Best treatment for erectile dysfunction: what works (2026)

What is the best treatment for erectile dysfunction? For most men it is a prescription tablet, and the rest of this guide explains why and what comes next if that doesn't work. If you came to this site looking for a pill that fixes erections, here is the honest answer up front: it exists, it is cheap, and it needs a prescription. The drugs that reliably help most men with erectile dysfunction (ED) are FDA-approved medicines, and generic versions of the two best known have been on US pharmacy shelves since the late 2010s. None of the supplements we review has evidence anywhere near theirs.

This guide covers what ED is, why it is worth a doctor's visit even if you only want a prescription, and the treatments the American Urological Association (AUA) and the National Institutes of Health describe, in roughly the order most men try them. It is general information, not medical advice: a clinician who knows your health and your medicines is the one who should pick a treatment with you.

What counts as ED, and how common it is

The NIH's kidney and urology institute (NIDDK) defines erectile dysfunction as a condition that prevents you from getting or keeping an erection firm enough for sex. An occasional bad night is not ED. A pattern that keeps happening is.

It is very common. NIDDK says research suggests between 30 million and 50 million US men have ED, about 40% of men are affected at age 40, and 70% report it by age 70. The classic Massachusetts Male Aging Study, which surveyed men aged 40 to 70 in the late 1980s, found that about half reported some degree of impotence, from minimal to complete. NIDDK is careful to add that ED becomes more likely with age but is not a routine part of aging: it usually has a cause, and causes can often be treated.

Why ED is a reason to see a doctor, not just a pharmacist

Erections depend on healthy blood vessels and nerves. The same things that damage arteries elsewhere damage the small arteries of the penis, and those are narrow enough to show trouble early. NIDDK lists heart and blood vessel disease, high blood pressure, diabetes, chronic kidney disease and obesity among the main causes, alongside nerve damage, hormone problems, many common medicines (some antidepressants and blood-pressure drugs among them), smoking, heavy drinking, anxiety and depression.

That link runs in a useful direction. In the placebo group of the large Prostate Cancer Prevention Trial, men aged 55 and over who developed ED had a higher risk of later heart attacks, strokes and other cardiovascular events than men who didn't, after adjusting for the usual risk factors; the authors called ED a harbinger of cardiovascular disease in some men. The AUA's 2018 guideline likewise tells clinicians to inform men that ED is a risk marker for underlying heart disease and other health conditions.

So the appointment is not a formality. A man whose ED is the first sign of high blood pressure, diabetes or narrowing arteries gains far more from finding that out than from any pill. If you take nitrates for chest pain (nitroglycerin, isosorbide), this is also where you learn that the standard ED drugs are off the table for you.

What the visit involves

According to NIDDK, expect questions about your health, your prescription and over-the-counter medicines and any supplements, your sexual function (desire, erections, ejaculation) and your mood and relationship. A physical exam looks for blood-vessel, nerve and hormone problems and for conditions of the penis itself such as Peyronie's disease. Blood tests may follow. Most men never need the specialist tests (penile ultrasound, overnight erection testing, an in-office injection test); they are for cases where the cause or the right treatment is unclear. Be honest about supplements: some interact with prescription drugs, and some sold for sex contain hidden prescription drugs (see our guide to tainted products).

How the AUA approaches treatment

The AUA's erectile dysfunction guideline (published in 2018 and summarized in the Journal of Urology) is the main US clinical guideline. It made one notable change from the old "first-line, second-line, third-line" ladder: it puts shared decision-making at the center. Men should be told about every treatment that isn't ruled out for them, with its benefits and risks, and any of them, whatever its invasiveness, can be a valid first choice. Choosing no treatment is also legitimate. In practice most men still start with tablets because they are easy, but nobody should be made to fail at pills before hearing about the alternatives.

Tablets: Viagra, Cialis and the other PDE5 inhibitors

Four oral drugs are FDA-approved for ED in the US, all in the same class, phosphodiesterase type 5 (PDE5) inhibitors. NIDDK describes them as oral medicines that improve blood flow to the penis. They do not cause an erection by themselves: you still need sexual stimulation, and they do nothing for desire.

