ED Treatment Options Compared: Effectiveness, Cost & Fit (2026)

Most ED guides walk you through one treatment at a time. This one does the opposite: it lines every option up next to every other, so you can see at a glance how they differ in the four ways that actually decide the choice. How does it work? How well does it work in the published evidence? What does it cost to keep using? And what kind of man, with what kind of life, does it suit?

It covers the full list. The four FDA-approved pills and the once-daily form of tadalafil. Newer formats such as films, orally disintegrating tablets, nasal sprays and gummies. Compounded multi-ingredient tablets, including the 4-in-1 formula sold by our top-ranked provider. Alprostadil injections and the compounded injection mix Trimix. The urethral pellet. Vacuum erection devices. Low-intensity shockwave therapy, platelet-rich plasma and stem cells. Penile implants. Testosterone, when it's genuinely low. Lifestyle change, pelvic floor training and therapy. And the supplements and "gas station" pills sold as shortcuts.

ED is common and treatable. It's also worth taking seriously, because ED can be an early warning sign of heart disease; our guide to ED as a warning sign of heart disease explains why. If you'd rather read the condition first and the treatments second, our complete guide to erectile dysfunction treatment covers causes and diagnosis in depth. If you already know you want an online prescription, our ED provider comparison ranks the licensed clinics.

Here is every mainstream ED option in one table. "Evidence" describes how the American Urological Association (AUA) guideline classes it, or what the best review we could read found; the sections below give the detail and the links. The AUA's own principle is worth keeping in mind as you read: in its erectile dysfunction guideline (Journal of Urology, 2018), it says men should be informed of all treatment options that are not medically contraindicated, "regardless of invasiveness or irreversibility, as potential first-line treatments," and that it is valid to begin with any of them.

Timing figures come from the MedlinePlus monographs for sildenafil, vardenafil, avanafil and alprostadil, and from the Cialis prescribing information on DailyMed. Treat them as typical ranges rather than promises. Every pill in the table needs sexual arousal to work; the injections and the pellet do not.

We compared treatments, not brands, using the same four questions for each: how it works, how well it works in the best evidence we could read, what it costs to keep using, and which men it suits. Nothing on this page is a rating we made up. Where a number appears, it comes from a named study, guideline, label or government page, linked where it's used, and every one of those sources was read on November 9, 2026.

Which sources carry the most weight

• Clinical guidelines first. The AUA erectile dysfunction guideline grades each recommendation by how strong the evidence is (Grade A, B or C) and how firm the advice is (Strong, Moderate or Conditional, plus "Clinical Principle" and "Expert Opinion"). We quote those grades so you can see the difference between "well proven" and "promising".
• Government and label information next. MedlinePlus monographs summarize each drug's prescribing information in plain language; the NIDDK, part of the National Institutes of Health, and the NHS give the official overview; the FDA explains what "compounded" and "tainted" mean.
• Trials and systematic reviews for the numbers. These are reported as their authors reported them, with the year and the population, because a figure from 1,000 men in a 1990s trial isn't the same as one from a 2025 Cochrane review.

What we did not do

We didn't rank treatments on a single score, because a treatment that's perfect for one man is wrong for another. We didn't publish prices that aren't dated in our ED treatment cost index, and we didn't use testimonials or forum posts.

How this page relates to our provider rankings

The provider facts later in this guide come from our own ED provider reviews, and the order matches our published ranking on the ED comparison page. Some providers may compensate us, which can affect placement but not the clinical content here. We are a comparison site, not a medical provider, and this page is written by the Treatments Hub Research Team; it is not a substitute for a clinician who knows your history.

"Effective" means different things in different studies, which is why you can't line up raw percentages from different treatments and pick the biggest. Knowing three measures makes every comparison on this page easier to read.

The IIEF erectile function score

The International Index of Erectile Function (IIEF) is a questionnaire. Its erectile function domain runs from 6 to 30, and higher is better. A 2025 Cochrane review used a change of 4 points as the minimal clinically important difference, meaning the smallest improvement a man would actually notice. A treatment can raise the average score by a "statistically significant" amount that's still below what most men would feel.

Successful intercourse

Many trials simply ask whether a man could have intercourse, either at least once during the study or on a share of attempts. This is closer to what most men care about, but it depends heavily on who was enrolled. A trial that first screens out men who didn't respond in clinic, as the urethral pellet trial did, will report higher home success than one that enrolls everyone.

Satisfaction

Satisfaction captures what the other measures miss: whether a treatment fits into a sex life. A vacuum device can produce a reliable erection and still be abandoned because it feels unspontaneous; an implant involves surgery but scores highly on satisfaction because it works on demand.

Why comparisons need care

• Different men. Men with diabetes or nerve damage after prostate surgery respond less strongly to pills, the AUA guideline notes, so a study full of them will look worse than one of otherwise healthy men.
• Different comparisons. Pill trials compare against placebo; implant studies usually don't have a control group at all.

So read each number below as "how this treatment performed in its own studies," and use the comparison to understand trade-offs, not to crown a winner.

In the published figures, injections and implants report the highest success and satisfaction, pills and vacuum devices work for most men, and shockwave therapy trails well behind. But "most effective" isn't the same as "best for you": the most reliable options are also the most invasive. Here are the headline results, each from its own source and measured its own way.

How to read the table

The pill figures come from large placebo-controlled trials and are the most robust. The injection and pellet figures are strong but older, and the pellet trial only sent men home with the drug after they'd responded in clinic, so its home success rate applies to responders. The implant figure measures satisfaction, not erections, in studies without a comparison group. The shockwave figure is the only one judged by its reviewers as possibly below the threshold men would notice.

What the table really shows is a trade-off curve. As you move from pills to injections to implants, reliability tends to go up, and so do effort, invasiveness and permanence. Most men start at the low-effort end and move along only if they need to; the AUA's point is that you're allowed to start wherever suits you. Our ED statistics guide covers response and drop-out rates.

Value means cost per successful use, not price per pill. A cheap treatment you stop using is poor value; a pricier one that works reliably and fits your life may be better. With that in mind, here's how the main routes compared in our ED treatment cost index, last updated October 14, 2026. Ranges are the index's representative US online ranges, not quotes from a single seller; always confirm the price at checkout.

Where the value sits for different men

• Occasional use: as-needed generic sildenafil is usually the cheapest route per occasion.
• Frequent use or a wish for spontaneity: daily generic tadalafil can work out cheaper per month than paying per dose, and it may also treat the urinary symptoms of an enlarged prostate, potentially replacing a second prescription.
• Pills don't work or can't be used: a vacuum device is a single purchase with no ongoing drug cost; injections cost little per dose but need clinic visits to start.
• Convenience matters most: compounded dissolvables and sprays charge for the format and the bundled service; whether that's worth it is personal.

