Erectile Dysfunction Treatment

The best erectile dysfunction treatment depends on how often you have sex, how quickly you want it to work and how you respond to it. The table below compares the four licensed PDE5 inhibitor medicines available in the UK by active ingredient, onset and duration. All figures are drawn from each medicine's Summary of Product Characteristics (SmPC), and your own results may vary. A systematic review and network meta-analysis in European Urology found that all four are more effective than placebo, with no major difference in safety between them.

Onset and duration times are typical ranges and vary from person to person. Always read the patient information leaflet supplied with your medicine.

Erectile dysfunction (ED), sometimes called impotence, is difficulty getting or keeping an erection firm enough for sex. It is very common and becomes more likely with age. The British Association of Urological Surgeons reports that ED is seen in around 50 to 55% of men aged 40 to 70, and it can also affect younger men.

An erection depends on healthy blood flow. ED happens when blood flow to the penis is reduced, or when the nerve signals involved are interrupted. Occasional difficulty due to tiredness, stress or alcohol is normal, but if it happens often or lasts for weeks, it is worth getting checked. Importantly, ED can be an early warning sign of an underlying condition, so it is not only about treating the symptom. A meta-analysis of prospective studies in the Journal of the American College of Cardiology found that men with ED have a significantly higher risk of cardiovascular disease.

"Erectile dysfunction is far more common than most men realise, and it is nothing to be embarrassed about. ED can be an early sign of conditions like heart disease, high blood pressure or diabetes. Even when the ED itself is straightforward to treat, we encourage men to see their GP for a general health check, because treating the whole picture matters more than treating the symptom alone."

- UK Meds Clinical Team

Common causes of erectile dysfunction

The causes of ED can be physical, psychological, hormonal or lifestyle-related, and often more than one plays a part. The most common causes include:

• Physical: High blood pressure, high cholesterol, diabetes, heart disease, obesity and narrowing of the arteries all reduce blood flow.
• Psychological: Stress, anxiety, depression and performance anxiety can interrupt the signals needed for an erection.
• Hormonal: Low testosterone or other hormonal changes can lower sex drive and affect erections, although low testosterone is a less common cause than many people assume.
• Lifestyle: Smoking, drinking too much alcohol, recreational drug use and a lack of exercise are all contributors.
• Medicines: Some prescribed medicines, including certain treatments for high blood pressure and depression, can contribute to ED.

Erectile dysfunction tablets work by improving blood flow to the penis when you are sexually aroused. Medicines like sildenafil (Viagra) and tadalafil (Cialis) belong to a group called phosphodiesterase type 5 (PDE5) inhibitors. Understanding the process helps explain why they only work with sexual stimulation.

When you are aroused, your nervous system releases nitric oxide into the blood vessels of the penis. This triggers a molecule called cyclic guanosine monophosphate (cGMP), which relaxes the smooth muscle in the penis so the blood vessels widen and fill with blood, producing an erection. The body then produces an enzyme, PDE5, that breaks cGMP down. PDE5 inhibitors block this enzyme, so cGMP stays active for longer and the erection is easier to get and keep.

"Tablets do not create an erection on their own. They support your body's natural response, so sexual stimulation is still needed for them to work. If you take a tablet and nothing happens without arousal, that is completely normal and not a sign that the medicine has failed."

- UK Meds Clinical Team

Watch our short explainer on how erectile dysfunction treatments work and how to choose the right option for you.

Most men respond well to PDE5 inhibitor tablets, and the majority notice improved erections after treatment. These erectile dysfunction medicines relax the blood vessels in the penis, allowing blood to flow in when you are aroused. Here is how the main options compare.

Sildenafil (generic Viagra)

Sildenafil is the active ingredient in Viagra and the most widely prescribed ED medicine in the world. Its effectiveness was established in a pivotal New England Journal of Medicine trial. It usually takes 30 to 60 minutes to work and lasts for around 4 hours. It is available as a low-cost generic version or as branded Viagra. The usual starting dose is 50mg.