• Sildenafil (brand name Viagra). The original, taken as needed before sex. Its MedlinePlus drug page covers how it is taken and its side effects.
• Tadalafil (Cialis). Lasts considerably longer, which is why it is often chosen by men who don't want to time things closely; it can also be prescribed as a low daily dose. See MedlinePlus on tadalafil.
• Vardenafil (Levitra). Similar in use to sildenafil; see MedlinePlus on vardenafil.
• Avanafil (Stendra). The newest of the four; it is not sold as a cheap generic the way the first two are.

They are cheap now

Price used to be the best argument for "natural" alternatives. It no longer is. Generic sildenafil launched in the US in December 2017, when Pfizer and Teva both started selling it at about half the brand's price, and more generic makers, including for tadalafil, have followed since, pushing prices down further. Pharmacy discount cards and cash prices vary a lot, so ask your pharmacy or check a price-comparison tool before you fill a prescription. In many cases a month of a generic costs less than a single bottle of the supplements we review.

The warnings that matter

• Never with nitrates. Taken with nitroglycerin and similar heart drugs, PDE5 inhibitors can drop blood pressure to dangerous levels. This is the single most important interaction, and it is the same reason tainted supplements with hidden sildenafil are dangerous.
• Alpha-blockers and other blood-pressure drugs need care and sometimes dose changes. Your prescriber and pharmacist should see your full medicine list.
• Common side effects include headache, flushing, stuffy nose, indigestion and, with tadalafil, back or muscle aches. The MedlinePlus pages list them.
• Seek care right away for an erection lasting more than four hours (priapism), NIDDK says, and for sudden vision or hearing loss or chest pain.

If a tablet doesn't work the first time, that is not proof it never will. Men are often told to try a drug several times, at the right dose and with the right timing relative to food and alcohol, before writing it off. That is a conversation for the prescriber, not a reason to double up on your own.

Lifestyle changes with real evidence behind them

Because so much ED is vascular, the things that help your heart tend to help erections, and there are trials to back that up. NIDDK says clinicians may suggest quitting smoking, limiting alcohol and staying active.

• Losing weight and moving more. In a two-year randomized trial in Italy, 110 obese men with ED (aged 35 to 55, without diabetes, hypertension or high cholesterol) were given either an intensive diet-and-exercise program or general advice. About a third of the intervention group regained normal erectile function, far more than in the control group. This trial was published in JAMA in 2004.
• Aerobic exercise. A 2018 systematic review of ten intervention studies concluded that about 160 minutes a week of moderate to vigorous aerobic exercise for six months (for example 40 minutes, four times a week) helped reduce ED in men whose ED was linked to inactivity, obesity, high blood pressure, metabolic syndrome or heart disease.
• Treating the underlying condition. Better control of diabetes and blood pressure, and reviewing medicines that cause ED as a side effect, are part of the job. Don't stop a prescribed drug on your own; ask whether an alternative exists.

Lifestyle change is slower than a tablet and works for fewer men on its own. It is also the only option on this list that lowers your risk of a heart attack at the same time.

When the cause is in your head (and that is not an insult)

Performance anxiety, stress, depression and relationship trouble cause or worsen ED in a lot of men, especially younger men whose blood vessels are fine. NIDDK notes that counselors can help lower anxiety and stress about sex, sometimes with a partner in the room. A tablet can help break the cycle of worry while counseling addresses the cause; the two are not either-or. Clues that the cause is at least partly psychological include normal morning erections, problems with a partner but not alone, and a sudden onset tied to a stressful event. Sex therapists certified by AASECT (the American Association of Sexuality Educators, Counselors and Therapists) specialize in exactly this.

If tablets don't work or aren't safe for you

Alprostadil: injection or urethral pellet

Alprostadil is a drug that widens blood vessels directly, so it can work when tablets don't. It is either injected with a very fine needle into the side of the penis or inserted as a small pellet into the urethra; NIDDK notes that a health care professional will teach you how to use them. It sounds worse than most men find it. The MedlinePlus page on urogenital alprostadil covers side effects, including pain and the risk of a prolonged erection that needs emergency treatment.