We don't list prices for shockwave therapy, PRP or implants because we couldn't find a primary source we trust for them; costs vary by clinic and, for implants, by insurance. Our guide to how much ED treatment costs goes further into insurance, subscriptions and hidden fees.

All four are PDE5 inhibitors, all four are FDA-approved for ED, and on average they work about equally well. The AUA's review of the trials, covering nearly a quarter of a million men, concluded that the four "have similar efficacy in the general ED population." The real differences are timing, duration, food and side effects. Source: AUA guideline, 2018.

Lead times come from MedlinePlus for sildenafil, tadalafil, vardenafil and avanafil; the 36-hour figure is from the Cialis prescribing information, which says it "improves erectile function compared to placebo up to 36 hours post dose." The side-effect column reflects the AUA's summary: average side-effect rates were similar across the four, except that indigestion was lowest with avanafil, flushing lowest with tadalafil, and muscle aches lowest with vardenafil and avanafil.

Choosing between them

• Sildenafil is the classic choice for occasional, planned sex, and the cheapest as a generic. Its main drawback is that a heavy meal can delay it. See how long sildenafil lasts.
• Tadalafil suits men who don't want to plan, because one dose covers up to a day and a half, or who want a daily routine. See sildenafil vs Cialis.
• Vardenafil behaves much like sildenafil and is an option if one of the others didn't suit; its disintegrating form dissolves on the tongue.
• Avanafil has the shortest lead time on its label, which appeals to men who value spontaneity.

Each drug's label lets a prescriber move the dose up or down depending on response and side effects, and the AUA gives a Strong Recommendation that the dose be titrated to the optimal level. That's a decision for your prescriber; our guide to sildenafil doses explained explains how it usually works. If one pill isn't right, switching to another is reasonable, and our guide to the best ED medicine works through more examples.

Not better, just different. The AUA's review found that "on demand dosing versus daily dosing for tadalafil appears to produce the same level of efficacy." What daily dosing changes is the experience: a small dose taken at about the same time every day keeps the drug in your system, so, as MedlinePlus puts it, "you may attempt sexual activity at any time between doses." Sources: AUA guideline; MedlinePlus, tadalafil.

Who daily tadalafil tends to suit

• Men who want spontaneity. No timing, no reaching for a pill, no explaining a pause.
• Men who are active often. Paying for one small daily dose can be simpler, and sometimes cheaper, than paying per occasion.
• Men who also have urinary symptoms from an enlarged prostate. MedlinePlus lists benign prostatic hyperplasia as an approved use of tadalafil, so one medicine may cover both. That's for a prescriber to judge, particularly if you already take a prostate medicine.
• Men for whom anxiety about "timing it right" is part of the problem. Removing the ritual can remove some of the pressure.

Who might prefer as-needed

• Men who have sex occasionally and would rather not take a pill every day.
• Men who get side effects such as back ache or headache, who may prefer to experience them only on the days they need the drug.
• Men on several other medicines, where a prescriber may prefer intermittent use.

The safety rules are identical either way: daily tadalafil is still a PDE5 inhibitor, still incompatible with nitrates and riociguat, and still needs care with alpha-blockers and other blood-pressure medicines. Our guide to daily vs as-needed tadalafil covers the decision in more detail, and our guide to ED pills and blood pressure medication covers the interactions.

There isn't one pill that's gentlest for everyone, but the pattern is consistent. The AUA guideline lists the most frequently reported side effects of PDE5 inhibitors as indigestion, headache, flushing, back pain, nasal congestion, muscle aches, visual disturbance and dizziness, and found average rates similar across the four drugs, with three exceptions: indigestion was lowest with avanafil, flushing lowest with tadalafil, and muscle aches lowest with vardenafil and avanafil. Most side effects followed a dose-response pattern, meaning they became more common as the dose went up. Source: AUA guideline, 2018.

What the side effects look like in practice

• Headache, flushing and a stuffy nose are the classic trio, the predictable result of a drug that widens blood vessels.
• Back and muscle ache is more associated with tadalafil; MedlinePlus lists pain in the back, muscles, arms or legs among its side effects. Source: MedlinePlus, tadalafil.
• Visual changes, such as a blue tinge or difficulty telling blue from green, appear in the monographs.
• Indigestion or heartburn is common across the class.

The rare effects that need urgent care

MedlinePlus tells men taking tadalafil to call a doctor immediately or get emergency treatment for a sudden decrease or loss of vision, a sudden decrease or loss of hearing, an erection lasting longer than four hours, or chest pain, among other serious symptoms; it notes that vision loss after this class of medicine was permanent in some cases, though it isn't known whether the drug caused it. The NIDDK gives the same warning for ED medicines taken by mouth, injection or suppository. Sources: MedlinePlus, tadalafil; NIDDK, treatment for ED.

If side effects are the problem, the usual fixes are a different dose, a different drug in the same class, or a different time of day, all of which are prescriber decisions. Swapping sildenafil for tadalafil, for example, trades a higher chance of flushing for a higher chance of back ache. Our full guide to ED medication side effects goes through each one and what helps.

The nitrate rule is the one absolute in ED treatment. The AUA guideline states that "the use of nitrate-containing medications in combination with a PDE5i can cause a precipitous drop in blood pressure," and that men taking nitrates regularly should not use them. MedlinePlus spells out the list for each drug: nitroglycerin in tablets, under-the-tongue tablets, sprays, patches, pastes and ointments; isosorbide mononitrate and dinitrate; riociguat (Adempas); and recreational nitrates such as amyl and butyl nitrite, known as "poppers". Sources: AUA guideline; MedlinePlus, avanafil; MedlinePlus, vardenafil.

Situations that need a clinician's judgment

• Heart disease. MedlinePlus asks men to tell their doctor if they've been advised to avoid sexual activity or have had heart surgery recently. ED itself can be an early sign of heart disease, which the AUA calls a "risk marker" worth evaluating; see ED as a warning sign of heart disease.
• Blood-pressure medicines and alpha-blockers. These aren't banned, but the combination can lower blood pressure further, so timing and dose matter. See ED pills and blood pressure medication.
• Kidney or liver disease. The AUA says PDE5 inhibitors should be used with caution, at least initially at lower doses, in mild to moderate kidney or liver impairment, and are generally not recommended in severe disease.
• Other interacting medicines. Some drugs change how PDE5 inhibitors are processed; MedlinePlus even lists omeprazole as a non-prescription product that may interact with avanafil. A full medication list on your intake form is essential.

