Can vacuum devices be used alongside PDE5 inhibitors or penile injections and how does timing work?
Executive summary
Vacuum erection devices (VEDs) are commonly used alone or together with PDE5 inhibitors and penile injections; clinical studies and reviews report improved outcomes when VEDs are combined with PDE5i or injections in men who do not respond to medicines alone (examples: improved IIEF and SEP scores after 4 weeks of combined VED+PDE5i) [1][2]. Timing protocols vary by purpose: for intercourse VEDs produce an erection within minutes; for penile‑rehabilitation regimens studies range from daily 5–10 or 10‑minute sessions to twice‑weekly programs, while injections are typically limited to a few times per week and PDE5i follow their usual dosing windows [3][4][5][6].
1. What the evidence says: combination increases success in some groups
Multiple clinical reports and systematic reviews describe that combining VEDs with PDE5 inhibitors or with intracavernosal injections can produce better erectile outcomes than monotherapy for selected patients — notably men who failed PDE5i alone or who are undergoing penile rehabilitation after prostate surgery. A 2009 salvage therapy study found statistically significant improvements in IIEF‑5 and sexual encounter outcomes after four weeks of combined VED + PDE5i use [1][2]. Larger recent reviews and guideline statements (5th International Consultation on Sexual Medicine) explicitly recommend offering VED alone or combined with other therapies for intercourse and rehabilitation [7][8].
2. How clinicians and studies time use for intercourse versus rehabilitation
For immediate use to enable intercourse, a VED typically produces tumescence within minutes and erection duration depends on the constriction ring; PDE5 inhibitors are used according to their labeled timing (for example sildenafil ~30–60 minutes before intercourse) and injections produce an erection usually within 5–15 minutes [6][5][3]. For penile rehabilitation (aimed at preserving tissue oxygenation and length after nerve injury), published regimens vary widely: randomized trials and programs report daily VED sessions of about 5–10 or 10 minutes, at minimum twice weekly up to daily, continued for months; injections for rehab are usually prescribed no more than ~2–3 times per week [4][3][9].
3. Practical sequencing when using two modalities together
Available reports indicate two practical approaches: (a) concurrent use for the same episode — e.g., take the PDE5i beforehand (per its timing), then apply the VED to produce/augment an erection for intercourse; (b) complementary schedules for rehabilitation — e.g., daily short VED sessions to increase tissue oxygenation with intermittent injections (weekly) or daily low‑dose PDE5i as background therapy. Studies describing combinations in rehab typically used regular VED sessions plus either daily or scheduled PDE5i or weekly injections; one trial found daily VED plus weekly intracavernous drug improved spontaneous erections compared with VED alone [10][11][12].
4. Safety considerations and contraindications to watch for
VED side effects are generally mild (bruising, numbness, ring discomfort), and some organizations warn against use in patients on anticoagulants or with bleeding disorders because bruising and hematoma risk increases [6][13]. Injections carry risks of pain, bleeding, and fibrosis if misused; injection frequency is traditionally limited (often 2–3x weekly), and proper training is essential to avoid scarring that can cause curvature [14][15]. Reports caution against sleeping with a constriction ring, especially if combined with PDE5i, because prolonged ischemia can cause injury [16].
5. Disagreements, gaps, and how to choose a schedule
Guidelines and trials agree that combination therapy can help selected patients, but evidence quality and optimal regimens are inconsistent: systematic reviews note limited and heterogeneous data, and call for randomized trials to define the best timing, pressure, duration and frequency of VED use [8][17]. Some centers favor daily short VED sessions for rehab and reserve injections for intermittent use; others implement twice‑weekly VED with daily low‑dose PDE5i — choices reflect local practice, patient tolerance, and surgical context [4][3][6].
6. Practical takeaway for patients and clinicians
For sexual activity, use PDE5i per labeled timing and apply a VED when needed to augment erection — many clinicians endorse combining them if monotherapy fails [1][6]. For penile rehabilitation after prostate surgery, begin VED therapy when clinically appropriate (studies often start 1 month to a few weeks after catheter removal) and follow a regimen tailored to evidence and patient tolerance (common schedules: daily 5–10 or 10‑minute sessions or at least twice weekly) while limiting injections to a few times weekly if used [11][18][5][9]. Discuss anticoagulation, bruising risk, ring use and injection training with your urologist before combining therapies [6][14].
Limitations: systematic reviews and guideline statements call out limited high‑quality, long‑term randomized data on optimal timing and combination regimens; clinical practice is heterogeneous and protocols vary between centers [8][17].