What are the short-term and long-term complication rates for vacuum erection devices compared with PDE5 inhibitors and intracavernosal injections?

1. VEDs: low‑risk device, weak long‑term data

VEDs cause mostly localized, mild adverse events—discomfort, bruising, numbness, skin irritation and pain from constricting rings—reported in guideline and review material; they are contraindicated in patients with bleeding disorders or on anticoagulants because of bleeding risk, but large, long‑term randomized safety trials are lacking and systematic reviews underline limited evidence for efficacy in refractory populations (Cleveland Clinic; Int J Impot Res systematic review) ^{[1] [2]}. The literature repeatedly states that while short‑term device‑related harms are minor, long‑term safety outcomes and definitive functional benefits after procedures such as radical prostatectomy are not firmly established ^{[1] [7]}.

2. ICIs: higher rates of serious, structural complications

Intracavernosal injection therapy carries measurable risks that include priapism and corporal fibrosis. Older and multicohort reports show fibrosis rates ranging from about 8% (alprostadil series) to 31% at 12 months in older papaverine‑based series, and priapism estimates of roughly 4% in one textbook summary up to ~7% in some cohort analyses; other reported complications include penile curvature (~10%), bruising (~7.6%) and pain (12–40%) depending on agent and series ^{[3] [4] [5] [8]}. Multiple sources stress the importance of dose titration, training and follow‑up to reduce these risks (NEJM; StatPearls) ^{[9] [3]}.

3. PDE5 inhibitors: first‑line, systemic side‑effect profile but no pooled rates here

Guidelines and reviews position PDE5 inhibitors as first‑line for most men; the Cleveland Clinic and StatPearls excerpts list common systemic adverse effects (headache, flushing, dyspepsia, visual disturbances, backache) and note that up to ~40% of men may not respond satisfactorily, but the provided search results do not supply pooled short‑ or long‑term complication rates or percentages for PDE5 inhibitors in the same numeric detail as for ICI ^{[1] [6]}. Available sources do not mention consolidated incidence figures for long‑term PDE5 adverse events in these excerpts; therefore an exact numerical comparison using the current material is not possible ^[6].

4. Head‑to‑head context: safety versus effectiveness tradeoffs

The material frames therapies by risk–benefit and failure pathways: PDE5 inhibitors are first‑line for efficacy and cost‑effectiveness; VEDs are low‑risk mechanical alternatives with mild local effects but limited long‑term efficacy data; ICIs are highly effective for producing erections but carry a measurable rate of serious local complications (fibrosis, priapism) and higher dropout over time ^{[1] [10] [11]}. Systematic reviews call for better randomized, long‑term comparisons between VEDs, PDE5 inhibitors and ICIs—evidence gaps are explicit in the literature ^{[2] [7]}.

5. Patient selection and mitigation matter

All sources emphasize tailoring therapy: anticoagulated patients are poor VED candidates (bleeding risk) and require counselling ^[1]. ICI risks fall when dose titration, training and surveillance are used; when supervised, alprostadil series are described as effective and “safe” but with known fibrosis/priapism risks to monitor ^{[9] [3]}. For PDE5 inhibitors the literature recommends optimizing cardiovascular and hormonal contributors and recognizing nonresponse in up to ~40% as a pathway toward combination or second‑line therapies ^{[1] [12]}.

6. Limitations and what’s missing in current reporting

The supplied sources give numeric complication figures for ICI (fibrosis, priapism, curvature, pain) and qualitative VED harms, but they do not provide a unified head‑to‑head dataset with comparable short‑ and long‑term incidence rates across all three modalities. Precise, pooled incidence rates for PDE5 inhibitor complications and long‑term (>1–5 year) VED safety outcomes are not present in these excerpts; systematic reviewers call for multicenter randomized trials to close these gaps ^{[2] [7]}.

7. Practical takeaway for clinicians and patients

Use PDE5 inhibitors first for most patients; consider VEDs when you want a low‑risk mechanical option (mind anticoagulation), and reserve ICI when oral agents fail or spontaneity is less important, understanding that ICI yields higher efficacy but also higher rates of fibrosis/priapism and requires training and follow‑up ^{[1] [3] [5]}. Consider combination therapy when single modalities fail—some studies suggest additive benefits ^[13].

If you want, I can extract and tabulate every numeric complication estimate per source (VED local adverse events, ICI priapism/fibrosis rates, PDE5 common adverse effects) so you can see side‑by‑side figures and the source for each number.