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For men who cannot use or do not respond to PDE5 inhibitors, second-line treatments include: Vacuum erection devices (mechanical pumps that draw blood into the penis) Intracavernosal injections (alprostadil injected directly into the penis) Intraurethral therapy (alprostadil pellets inserted into the urethra) Testosterone replacement therapy (only when hypogonadism is confirmed through repeat blood testing) Psychosexual counselling or cognitive behavioural therapy may benefit men whose ED has significant psychological components or is causing relationship difficulties

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