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ED Treatments Compared: Pills, Shockwave, PRP and Penile Implant

An escalation guide to erectile dysfunction treatment with the evidence level at each rung, from risk-factor treatment and tadalafil to injections, shockwave, PRP and penile prosthesis.

By Adelinda Manna, medical and veterinary content writer · Updated

Short answer

Start with risk-factor treatment and a properly optimized PDE5 inhibitor. If pills fail, guideline-supported next steps include injections, vacuum devices and a penile implant. The AUA classifies shockwave as investigational and advises against PRP outside trials; the EAU gives shockwave a weak recommendation. An implant is the definitive option when other treatments fail or are declined.

At a Glance
Guideline-supported rungs Lifestyle, PDE5 inhibitors, injection, vacuum device, implant[1]
AUA position on shockwave Investigational (Conditional, level C)[1]
AUA position on PRP Not outside clinical trials (expert opinion)[1]
Shockwave course, US clinics (2021) Mean $3,338; range $600 – $16,200[7]
Penile prosthesis, cost band $8,000 – $25,000

When erectile dysfunction pills seem not to work, the question is rarely “which expensive treatment next” and more often “has the first treatment been given a fair trial, and what does the evidence say about each alternative?” This page lays out the commonly described escalation ladder, states the evidence level and guideline position for each rung as reported in sources read for this article, and links to the procedure page for each.

A ladder is a way to organize options, not a required sequence

The AUA erectile dysfunction guideline (Burnett et al., Journal of Urology, 2018; erratum 2022) is built on shared decision-making. Its abstract advises clinicians to present all treatment options that are not contraindicated, regardless of invasiveness or reversibility, as potential first-line choices.[2] A 2026 comparison of eleven guidelines reports that the AUA uses no stepwise framework, that the EAU treats pills, vacuum devices and injections as acceptable first-line options with prosthesis second-line, and that the USANZ and CUA use a three-tier ladder: PDE5 inhibitor first, then injection or vacuum device, then prosthesis.[1] The ladder below follows the three-tier convention for clarity. Guideline positions are described as summarized in that 2026 comparison, which lists the AUA guideline as the 2018 version and the EAU guideline as the 2025 version; consult the guideline texts for exact wording.

The escalation ladder at a glance

RungEvidence level and guideline positionTypical costRead more
1. Lifestyle and risk-factor treatment Meta-analysis of 6 randomized trials (740 men): IIEF-5 improved by a weighted mean difference of 2.66 points (95% CI 1.86–3.47); the 4 lifestyle-modification trials (597 men) gave 2.40 (95% CI 1.19–3.61).[3] All major guidelines advocate lifestyle change, without specific evidence grades.[1] Varies; no site estimate PDE5 optimization (includes risk-factor review)
2. PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) AUA: Strong recommendation, evidence level B. EAU: Strong, level 1a.[1] An overview of 23 systematic reviews found efficacy and safety versus placebo well documented, while comparisons between agents are mostly low or very low quality.[4] Editorial: generic sildenafil about $0.50 – $2.00 per dose via discount programs; daily generic tadalafil about $30 – $100 per month PDE5 inhibitor optimization
3. Intracavernosal injection AUA: Moderate recommendation, level C. EAU: Strong, level 1a, as a first- or second-line alternative; dropout 41%–68%, mainly in early months.[1] Not estimated on this site No dedicated page yet
4. Vacuum erection device AUA: Moderate recommendation, low evidence level; a rescue option combined with a PDE5 inhibitor. EAU: Weak, level 2b; dropout 50%–64%.[1] Not estimated on this site Penile rehabilitation protocol
5. Testosterone, where deficiency is documented Testing is recommended (AUA Moderate; EAU Strong).[1] In 790 men aged 65 or older with testosterone below 275 ng/dL and symptoms, one year of testosterone gel increased sexual activity, desire and erectile function versus placebo.[5] Adding testosterone in hypogonadal men improves erectile function in an overview of reviews.[4] Editorial: about $150 – $500 per month Testosterone replacement therapy
6. Low-intensity shockwave (Li-ESWT) AUA: investigational (Conditional recommendation, level C). EAU: Weak recommendation, citing level 1a evidence of mild improvement in mild vasculogenic ED.[1] Meta-analysis of 16 randomized trials (1,064 men): IIEF mean difference about 3 points at 1, 3 and 6 months, some below the 4-point minimal clinically important difference.[6] Not FDA approved for ED as of a 2022 report.[7] Mean $3,338 per course (range $600 – $16,200), 99 US clinics priced in 2021;[7] site band $3,000 – $6,000 Li-ESWT; acoustic wave therapy
7. Platelet-rich plasma (PRP) AUA: PRP should not be offered outside clinical trials (expert opinion); stem cell therapy is investigational (Conditional, level C). EAU: level 1b evidence in primary organic ED, but insufficient to recommend outside trials.[1] Systematic review: 17 studies, 1,099 men, 4 randomized trials, small to moderate benefit, mostly high risk of bias.[8] Editorial: about $1,500 – $4,000 per session PRP for ED; PRF injection
8. Penile prosthesis AUA: evidence level C. EAU: Strong recommendation for refractory cases, men unsuited to less invasive options or those preferring definitive treatment. ICSM: Strong.[1] Satisfaction 69%–88% in individual series cited by a 2024 review.[9] Editorial: malleable $8,000 – $15,000; inflatable $15,000 – $25,000 Inflatable; malleable

Guideline grades are those reported in the 2026 comparison and may differ in wording from the original guideline text.[1] Costs are editorial estimates unless a source is cited. Shockwave pricing is from a telephone survey of clinics in 8 US metropolitan areas in 2021 and is not a national average.[7]

Before escalating: has the pill had a fair trial?

