Erectile Dysfunction (ED) — Treatment Options

Last updated: 20 Aug 2025

Medical disclaimer: Educational content only. Seek care for chest pain during sex or a painful erection lasting > 4 hours.

Table of Contents

Overview & Treatment Algorithm
Universal Foundation (Non-medical)
Treatment Ladders by Etiology
Medications
Devices
Urethral & Intracavernosal Therapy
Hormone & Endocrine Factors
Procedures & Surgery
Emerging / Experimental
Non-medical Strategies
Step-by-Step Regimens
Safety & Red Flags
Key Guidelines & References

Overview & Treatment Algorithm

ED is usually multifactorial. Base care on history, focused exam, and selective labs (lipids, glucose/HbA1c, two morning total testosterone tests ± SHBG/free T if borderline, TSH; consider prolactin if low libido). Treat cardiometabolic risks and apply sexual-activity safety principles.

Condensed algorithm

Fix contributors (BP, glycemia, lipids, weight, sleep apnea, smoking; review meds).
Layer foundation (exercise, pelvic floor, diet, sleep/OSA, psychosexual support).
Start a PDE5 inhibitor unless contraindicated; teach correct use and titrate.
If inadequate → add VED or move to MUSE/ICI.
Refractory or preference → penile implant; treat Peyronie’s if structural.

Universal Foundation (Non-medical)

Exercise & Pelvic Floor

Aerobic ≥ 150–300 min/week or vigorous 75–150 + 2–3 resistance sessions/week.
Pelvic floor training: 3 sets/day × 10; 3–5 s hold/relax → progress to 10 s; add 10 quick flicks before penetration.

Diet & Weight

Mediterranean/DASH; reduce ultra-processed sugars/fats; 7–10% weight loss if overweight.

Sleep & Stress

Screen for OSA (STOP-BANG); treat OSA (CPAP) when present.
CBT-I for insomnia; mindfulness/CBT for performance anxiety.

Substances & Medications

Stop nicotine; moderate alcohol; avoid vasoconstrictive drugs.
Where safe, use ED-sparing alternatives (e.g., bupropion instead of an SSRI).

Psychosexual & Relationship Support

Sex therapy/CBT, sensate-focus, graduated exposure; couples communication work.

Treatment Ladders by Etiology

Vasculogenic (arteriogenic/mixed metabolic)

Foundation + PDE5 inhibitor.
Optimize timing/dose; try ≥ 6–8 attempts under ideal conditions.
Add VED ± constriction ring or move to MUSE/ICI.
Penile implant if refractory.

Venogenic (“venous leak”)

Emphasize constriction rings and VED; PDE5i as tolerated.
Venous ligation has limited durability; implant is definitive.

Neurogenic (SCI, MS, diabetic neuropathy; post-pelvic surgery)

PDE5i may work with incomplete lesions; VED and ICI are highly effective.
Post-prostatectomy: early rehab common (PDE5i ± VED). Implant for definitive restoration if needed.

Endocrine

Treat confirmed hypogonadism (two low morning T + symptoms). TRT may enhance PDE5i response; monitor hematocrit, PSA per age/risks, lipids; discuss fertility suppression.
Correct thyroid disease and hyperprolactinemia as indicated.

Psychogenic dominant

Short course PDE5i + structured sex therapy (CBT, mindfulness, sensate-focus). Prefer bupropion where antidepressants are needed.

Medication-induced

Switch offending drug when safe; add PDE5i if switch not possible.

Structural (Peyronie’s)

If curvature prevents penetration: collagenase injections, traction, or surgery; layer ED ladder as needed.

Post-cancer therapy (prostatectomy, radiation)

Counsel early; daily or on-demand tadalafil; add VED; ICI for reliability; implant when ready.

Medications

PDE5 inhibitors enhance nitric-oxide–mediated cGMP. Sexual stimulation is required.

Drug	Start dose	Onset	Duration	Notes
Sildenafil	50 mg (25–100)	30–60 min	4–6 h	Avoid high-fat meals; possible visual hue.
Tadalafil	10 mg PRN (5–20) or 5 mg daily	30–45 min	Up to 36 h	Food independent; daily helps spontaneity and LUTS.
Vardenafil	10 mg (5–20)	30–60 min	4–5 h	ODT option; avoid high-fat meals.
Avanafil	100 mg (50–200)	15–30 min	~6 h	Fastest onset in class.

