Erectile dysfunction treatment options compared

Published 22 October 2026

There is no single right treatment for erectile dysfunction, only the one that fits the cause, the severity and the way you live. This page sets the main options side by side and explains how each works, what it asks of you and where it tends to fall short. It is meant to help you think the choice through before you see a specialist, not to replace that conversation.

What are the treatment options for erectile dysfunction?

The main options are tablets (PDE5 inhibitors), alprostadil as a cream, urethral pellet or injection, vacuum erection devices, low-intensity shockwave therapy and a penile prosthesis. Alongside all of them sit lifestyle change, treatment of any underlying condition and, where relevant, psychological therapy.

These are often pictured as a ladder, with tablets at the bottom and an implant at the top. The European Association of Urology (EAU) guideline recommends tablets first, but it also accepts injections as an alternative first-line choice for well-informed men, and supports an implant where other treatments fail or where a man prefers it after a full discussion. The order is a default, not a rule. It also recommends that lifestyle and risk-factor changes start before, or alongside, any treatment — not after it.

How do ED treatments compare side by side?

They differ most in speed, spontaneity and invasiveness: tablets need no procedure but some planning, injections and pumps are set up each time, and an implant is ready on demand but needs surgery. The evidence behind each row follows below.

Scroll the table sideways to see every column

Sildenafil vs tadalafil: what is the difference?

In effectiveness, very little: the EAU guideline finds no demonstrated difference in efficacy between sildenafil, tadalafil, vardenafil and avanafil. The differences are practical — onset, how long the window lasts, food and side effects — and it suggests basing the choice on how often you have sex and your own experience of the tablets.

All four work the same way. During arousal, nerves release chemical messengers that relax the erectile tissue so blood flows in; an enzyme, PDE5, gradually switches that signal off. The tablets slow the switch-off. That is why none of them produces an erection without sexual stimulation, and why they tend to work less well where nerves or blood vessels are badly damaged.

• Sildenafil: in the EAU guideline’s data, effective from 30–60 minutes, with a window of up to 12 hours. A high-fat meal can delay it.
• Tadalafil: effective from about 30 minutes, peaking at around two hours, with a window of up to 36 hours. Unlike the other three, it is not listed as delayed by high-fat meals, and it can also be taken as a lower daily dose.
• Vardenafil: effective from 30 minutes, and in some men sooner. A high-fat meal can delay it.
• Avanafil: designed to be taken 15–30 minutes before sex. A high-fat meal can delay it.

Tadalafil’s long window reflects how slowly it is cleared: its half-life is about 17.5 hours, against 2.6–3.7 hours for sildenafil. A long window is not a long erection — the tablet makes an erection possible in response to arousal, nothing more. Daily tadalafil means taking a tablet and having sex no longer need to be linked, and it is also licensed for urinary symptoms from an enlarged prostate, which is worth raising if you have prostate symptoms.

Side effects are generally mild. Headache is common to all four; flushing is reported more with sildenafil and vardenafil, and indigestion, back pain and muscle aches more with tadalafil. If tablets seem not to work, our erectile dysfunction treatment page explains what we check first.

In the UK, sildenafil and tadalafil can both be bought from a pharmacy after speaking with a pharmacist, although they are mostly prescribed. If you buy either without a prescription, the NHS advises a check-up with your doctor within six months, because erection problems can be a sign of conditions such as diabetes or heart problems.

Are penile injections a good option for erectile dysfunction?

For many men, yes. Injecting a small dose of alprostadil into the side of the penis is a highly effective non-surgical treatment, which the EAU guideline supports as second-line or, for well-informed men, alternative first-line treatment.

Alprostadil acts directly on the erectile tissue rather than amplifying the nerve signal, so it can work where nerves have been affected — it is one of the treatments used in recovery after prostate cancer surgery. Effectiveness is reported above 70%, including in men with diabetes or cardiovascular disease, with an erection 5–15 minutes after injecting. In men with a history of heart or circulatory disease, though, one large study found a higher risk of a further cardiovascular event with alprostadil than with tablets, so this is part of the discussion with your consultant.

The commonest problem is pain, which usually settles with continued use. Erections lasting longer than wanted occur in about 5%, priapism in about 1% and scarring in about 2%; scarring in the outer sheath of the penis can signal early Peyronie’s disease. Whole-body side effects are uncommon, mainly mild low blood pressure. Injections are not suitable for men at risk of priapism or with bleeding disorders. Between 41% and 68% of men stop, mostly within two to three months; careful training and follow-up are linked with sticking with it.

For men who prefer to avoid needles, alprostadil also comes as a cream or a urethral pellet. The pellet is less invasive but less effective than injections, with erections sufficient for intercourse in roughly 30–66% of men; data on the cream are still limited. Local burning or pain is common with both.

Does a vacuum pump work for erectile dysfunction?

Yes. Because it is purely mechanical, a vacuum device does not rely on nerves, hormones or blood-vessel response. A cylinder over the penis is pumped to draw blood in, and a ring moved onto the base holds it. The EAU guideline reports erections satisfactory for intercourse in up to 90% of men regardless of cause, yet satisfaction ranges from 27% to 94% and long-term use falls to 50–64% after two years: it works, but it has to be set up each time. Side effects include pain, being unable to ejaculate, small pinpoint bruises (petechiae), bruising and numbness. The ring must come off within 30 minutes to avoid skin damage, and the devices should not be used with bleeding disorders or blood-thinning (anticoagulant) medicines. For well-informed older men who have sex infrequently and want a drug-free option, they may be the treatment of choice.

