Choosing the Right Pill to Treat ED

[10] Counseling can be used if the underlying cause is psychological, including how to lower stress or anxiety related to sex.

What Injections and Suppositories Treat Erectile Dysfunction?

Some authors recommend the use of sildenafil by mouth to replace the injectable drugs in cases of contraindications, although the efficacy of such medication is controversial. Before the injection of the chosen drug, the flow pattern is monophasic, with low systolic velocities and an absence of diastolic flow. After injection, systolic and ed medications diastolic peak velocities should increase, decreasing progressively with vein occlusion and becoming negative when the penis becomes rigid (see image below). The reference values vary across studies, ranging from > 25 cm/s to > 35 cm/s. Values above 35 cm/s indicate the absence of arterial disease, values below 25 cm/s indicate arterial insufficiency, and values of 25–35 cm/s are indeterminate because they are less specific (see image below).

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The data obtained should be correlated with the degree of erection observed. If the peak systolic velocities are normal, the final diastolic velocities should be evaluated, those above 5 cm/s being associated with venogenic ED. Graphs representing the color Doppler spectrum of the flow pattern of the cavernous arteries during the erection phases. A: Single-phase flow with minimal or absent diastole when the penis is flaccid. B: Increased systolic flow and reverse diastole 25 min after injection of prostaglandin. [12] Medications by mouth and vacuum erection devices are first-line treatments,[10]: 20, 24 followed by injections of drugs into the penis, as well as penile implants.

[10]: 25–26 Vascular reconstructive surgeries are beneficial in certain groups.

Society and culture

In many cases, the diagnosis can be made based on the person's history of symptoms. In other cases, a physical examination and laboratory investigations are done to rule out more serious causes such as hypogonadism or prolactinoma. One of the first steps is to distinguish between physiological and psychological ED. Determining whether involuntary erections are present is important in eliminating the possibility of psychogenic causes for ED. [4] Obtaining full erections occasionally, such as nocturnal penile tumescence when asleep (that is, when the mind and psychological issues, if any, are less present), tends to suggest that the physical structures are functionally working.

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[44][45] Similarly, performance with manual stimulation, as well as any performance anxiety or acute situational ED, may indicate a psychogenic component to ED. Another factor leading to ED is diabetes mellitus, a well known cause of neuropathy. [4] ED is also related to generally poor physical health, poor dietary habits, obesity, and most specifically cardiovascular disease, such as coronary artery disease and peripheral vascular disease. [4] Screening for cardiovascular risk factors, such as smoking, dyslipidemia, hypertension, and alcoholism, is helpful. In some cases, the simple search for a previously undetected groin hernia can prove useful since it can affect sexual functions in males and is relatively easily curable. [56] Treatments, other than surgery, do not fix the underlying physiological problem, but are used as needed before sex.

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The current – as of April 2025[update][46] – edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) lists Erectile Disorder (ICD-10-CM code: F52.21) as a diagnosis. [47] According to the DSM, it "is the more specific DSM-5 diagnostic category in which erectile dysfunction persists for at least 6 months and causes distress in the individual. "[47] The ICD-10, to which the DSM refers regarding Erectile dysfunction,[47] lists it under Failure of genital response (F52.2). [48] The latest edition of the ICD – namely, the ICD-11 – lists the condition as Male erectile dysfunction (HA01.1). Penile ultrasonography with doppler can be used to examine the erect penis.

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Most cases of ED of organic causes are related to changes in blood flow in the corpora cavernosa, represented by occlusive artery disease (in which less blood is allowed to enter the penis), most often of atherosclerotic origin, or due to failure of the veno-occlusive mechanism (in which too much blood circulates back out of the penis). Before the Doppler sonogram, the penis should be examined in B mode, in order to identify possible tumors, fibrotic plaques, calcifications, or hematomas, and to evaluate the appearance of the cavernous arteries, which can be tortuous or atheromatous. Erection can be induced by injecting 10–20 μg of prostaglandin E1, with evaluations of the arterial flow every five minutes for 25–30 min (see image). The use of prostaglandin E1 is contraindicated in patients with predisposition to priapism (e.g., those with sickle cell anemia), anatomical deformity of the penis, or penile implants. Visual and tactile stimulation produces better results. The PDE5 inhibitors sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are prescription drugs which are taken by mouth. [10]: 20–21 As of 2018, sildenafil is available in the UK without a prescription.

• Amikacin: Aminoglycoside antibiotic for serious Gram-negative infections.
• Gentamicin: Treats septicemia, meningitis, and urinary tract infections.
• Tobramycin: Used for Pseudomonas infections, especially in CF patients.
• Streptomycin: An aminoglycoside for tuberculosis and plague.
• Neomycin: Topical and oral for bowel decontamination and skin infections.
• Kanamycin: Used for certain bacterial infections, often in combination therapy.
• Paromomycin: Treats intestinal parasitic infections like amoebiasis.
• Spectinomycin: Alternative treatment for gonorrhea.
• Amikacin: Potent against multidrug-resistant bacteria.
• Netilmicin: Broad-spectrum aminoglycoside for severe infections.
• Gentamicin (topical): Used for skin infections and wounds.

[58] Additionally, a cream combining alprostadil with the permeation enhancer DDAIP has been approved in Canada as a first line treatment for ED. [59] Penile injections, on the other hand, can involve one of the following medications: papaverine, phentolamine, and prostaglandin E1, also known as alprostadil. [10] In addition to injections, there is an alprostadil suppository that can be inserted into the urethra.

Once inserted, an erection can begin within 10 minutes and last up to an hour.

