PDE-5 inhibitors and alprostadil are the medications most commonly used for erectile dysfunction treatment. Of PDE-5 inhibitors, Viagra or sildenafil is the most effective and Stendra or avanafil is the one with the lowest incidence of side effects. Cialis or tadalafil has the longest duration of action and is also the cheapest if comparing the prices of the generics. Among brand-name PDE-5 inhibitors, Levitra is the cheapest. Alprostadil is available as injectable solution, intraurethral suppositories and topical cream. The success rates for treatment with alprostadil range between 56% and 100% depending on the form of the drug and the cause of ED. The side effects of alprostadil are mild and well-tolerated.

How to Choose the Right ED Medication

Erectile dysfunction is a condition that can easily be managed nowadays. According to WebMD, it can be treated with medications, surgery, vacuum pumps, psychotherapy or lifestyle changes. The current article focuses on the former of these options listing the most effective ED medications.

PDE-5 Inhibitors

PDE-5 (phosphodiesterase type 5) is a substance capable of preventing or stopping an erection due to its effect on blood vessel walls. PDE-5 inhibitors are medications that fight ED by blocking the action of phosphodiesterase type 5. They are effective in 69% of men with ED and cause relatively mild side effects reported by 32-45% of the patients. The most common side effects are headache, flushing and dyspepsia.

The most widely used PDE-5 inhibitors are listed in the table below along with their characteristic features. The prices come from Pharmacy Checker and may vary from country to country.

Effect of PDE-5 Inhibitors
Viagra (sildenafil) Levitra (vardenafil) Cialis (tadalafil) Stendra (avanafil)
Treatment success rate, % 89.1 79.1 85.5 77
Incidence of side effects, % 43 32.8 45.8 12.5
Onset of action, min 30-60 15-30 15-45 15
Duration of effect, hours 12 12 36 6
Brand-name price online, per pill, USD From $6.15 From $4.99 From $10.46 From $5.13
Generic price online, per pill, USD From $0.33 From $0.55 From $0.18 N/A
Average national price in the US, per pill, USD $41.53 $39.59 $45.54 $34.50

PDE-5 inhibitors are the first-line treatment prescribed to patients with ED as long as they don’t have any contraindications to the use thereof. Such contraindications include concomitant use of nitrate medications, nitrate-based recreational drugs or guanylate cyclase (GC) stimulators, hypersensitivity to their components as well as cardiovascular conditions during which sex is to be avoided altogether.

There are also other conditions that require taking PDE-5 inhibitors with caution due to increased risk of adverse reactions. These include:

  • Cardiovascular disorders (recent history of infarction, stroke, serious hyper- or hypotension, cardiac failure, coronary artery disease)
  • History of NAION (non-arteritic anterior ischemic optic neuropathy) or underlying NAION risk factors
  • Use of alpha-blockers or anti-hypertensives
  • Use of protease inhibitors
  • Use of other ED treatments

The conditions listed above do not serve as direct contraindications for the use of PDE-5 inhibitors, but you should discuss the risks and potential benefits of taking them with your doctor if any of these conditions apply to you.

Simply taking drugs like Viagra doesn’t cause an erection. Sexual stimulation is required to trigger this physical process.

Alprostadil

This medication, a synthetic version of prostaglandin E1 or PGE1, also works by relaxing the smooth muscles in blood vessels and increasing blood flow throughout the body including the penis. Its main difference from PDE-5 inhibitors is the fact that it can cause erections without sexual stimulation, which is important for patients with nerve damage in pelvic area.

prostaglandin infographic

Alprostadil is currently available in 3 forms:

  • Solution for injections – Caverject Impulse, Edex
  • Intraurethral suppositories – MUSE
  • Topical cream – Vitaros

Injectable alprostadil works in 60-70% of the patients with ED resulting from cardiovascular conditions and 100% of the patients with ED resulting from nervous system disorders, according to a research by S.H. Tariq and J.E. Morley. The medication should be injected directly into the penis. The injections cause little or no discomfort at all. The side effects include mild penile pain (44% of the patients), prolonged erection (8%) and formation of fibrous tissue at the site of the injection (4%). Priapism was observed in 0.9% of the cases and is the only common side effect of alprostadil that requires emergency medical attention.

Intraurethral alprostadil suppositories come as small pellets half the size of a rice grain. They are to be inserted about 1 inch deep into the urethra using a special plastic applicator. Treatment with intraurethral alprostadil shows lower success rates compared to the injections with 56% patients achieving erection. Most common side effects include pain and discomfort in the penis and bleeding from the urethra and are observed in 17% of the patients.

Topical alprostadil cream is currently pending FDA approval and is not available for purchase in the US. It is sold under the trade name Vitaros in Canada, EU countries, India, Russia, etc. It is applied to the head of the penis triggering an erection 45 minutes after use. The clinical trials described by James Anaissie and Wayne JG Hellstrom report success rates of 67-75%. The same study states that the incidence rate of treatment-related adverse effects reaches 50% but stresses that these effects are well-tolerated. Common side effects of topical alprostadil include mild penile burning and pain and erythema.

PDE-5 inhibitors are the first-line medical treatment to be considered in patients with ED. Alprostadil in any of its 3 forms is an important second-line option. Treatment with alprostadil is usually chosen by non-responders to PDE-5 inhibitors and patients in whom the use of Viagra and similar medications is contraindicated for one reason or another.

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