Does shockwave therapy work for ED?

It can help some men, modestly. The EAU guideline concludes that low-intensity shockwave therapy can produce a mild improvement in men whose ED is caused by reduced blood flow (vasculogenic ED). The current version (limited update, March 2026) gives it a weak recommendation, with or without tablets, for:

• men with mild vasculogenic ED;
• well-informed men who do not wish to take, or are not suitable for, tablets;
• men with vasculogenic ED who respond poorly to tablets.

The guideline notes it is the only marketed treatment that might offer a cure, but describes the improvement as modest, with 40–80% of men reporting a satisfactory result across studies. Benefit appears one to three months after the course and then gradually declines, although some effect has been seen up to five years later. Results vary partly because studies used different machines, wave types (focused or radial), energy settings and schedules; one randomised trial of radial waves found no difference from placebo.

If you are considering it, ask what type of device is used and whether your ED has been assessed as vascular in origin; your consultant can advise whether you fit the groups above. Shockwave for ED is a separate question from Peyronie’s disease, for which we do not currently recommend shockwave therapy.

Penile implant vs injections: when is surgery the right step?

An implant is usually considered when other treatments have not worked, are unsuitable or have become a burden — or when a fully informed man prefers a definitive solution. Inflatable implants use a pump to fill cylinders in the penis with fluid when an erection is wanted; three-piece devices have a separate reservoir, while two-piece devices can suit men in whom placing one is riskier, for example after previous abdominal surgery. Semi-rigid implants are bendable rods that keep the penis firm, simpler to use but harder to conceal.

• Reversibility: injections can be stopped at any time; an implant involves replacing the erectile tissue, so it is permanent.
• Satisfaction: in the guideline’s data, satisfaction with implants is high, at 92–100% of patients and 91–95% of partners with appropriate counselling. Injections also score well (87–93.5% of patients), but many men stop.
• Risks: injection side effects are mostly local and short-lived. Implant surgery carries operative risks plus infection and mechanical failure; infection rates of 2–3% are reported for first implants in low-risk patients at high-volume centres (BAUS’s patient leaflet gives 1 to 2 in 100), and diabetes increases the risk. An infected implant usually has to be removed.

A man who uses injections happily may never need surgery; one who has stopped because of pain or effort may be better served by an implant. Because an implant cannot be undone, it is worth taking time over the decision and asking how often the surgeon performs the operation.

Why does treating the cause matter when choosing a treatment?

Because the cause changes which options are safe and which are likely to work. Nitrate medicines rule out tablets, and blood thinners rule out a vacuum device. Nerve damage after pelvic surgery can make tablets less reliable and point towards injections instead. Men with confirmed low testosterone who do not respond to tablets may respond once testosterone treatment starts (see testosterone replacement therapy). ED can also be an early sign of heart and circulation problems, including in younger men (see our guide to erectile dysfunction in young men), so a tablet that works should not end the conversation. We explain how we assess the cause on our erectile dysfunction treatment page.

When does ED treatment need urgent medical help?

Get urgent help for an erection that will not go down, and for chest symptoms, a severe reaction or sudden problems with sight or hearing after taking an ED medicine. Never combine an ED tablet with nitrates.

• Prolonged erection (priapism): if an erection lasts more than 3 to 4 hours — or a painful erection more than 1 hour if you have sickle cell disease — call 999 or go to A&E. Do not drive yourself. It needs hospital treatment quickly to avoid permanent damage, and some ED treatments, including injections, can cause it.
• Nitrates: never combine a PDE5 inhibitor with nitrate medicines such as GTN spray, with nicorandil, or with poppers. The guideline lists this as an absolute contraindication because blood pressure can fall unpredictably and dangerously. If you need emergency care for chest pain, tell the team you have taken an ED tablet, because the nitrate medicines often used for chest pain must not be combined with it.
• Heart symptoms: tight or squeezing chest pain, breathlessness or sweating after taking an ED medicine means calling 999.
• Other serious reactions: call 999 for signs of a severe allergic reaction (a swollen throat or tongue, difficulty breathing) or a seizure. For sudden problems with your eyesight or hearing, which the NHS lists as a serious side effect of tadalafil, get urgent advice from NHS 111.

We do not give dosing advice on this page; take any ED medicine only as prescribed or as advised by the pharmacist who supplied it.

How do you choose between ED treatment options?

We usually start with the cause, then weigh the options against how often you have sex, how much planning you accept, your other medicines and conditions, and how you and your partner feel about needles, devices or surgery. Our consultants practise at Guy’s & St Thomas’, named by Newsweek in 2025 as the number one urology service in Europe. We consult at three HCA locations in London: HCA at The Shard, HCA at Canary Wharf and HCA at Guy’s Hospital. Self-funding patients need no GP referral; insured patients usually do. See our fees and insurance page, read about our consultants or contact us — the phone line, +44 7889 318584, is open Monday to Friday, 8am to 4pm.

Frequently asked questions

References and further reading