In short
Overview
There are more treatments for erectile dysfunction than most men are offered, and the first one usually works if it is taken correctly.
Direct Answer
First line is a PDE5 inhibitor tablet. Across the four available, successful intercourse rates are 68 to 69 per cent against 33 to 35 per cent on placebo.
If tablets fail, second line is a vacuum device, then self injection or intraurethral treatment, with a penile implant for men who cannot use or have not responded to anything else.
Before any of it, cardiac risk is graded. Nitrates in any form are an absolute contraindication.
Who This Applies To
Before treatment: the cardiac step
| Low cardiac risk | Treatment can proceed |
| Intermediate risk | Exercise stress test first. A positive test means further cardiac assessment |
| High risk | Cardiology review before any ED treatment |
| Taking nitrates | Absolute contraindication to the standard tablets, regular or occasional |
Sexual activity is exertion, and these drugs interact dangerously with nitrates. This is a sequence, not a formality.
Option Comparison / Decision Criteria
On an empty stomach for maximum effect
At the correct interval for that specific drug
With arousal. They do not produce an erection on their own
A high fat meal delays sildenafil and lowers vardenafil’s peak by about 18 per cent, but does not affect tadalafil
Tried first, being non invasive and less expensive
, for men who cannot use or have not responded to other options
Why an In-Person Physician Review Matters
Treating the cause as well as the symptom Erectile dysfunction shares its mechanism with cardiovascular disease and usually arrives first.
Men reporting it had twice the rate of undiagnosed diabetes in one national survey. So smoking, obesity, blood pressure, diabetes and lipids are identified and treated in their own right. That is not an add on: aerobic exercise improved erectile function against placebo in a meta analysis of 11 trials, and exercise of 18 MET hours a week or more was associated with better sexual function. Where testosterone fits Measured in all men with erectile dysfunction, and treated where unequivocally low. It is added to a tablet rather than used instead of one, because it improves libido more reliably than erections. Combination appears most useful for men with low testosterone who did not respond to a tablet alone, with the greatest gains below 231 ng/dL. Side effects, in proportion Flushing in about 12 per cent, headache in about 11, indigestion in about 5. Sildenafil occasionally causes a blue tinge to vision lasting two to three hours. Rare but serious: optic nerve damage and retinal problems, at a combined absolute risk of 2 to 4 cases per 10,000 person years, and rare sudden hearing loss, usually one sided and within 24 hours. Any visual or hearing symptom needs prompt assessment.
Frequently Asked Questions
They work about equally well, so it comes down to onset, duration, food effects and cost. Tadalafil lasts up to 36 hours, avanafil can work in 15 minutes, sildenafil has the longest safety record.
Often it is the instruction rather than the drug. Retrying properly, on an empty stomach at the right interval and with arousal, rescues about 25 to 30 per cent of apparent non responders. After that the dose is raised before the drug is changed.
Not if it includes nitrates in any form, regularly or occasionally. That is absolute. Alpha blockers need care rather than exclusion, and avanafil is started at a lower dose in men taking one.
A vacuum device first, being non invasive and less expensive, then penile self injection or intraurethral alprostadil, with a penile implant for men who cannot use or have not responded to the others.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.