Treatment guide

Erectile Dysfunction Treatment: The Options, in the Order Doctors Use Them

Most men start with the least invasive step and move on only if it falls short. Here is each step and what the sources say about it.

Men's Health Weekly staff · October 30, 2026

The quick answer

The NIH says clinicians treat the underlying cause of ED when possible, and describe lifestyle changes, counseling, medicines, injections, suppositories, vacuum devices and surgery as the options.¹
In a randomized trial of 110 obese men, a two-year weight loss and activity program raised the average erectile function score from 13.9 to 17, while the control group stayed at 13.6.²
A meta-analysis of 7 trials (478 men) found exercise improved erectile function scores by 3.85 points on average, though the trials carried moderate to high risk of bias.³
Oral PDE5 inhibitors are a first-line treatment, but 30% to 40% of men show little or no response to on-demand use of one.⁴
The FDA-approved ED pills carry a nitrate contraindication, so a clinician needs the full medicine list before prescribing.⁵

ED treatment is a ladder, not a single product. The NIH says health care professionals treat the underlying cause when they can, and otherwise focus on improving sexual function.¹ In practice that means lifestyle changes and a medicine review first, then an oral pill from the PDE5 inhibitor class, then injections, suppositories, a vacuum device or surgery for men who need more. Which step fits depends on the cause, other conditions and the medicines a man already takes, so a clinician's review comes before any of them.

Our pick: Quattro from Vea Health, if you want to start online Sponsored

This is our pick for the online step because we have a financial relationship with Vea Health. It is one route among several, and the steps below apply whichever you choose.

Vea Health describes Quattro as a compounded sublingual dose that combines sildenafil, tadalafil, vardenafil and apomorphine, prescribed only after a licensed clinician reviews your health history, with no charge unless a clinician approves the prescription.⁶ It suits a man who wants a dissolving format and is comfortable that it is compounded. Compounded drugs are not FDA-approved and have not been reviewed by the FDA for safety or effectiveness.⁷ The sildenafil label also says combinations with other ED treatments have not been studied, so the clinician should check it against everything you take, nitrates above all.⁵ If you would rather start with an FDA-approved tablet, the sections below show how those are prescribed, and our comparison of online ED pills lays out the formats side by side.

What are the ED treatment options?

Step	What it involves	What the sources say
Lifestyle changes	Quitting smoking, limiting alcohol, more activity, a healthy weight, a healthy eating plan, stopping recreational drugs¹	Improved scores in randomized trials²³
Counseling	Helps when anxiety, stress or mental health affects ED; partners may attend¹	Recommended by the NIH where emotional factors play a part¹
Medicine review	A clinician checks whether a medicine you need for another condition is contributing¹	Do not stop any medicine on your own¹
Oral PDE5 inhibitors	Sildenafil, tadalafil, vardenafil and avanafil improve blood flow to the penis¹	First line; 30% to 40% show little or no response to on-demand monotherapy⁴
Testosterone with a PDE5 inhibitor	For men who have ED and low testosterone¹	Appears safe, but no trial found a better result than the pill alone in men who had failed a PDE5 inhibitor⁴
Injections and suppositories	Taught by a clinician; an injection produces an erection by raising blood flow, a suppository is placed in the urethra¹	High success in PDE5 non-responders, but injection is painful⁴
Vacuum erectile device	A tube, pump and elastic ring that draw blood into the penis¹	Can feel cold or numb and cause painless bruising¹
Surgery	An implanted prosthesis, or arterial repair that works best in younger men¹	Most men with ED do not need it¹

Do lifestyle changes help ED?

They can, and they are the one step that also helps the underlying cause. In a randomized, single-blind trial, 110 obese men aged 35 to 55 with ED were given either detailed advice to lose 10% or more of their body weight and exercise more, or general information about food and exercise. After two years, the intervention group's average erectile function score rose from 13.9 to 17, the control group's stayed at 13.6, and 17 men in the intervention group versus 3 in the control group reached a score of 22 or higher.² The authors concluded lifestyle changes were associated with improvement in about one third of obese men with ED at baseline.²

A later meta-analysis pooled 7 trials with 478 men who had ED and found exercise raised erectile function scores by 3.85 points on average, with aerobic exercise at moderate to vigorous intensity looking best. The authors rated the risk of bias as moderate to high, mainly because participants cannot be blinded to exercise.³ So the direction is consistent, but the evidence is not strong enough to promise any particular change. The NIH lists the same habits, and recommends at least 150 minutes of moderate activity a week.¹

What do ED pills do, and who should not take them?

PDE5 inhibitors are oral medicines that improve blood flow to the penis and may help a man get and keep an erection.¹ Four have FDA-approved ED labels; which ED pills are FDA-approved covers each, and our ED medications list gives the full range.

The safety limits are not minor. The Viagra label contraindicates use with nitrates in any form, because sildenafil potentiated their blood-pressure-lowering effect, and with riociguat.⁵ The NIH tells men to seek care right away for an erection lasting longer than 4 hours, and for vision or hearing loss after an oral ED medicine.¹ ED can also be an early sign of heart disease, which is one reason the visit should include a health history and not only a prescription.⁸

What if the first pill does not help?

