A Decision-Making Guide to ED Drugs

The 8 most important factors to consider when deciding whether to try Erectile Dysfunction (ED) drugs

An estimated 30 million men in the United States — and as many as 100 million worldwide — are thought to suffer from Erectile Dysfunction (ED), which occurs when a man is unable to achieve — and sustain — the kind of erect penis needed for successful sexual intercourse.

While many men try to remedy their ED with such blockbuster drugs as Viagra and Cialis, not all men are good candidates for these drugs due to health problems like prior heart attacks, diabetes, liver or kidney problems. Other candidates may be more susceptible to the drugs’ side effects, which can include sudden blindness or vision loss, painful erections, headaches, dizziness, or muscle or back pain.

Below you’ll find the 8 most important factors to consider when deciding whether to try ED drugs. You can also look at our companion ED Drug Comparison Chart.

Age alone won’t cause ED, although it does become more prevalent as men grow older and as many as half of men between 40 and 70 have either passing or chronic ED. More commonly ED is caused by what is now known to be a long list of medical, psychological and lifestyle factors such as vascular disease (which accounts for about 40% of cases in men 50 and older), diabetes (which may account for another 30% of cases), prostate surgery, high blood pressure, thyroid problems, obesity, smoking, high cholesterol levels, high lipid levels, multiple sclerosis, depression, performance anxiety, and too much alcohol.When a man is sexually excited, the penis typically fills with roughly 20 times as much blood as normal and it becomes both larger and harder — unless some factor (or combination of factors) short-circuits the process.

ED may also be caused by certain over-the-counter drugs like antihistamines and heartburn medications, as well as prescription drugs like those for treating high blood pressure, depression, anxiety, cancer, and epilepsy. Contrary to what many consumers think, only 3 to 6% of all cases appear to be due to a low level of testosterone, and men who have low testosterone can still have erections.

Because ED can have so many causes, treating it effectively often requires medical supervision, as well as the time and patience to try different approaches, if necessary.

“There is such variability to ED,” said urologist Kevin Campbell, MD, the director of the Men’s Sexual Health Clinic, which is part of the Cincinnati, Ohio-based Urology Group. “You might get a 45-year-old man who tells you he doesn’t get erections like he used to, or maybe a 65-year-old diabetic who hasn’t had an erection in five years, but who’s now in a relationship.”

“It depends on the situation,” he added. “If you’re a guy who had radical prostate surgery and there is nerve damage, I don’t feel the need to try all the medications.”

Consumers now spend an estimated $4 to $5 billion a year on erectile dysfunction drugs that are most often taken by mouth, injected into the penis, or used as a penile suppository. In 1998, Viagra became the first oral drug to win the approval of the federal Food and Drug Administration, and since then the famous “little blue pill” has been followed by other drugs that claim to offer new benefits, whether it’s producing erections faster and with fewer side effects, or allowing a drug to remain active for a longer period of time, as well be taken more conveniently and discreetly.


Image courtesy Transparency Market Research.

Some drugmakers are continuing the push to try to make certain ED drugs available without a prescription. While past efforts to make Viagra available over the counter failed because of objection from regulators, Sanofi, the French drug company, announced last spring that it was buying the rights to seek approval for eventually selling Cialis without a prescription once the drug loses its patent protections (2017 in the U.S.).

Here are 8 things you need to know before taking any ED drug:

1. Medical problems and lifestyle issues need to be addressed first

ED is often a sign of far more serious health problems, so physicians say it should be treated first by addressing issues like diabetes, high blood pressure (present in about 20% of men with ED), and severe heart disease (found in about 5% of ED sufferers).

In many cases, even small lifestyle changes can make a big difference. In one study, researchers found that men who had type 2 diabetes but who adhered most closely to the so-called Mediterranean diet (high in foods like fruits, vegetables, olive oil, nuts and fish) had the lowest incidence of ED.

Prominent medical groups like the American College of Physicians and American Urological Association recommend that men who still have ED after addressing medical and lifestyle issue first consider taking drugs like Viagra and Cialis before moving to more invasive procedures like penis injections, penis pumps, implants and vascular surgery.

2. Some drugs you are on can cause ED

Talk to your doctor. Some OTC and prescription medicines can cause ED. Medicines that can cause ED include: antidepressants, antihistimines, anti-anxiety drugs, diuretics, high blood pressure drugs, antiarrhythmics, muscle relaxants, prostate and chemotherapy drugs, some NSAIDS, some antacid and heartburn drugs and Parkinson’s drugs.

3. ED drugs are effective

Oral drugs

The most commonly used ED medications belong to a group of drugs called phosphodiesterase inhibitors (PDE-5) because they turn off an enzyme that blocks the formation of an erection. So far, the FDA has approved five such drugs: Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil), Stendra (avandafil), and Staxyn (a rapidly dissolving form of Levitra that is placed on the tongue).

