Question explored with the scientific record
Interventions for erection failure on men
The short version: PDE5 inhibitor pills work well for many men, but the evidence is almost entirely from short, manufacturer-funded trials that measure questionnaire scores, not long-term health.
The retrieved evidence is dominated by drug-company sponsored trials of PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) that run 3 to 12 months [1][2][3]. They consistently show improvements in erectile function scores and intercourse success rates compared to placebo [1][2][3]. For example, in one trial avanafil 100 mg raised the average erectile function score from about 12.7 to 18.1, while placebo moved from 12.4 to 13.9 [4]. A 2025 meta-analysis of 10 studies in diabetic men found PDE5 inhibitors roughly 2.7 times more likely to produce improvement than placebo [5]. These are real effects for the short term.
But the safety picture is thin. The most common side effects are headache (9-16%), flushing (3-10%), and dyspepsia (4-12%) [9]. Priapism (prolonged erection) is reported at 2.5-2.7% [9]. The trials are too short and too small to detect rare but serious harms like non-arteritic ischemic optic neuropathy or sudden hearing loss. The 2019 safety review notes that direct head-to-head safety comparisons among the drugs are largely missing [9]. No retrieved study compares PDE5 inhibitors to a genuinely untreated group over years, so the long-term trade-off between symptom relief and unknown risks is simply not studied.
| Drug | Typical IIEF-EF score improvement vs placebo | Most common side effects |
|---|---|---|
| Sildenafil | ~10 points (22 vs 12 at 12 weeks) [2] | Headache 16%, flushing 10% [2] |
| Tadalafil | ~9 points (24 vs 15 at 12 weeks) [2] | Headache, dyspepsia [3] |
| Avanafil | ~5 points (18 vs 14 at 12 weeks) [4] | Flushing (most common) [1] |
For men who cannot take pills or do not respond, the evidence covers injectable alprostadil (about 50% report pain at the injection site) [9], intraurethral alprostadil (25-43% urethral pain) [9], and penile implants (satisfaction around 86% but infection risk 1.5-4% depending on device and patient factors) [6][7][8]. Low-intensity shockwave therapy showed some improvement in a single small uncontrolled study of 22 men [10], but that design cannot separate real effect from placebo or natural recovery.
My call: PDE5 inhibitors are reasonably effective for short-term symptom relief in most men with erectile dysfunction, but the evidence base is funded by the manufacturers, short-term, and silent on long-term safety. Confidence: moderate for short-term efficacy, low for long-term safety.
Sources used 10
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Efficacy and safety of avanafil for treating erectile dysfunction: results of a multicentre, randomized, double‐blind, placebo‐controlled trial
This study evaluates the efficacy and safety of avanafil, a selective phosphodiesterase type 5 inhibitor, in treating erectile dysfunction over a 12-week period in Korean patients, demonstrating significant improvements in erectile function compared to placebo.
DOI: 10.1111/j.1464-410X.2012.11095.x -
Phosphodiesterase type 5 inhibitors for erectile dysfunction
A comprehensive 2005 review of phosphodiesterase type 5 inhibitors (sildenafil, vardenafil, tadalafil) for erectile dysfunction, detailing their mechanisms via NO–cGMP signaling, pharmacokinetics, efficacy across etiologies, safety, drug interactions, and clinical use considerat…
DOI: 10.1111/j.1464-410X.2005.05614.x -
Tadalafil
This study reviews the efficacy and safety of tadalafil, a phosphodiesterase type 5 inhibitor, in treating erectile dysfunction in men, demonstrating significant improvements in erectile function and tolerability compared to placebo.
DOI: 10.2165/00003495-200363200-00004 -
A Randomized, Double‐Blind, Placebo‐Controlled Evaluation of the Safety and Efficacy of Avanafil in Subjects with Erectile Dysfunction
This study evaluates the safety and efficacy of avanafil, a novel phosphodiesterase type 5 inhibitor, in treating erectile dysfunction in men, demonstrating significant improvements in erectile function compared to placebo across multiple doses.
DOI: 10.1111/j.1743-6109.2011.02629.x -
The safety and efficacy of phosphodiesterase type 5 inhibitors in the treatment of diabetic erectile dysfunction: a systematic review and meta-analysis
A meta-analysis of 10 studies found that PDE-5 inhibitors were significantly more effective than placebo in diabetic erectile dysfunction (age ≥55 years: 2.73; age <55 years: 2.61; P < 0.00001), with no publication bias.
DOI: 10.7717/peerj.20147 -
Determinants of Patient Satisfaction Following Penile Prosthesis Surgery
This study investigates the determinants of patient satisfaction following penile prosthesis surgery, revealing that factors such as Peyronie's disease, body mass index over 30, and history of radical prostatectomy are associated with lower satisfaction rates compared to the gen…
DOI: 10.1111/j.1743-6109.2006.00278.x -
Long-Term Infection Rates in Diabetic Patients Implanted With Antibiotic-Impregnated Versus Nonimpregnated Inflatable Penile Prostheses: 7-Year Outcomes
This study evaluates the long-term infection rates in diabetic patients with inflatable penile prostheses, demonstrating that antibiotic-impregnated implants significantly reduce the need for revision surgeries due to infection compared to nonimpregnated implants over a 7-year p…
DOI: 10.1016/j.eururo.2011.01.046 -
Long-Term Infection Outcomes of 3-Piece Antibiotic Impregnated Penile Prostheses Used in Replacement Implant Surgery
A large retrospective cohort study of replacement AMS 700 penile prostheses comparing minocycline/rifampin impregnated devices to nonimpregnated devices, demonstrating significantly fewer infection-related secondary revisions over up to 6.6 years with projected 10-year infection…
DOI: 10.1016/j.juro.2012.04.116 -
An update on the drug safety of treating erectile dysfunction
A narrative literature review (1980–2019 PubMed search) synthesizing the safety profile and adverse effects of erectile dysfunction therapies, particularly PDE5 inhibitors, across cardiovascular, hearing, ocular, oncologic, priapism, and reproductive domains, concluding mostly s…
DOI: 10.1080/14740338.2019.1659244 -
EFFECTIVITY OF LI-ESWT FOR ERECTILE DYSFUNCTION MANAGEMENT BASED ON EHS AND IIEF-5
In a single-group pre-post study of 22 men with erectile dysfunction, monthly low-intensity extracorporeal shockwave therapy (LI-ESWT) for 8 months was associated with significant increases in IIEF-5 and EHS scores.
DOI: 10.32421/juri.v29i2.788