This is common. A systematic review of second-line oral options notes that 30% to 40% of men show little or no response to on-demand PDE5 inhibitor monotherapy.⁴ The usual next questions are about use, not strength: whether the pill was taken at the right time and dose, and whether another PDE5 inhibitor or a low-dose daily regimen is worth trying. The review found low-dose daily tadalafil, alone or with on-demand sildenafil, produced similar score gains when standard regimens failed, found no better result from adding an alpha-blocker, and called efficacy of other add-ons uncertain.⁴ It also points out that alprostadil injection has a high success rate in these men but is painful.⁴

Are injections, vacuum devices and surgery worth considering?

For some men, yes. Injectable medicines cause a quick, automatic erection by increasing blood flow, and a clinician teaches the technique.¹ Vacuum devices suit men who prefer to avoid medicine or cannot take it, though they can feel cold, look purple or bruised, and may weaken ejaculation without affecting orgasm.¹ Surgery is for men who tried everything else and is not needed by most.¹ All of these are decided with a clinician, usually a urologist; which doctor to see for ED explains who treats what.

How do you start treatment online?

An online visit can cover the first rungs: a questionnaire, a clinician's review and a prescription filled by a pharmacy. What to look for is the same as in person. A real review of your health history and medicines, a named drug and strength, and a licensed pharmacy. The NIH advises against ordering an ED medicine online before talking with a health care professional, because medicines and supplements can interact.¹ Products sold with no prescription are the riskiest route; the FDA warns that sexual enhancement products are likely to contain hidden drug ingredients.⁹ Our list of questions to ask before an online ED prescription is a checklist for the visit, and how to fix erectile dysfunction covers the causes that may be driving it.

Bottom line

Start with the habits and the medicine review, add a PDE5 inhibitor if a clinician judges it safe, and move to injections, devices or surgery only if needed. Each step has real limits, and none is guaranteed to help. Talk to a clinician before any of them, especially if you take nitrates or have heart disease.

Important safety information. PDE5 inhibitors (sildenafil, tadalafil, vardenafil) must not be taken with nitrates in any form, including nitroglycerin, or with guanylate cyclase stimulators such as riociguat, and need caution with alpha-blockers.⁵ The most common side effects are headache and flushing.⁵ An erection lasting more than four hours needs emergency care.¹⁰ Apomorphine commonly causes nausea.¹¹ Only a licensed clinician who knows your health history and medications should decide whether any of these are safe for you.

Your questions

What is the first treatment for erectile dysfunction?

The NIH says clinicians treat the underlying cause when possible and may suggest lifestyle changes, counseling, a review of your current medicines, and oral PDE5 inhibitors. Which comes first depends on the cause and your health.

What if ED pills do not help?

A review found 30% to 40% of men show little or no response to on-demand PDE5 inhibitor monotherapy. Options include a low-dose daily tadalafil regimen, injections or suppositories, a vacuum device, or surgery, chosen with a clinician.

Can lifestyle changes treat ED?

They improved erectile function scores in randomized trials, including a two-year weight loss and activity trial in obese men and a meta-analysis of exercise trials. Results varied, and the evidence carries bias risk.

Is it safe to get ED treatment online?

It can be when a licensed clinician reviews your health history and medicines and a licensed pharmacy fills the prescription. The NIH advises talking with a health care professional before ordering an ED medicine online.

Do you need surgery for ED?

Most people with ED do not. The NIH describes surgery as an option when other treatments have been tried and ED does not improve.

Sources

National Institute of Diabetes and Digestive and Kidney Diseases. Treatment for Erectile Dysfunction. National Institutes of Health. Accessed October 30, 2026.
Esposito K, et al. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial. JAMA. 2004. PubMed 15213209.
Silva AB, et al. Physical activity and exercise for erectile dysfunction: systematic review and meta-analysis. Br J Sports Med. 2017. PubMed 27707739.
Munk NE, et al. Systematic review of oral combination therapy for erectile dysfunction when phosphodiesterase type 5 inhibitor monotherapy fails. Sex Med Rev. 2019. PubMed 30711478.
Pfizer. VIAGRA (sildenafil citrate) prescribing information. DailyMed, U.S. National Library of Medicine.
Vea Health. Quattro. Accessed October 26, 2026.
U.S. Food and Drug Administration. Compounding and the FDA: Questions and Answers.
Thompson IM, et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA. 2005. PubMed 16414947.
U.S. Food and Drug Administration. Sexual Enhancement and Energy Product Notifications. Accessed October 26, 2026.
Eli Lilly. CIALIS (tadalafil) prescribing information. DailyMed, U.S. National Library of Medicine.
Dula E, et al. Double-blind, crossover comparison of 3 mg apomorphine SL with placebo and with 4 mg apomorphine SL in male erectile dysfunction. Eur Urol. 2001. PubMed 11464037.