Tadalafil (generic Cialis)

Tadalafil works in a similar way to sildenafil but lasts much longer, up to 36 hours, which is why it is sometimes called the "weekend pill". This longer window means you do not need to plan sex as precisely.

Daily tablets

For men who have sex often, a low daily dose of tadalafil (2.5mg or 5mg) can be taken every day. This keeps a steady level of medicine in your system, so you are ready without needing to take a tablet beforehand. Your prescriber can advise whether a daily or on-demand approach suits you better.

Vardenafil (Levitra)

Vardenafil, sold under the brand name Levitra, is another PDE5 inhibitor taken when needed. It typically works within 25 to 60 minutes and lasts 4 to 5 hours. It is an alternative for men who do not get on well with other tablets.

Avanafil (Spedra)

Avanafil, the active ingredient in Spedra, has the fastest onset of the four, working in as little as 15 minutes. It lasts around 4 to 6 hours, which makes it a good option if you prefer not to plan too far ahead.

"There is no single best erectile dysfunction pill. The right choice comes down to how often you have sex, how quickly you want the treatment to work and how your body responds. It is common to try one medicine and then switch to another, and generic versions work in exactly the same way as the branded ones at a lower price."

- UK Meds Clinical Team

If you cannot take tablets, there are several effective alternatives to oral erectile dysfunction medicines. These suit men who find tablets hard to swallow, experience side effects, or cannot take PDE5 inhibitors because of another medicine or condition.

• Vitaros (alprostadil) cream: A cream for erectile dysfunction applied to the tip of the penis. It contains alprostadil, works locally within 5 to 30 minutes, and is a useful option for men who cannot take PDE5 inhibitors. An integrated analysis of more than 1,700 patients found that topical alprostadil cream improves erectile function. It is sometimes described as an erectile dysfunction gel.
• Topical ED gel (Eroxon): An over-the-counter gel applied to the head of the penis. It works physically rather than through the bloodstream, stimulating nerve endings with a cooling and warming sensation, and can start to work within around 10 minutes. In phase 3 clinical trials, around 60% of men saw a clinically meaningful improvement in erectile function. Because it does not work in the same way as tablets, it may suit some men who cannot use PDE5 inhibitors, though you should still read the leaflet and get medical input if you have a heart condition.
• Vacuum pumps: Non-invasive devices that draw blood into the penis using suction, with a ring placed at the base to maintain the erection.
• Penile injections: Alprostadil can also be given as an injection, usually started under specialist guidance for men who do not respond to other treatments.
• Shockwave therapy: A non-invasive treatment that uses low-intensity sound waves to encourage blood vessel repair, sometimes used for men recovering from prostate treatment. A meta-analysis of randomised controlled trials reports improved erectile function compared with sham treatment, though protocols vary. Availability varies, and it is usually accessed through a specialist.
• Penile implants: A surgical option, usually considered a last resort when other treatments have not worked.

You may also come across ED sprays, such as sildenafil oral sprays, which are a newer format for men who prefer not to take a tablet. Availability changes over time, so the range we offer is shown on our treatment pages.

Erectile dysfunction medicines are generally safe and well tolerated, but like all medicines, they can cause side effects. Most are mild and short-lived because you only take the tablet for a short time. In a pooled analysis of 48 sildenafil trials, side effects were generally mild, most commonly headache, flushing and indigestion. The table below shows the most common side effects reported for each medicine.

This is not a full list. For every reported side effect and how often it occurs, read the patient information leaflet supplied with your medicine, or speak to a pharmacist or prescriber.

Erectile dysfunction medicines are safe for most men, but there are serious situations where they should not be used, and a few warning signs that need urgent attention. Please read this section carefully before starting any treatment.

Who should not take PDE5 inhibitors?

Some men should not take PDE5 inhibitors, or should speak to a prescriber first. Do not take these medicines, and tell your prescriber, if you:

• Have recently had a heart attack or stroke
• Have very low or uncontrolled high blood pressure
• Have a serious heart or liver problem
• Have lost vision in one eye because of a problem with blood flow to the nerve (known as NAION)
• Have a rare inherited eye disease such as retinitis pigmentosa

You should also talk to a prescriber first if you have sickle cell anaemia, multiple myeloma or leukaemia, a physical deformity of the penis such as Peyronie's disease, or a history of stomach ulcers or bleeding problems.