If pills are ruled out

Being unable to take PDE5 inhibitors doesn't mean being unable to treat ED. A vacuum device involves no drug at all. Alprostadil, used as an injection or pellet, works by a different route, though it has its own list of conditions to discuss with a prescriber. And an implant is an option for men who want a permanent solution. The AUA specifically describes the urethral pellet and injections as options for men for whom PDE5 inhibitors are contraindicated. Never combine a PDE5 inhibitor with nitrates, and seek emergency care for chest pain, an erection lasting over four hours, or sudden loss of vision or hearing.

They're more convenient for some men, but they aren't stronger, and only a few are FDA-approved. Most new ED formats contain the same PDE5 drugs as standard tablets. The questions worth asking about any of them are: is this exact product FDA-approved, or compounded? And is the speed claim from an independent trial or from the company selling it?

The FDA-approved options

Vybrique is sildenafil in a thin film that dissolves on the tongue without water; the FDA approved it on February 5, 2026. Vardenafil also comes as a rapidly disintegrating tablet that dissolves in the mouth without water. MedlinePlus warns that the disintegrating tablet "cannot be substituted for" the regular vardenafil tablet and comes in only one strength, so a prescriber who needs to adjust the dose may switch you back to standard tablets. Source: MedlinePlus, vardenafil.

The compounded options

The vardenafil nasal spray Roxus became available in the US in October 2026 as a compounded product, which Medscape reported is "not approved by the U.S. Food and Drug Administration (FDA) for safety or efficacy." Our SHED review notes that its faster-onset messaging is a brand claim we haven't independently verified, and that there is less independent long-term data for intranasal ED medication than for oral pills. Rex MD's Ignite gummy and Quad by MEDVi's dissolvable dose are also compounded, prescription-only products; the next section explains what that means.

So which format should you choose?

Choose a format for the life it fits, not the speed it promises. If you dislike swallowing tablets, a film, disintegrating tablet or dissolvable can be worth the extra cost; if price matters most, standard generic tablets are the value choice. Our guide to the fastest-acting ED treatments compares onset times format by format, and Quad vs BlueChew compares a compounded dissolvable with a chewable.

They can be, for the right man, but they are a different kind of product from an FDA-approved generic, and it pays to understand the trade. A compounded ED medication is made by a pharmacy to a prescriber's order, typically combining two or more actives, such as sildenafil and tadalafil, sometimes with other ingredients, in one dose and often in a dissolvable form.

What the FDA says

The FDA's consumer page is clear: "compounded drugs are not FDA-approved," which means the agency "does not review these drugs before they are marketed to evaluate their safety or effectiveness." Compounding serves real needs, the FDA notes, such as a patient who needs a medicine without a certain dye or can't swallow a tablet. But it also warns that poor compounding practices can cause serious quality problems, including contamination or products that don't have the strength, quality and purity they should. Source: FDA, human drug compounding, consumer information (current as of June 9, 2026).

What that means for you

• The evidence is for the ingredients, not the blend. Sildenafil and tadalafil have been studied in large trials as single drugs. A specific combination at a specific strength hasn't been through the same process, so a claim that it works "better" than a generic is a claim, not a trial result.
• The safety rules don't change. Any product containing a PDE5 inhibitor carries the same nitrate and riociguat prohibition.
• The pharmacy matters. Ask which licensed pharmacy compounds your medicine.

An example: Quad by MEDVi

Quad by MEDVi, the product behind our top-ranked provider, is a compounded 4-in-1 dose that dissolves under the tongue. Our Quad review describes the formula as sildenafil and tadalafil (two PDE5 inhibitors), L-citrulline (an amino acid the body converts toward nitric oxide) and apomorphine (a dopamine agonist acting on the brain's arousal pathway). The review notes that the apomorphine component is associated with nausea in some men, that it's positioned for men for whom a single standard pill underperformed, and that it typically costs more than a plain generic. Its listed starting price in our cost index was $114 a month (from $179), as of October 14, 2026.

Who compounded blends suit

Men who tried a standard pill and wanted more, men who strongly prefer a dissolvable format, and men who like having consultation, support and delivery bundled into one plan. Men who have never tried ED treatment are usually better starting with an affordable single-ingredient generic, as our Quad review itself says. For a category comparison, see our guide to the best 4-in-1 ED medications and Quad vs Rugiet.

The FDA's sexual enhancement notifications page is blunt. Products that claim to help with sexual enhancement or treat sexual dysfunction, including "male enhancement supplements, erectile dysfunction treatments, male energy pills and stamina pills," are likely to be contaminated with dangerous hidden ingredients. They're "sometimes falsely advertised as dietary supplements, food and/or all-natural treatments," often have many positive reviews, are sold online and in stores, and "pose a serious health risk and are not guaranteed to work." The page, updated as recently as October 15, 2026, lists new products almost every month, and the FDA says the list "covers only a small fraction" of contaminated products. Source: FDA, sexual enhancement and energy product notifications.

Why hidden ingredients are dangerous

One example from May 29, 2026 shows the problem. FDA laboratory analysis of Erectus Plus, a male enhancement product sold on websites including eBay, found sildenafil, tadalafil and testosterone propionate that weren't on the label. The FDA warned that these undeclared ingredients "may interact with nitrates found in some prescription drugs, such as nitroglycerin, and may lower blood pressure to dangerous levels." The same notice reminds readers that FDA approval of Viagra and Cialis "is restricted to use under the supervision of a licensed health care professional." Source: FDA, Erectus Plus notification, May 29, 2026. For a man who takes nitrates for his heart, an "herbal" product secretly containing a prescription drug is exactly the combination the warnings exist to prevent. That's the real risk of OTC ED products: not that they don't work, but that you can't know what's in them.

What about the UK?

Readers outside the US may have seen that sildenafil can be bought from a pharmacy without a GP prescription in the UK. The NHS confirms you can get sildenafil "on prescription or you can buy it from a pharmacy," but you need a prescription for the other PDE5 inhibitors, and it urges care buying online "as many websites sell fake medicines."

Natural approaches that do have evidence

The natural approaches with real evidence behind them aren't capsules; they're lifestyle change and pelvic floor training, covered next. The NIDDK asks men to talk with a health care professional before using dietary supplements or alternative medicines for ED, because they can affect how other medicines work. Source: NIDDK, treatment. Our guides to over-the-counter ED treatment and natural ED remedies look at individual products and claims.

Not usually on their own, and not quickly, but they're the one ED treatment that, in the AUA's words, also improves "overall health," and for some men they're enough. The AUA gives a Moderate Recommendation that clinicians counsel men with ED and related health conditions that lifestyle changes, including diet and more physical activity, "improve overall health and may improve erectile function." It describes the effect on erections as "small positive," with "broader, positive effects on overall health," and notes that a healthier lifestyle can make other ED treatments more likely to work. Source: AUA guideline.