Vacuum erection devices

A plastic cylinder and pump draw blood into the penis, and a band at the base holds it there. No drugs, so they are an option for men on nitrates. NIDDK notes they can cause a cold or numb feeling and may weaken ejaculation. Buy a medical device (your urologist can recommend one), not a novelty pump, and never leave the band on longer than the instructions allow.

Penile implants

For men who haven't been helped by other treatments, a urologist can implant a prosthesis: either malleable rods or an inflatable device controlled by a pump in the scrotum, as NIDDK describes. It is surgery, with the risks of surgery (infection, mechanical failure), and it is permanent: it replaces natural erections rather than restoring them. The AUA counts it among the options to discuss from the start, not a last resort to hide.

What the guideline says about testosterone and newer treatments

Testosterone. Low testosterone mostly lowers desire; it is a less common direct cause of erection problems. Testosterone therapy is for men with a diagnosed deficiency (low levels on repeat morning blood tests plus symptoms), and on its own it often doesn't fix ED. Our guide to testosterone boosters covers how deficiency is diagnosed and why over-the-counter "T-boosters" are a different matter.

Shockwave therapy, stem cells, platelet-rich plasma. Clinics advertise all three. The AUA's 2018 guideline classed low-intensity shockwave therapy as investigational, and stem-cell and platelet-rich plasma injections likewise, meaning they should be offered in clinical trials rather than sold as established cures. Research has continued since, but if a clinic wants several thousand dollars up front for a package of sessions, ask what evidence and what guideline supports it, and get a urologist's second opinion.

Can you buy ED pills online safely?

Telehealth services that prescribe generic sildenafil or tadalafil after an online consultation are legal and convenient, and for many men they are how this gets solved. What isn't safe is a website that sells "generic Viagra" with no prescription. NIDDK is blunt: don't order an ED medicine online before talking with a health care professional. The FDA's BeSafeRx program lists what a legitimate online pharmacy looks like:

• It requires a valid prescription.
• It is licensed by a US state board of pharmacy.
• It has a US physical address and a licensed pharmacist you can reach.
• It does not sell prescription drugs at prices that look too good to be true, or ship from outside the country.

A telehealth visit should still ask about your heart, blood pressure and medicines. If it doesn't, that is a bad sign, and the warning about ED being an early sign of heart disease still applies: an online prescription is not a substitute for a check-up if you haven't had one in years.

Do you need a prescription for Viagra or Cialis?

Yes. In the US, sildenafil (Viagra), tadalafil (Cialis), vardenafil and avanafil are prescription-only. A telehealth service can prescribe them after an online consultation, which is legal; a website that sells them with no prescription is not, and its pills may not be what the label says.

Which is better, Viagra or Cialis?

Neither is better for everyone. Both work in a similar way; tadalafil lasts considerably longer and can be taken as a low daily dose, while sildenafil is taken as needed before sex. Side effects differ slightly. Your prescriber can help you choose, and generic versions of both are widely available.

Is ED a sign of heart disease?

It can be. ED shares causes with heart disease, and in a large US trial men who developed ED had a higher later risk of heart attacks and strokes. That is why the AUA guideline says men with ED should be told it can be a risk marker, and why a check-up is worth more than any pill.

Our reviews of VigRX Plus and Extenze and the male enhancement pill comparison show how far the supplements fall short of these treatments.

Do male enhancement supplements work for ED?

Dietary supplements are not reviewed by the FDA for safety or effectiveness before they are sold, and a supplement may not legally claim to treat a disease such as ED. That is why the labels say "supports male performance" rather than "treats erectile dysfunction." Some herbal ingredients have small studies behind them; none has the evidence of the drugs above, and a few carry real risks. Worse, the FDA keeps finding sexual-enhancement products that work only because they secretly contain prescription drugs. Read what the evidence says about each ingredient and how to spot tainted products before you spend money on a bottle.

If you still want to try one, our reviews say what is in each product, what the evidence shows and who should not take it. Start with VigRX Plus or Extenze, and tell your doctor what you are taking.