Try at least 6–8 optimized attempts before calling failure.
Absolute contraindications: any nitrates or riociguat. Nitrate-free windows: 24 h (sildenafil/vardenafil/avanafil), 48 h (tadalafil).
Caution with alpha-blockers; separate dosing and start low.

Devices

Vacuum erection device (VED)

Lubricant; gradual negative pressure; apply ring; remove within 30 minutes.
Useful with or without PDE5i; helps penile rehab after prostatectomy.

Penile constriction rings

Helpful in venous-leak; do not exceed 30 minutes.

Urethral & Intracavernosal Therapy

Intraurethral alprostadil (MUSE)

Dose 125–1000 micrograms; onset 10–15 min; success about 30–60%.
AEs: urethral burning/bleeding; condom if partner is pregnant.

Intracavernosal injection (ICI)

Agents: alprostadil; bi-mix (papaverine + phentolamine); tri-mix (alprostadil + papaverine + phentolamine).
Efficacy 70–90%. Teach sterile technique; 29–31G needle; 10 or 2 o’clock mid-shaft; compress 2–3 min; alternate sides.
Risks: priapism (seek care if > 4 h), penile pain, fibrosis. Start low and titrate.

Hormone & Endocrine Factors

Measure morning total testosterone twice; if borderline add SHBG/free T; add LH/FSH when low T to classify.
TRT only for confirmed hypogonadism with symptoms; monitor hematocrit, lipids, PSA per age/risks; discuss fertility suppression (consider clomiphene or hCG if fertility desired).
Correct thyroid and prolactin disorders as indicated.

Procedures & Surgery

Penile prosthesis (implant)

Malleable vs inflatable (2- or 3-piece). Three-piece is most natural.
High satisfaction when counseling is thorough; infection 1–3% (higher with diabetes); irreversible.

Vascular surgery

Consider only in selected young men with focal arterial injury; venous ligation often temporary.

Emerging / Experimental Options

Low-intensity shockwave therapy (LI-ESWT): mixed evidence; possible help in mild vasculogenic ED; protocol variability; informed consent needed.
PRP/“P-shot”, stem cells, exosomes, gene therapy: insufficient high-quality evidence for routine care.

Non-medical Strategies

Pelvic floor protocol (8–12 weeks)

Identify the muscle (stop urine once to locate; do not train during voiding).
3 sets/day × 10; 3–5 s hold/relax → progress to 10 s.
Add 10 rapid contractions immediately before penetration.
Use paced breathing to reduce sympathetic overdrive.

Performance-anxiety reset (CBT-style)

Education; sensate-focus steps; cognitive restructuring; mindfulness during intimacy.

Partner technique & context

Lubrication; positions reducing perineal pressure; align timing with meds (e.g., tadalafil).
Brief porn reduction if overuse suspected to reset arousal cues.

Step-by-Step Regimens

Typical mixed vasculogenic ED

Labs: T × 2 ± SHBG/free T; HbA1c; fasting lipids; TSH.
Start tadalafil 10 mg PRN (or 5 mg daily if frequent activity/BPH).
Lifestyle block: exercise + Kegels; Mediterranean diet; sleep/OSA pathway; smoking cessation.
If inadequate after ≥ 6–8 optimized trials → add VED or switch to sildenafil 100 mg PRN; consider daily tadalafil.
If still inadequate → MUSE or ICI with teaching and priapism plan.
Refractory/preference → implant consult.

Hypogonadism-driven ED

Confirm low T twice + symptoms; classify with LH/FSH.
Start TRT or fertility-preserving alternatives (clomiphene/hCG) with monitoring.
Re-trial PDE5i after T normalizes if needed.

Neurogenic / Post-prostatectomy

Daily tadalafil 5 mg or on-demand; add VED.
Move to ICI if needed.
Consider implant when recovery plateaus.

Venous-leak phenotype

PDE5i trial; correct ring sizing/timing; VED for reliability.
If failure persists → implant rather than venous surgery.

Safety & Red Flags

Do not combine PDE5 inhibitors with nitrates or riociguat.
Painful erection > 4 h after ICI is an emergency.
Unstable angina, recent MI/stroke, or decompensated HF → cardiology clearance first.
New severe curvature, painful plaques, hematuria, or systemic symptoms need evaluation.

Key Guidelines & References

EAU Sexual & Reproductive Health Guidelines (latest).
AUA Erectile Dysfunction Guideline; AUA Testosterone Deficiency Guideline.
Endocrine Society Testosterone Therapy CPG.
Princeton IV Consensus on sexual-activity risk.
Systematic reviews on LI-ESWT and injection therapies.