described as an option with evolving evidence rather than an established treatment. Australian patient-facing health information notes that acoustic shockwave therapy has not yet been proven to cure erectile dysfunction and remains under investigation. It may be considered for carefully selected men with vasculogenic ED after assessment, and only where the limitations are clearly understood. You can read more on our linear shockwave therapy page and in our post on how shockwave therapy works for ED.
Treating the underlying cause
This one runs alongside the whole ladder instead of sitting on it. In practice it involves a medication review, a testosterone check where the symptoms point that way, attention to blood pressure, cholesterol, blood sugar and weight, and a sleep study if sleep apnoea looks likely.
If you read nothing else here, read this. For many men, erectile difficulty is the earliest outward sign that the arteries are narrowing, and it can show up years before any chest symptoms do. The same small arteries that supply the penis supply the heart, and they narrow in the same way. Any man with new ED should have his cardiovascular risk assessed properly. Our page on ED and related health issues explains these connections further.
Definitive option: penile implant surgery
Some men reach a point where the erectile tissue no longer answers to tablets or injections. An implant is what is left at that stage. Plenty of men arrive at the idea with a sense of defeat, which is not how urologists see it, because for certain anatomy it is the option most likely to help. The prosthesis sits inside the erectile tissue and inflates from a small pump that nobody can see.
As with any surgery there are risks, including infection and device-related complications, and the decision is made only after a full discussion of the alternatives. You can read more on our penile prosthetic surgery page.
How a urologist decides which step is right for you
Nobody climbs the ladder blind. Everything starts with the assessment, and that is where specialist care parts company with another repeat script.
The first appointment leans heavily on history. When the trouble started. Whether it came on overnight or crept up over a year or two. Whether you still wake with erections. What else you are taking, and what has been tried already and at what dose. Then an examination of the genitals, a feel for any curvature or firm plaque in the shaft, and a blood pressure reading. Bloods generally cover morning testosterone, fasting glucose or HbA1c, and a lipid profile.
Imaging is not needed for everyone. A penile duplex Doppler ultrasound may be arranged where a vascular cause is suspected, where ED is severe in a younger man, or where surgery is being considered. Matching the treatment to the cause is the entire exercise. Our guide on preparing for your appointment will help you get more out of the first consultation.
What “success” realistically looks like
A useful definition of success is erectile function that is reliable and satisfying for you now. Being 25 again is not on offer, and the difference matters more than it sounds. Men who measure a treatment against their twenties often walk away disappointed by a result that is, clinically speaking, working.
Most men who work through the ladder with a specialist find an option that suits them. ED is a treatable condition, and the men who do badly are usually the ones who stopped after the first tablet failed.
There is an emotional side to this that rarely gets said out loud in a consulting room. Losing erectile function affects confidence and relationships, and most men have carried it quietly for a while before they book. That is normal, and worth mentioning at the appointment.
When to stop waiting and see a specialist
Book an assessment with a urologist if any of the following apply:
- Tablets have been tried properly at an adequate dose and have not worked
- ED has developed after prostate, bladder or pelvic surgery
- You have diabetes, heart disease, high blood pressure or high cholesterol
- The onset was sudden rather than gradual
- There is penile curvature, a palpable lump, or pain with erections
- You are under 40
- The problem is causing you significant distress
In Australia, you will need a referral from your GP to claim a Medicare rebate on a specialist consultation. Your GP can also organise the initial blood tests, which makes the first appointment considerably more useful. If you are unsure whether your symptoms warrant an assessment, our short erectile dysfunction quiz is a reasonable starting point.
Why choose Dr Katelaris for erectile dysfunction treatment in Sydney & North Shore
Dr Phillip Katelaris is a specialist urologist and urological surgeon with more than 35 years of clinical experience. He holds Fellowship of the Royal Australasian College of Surgeons (FRACS) and is a member of the Urological Society of Australia and New Zealand (USANZ). His training includes postgraduate surgical work in Germany and robotic surgery training in the United States, and he performs procedures at Sydney Adventist Hospital.