As a group, PDE-5 inhibitors allow about 7 out of every 10 men to have successful intercourse, although they may work less well in some men who have diabetes and who have recently had radical prostatectomy, when the entire prostate gland is surgically removed, often because of cancer.

Side effects with the drugs are usually mild to moderate. Because they basically work the same way, they’re usually prescribed on the basis of their convenience, cost, side-effect profiles, and the often strong personal preferences that men develop for certain drugs. Some men, for example, claim in online reviews that Viagra appears to kick in faster and produce a firmer erection than Cialis, even though it is effective in the body for only about 4 hours (versus 36 hours for the “weekender” version of Cialis). In general, all PDE-5 drugs, in order to work, require that a man also be sexually stimulated.

Penile injections

The American Urological Association says so-called intracavernosal penile injections are the most effective way to treat ED without surgery, even though the procedure is invasive (it requires that a man self-inject a needle into the side of his penis) and also carries a higher risk for priapism, a rare, but potentially serious medical condition associated with erections that last 4 hours or more.

Penile injections are now commonly prescribed when none of the PDE-5 drugs appear to work, or for men who want a more rigid erection with less stimulation. They’re also used to treat men who have ED because of nerve damage from severe prostate surgery.

The injections usually contain alprostadil, a powerful vasodilator. Alprostadil is either used alone (in products like Caverject and Edex) or mixed with medications like papaverine and phentolamine (in so-called tri-mix and bi-mix combinations) to increase both the efficacy of the injection and decrease penile pain. Urologists often turn to specialty pharmacies to custom-make tri-mix and bi-mix formulations for their patients.

The injections have drawbacks. For one, men often need to be taught how to do them correctly, to minimize bruising and pain. It can also take 6 or more injections before the right dosage is found. Most men, however, see a reaction in about 5 minutes, and erections typically last about an hour.

In Cincinnati, Dr. Campbell likes to recommend penile injections because he’s found they’re about 80% effective for treating ED. He’s also discovered that a tri-mix injection can cost his patients as little as $5 per injection.

Penile suppositories

Alprostadil also comes in the form of a penile suppository, MUSE (Medicated Urethral System for Erections), that is about the size of a grain of rice. Using a special applicator, a man typically slips MUSE about an inch into his urethra before he wants to have sex; erections typically occur within 5 to 10 minutes and last for 30 to 60 minutes. In clinical trials, the drug was found to help about 65% of men have intercourse compared to about 19% of the men who were taking a placebo. Some physicians, however, say it is both expensive and effective only 20 to 40% of the time at creating an erection hard enough to allow for sex. Still, unlike PDE-5 inhibitors, MUSE can be used by men who are taking nitrate-based drugs, and it’s often effective for men who have severe vascular disease, diabetes, as well as those who have undergone prostate surgery.

Testosterone replacement therapy

Boosting testosterone doesn’t always amp up erections. Still, for the small number of men who have ED because of low testosterone, testosterone patches, gels and, increasingly, longer-acting testosterone pellets have been shown to help.

Penile creams

So far, a penile cream for treating ED has been approved for use only in Canada and Europe. The cream, Vitaros, also contains the vasodilator alprostadil, but it’s applied with a special, disposable applicator to the tip of the penis 5 to 30 minutes before a man wants to have sex.

Unlike the PDE-5 inhibitors, Vitaros isn’t swallowed so it may eventually prove to have fewer side effects. Some men, however, report a burning sensation in the penis when they use it, and women may experience mild vaginal burning, itching or vaginitis. It should not be used with anyone who is pregnant, breastfeeding, or considering pregnancy. Men who take it also need to avoid driving or using machinery for up to 2 hours afterward because of the risk of dizziness and fainting. Still, studies have already shown that the cream appears to be both well-tolerated and helps improve erections in men who have medical conditions like diabetes and cardiovascular disease.

4. Side effects are often minimal but some men need to avoid the drugs entirely

As anyone who’s ever watched the ads already knows, ED medications often appear to come with a long list of side effects, some of them are frightening, like the potential for sudden loss of hearing or blindness.

In general, ED drugs like Viagra and Cialis carry minimal to moderate side effects, and the medications can often be used safely, even in men who have cardiovascular problems, say physicians like Dr. Campbell. “The number of people who can’t take ED drugs because of side effects is less than 5%, usually in the range of 2 to 3%,” he said.

For drugs like Viagra, Levitra and Cialis, the most common side effects are headaches, heartburn, facial flushing, and a stuffy or running nose. Many Cialis users, on the other hand, complain about back and leg pain. According to Eli Lilly, the company that makes Cialis, men who get back pain and muscle aches with Cialis usually get it 12 to 24 hours after taking the drug, and the pain typically stops within 48 hours.

