What are the proven medical treatments for erectile dysfunction and how do they compare?

1. PDE5 inhibitors: the predictable workhorse

Oral PDE5 inhibitors increase penile blood flow in response to sexual stimulation and remain the first-line pharmacotherapy for most patients because randomized trials and decades of clinical use show consistent efficacy and known risks, making them the default starting point in contemporary guidelines ^{[3] [1] [2]}. Differences among agents matter clinically: onset and duration vary (e.g., avanafil and sildenafil act faster, tadalafil lasts longer), tolerability and drug interactions (notably with nitrates) guide choice, and generics have widened access without changing the fundamental evidence base ^{[2] [5]}.

2. Injectable and intraurethral therapies: potent, close to the target

For men who do not respond to or cannot take PDE5 inhibitors, intracavernosal injections (alprostadil alone or combinations) and intraurethral alprostadil produce reliable erections by directly relaxing penile smooth muscle; they offer higher efficacy rates but require patient training and carry local side effects such as pain or fibrosis ^{[4] [6]}. The medicated urethral system (MUSE) and tailored injection regimens have been studied historically and remain part of second-line pathways because they bypass systemic mechanisms that limit oral drugs ^{[6] [4]}.

3. Mechanical and surgical options: vacuum devices to prostheses

Vacuum erection devices provide a non-pharmacologic, reversible alternative that is effective for many men but can be cumbersome and affect spontaneity, while inflatable or malleable penile prostheses deliver the most definitive, durable solution with high satisfaction in appropriately selected patients, carrying the risks of surgery and device complications ^{[1] [6]}. International recommendations frame these as escalation steps when less invasive therapies fail or are contraindicated ^[1].

4. Hormonal, lifestyle and psychological interventions: treating causes, not just symptoms

Low testosterone replacement can improve libido and, in some men, erectile function, but it is appropriate only after testing and clinical correlation; lifestyle interventions — weight loss, exercise, smoking cessation — and psychosocial therapies address common vascular and psychogenic contributors and are recommended alongside medical treatments ^{[5] [7] [1]}. Clinical reviews stress that ED management should be personalized and include partner and psychosocial needs, not only pills ^[1].

5. Emerging regenerative and device-based therapies: hopeful but experimental

Low-intensity shockwave therapy, platelet-rich plasma (PRP), stem cell approaches, gene therapy, and novel topical or device-based products are widely discussed and commercially offered, and early trials show promise for some patients, but long‑term safety and efficacy remain unproven and these remain investigational outside controlled study settings ^{[6] [8] [2] [9]}. Industry marketing and clinic-promoted branded protocols (e.g., COREWAVE™, P‑Shot) have outpaced definitive evidence; major reviews call for larger randomized trials before these replace established care ^{[9] [6]}.

6. How treatments compare in practice: efficacy, practicality and risk

In comparative terms, PDE5i are high on convenience and moderate-to-high efficacy for many etiologies, injections and prostheses are higher-efficacy options for refractory cases but impose greater procedural or lifestyle burdens, and mechanical devices are effective yet intrusive; hormonal and lifestyle measures target root causes and augment other therapies but rarely suffice alone ^{[3] [4] [1]}. Safety profiles vary: systemic side effects and contraindications steer away from PDE5i in some cardiac patients, injections risk local complications, and surgery requires acceptance of permanent implant-related risks — information reflected in contemporary consensus guidance ^{[1] [4]}.

7. Choosing a path: individualized, guideline-driven care

Current expert guidance recommends a structured diagnostic workup followed by stepwise treatment: start with PDE5 inhibitors and lifestyle/psychosocial measures, escalate to intracavernosal or device therapy if needed, and consider prosthesis for definitive treatment; experimental regenerative options should be considered only in research contexts or with full disclosure of limited evidence ^{[1] [6] [2]}. Public-facing clinics and advertisers sometimes blur boundaries between proven and experimental therapies, so guideline context and informed consent remain essential ^{[9] [8]}.