The trial that's still the reference point

A randomized trial published in JAMA in 2004 followed 110 obese men aged 35 to 55 with ED but without diabetes, high blood pressure or high cholesterol. Half got detailed support to lose at least 10% of their body weight through eating less and exercising more; the other half got general advice. After two years, the intervention group's average erectile function score rose from 13.9 to 17, while the control group's stayed flat, and 17 men in the intervention group reached a normal score against 3 in the control group. The authors concluded that lifestyle changes were associated with improved sexual function "in about one third of obese men." Source: Esposito et al., JAMA, 2004.

What the official advice includes

The NIDDK lists the changes clinicians may suggest: quitting smoking, limiting or stopping alcohol, more physical activity, a healthy weight, a healthy eating plan, and stopping recreational and illicit drugs. It points to the US guideline of at least 150 minutes a week of moderate activity, such as brisk walking. The NHS adds two specifics: keep alcohol to no more than 14 units a week, and if you cycle more than three hours a week, take a break for a while. Sources: NIDDK, treatment and prevention; NHS, erectile dysfunction.

Lifestyle versus pills: not either-or

The real comparison isn't lifestyle versus medication, but lifestyle plus medication versus medication alone. A pill works tonight; weight loss and fitness work over months and change the conditions the pill is working against. For men whose weight is a major factor, our guide to GLP-1 medicines and ED reviews what the newer weight-loss drugs do and don't show. Men with diabetes should also read ED and diabetes.

They can, according to a small randomized trial, and they're drug-free and can be done alongside other treatments. The trial described below started from a simple observation: the pelvic floor muscles are active in normal erectile function, so weak ones could be part of the problem, and strengthening them might help.

What the trial found

A randomized controlled trial published in the British Journal of General Practice in 2004 enrolled 55 men with ED, with a median age of 59. Men in the intervention group did pelvic floor exercises with biofeedback plus lifestyle advice; the control group got lifestyle advice only for three months, then switched to exercises. At three months, the exercise group's erectile function score had improved by 6.74 points more than controls, and it improved further at six months. Overall, 40% of participants regained normal erectile function, 34.5% improved and 25.5% did not improve. Source: Dorey et al., Br J Gen Pract, 2004.

How to read that result

• It's one modest-sized trial, run by a specialist team with biofeedback equipment and supervised technique, so results from exercises learned from an app or video may differ.
• It needs consistency. The benefit built over months of regular practice.
• It involves no drugs or devices, so it doesn't add interactions to anything else you take.

Who it suits

Men who'd like to try a non-drug approach first, and men who'd like to add something to a pill that's only partly working. A physiotherapist with experience in men's pelvic health can teach the technique properly. It isn't a replacement for a medical check if your ED is new, worsening or comes with other symptoms, since ED can be a sign of a vascular problem worth investigating.

Yes, especially when anxiety, stress or relationship strain is part of the picture, and it works well alongside medication. The AUA gives a Moderate Recommendation that, for men being treated for ED, "referral to a mental health professional should be considered to promote treatment adherence, reduce performance anxiety, and integrate treatments into a sexual relationship." For men whose ED is predominantly psychological, it says providers should offer a referral "as either an alternative or adjunct to medical treatment." Source: AUA guideline.

What the reviews show

A Cochrane review of psychosocial interventions, covering 11 trials and 398 men, found that group psychotherapy reduced the number of men with persistent ED compared with men on a waiting list, with the benefit maintained at six months. A related meta-analysis in the Journal of Sexual Medicine in 2008 found that men given psychotherapy plus sildenafil improved significantly and were less likely to drop out than men given sildenafil alone, and found no difference between psychological treatment and injections or vacuum devices in the trials that compared them. The studies are small and old, so the certainty is modest. Sources: Cochrane Database of Systematic Reviews, 2007; Journal of Sexual Medicine, 2008.

Signs psychology is playing a part

The AUA notes that the presence of nighttime or morning erections suggests, though doesn't confirm, a psychological component, and lists situational factors clinicians ask about, such as ED that happens only in specific contexts or only with a partner. It also points out that psychological factors such as depression, anxiety and relationship conflict can be either a primary cause or a secondary one, layered on top of a physical problem.

Therapy compared with pills

• Pills work quickly, but they don't address anxiety or relationship strain themselves.
• Therapy takes longer and needs engagement, but the Cochrane review found group therapy's benefit maintained at six months, and the AUA describes it as helping couples communicate about sex and fold treatments into their relationship.
• Together, the evidence suggests, they do better than either alone for many men.

The NIDDK notes that a counselor may suggest bringing a partner to sessions. In the UK, the NHS points to accredited sex therapists through the College of Sexual and Relationship Therapists. Sources: NIDDK; NHS. If you're younger and anxiety feels like the main issue, our guide to ED in your 20s and 30s is written for you, and what causes erectile dysfunction explains how the causes interact.

You can get most of the first-line options online, but not all of them. Licensed telehealth services can prescribe PDE5 pills, daily tadalafil, and, at some services, compounded dissolvables and nasal sprays, after reviewing your health questionnaire. Treatments that need hands-on care, such as injections, the urethral pellet, shockwave therapy and implants, start with an in-person visit, because the AUA says an in-office test should be performed before injections or the pellet are used at home.

What a legitimate online service looks like

Every legitimate provider requires a prescription, and so a clinician's review of your health and medicines, before anything ships. The FDA's checklist for a safe online pharmacy is short: it "always requires a doctor's prescription," gives a US physical address and phone number, has a licensed pharmacist available, and is licensed with a state board of pharmacy. Warning signs include no prescription requirement and "prices that seem too good to be true." Source: FDA BeSafeRx, considering an online pharmacy.

The trade-off of going online

Online care removes the waiting room, and for straightforward ED in an otherwise healthy man it does the job well. What it can't do is examine you or run a heart work-up. If your ED is new and you have heart risk factors, or you've never had a check-up, an in-person visit is worth it as well. Our guides to getting ED treatment online, buying ED medication online safely and ED treatment near you vs online cover the steps.

If you've decided an online prescription fits, it helps to start with a service that keeps the clinician review central and is clear about what it prescribes. Our three highest-ranked online ED providers are below.

The online providers we rank differ less in the medicines they can prescribe than in format, focus and how they package care. Here's how the three highest-ranked compare, using only what our own reviews record, in our ranking order: Quad by MEDVi, DirectMeds and Rex MD.