Medicines and substances to avoid

How to take ED medicines safely

Take only one dose of an on-demand ED tablet in any 24-hour period. Do not take two different erectile dysfunction medicines on the same day, although some men do use different types on different days. The daily low-dose tadalafil tablet is the exception, as it is designed to be taken once every day. Remember that sexual stimulation is always needed for the medicine to work.

When to seek urgent medical help

Stop and get urgent medical help if you experience any of the following while taking an ED medicine:

• An erection that lasts more than four hours (priapism). This is a medical emergency and needs immediate attention to avoid lasting damage.
• A sudden loss or reduction of vision, or a sudden change in hearing. Stop taking the medicine and seek help straight away.
• Chest pain, especially during or after sex. Do not take a nitrate to relieve it. Call for emergency help.
• Signs of a serious allergic reaction, such as swelling of the face, lips or throat, or difficulty breathing.

Improving your general and heart health often improves erection quality too, and lifestyle changes can work alongside or sometimes reduce the need for medication. In a randomised controlled trial published in JAMA, around a third of obese men with ED regained normal erectile function through weight loss and more physical activity. Helpful changes include:

• Pelvic floor exercises: Also known as Kegels, these strengthen the muscles that help you keep an erection.
• Diet and alcohol: Cutting back on alcohol and eating a heart-healthy diet can improve blood flow.
• Weight and exercise: Losing excess weight and staying active can significantly reduce ED symptoms for many men.
• Stopping smoking: Smoking narrows the blood vessels, so quitting can make a real difference.

If your first erectile dysfunction treatment does not seem to work, do not give up after a single attempt. It often takes several tries at the right dose before you know whether a medicine suits you. Guidance from the British Society for Sexual Medicine suggests trying an individual medicine on at least six to eight separate occasions, at the maximum dose you can tolerate and with sexual stimulation, before deciding it is not effective.

A few practical things can affect how well tablets work, such as taking them too soon before sex, taking sildenafil with a heavy meal, or drinking alcohol. If you have given a treatment a fair trial and it still is not working, a prescriber can review your dose or suggest an alternative, and it is worth seeing your GP to check for any underlying cause.

"The most common reason a tablet seems to fail is that it has not had a proper trial. Give a medicine several attempts at the right dose before switching. If it still is not working after that, there are good alternatives, and it is a signal to check in with your GP rather than something to feel disheartened about."

- UK Meds Clinical Team

You can get erectile dysfunction treatment online through UK Meds without a face-to-face GP appointment. UK Meds is an online prescription service. Independent registered prescribers assess your consultation and, if a treatment is suitable, our partner pharmacy dispenses and delivers it discreetly. Here is how it works:

• No appointment needed: You complete a short, private online consultation about your symptoms and health. There is no need to see anyone face to face.
• Clinical review: A registered prescriber reviews your answers to make sure the treatment is safe and appropriate for you. They may contact you if they need more information.
• Discreet delivery: If approved, your medicine is dispensed by our partner pharmacy and posted in plain, unbranded packaging.

Branded and generic tablets contain the same active ingredient and work in the same way, so generics are usually the better-value choice. Some treatments, including Viagra Connect (sildenafil) and Cialis Together (tadalafil), are available over the counter after a pharmacist check.

"Erectile dysfunction is common, treatable and nothing to feel awkward about. For most men, a PDE5 inhibitor tablet like sildenafil or tadalafil works well, and there are creams, gels and other options when tablets are not suitable. Whichever route you take, the two rules that matter most are these: never combine these medicines with nitrates or poppers, and seek urgent help for an erection lasting more than four hours. Just as importantly, treat ED as a prompt to look after your wider health, because it can be an early sign of heart or circulation problems. If you are unsure what is right for you, complete a consultation and let a registered prescriber guide you, or speak to your GP."

- UK Meds Clinical Team