Medication Treatments for Erectile Dysfunction

1. First-line Therapy: PDE5 Inhibitors

Phosphodiesterase type 5 (PDE5) inhibitors are the most commonly prescribed and effective oral medications for ED. They enhance the nitric oxide–cGMP pathway, increasing penile blood flow during sexual stimulation. Common options include:

  • Sildenafil (Viagra): Onset ~1 hour, duration ~4  hours. Side effects: headache, flushing, dyspepsia, visual changes (blue tint).

  • Tadalafil (Cialis): Onset ~4-6 hours, lasts 24–36 hours. Also treats BPH (an enlarged prostate). Side effects: muscle aches, back pain.

  • Vardenafil (Levitra/Staxyn): Fast onset (~10–60 min), duration ~5  hours, generally well tolerated.

  • Avanafil (Stendra): Quickest onset (~15–30 min), lasts up to 12  hours

Important considerations:

  • Contraindicated with nitrates (risk of hypotension).

  • Use lowest effective dose and adjust for liver or kidney impairment.

  • Side effects vary by agent; sildenafil may impact vision due to PDE6 inhibition, tadalafil may cause musculoskeletal symptoms.

2. Second-line Options: Local Vasoactive Therapies

Intracavernosal Injections (ICIs)

Deliver medication directly into the corpora cavernosa for rapid, reliable erections (within 2–15 min).

  • Bimix (papaverine and phentolamine): Typically starts at low doses and titrate up. Max 3x/week; watch for priapism and fibrosis.

  • Trimix (alprostadil + papaverine + phentolamine): Often more effective, lower pain, available via compounding pharmacies; risk of bruising or priapism.

ICIs are ideal for men who are non-responsive or intolerant to PDE5 inhibitors, or part of penile rehabilitation programs following prostatectomy.

Intraurethral Suppositories

  • Alprostadil urethral pellets: Inserted into the urethra ~10 min before sex to induce erection. Lower efficacy than injections but useful if injections are not viable.

3. Adjunctive Hormonal Therapy

  • Testosterone replacement may be appropriate in men with hypogonadism; less effective in isolating ED but may restore libido and enhance response to PDE5 inhibitors .

4. When to Consider Escalation

If oral or local medications fail or are unsuitable, discuss these with your urologist:

  • Vacuum erection devices (VEDs): Non-invasive; useful alone or combined with medications.

  • Penile prosthesis: Inflatable or malleable implants have >90% satisfaction, excellent for refractory cases or post-Peyronie’s / radical prostatectomy patients.

✦ Tailoring Treatment and Safe Use

Choice depends on:

  • Underlying health and comorbidities (e.g., heart disease, diabetes),

  • Patient preference (oral vs injection vs device),

  • Side effect profile, and

  • Cost and convenience.

Always start medication under medical supervision. Lifestyle modifications—weight loss, smoking cessation, blood pressure control—improve medication effectiveness and overall outcomes.