Quad by MEDVi

Our top pick, because it does something single-ingredient options don't: it combines several actives into one fast-dissolving dose, prescribed through a real telehealth flow. Our review's pros are a genuinely differentiated multi-ingredient formula, a real alternative for men who dislike swallowing pills, an Rx-only flow with a licensed provider making the call, and discreet, fast delivery. Its cons are the compounding status, a higher cost than a plain generic, and an intake that matters more because several actives are combined. See also Quad vs DirectMeds and Quad vs Hims.

DirectMeds

A licensed online service running the standard telehealth flow: online intake, a licensed-clinician review, and discreet direct-to-door delivery, with online follow-up and refills. Our review flags that we haven't independently verified its exact ED medications and current pricing, so confirm both on its site. It's a credible option to compare against the others; see DirectMeds vs Rex MD.

Rex MD

One of the broadest ED menus we rank, from an established national men's-health brand: generics, brand-name pills, daily tadalafil and the exclusive Ignite gummy, with free 2-day delivery. Our review's honest caveat is subscription billing: buyers report surprise auto-refill charges and cancellation friction, so confirm the refill schedule and cancellation terms up front.

Other providers worth knowing

Further down our ranking, DudeMeds is the value-minded choice for the standard medication at a low price; BraveRX offers a simple online consultation; Peter MD puts ED on the same platform as testosterone care; and SHED prescribes the Roxus vardenafil nasal spray. Our Hims review covers a well-known brand offering generic pills and chewables. Every one of them requires a clinician's review before prescribing, which is the safeguard that matters most. The full ranking is on our ED comparison page.

Testosterone often gets the blame for ED, but the evidence gives it a narrower role: it's a treatment for a confirmed deficiency, not for erections as such. The AUA recommends that men with ED have a morning total testosterone level measured, and defines testosterone deficiency as a total level below 300 ng/dL together with symptoms and signs. A man whose level is normal has no deficiency to treat. Source: AUA guideline.

What the best recent trial showed

The TRAVERSE trial enrolled 5,204 men aged 45 to 80 with two testosterone readings below 300 ng/dL, symptoms of low testosterone, and heart disease or raised heart risk. Within it, 1,161 men with low libido joined a sexual function study and were randomized to testosterone gel or placebo gel. Over two years, testosterone improved sexual activity, symptoms of low testosterone and sexual desire, "but not erectile function," compared with placebo. Source: TRAVERSE Sexual Function Study, J Clin Endocrinol Metab, 2024.

How testosterone fits alongside other treatments

• Low desire plus ED, with a confirmed low level: testosterone may restore desire and help a PDE5 inhibitor work better. The NIDDK notes that clinicians may prescribe testosterone with PDE5 inhibitors for men who have ED and low testosterone, given as an oral medicine, a patch or a gel. Source: NIDDK, treatment.
• ED with a normal level: testosterone isn't the answer; the other treatments on this page are.

Testosterone needs blood tests before treatment and monitoring during it, which is why it sits on a different track from an ED prescription. Our guide to whether low testosterone causes ED explains the test results, and our testosterone replacement therapy comparison reviews clinics that test and treat it.

Injections are among the most reliable ED treatments and often work where pills don't, but they involve a needle and need training to start. They work by a different route: alprostadil, a synthetic form of prostaglandin E1, relaxes the muscles and blood vessels of the penis directly, so it doesn't depend on the nerve signal a PDE5 inhibitor protects. MedlinePlus says an erection may occur within 5 to 20 minutes after an injection and should last about 30 to 60 minutes. Source: MedlinePlus, alprostadil (urogenital).

How well injections work

The AUA's review found that the share of men achieving an erection sufficient for intercourse ranged from 53.7% to 100% across injection studies, "without marked differences across medications or medication combinations," and that satisfaction ranged from 46.3% to 98.8%. In a landmark six-month self-injection study of 683 men published in the New England Journal of Medicine in 1996, men reported being able to have sexual activity after 94% of injections, and men and partners rated it satisfactory after 87% and 86% of injections respectively. Sources: AUA guideline; NEJM, 1996.

The risks to weigh

In that same study, penile pain, usually mild, occurred in 50% of men at some point but after only 11% of injections; prolonged erections occurred in 5% of men, priapism in 1%, and scarring-related complications in 2%. The AUA reports the lowest priapism rates, a mean of 1.8%, in studies using alprostadil, and scarring or plaque across injection studies ranging from 4.5% to 13%. It stresses that finding the right dose in clinic and teaching dose adjustment "is critical to minimize the risk of priapism." An erection lasting more than four hours needs emergency care. Sources: NEJM, 1996; AUA guideline.

Who injections suit

Men who can't take PDE5 inhibitors, men who tried pills properly without success, men with nerve damage after prostate surgery or from diabetes, and men who simply prefer a reliable, fast, on-demand option to a daily pill. Some men never get used to the needle, and that's a perfectly good reason to choose something else.

Trimix is a compounded injection that combines alprostadil with two other medicines that widen blood vessels, papaverine and phentolamine. The AUA explains that alprostadil is the only injectable ED medicine FDA-approved in the US and the only one typically used alone; the others "are typically used in combination with one another," including alprostadil plus papaverine plus phentolamine (Trimix) and a four-drug mix that adds atropine. It adds that although these non-prostaglandin agents have been used successfully for decades, "none are formally FDA-approved for this indication." Source: AUA guideline.

Why clinicians use mixtures

Combining drugs that work by different mechanisms can produce an erection where one drug alone doesn't, and the AUA notes that pain rates are highest when papaverine or alprostadil are used as single agents, and when papaverine is combined with phentolamine. The AUA also reports that satisfaction was lowest in studies using papaverine (a mean of 53.4%), so the specific recipe matters.

Trimix compared with alprostadil alone

Because Trimix is compounded, everything the FDA says about compounding applies: no pre-market review for safety or effectiveness, and quality that depends on the pharmacy. Source: FDA, human drug compounding. That doesn't make it a poor choice; the AUA notes these agents have been used to manage ED successfully for decades. It does mean it should come from a clinician who examines you, tests your response in the office and teaches you to adjust the dose, not from an online checkout.

Our full guide to Trimix for ED covers how it's started and what it costs.

It's a reasonable option for men who want to avoid needles, but it's generally less reliable than an injection. The urethral suppository is a small pellet of alprostadil placed into the opening of the penis with an applicator, where it's absorbed into the surrounding tissue. MedlinePlus says an erection may occur within 5 to 10 minutes after using the pellet. Source: MedlinePlus, alprostadil (urogenital).

What the evidence shows

The main trial, published in the New England Journal of Medicine in 1997, tested the pellet in 1,511 men aged 27 to 88 with ED from physical causes. In the clinic, 65.9% had erections sufficient for intercourse. Those men then went home with either alprostadil or placebo for three months: 64.9% of the alprostadil group had intercourse at least once, against 18.6% on placebo, and on average 7 of 10 uses were followed by intercourse in men who responded. Efficacy was similar regardless of age or cause, including vascular disease, diabetes, surgery and trauma. Source: MUSE Study Group, NEJM, 1997.

