Erectile dysfunction treatment: evidence‑based review (for educational purposes only)

Disclaimer: This article is for informational purposes and does not replace professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare professional regarding concerns about erectile dysfunction (ED) or before starting any therapy.

Quick summary

Erectile dysfunction (ED) is common, especially with increasing age, and is often linked to cardiovascular risk factors, diabetes, stress, or medication side effects.
First‑line medical treatment usually involves oral medications called PDE5 inhibitors (such as sildenafil or tadalafil), which are effective for many men.
Lifestyle changes—regular exercise, weight management, quitting smoking—can significantly improve erectile function and overall health.
Psychological factors (stress, anxiety, relationship issues) frequently contribute and may require counseling or sex therapy.
When pills are not effective or suitable, other options include vacuum devices, injections, hormone therapy (in selected cases), or surgery.

What is known

1. Erectile dysfunction is common and often has physical causes

ED is defined as the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity. According to major urological associations, it affects millions of men worldwide and becomes more common with age. However, it is not an inevitable part of aging.

Well‑established physical risk factors include:

Cardiovascular disease and atherosclerosis (narrowed arteries)
High blood pressure
Diabetes
Obesity and metabolic syndrome
Smoking
Low testosterone (in some cases)

ED is sometimes an early warning sign of cardiovascular disease. Blood vessels in the penis are smaller than coronary arteries, so symptoms may appear earlier.

2. Oral medications (PDE5 inhibitors) are effective for many men

Drugs such as sildenafil, tadalafil, vardenafil, and avanafil increase blood flow to the penis by enhancing the effect of nitric oxide. Clinical trials and guidelines from organizations such as the American Urological Association (AUA) and the European Association of Urology (EAU) show that these medications improve erections in a large proportion of men.

They require sexual stimulation to work and are generally safe when prescribed appropriately. However, they are not suitable for everyone—particularly men taking nitrates for chest pain.

3. Lifestyle interventions can improve erectile function

There is strong evidence that improving cardiovascular health also improves erectile health. Randomized trials and observational studies show benefits from:

Regular aerobic exercise
Weight loss in overweight individuals
Smoking cessation
Reducing excessive alcohol intake

In some men with mild ED, lifestyle changes alone can significantly improve symptoms.

4. Psychological factors matter

Performance anxiety, depression, chronic stress, and relationship issues can either cause or worsen ED. Cognitive behavioral therapy (CBT), sex therapy, or couples counseling have demonstrated benefit, particularly when psychological factors are prominent.

5. Second‑line and surgical options are available

For men who do not respond to oral medications, evidence supports:

Vacuum erection devices (mechanical pumps)
Intracavernosal injections (medication injected into the penis under medical supervision)
Intraurethral suppositories
Penile implants (surgical option with high satisfaction rates in selected patients)

Penile prosthesis surgery is generally reserved for cases where other treatments fail or are not appropriate.

What is unclear / where evidence is limited

Long‑term effectiveness of some newer therapies: Low‑intensity shockwave therapy shows promise, but long‑term data and standardized protocols are still limited.
Supplements and herbal remedies: Products marketed as “natural Viagra” often lack high‑quality evidence. Some may contain undeclared prescription drugs. Evidence for supplements such as ginseng or L‑arginine is mixed and generally low to moderate in quality.
Testosterone therapy in men without clear deficiency: Testosterone replacement helps men with confirmed hypogonadism, but its benefit in men with normal levels is uncertain.
Psychological vs. physical causes: Many cases involve both, and it can be difficult to determine the main driver without careful evaluation.

Overview of approaches

Management of erectile dysfunction typically follows a stepwise approach guided by clinical guidelines.

Lifestyle and risk factor modification

Improving heart health is foundational. This includes physical activity, balanced nutrition, weight management, and addressing conditions such as high blood pressure and diabetes. For more on prevention strategies, see our men’s health prevention guide.

Oral medications (PDE5 inhibitors)

These are usually first‑line therapy unless contraindicated. They differ in onset and duration of action, but all enhance blood flow during sexual stimulation. A healthcare professional determines suitability based on medical history and current medications.

They should not be combined with nitrates due to the risk of dangerous drops in blood pressure.

Hormone therapy

If blood tests confirm low testosterone along with symptoms, testosterone replacement therapy may be considered under medical supervision. Monitoring is required due to potential risks.

Mechanical devices

Vacuum erection devices create negative pressure to draw blood into the penis. They are non‑invasive and can be effective, especially when medications are not suitable.

Injection or intraurethral therapies

Medications delivered directly to penile tissue can produce reliable erections. These are typically introduced and monitored by specialists.

Surgical treatment

Penile implants are considered when other treatments fail. Satisfaction rates are high among appropriately selected patients, but surgery carries standard surgical risks.

Psychological support

Therapy may be especially helpful in younger men or when stress and anxiety are significant contributors. Learn more in our sexual health blog section.

Evidence summary table

Statement	Confidence level	Why
PDE5 inhibitors improve erectile function in many men	High	Supported by multiple randomized controlled trials and international guidelines
Lifestyle changes can improve mild ED	High	Consistent evidence linking cardiovascular health improvements with erectile function
Shockwave therapy is effective long term	Medium–Low	Promising short‑term studies but limited long‑term, large‑scale data
Herbal supplements are safe and effective	Low	Variable quality studies; risk of contamination or undeclared ingredients
Penile implants have high satisfaction rates	High	Long‑term registry data and surgical outcome studies support effectiveness

Practical recommendations

General safe measures

Engage in regular moderate physical activity (as medically appropriate).
Stop smoking and limit alcohol intake.
Manage chronic conditions such as diabetes and hypertension.
Prioritize sleep and stress reduction.

When to see a doctor

ED persists for several weeks or months.
You have risk factors for heart disease.
You experience chest pain, shortness of breath, or other cardiovascular symptoms.
You suspect medication side effects.
There is reduced libido or symptoms of low testosterone.

How to prepare for a consultation

List all medications and supplements you take.
Note when symptoms started and whether they are situational or consistent.
Be ready to discuss medical history, lifestyle habits, and stress levels.
Consider bringing your partner if appropriate.

You may also find it helpful to review our overview of common causes of erectile dysfunction and related articles in the Uncategorized health resources section for broader context.

Sources

American Urological Association (AUA). Erectile Dysfunction Guideline.
European Association of Urology (EAU). Guidelines on Sexual and Reproductive Health.
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Erectile Dysfunction.
Mayo Clinic. Erectile dysfunction – Diagnosis and treatment.
National Health Service (NHS). Erectile dysfunction (impotence).