Still, some men need to take PDE-5 drugs with caution and under medical supervision, or avoid them entirely. They should be avoided by anyone who is taking nitrate-based medicines, like those used to treat angina (chest pain) or found in street drugs called “poppers” because the combination can lead to dangerously low blood pressure. While the drugs do not appear to lead to a much higher risk of heart attacks, they’re typically prescribed with caution — or avoided entirely — in men who have severe heart disease, high blood pressure, or who have had a heart attack or stroke within the last 4 months. Men who have reduced liver function, or kidney problems, or who require dialysis also need to be careful.

When it comes to sudden vision loss, the concern with drugs like Viagra and Cialis has been that they may double the risk of developing a rare, but potentially serious eye condition called non-arteritic anterior ischemic optic neuropathy (NAION), which can cause permanent vision loss.

The incidence of NAION is now quite low: between 2.5 and 11.8 cases a year for every 100,000 men 50 or over. The condition has been linked to factors like hypertension, diabetes, smoking and sleep apnea, as well as an anatomical problem with the optic nerve usually referred to as a “crowded” optic disc. It’s still not clear whether the higher incidence of NAION among men who take ED drugs is due to the drugs themselves, or to the many medical problems that often cause ED.

5. Compliance can be a big hurdle

Men often have a hard time complying with a plan to take erectile dysfunction drugs; sometimes the problem is the effectiveness of the drug itself, but it can also be a matter of unrealistic expectations or a need for more spontaneity. Some research suggests that as many as 40% of men switch at least once between oral drugs like Viagra and Cialis, and between 30 and 60% eventually opt out entirely.

Compliance can also be a problem with penile injections, even though the needles themselves are very small, said Dr. Campbell. “If you look at patients a year later, only about 50% of patients are still doing it,” he said. “Men get frustrated with the lack of spontaneity, and sometimes they get a pain in their penis.”

6. Watch for drug interactions

As with other medications, ED drugs can affect the action of other drugs, and the combination can worsen side effects. With PDE-5 drugs like Cialis, for example, tell your doctors if you are also taking nitrate-based drugs, alpha-blockers (like those used for high blood pressure and prostate problems), protease-inhibitor medicines for HIV infections, anti-fungal drugs, and some types of antibiotics like erythromycin, clarithromycin or telithromycin.

7. Beware of imitators

Some of the most counterfeited drugs in the world are drugs like Viagra and Cialis, and regulators estimate that half of all ED drugs sold online may actually be bogus. For that reason, it’s best to buy oral ED drugs from an accredited local pharmacy, or an accredited online pharmacy, To find an accredited online source, check the information that now often appears on the websites of drugmakers like Eli Lilly, which makes Cialis.

Many Internet sites also claim to offer “dietary supplements” and “all natural” products for treating ED or otherwise boosting sexual potency.

The supplements often appeal to men who want to avoid having to get a prescription from a doctor, or who think the products are safer than conventional drugs, especially if they have medical problems like heart disease or diabetes.

But in 2010 an FDA investigation found that a third of these “dietary supplements” contained either sildenafil — the active ingredient in Viagra — or substances similar to both Viagra and Levitra. Since 2004, the FDA has compiled a list of 30 such supplements that may pose hazardous side effects because they carry powerful ingredients that aren’t listed on their labels.

8. Some men prefer non-drug alternatives

When oral drugs and injections prove to be ineffective, men are often asked to consider alternatives like so-called vacuum erection devices, penile implants, or vascular surgery. While some of the alternatives require surgery, many are highly effective.

Many men like vacuum erection devices, which are essentially hollow tubes placed over the penis and powered with a pump to draw air out and bring blood in (a constriction ring is placed at the base of the penis to maintain the erection). The devices tend to be reliable, easy to use (some training is required first), and usually work between 80 and 90% of the time. Men who don’t like the devices often complain that they’re bulky and create erections that can feel wobbly at the base of the penis. The devices can’t be used with men who have had bleeding disorders, sickle cell anemia or priapisms. For better results, the devices are sometimes paired with PDE-5 drugs.

Penile implants also get high marks, and physicians report that as many as 9 out of every 10 men say they like the results. The implants now come in two forms: malleable implants that a man bends upward when he wants to have sex, and more-popular inflatable models that make use of a pump in the scrotum to draw fluid into the rods of the implant inside the penis. While penile implants need to be surgically inserted, they have a low rate of mechanical failure, and cause infections after surgery only 1 to 2% of the time, according to Dr. Campbell.

Sana Siwolop

Sana Siwolop

Sana is a New York-based science and business journalist who has written for national publications, including The New York Times, Business Week and Discover. She teaches journalism at St. John's University in New York City.

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