Other studies have been less impressive. The AUA reports successful intercourse rates from 29.5% to 78.1% across studies, and classes the pellet as a Conditional Recommendation, a notch below injections. Source: AUA guideline.

Side effects

In the 1997 trial, the most common side effect was mild penile pain, after 10.8% of treatments, and low blood pressure occurred in the clinic in 3.3% of men; no men had priapism or penile scarring. The AUA says the pellet shouldn't be prescribed until a man has had instruction, an initial dose test in the office and counselling about side effects.

Pellet or injection?

• Choose the pellet if you can't face a needle.
• Choose an injection if reliability matters most; the AUA's ranges for injections sit higher.
• Either suits men who can't take PDE5 inhibitors; the AUA names both as options for them.

A vacuum erection device (VED) has three parts, the NIDDK explains: a plastic tube placed over the penis, a pump that creates a vacuum and draws blood in, and an elastic ring slid onto the base to keep the erection once the tube is removed. You may need some practice to get it right. Source: NIDDK, treatment.

What the evidence says

The AUA gives VEDs a Moderate Recommendation and notes they're effective in the general ED population and in men with diabetes, spinal cord injury and after prostate removal. A 2026 meta-analysis of 18 studies and 1,065 men with ED that hadn't responded to PDE5 inhibitors found pooled efficacy (successful intercourse or satisfaction) of 80%, with 82.9% in mixed causes, 73.0% with diabetes, 71.8% after spinal cord injury and 84.5% after prostate removal. The most common side effect was bruising, in 24.3% of men. A 2026 French systematic review behind national guidelines adds that VEDs improve outcomes combined with PDE5 inhibitors, have a favourable safety profile, and that long-term adherence varies. Sources: AUA guideline; Int J Impot Res, 2026; Fr J Urol, 2026.

The trade-offs

• It feels different. The NIDDK says VEDs can make the penis feel cold or numb, look purple or bruised (bruises are usually painless and fade in a few days), and may weaken ejaculation, though this doesn't affect the pleasure of orgasm.
• It's less spontaneous. It has to be set up before sex, which some couples fold into foreplay and others never get used to.
• Some men should take care. The AUA advises caution for men on blood thinners, with bleeding disorders, or with a history of priapism.

Who a pump suits

Men who can't take ED medicines, including men on nitrates; men who want a one-off purchase with no ongoing drug costs; men recovering erections after prostate surgery; and couples who'd like a reliable backup alongside a pill. The NHS notes vacuum pumps "work for most men and can be used if medicine is not suitable or does not work," though they aren't always available on the NHS. Source: NHS. The AUA notes they can be bought over the counter or on prescription, so ask a clinician which device to choose and how long the ring may stay on.

Low-intensity extracorporeal shockwave therapy (Li-ESWT, often shortened to LiSWT) delivers low-energy acoustic pulses to the penis over several sessions, with the aim of stimulating new blood vessel growth. It's widely advertised. The evidence is more cautious than the advertising.

What the guideline says

The AUA classes Li-ESWT as investigational (a Conditional Recommendation on Grade C evidence), because "findings from randomized sham-controlled trials... do not clearly indicate that benefits reliably outweigh risks/burdens." A 2019 review comparing guidelines noted that European guidance is more permissive, allowing it with a weak recommendation in mild vascular ED or in men who respond poorly to pills. Sources: AUA guideline; International Journal of Impotence Research, 2019.

What the best review found

The 2025 Cochrane review included 21 randomized trials and 1,357 men aged 39 to 65, most with mild or mild-to-moderate ED; it excluded men who'd had their prostate removed. Compared with sham treatment:

• Erectile function scores rose by 3.89 points in the short term, just under the 4-point threshold the reviewers used for a noticeable change, so "this small effect may not be clinically important."
• In the longer term (more than three months), scores rose by 5.25 points in five studies, which may be an improvement.
• There was little to no difference in treatment-related side effects.
• No study reported patient or partner satisfaction or sexual quality of life.
• The certainty of evidence was low for every outcome, and "several studies were industry-funded, mainly by device makers."

Source: Cochrane Database of Systematic Reviews, 2025.

Should you try it?

If you're considering it, think of it as paying for an unproven treatment. Ask the clinic about its protocol, the number of sessions, the total cost, and what happens if it doesn't help. It's most plausible for men with mild ED from vascular causes, the group most trials studied. It isn't a substitute for checking your heart, and it shouldn't delay treatments with stronger evidence. Our latest ED treatments roundup tracks newer options as evidence develops.

Neither is a recommended ED treatment. The AUA guideline says intracavernosal stem cell therapy "should be considered investigational," and platelet-rich plasma (PRP) "should be considered experimental." On PRP it goes further: it "should not be offered to men with ED unless it is administered in the context of an institutional review board approved experimental clinical research protocol," and when the guideline was written, "no full-text peer-reviewed publications" were available to form an evidence base. Source: AUA guideline.

What these treatments are

• PRP, sometimes sold as a "P-shot," involves drawing your blood, concentrating the platelets, and injecting the result into the penis.
• Stem cell therapy injects cells intended to regenerate erectile tissue or blood vessels.

How to tell research from a sales pitch

A legitimate research protocol is approved by an ethics committee (an institutional review board), explains that the treatment is unproven, and collects data. A clinic charging a fee for a "P-shot" or "stem cell" package is not running a research protocol, whatever its marketing says. If you're interested in contributing to research, ask a urologist about trials, or search the US registry at clinicaltrials.gov.

Compared with treatments that work

The contrast is stark. Injections, the urethral pellet, vacuum devices and implants each have decades of data, defined risks and guideline support; PRP and stem cells have none of those yet. For a man who's tried pills without success, those established options are the evidence-based next steps.

An implant is the right choice for men who want a permanent, on-demand solution, usually after other treatments haven't worked or haven't suited them, and who accept that surgery is irreversible. The AUA gives a Strong Recommendation that men with ED be informed about penile prosthesis implantation, and says it has been performed successfully in the general ED population and in many special groups. Source: AUA guideline.

How implants work

The NIDDK describes two kinds: a device made erect using a pump placed in the scrotum, and a rod the man controls himself. It also notes that most men with ED do not need surgery, and that implants are considered when other options haven't helped. Source: NIDDK, treatment.