His practice covers the full erectile dysfunction treatment ladder, from medical management and dose optimisation through injection therapy and linear shockwave therapy to penile prosthetic surgery. He has performed penile prosthetic surgery in Sydney for many years, and performed the first vasectomy reversal in Australia using the ROBOTICSCOPE platform.
Assessment comes before prescribing here, rather than the other way around. Treatment follows the cause the assessment identifies, and time is set aside to go through the options and the risks that come with each of them. Written informed financial consent is provided before any procedure, so you know the out-of-pocket cost in advance.
Dr Katelaris consults at three locations:
- Hornsby: Level 1, 51 Palmerton Road, Hornsby NSW 2077
- Castle Hill: 60 Cecil Avenue, Castle Hill NSW 2077
- St Leonards: Level 3, Suite 11, North Shore Private Hospital, Westbourne Street, St Leonards NSW 2065
You can confirm Dr Katelaris’s registration and credentials on any of these independent profiles:
More detail is available on the about Dr Phillip Katelaris page.
Frequently asked questions
What is the most successful treatment for erectile dysfunction?
In published studies, penile implants record the highest satisfaction and reliability figures of any option, although they are reserved for men who have not responded to less invasive treatments and they carry the risks of surgery, including infection and device failure. Most men never reach that point, because tablets or injection therapy sort the problem out earlier. The treatment that works best is the one aimed at the cause, which is why the assessment matters more than any single therapy.
What should I do if Viagra or Cialis stops working?
See a urologist for reassessment rather than increasing the dose yourself. Tablets usually stop working because the underlying cause has progressed, a new medication is interfering, or the dose and timing need adjusting. Second-line options such as injection therapy work in many men for whom tablets have failed.
Can erectile dysfunction be reversed without medication?
Sometimes. If something reversible is driving it, such as weight, poorly controlled blood sugar, smoking, heavy drinking, untreated sleep apnoea or a side effect of another medication, dealing with that can be enough to bring natural erections back. Once the erectile tissue itself has changed, ongoing treatment is usually needed.
How much does erectile dysfunction treatment cost in Australia?
It depends on which treatment you end up having, and the range runs from subsidised tablets through to implant surgery. A Medicare rebate applies to specialist consultations when you hold a valid GP referral. Katelaris Urology issues written informed financial consent before any procedure, so the out-of-pocket figure is confirmed with you beforehand.
Do I need a referral to see a urologist for erectile dysfunction in Sydney?
Yes. In Australia you need a GP referral to claim a Medicare rebate on a specialist consultation. Your GP can also arrange initial blood tests, which makes the first specialist appointment more productive.
Book a consultation
If tablets have stopped working, the next step is an assessment rather than a higher dose. Contact Katelaris Urology on (02) 9477 7904 to arrange a consultation at Hornsby, Castle Hill or St Leonards.
Further reading
- Erectile Dysfunction: Symptoms, Causes and Treatment
- What Are the Symptoms of Erectile Dysfunction and What Treatment Options Do I Have?
- What Does an Erectile Dysfunction Specialist Do? A Patient’s Guide
- Erectile Dysfunction After Prostate Cancer Treatment: Recovery, Rehabilitation and Your Options
Medical references
- Healthdirect Australia. Erectile dysfunction
- Healthdirect Australia. Erectile dysfunction medicines
- Healthy Male (Australian Government funded). Erectile dysfunction: causes, diagnosis and treatment
- Lowy M, Ramanathan V. Erectile dysfunction: causes, assessment and management options. Australian Prescriber 2022;45:159-61.
- Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine. Clinical guidelines on the management of erectile dysfunction. Medical Journal of Australia 2022;217(6).
- Cleveland Clinic. Erectile dysfunction: causes, diagnosis and treatment
Disclaimer: Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner. This article is general information and is not a substitute for individual medical advice.
Dr Phillip Katelaris MED0001030858