The bottom line

Longitudinal, ventral ultrasound of the penis, with pulsed mode and color Doppler. Flow of the cavernous arteries at 5, 15, and 25 min after prostaglandin injection (A, B, and C, respectively). The cavernous artery flow remains below the expected levels (at least 25–35 cm/s), which indicates ED due to arterial insufficiency. Tests such as the bulbocavernosus reflex test are used to ascertain whether there is enough nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal.

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A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger in the anus. It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge. A significant proportion[quantify] of males who have no sexual dysfunction nonetheless do not have regular nocturnal erections. [12] Medications to treat ED may cause a side effect called priapism.

• Sildenafil food interactions: High-fat meals can delay its absorption and onset.
• Tadalafil food interactions: Not significantly affected by food intake.
• Vardenafil food interactions: High-fat meals can reduce its absorption and effectiveness.
• Avanafil food interactions: Can be taken with or without food.
• Alcohol interactions: Can increase side effects like dizziness and lower blood pressure.
• Grapefruit juice: Can interact with many medications, including some PDE5 inhibitors.
• Nitrate interactions: Absolute contraindication with any form of organic nitrates.
• Alpha-blocker interactions: Can cause additive blood pressure-lowering effects.
• Antifungal interactions: Drugs like ketoconazole can increase levels of PDE5 inhibitors.
• HIV protease inhibitor interactions: Can significantly increase levels of PDE5 inhibitors.

Prevalence of diagnosis or prescription was the highest for age group 60–69 at 11.5%, lowest for age group 18–29 at 0.4%, and 2.1% for 30–39, 5.7% for 40–49, 10% for 50–59, 11% for 70–79, 4.6% for 80–89, 0.9% for ≥90, respectively.

• Priapism: A medical emergency; an erection lasting more than 4 hours.
• Fibrosis: Scar tissue formation inside the penis from repeated injections.
• Hypotension: A severe drop in blood pressure, especially with drug interactions.
• Cardiovascular events: Risk of heart attack or stroke, especially in at-risk men.
• Hearing loss: Sudden decrease or loss of hearing, sometimes accompanied by tinnitus.
• Vision loss: Non-arteritic anterior ischemic optic neuropathy (NAION).
• Testosterone therapy risks: Acne, sleep apnea, erythrocytosis, prostate growth.
• Allergic reactions: Rash, itching, or swelling, though rare.
• Injection site reactions: Bruising, bleeding, or infection.
• Device-related risks: Infection or mechanical failure with implants or pumps.

Focused shockwave therapy involves passing short, high frequency acoustic pulses through the skin and into the penis. These waves break down any plaques within the blood vessels, encourage the formation of new vessels, and stimulate repair and tissue regeneration. Focused shockwave therapy appears to work best for males with vasculogenic ED, which is a blood vessel disorder that affects blood flow to tissue in the penis.

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This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis. Technique in which fluid is pumped into the penis at a known rate and pressure. It gives a measurement of the vascular pressure in the corpus cavernosum during an erection. Cavernosography measurement of the vascular pressure in the corpus cavernosum. Saline is infused under pressure into the corpus cavernosum with a butterfly needle, and the flow rate needed to maintain an erection indicates the degree of venous leakage.

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The leaking veins responsible may be visualized by infusing a mixture of saline and x-ray contrast medium and performing a cavernosogram. [52] In Digital Subtraction Angiography (DSA), the images are acquired digitally. This is similar to magnetic resonance imaging. Magnetic resonance angiography uses magnetic fields and radio waves to provide detailed images of the blood vessels. The doctor may inject into the patient's bloodstream a contrast agent, which causes vascular tissues to stand out against other tissues, so that information about blood supply and vascular anomalies is easier to gather. The treatment is painless and has no known side effects. Treatment with shockwave therapy can lead to a significant improvement of the IIEF (International Index of Erectile Function).

• Penicillin: An antibiotic used to treat bacterial infections including syphilis and pneumonia.
• Amoxicillin: A broad-spectrum penicillin effective against ear, nose, throat, urinary tract infections.
• Ciprofloxacin: A fluoroquinolone used for urinary, respiratory, and gastrointestinal bacterial infections.
• Metronidazole: An antimicrobial for treating bacterial and parasitic infections like giardiasis and bacterial vaginosis.
• Doxycycline: A tetracycline antibiotic used for respiratory infections, Lyme disease, and acne.
• Ceftriaxone: A cephalosporin antibiotic for severe infections like meningitis and gonorrhea.
• Vancomycin: Used to treat serious Gram-positive infections, including MRSA.
• Azithromycin: A macrolide antibiotic for respiratory infections, chlamydia, and skin infections.
• Clindamycin: Effective against anaerobic bacteria and certain protozoal infections.
• Levofloxacin: A fluoroquinolone used for pneumonia, urinary tract infections, and skin infections.
• Trimethoprim-Sulfamethoxazole: Combines antibiotics for urinary tract infections and certain pneumonia cases.

Men with low levels of testosterone can experience ED.

How should this medicine be used?

The Erection Hardness Score (EHS) is a single-item Likert scale used to assess the subjective hardness of the penis as reported by the patient. It ranges from 0 (indicating the penis does not enlarge) to 4 (indicating the penis is completely hard and fully rigid). Developed in 1998, the EHS is widely used in super p force 160mg clinical trials and is recognized for its ease of administration and strong association with sexual function outcomes. It has been validated across various causes of erectile dysfunction and in patients treated with phosphodiesterase type 5 inhibitors (PDE5), showing robust psychometric properties and responsiveness to treatment. In general, exercise, particularly of the aerobic type, is effective for preventing ED during midlife. Taking testosterone may help maintain an erection. [66] Males with type 2 diabetes are twice as likely to have lower levels of testosterone, and are three times more likely to experience ED than non-diabetic men. A vacuum erection device helps draw blood into the penis by applying negative pressure. This type of device is sometimes referred to as penis pump and may be used just prior to sexual intercourse.