Satisfaction and complications

A systematic review and meta-analysis published in Andrology in 2025 pooled 83 studies covering 12,132 men followed for an average of almost four years. It found 83% of men were satisfied, with satisfaction higher with three-piece inflatable devices, independent of age and increasing over time; partners' satisfaction was somewhat lower than men's. Long-term complications were limited, from 3% for erosion to 4.6% for mechanical failure, and complications were strongly associated with diabetes. Source: Andrology, 2025.

The AUA describes infection as the most serious complication: it usually occurs within the first three months and typically means removing the device. Observational studies suggest models with infection-inhibiting coatings have much lower infection rates, with most series reporting 1% to 2%. Surgery shouldn't be done when there's an active infection anywhere, including a urinary infection. Source: AUA guideline.

Implants compared with other treatments

• Versus pills and injections: no timing, no needles, no medicine; but it's surgery that the AUA describes as "invasive and essentially irreversible."
• Versus vacuum devices: far more spontaneous, and satisfaction is high; but a pump is reversible and cheap.
• Versus vascular surgery: the AUA does not recommend penile venous surgery, and limits arterial reconstruction to young men with a specific arterial blockage and no wider vascular disease.

Because the decision is essentially irreversible, the AUA stresses counselling about short- and long-term expectations. A urologist who performs implants regularly is the right person to discuss it with.

The best way to use this comparison is to start from your situation, not from the treatment. The table below matches common situations to the options usually worth raising with a clinician first. It's a starting point for that conversation, not a prescription, and the AUA's principle still applies: any option that isn't ruled out for you is a legitimate choice.

Three questions that narrow it down

1. Can you safely take a PDE5 inhibitor? If you take nitrates or riociguat, the answer is no, and the choice moves straight to the non-pill options.
2. How much do you value spontaneity versus effort? Daily tadalafil and implants are the most spontaneous; vacuum devices and injections need some preparation each time.
3. How do you feel about needles, devices and surgery? There are good options at every level of invasiveness, and the right one is the one you'll actually use.

For men under 40, our guide to ED in your 20s and 30s covers the causes and options that matter most at that age. For a comparison of the pill brands and their alternatives, see alternatives to Viagra and Cialis.

These three groups often need a different plan, because their ED tends to be more severe and pills tend to work less strongly. The AUA notes that men with diabetes and men who have had their prostate removed "have more severe ED at baseline and respond less robustly to PDE5i." That doesn't mean pills won't help; it means the plan should include the stronger options from the start if needed. Source: AUA guideline.

Diabetes

PDE5 inhibitors remain a reasonable first choice for most men with diabetes, and the NIDDK advises keeping blood glucose, blood pressure and cholesterol close to target to help prevent and treat sexual problems, noting that men with diabetes may develop ED 10 to 15 years earlier than men without it. If pills don't do enough, the evidence for other options holds up well: the AUA says injections and vacuum devices are effective in men with diabetes, the 2026 vacuum meta-analysis found 73.0% efficacy in that group, and the urethral pellet trial found similar efficacy regardless of cause, including diabetes. One caution: the 2025 implant meta-analysis found complications strongly associated with diabetes, which is worth discussing with a surgeon. Sources: Int J Impot Res, 2026; NEJM, 1997; Andrology, 2025. Our guide to ED and diabetes goes further.

Heart disease

The AUA says men should be counselled that ED is a risk marker for underlying cardiovascular disease, and cites findings from the Prostate Cancer Prevention Trial that ED was as strong a predictor of future cardiac events as smoking or a family history of heart attack. For men with known heart disease, the big question is nitrates: if you take them, PDE5 inhibitors are out and non-drug or local treatments are in. If you don't, it's worth having a cardiologist or primary care doctor confirm you're fit for sexual activity first. Source: AUA guideline. See ED as a warning sign of heart disease.

After prostate cancer treatment

Even with nerve-sparing surgery, many men experience ED afterwards, and the AUA reports that about 36% of men develop new ED within two years of pelvic radiation. It also advises that early use of PDE5 inhibitors after surgery or radiotherapy "may not improve spontaneous, unassisted erectile function," though pills can still help erections on demand. Injections, vacuum devices (84.5% efficacy after prostate removal in the 2026 meta-analysis) and implants all work well in this group, and the AUA notes that psychological support is an integral part of recovery. Sources: AUA guideline; Int J Impot Res, 2026.

Step 1: rule out the common mistakes

• No arousal. MedlinePlus explains that each pill works by increasing blood flow "during sexual stimulation"; none produces an erection on its own.
• Wrong timing or a heavy meal. A high-fat meal can delay sildenafil, per MedlinePlus.
• Too few attempts. The AUA says men should be told "more than one trial with the medication may be required to establish efficacy."
• A dose that was never adjusted. The AUA gives a Strong Recommendation that PDE5 inhibitor doses be titrated for optimal effect; that's a prescriber's job.

Sources: AUA guideline; MedlinePlus, sildenafil. Our guide to sildenafil doses explained covers what a "failed" dose usually means.

Step 2: look for something blunting the response

The conditions behind ED can also blunt a pill. The AUA notes that men with diabetes respond less robustly, and that PDE5 inhibitors "may be more effective if combined with testosterone therapy" in men with confirmed deficiency. The NIDDK notes that some medicines for other conditions cause ED, and that a clinician may change the dose or switch the drug. Sources: AUA guideline; NIDDK.

Step 3: change within the pill family

A different PDE5 inhibitor, daily rather than as-needed tadalafil, or a compounded blend are all options to discuss. Expectations should be realistic: the AUA found the four drugs similar on average, so switching helps some men more than others.

Step 4: move to a different mechanism

Injections, the urethral pellet, vacuum devices and implants don't rely on the same pathway, which is why they work for many men pills don't. The 2026 vacuum meta-analysis was specifically in men whose ED hadn't responded to pills, and found 80% pooled efficacy. Source: Int J Impot Res, 2026. You don't have to work through these in order; the AUA says men may begin with any option, regardless of invasiveness.

Some can, and a few combinations have evidence behind them, but certain combinations are dangerous and every one should be set up by a prescriber. The rule of thumb: combine across categories with a clinician's guidance, never stack products from the same category on your own.

Combinations with evidence or guideline support

• PDE5 inhibitor plus testosterone, in men with confirmed deficiency. The AUA says the pill "may be more effective if combined with testosterone therapy." Source: AUA guideline.
• PDE5 inhibitor plus a vacuum device. A 2026 systematic review found VEDs "enhance outcomes in combination with phosphodiesterase type 5 inhibitors." Source: Fr J Urol, 2026.
• PDE5 inhibitor plus therapy. In the 2008 meta-analysis, men given psychotherapy plus sildenafil improved and were less likely to drop out than men given sildenafil alone. Source: J Sex Med, 2008.
• Any treatment plus lifestyle change. The AUA says a healthier lifestyle can increase the probability that ED treatments work.
• Several injectable drugs together, such as Trimix, which the AUA describes as standard practice under a clinician's supervision.

Combinations to avoid

• Any PDE5 inhibitor with nitrates or riociguat. Never.
• Two ED products at once without a prescriber's say-so, such as a pill on top of a compounded blend, a spray plus a tablet, or a "natural" supplement that may secretly contain a PDE5 inhibitor. Compounded blends already combine drugs, and stacking adds to the dose.
• A PDE5 inhibitor with alpha-blockers or other blood-pressure medicines, unless a prescriber has set the timing and dose; see ED pills and blood pressure medication.
• Injections or the pellet with anything else unless the prescriber who trained you agrees, because prolonged erection is the key risk.

Never combine a PDE5 inhibitor with nitrates, and seek emergency care for chest pain, an erection lasting over four hours, or sudden loss of vision or hearing.

Choose a provider that requires a genuine clinician review, tells you clearly what it prescribes and whether it's FDA-approved or compounded, and is upfront about billing. Treatment quality matters more than branding. These are the checks we apply in our ED provider reviews.

The checks that matter

1. A real prescription step. The FDA's first sign of a safe online pharmacy is that it "always requires a doctor's prescription." A site that sells ED medicine without one is a red flag. Source: FDA BeSafeRx.
2. A thorough intake. A good questionnaire asks about heart health, blood pressure, nitrates, alpha-blockers and every other medicine you take. If it doesn't, it isn't screening you properly.
3. Clarity on what you're getting. Is it a generic, a brand-name drug, or a compounded product? If compounded, which licensed pharmacy makes it?
4. A US address, a pharmacist and state licensing. The FDA lists a US physical address and phone number, a licensed pharmacist to answer questions, and state board of pharmacy licensing as signs of a safe pharmacy.
5. Transparent billing. Know whether it's a subscription, how refills are charged, and how to cancel. Our Rex MD review, for example, flags recurring complaints about auto-refill charges after cancellation.
6. Access to a clinician afterwards. You should be able to ask about side effects or a dose change without starting over.
7. Prices that make sense. The FDA warns against "deep discounts or prices that seem too good to be true."

Match the provider to the treatment you want

• Want a compounded multi-ingredient dissolvable? Our top-ranked Quad by MEDVi is built around one.
• Want a straightforward online flow with standard prescription options? DirectMeds runs one; confirm its current lineup on its site.
• Want the widest menu, including brand-name pills and a gummy? Rex MD, with an eye on its subscription settings.
• Want the lowest price on standard generics? Our DudeMeds review describes it as the value-minded choice.
• Want a nasal spray? SHED prescribes Roxus.

Our guides to how to get ED treatment online and the best ED treatments compared walk through the process and the clinic categories in more detail.

See a doctor in person if your ED came on alongside other health changes, if you have heart symptoms or risk factors you haven't had checked, or if you need a treatment that has to be started in clinic. Online care is a good fit for straightforward ED; it's not a substitute for an examination when something else may be going on.

Get emergency care for

• Chest pain, especially during or after sex.
• An erection lasting more than four hours, with or without pain, after any ED treatment.
• Sudden loss of vision or hearing after taking an ED medicine.

These warnings appear in the MedlinePlus tadalafil monograph and the NIDDK's treatment page. If you've taken a PDE5 inhibitor and need emergency treatment for chest pain, tell the medical team, because nitrates must not be given on top of it.

Book an in-person appointment if

• Your ED is new and you have heart risk factors such as high blood pressure, high cholesterol, diabetes, smoking or a family history of heart disease. The AUA calls ED a risk marker for cardiovascular disease that "may warrant evaluation and treatment."
• You've noticed other symptoms, such as a curve or lump in the penis, pain, low desire with tiredness, or urinary changes.
• You want injections, the urethral pellet, shockwave or an implant, all of which start in clinic.
• Your ED followed prostate surgery, radiation or a pelvic injury.
• You're on many medicines and want them reviewed together, including whether one is causing the ED. The NIDDK says a clinician may switch a medicine that's causing ED, but advises, "Do not stop taking any medicines on your own."

The NHS puts it simply: see a GP if erection problems keep happening, because "it might be a sign of a health condition that can be treated." Sources: AUA guideline; NIDDK; NHS. Our guide to ED treatment near you vs online helps you decide which route fits.

A few good questions turn a short consultation, online or in person, into a plan that fits.

About the cause

• Do my symptoms suggest a physical cause, a psychological one, or both?
• Should I have my blood pressure, blood sugar, cholesterol or a morning testosterone level checked? The AUA recommends a morning testosterone test for men with ED.
• Could any of my current medicines be contributing?
• Does my ED mean I should have my heart checked?

About the treatment

• Is this treatment FDA-approved, or compounded? If compounded, which pharmacy makes it?
• How quickly should it work, and how long will it last?
• What side effects are common, and which ones mean I should stop and get help?
• How many attempts should I make before deciding it isn't working?
• What will we try next if it doesn't work?

About safety

• Is it safe with every medicine I take, including any for blood pressure, the prostate or the heart?
• Is there anything I should never combine it with? (For PDE5 inhibitors: nitrates, riociguat and poppers.)
• Is it safe with my alcohol use?

About cost and convenience

• What's the total monthly cost, including consultations and shipping?
• Is this a subscription, and how do I pause or cancel?
• Is a generic version available, and would it work as well for me?

Asking these isn't being difficult; it's what good shared decision-making looks like, which is exactly what the AUA describes as "the cornerstone" of ED care. Source: AUA guideline. If you'd like to prepare by reading about side effects first, see our ED medication side effects guide.

Every ED treatment involves a trade-off between reliability, effort, invasiveness and cost, and the best one is the one that fits your health and your life. For most men, that starts with a generic PDE5 inhibitor, sildenafil for occasional use or tadalafil for spontaneity, alongside the lifestyle changes that also protect the heart. Compounded dissolvables and new formats offer convenience at a higher price and with thinner evidence. When pills don't suit or don't work, alprostadil injections, the urethral pellet, vacuum devices and implants each work for many men, and therapy helps whenever anxiety is part of the story. Shockwave therapy remains investigational, and PRP experimental.

Whatever you choose, let a licensed clinician check your medicines and your heart first. Never combine a PDE5 inhibitor with nitrates, and seek emergency care for chest pain, an erection lasting over four hours, or sudden loss of vision or hearing. To compare licensed online providers, see our ED treatment comparison; for the condition itself, read our complete guide to erectile dysfunction treatment; and for prices, see the ED treatment cost index.

This article is general information, not medical advice. Talk to a licensed clinician about your own situation before starting, stopping or changing any treatment.