The guideline comparison reports that incorrect use accounts for 56%–81% of PDE5 inhibitor treatment failures, and that the AUA states 23.6%–58.5% of apparent non-responders respond after re-education; ISSM and ICSM describe these men as “pseudo-non-responders.”[1] The same review notes that no single agent or dose is preferred, that the AUA advises the lowest dose with acceptable results while the ICSM recommends titrating to the maximum tolerated dose, and that guidelines differ on whether switching to daily tadalafil helps partial responders.[1] A structured review of agent, dose, timing and expectations is therefore the first step; see PDE5 inhibitor optimization.

Safety limits matter here. The tadalafil prescribing information contraindicates its use with any organic nitrate, and warns patients to seek emergency care for an erection lasting longer than four hours.[10]

Tadalafil vs shockwave therapy

The sources read for this page contain no head-to-head trial of tadalafil against shockwave therapy, so a direct comparison cannot be made honestly. What can be said is that the two sit at very different evidence levels. PDE5 inhibitors carry Strong guideline recommendations at the AUA and EAU and are supported by 23 systematic reviews.[1, 4] Shockwave therapy is classified as investigational by the AUA and, as of a 2022 report, by the SMSNA, and it is not FDA approved for ED.[1, 7] The EAU is more permissive, giving a Weak recommendation, and the 2022 meta-analysis of 16 randomized trials found a pooled IIEF improvement of about 3 points that persisted to 6 months. The authors note that some of these gains fall below the 4-point minimal clinically important difference, that follow-up was mostly 1 to 6 months, and that not every control group received a true sham.[6] The AUA summary also notes heterogeneity across trials and decaying efficacy.[1]

Market practice outpaces the evidence. A telephone survey of clinics found 152 offering shockwave in 8 US metropolitan areas; only 25% of providers were urologists, 13% were nonphysicians, no standard protocol existed for device type or settings, and 18% of clinics required a consultation before disclosing a price.[7] If you are considering shockwave, ask the questions at the end of this page.

PRP: what the trials show

A 2024 systematic review of PRP for erectile dysfunction and Peyronie’s disease included 17 studies (4 randomized trials, 11 prospective cohorts, 3 retrospective) with 1,099 men. It found small to moderate benefit and mild, transient side effects, but most studies were at high risk of bias and PRP preparation varied.[8] The randomized trials disagree. One (60 men) reported that 76%, 69% and 69% of the PRP group met the minimal clinically important difference at 1, 3 and 6 months versus 25%, 39% and 27% with placebo; another (61 men) found no significant between-group difference in erectile function and high dropout.[8] The authors note that PRP is not recommended by the EAU or AUA guidelines, describe it as experimental, and warn that it is marketed despite the uncertainty.[8]

Clinical note: “Investigational” does not mean ineffective. It signals that the guideline panel judged the evidence insufficient to support routine use. Patients who choose shockwave or PRP should do so after a documented diagnosis, with a realistic expectation of modest benefit, and without delaying an effective treatment such as an optimized PDE5 inhibitor.

When to consider a penile implant

The EAU gives penile prosthesis a Strong recommendation for refractory cases, for men unsuitable for less invasive options, and for those who prefer definitive treatment, and the ICSM gives a Strong recommendation for motivated men who are unwilling to trial other options or who have a suboptimal response; all guidelines stress irreversibility and counseling.[1] Individual series report satisfaction of 69%–88% depending on device.[9] Medicare’s national policy on impotence states that Medicare may pay for diagnosis and treatment, and names penile prosthesis implantation as an example of surgical treatment.[11] Commonly considered reasons to move to an implant are:

  • a properly optimized PDE5 inhibitor has failed or is not tolerated, and injection or a vacuum device has been tried, declined or is unsuitable;
  • you prefer a definitive treatment to ongoing therapy, which the EAU names as one of its indications;
  • erectile dysfunction coexists with Peyronie’s disease (see Peyronie’s surgery options).

To choose between device types, see inflatable vs malleable penile implant, and for the budget see penile implant cost.

When to see a specialist

  • At first diagnosis. Erectile dysfunction shares modifiable risk factors with coronary artery disease, so an evaluation is more than a prescription.[3]
  • If pills do not work after correct use. Ask for a review of how, when and at what dose you take them before concluding they have failed.[1]
  • If you take nitrate medicines or have heart disease. Do not start a PDE5 inhibitor without medical advice.[10]
  • If an erection lasts longer than four hours. Seek emergency care.[10]
  • If you have symptoms of low testosterone, or have never had it checked. Guidelines recommend testosterone testing in men with erectile dysfunction.[1]
  • Before paying for shockwave or PRP. See a urologist who can confirm the cause, ideally with ABU board certification, SMSNA membership or andrology fellowship training (see our credential standard); a penile Doppler ultrasound can help define a vascular cause.

Questions to ask before paying for shockwave or PRP

  • How is this treatment classified by the AUA, and is the device or preparation FDA approved or cleared for erectile dysfunction?
  • Which exact device or preparation protocol do you use, and what outcome data do you have from your own patients?
  • How many sessions, over what period, and what is the total cost including any maintenance?
  • How will we measure whether it worked (for example, a questionnaire at baseline and 3 months), and what is the plan if it does not?
  • Have I had a documented evaluation, and have my medications and testosterone been optimized first?
  • Are you refundable, and does my insurance cover any part of this?

Sources

  1. Gillman N, Chung E. Guideline of guidelines: a scoping review on comparison of major clinical guidelines for erectile dysfunction. Transl Androl Urol. 2026;15(7):254. https://pmc.ncbi.nlm.nih.gov/articles/PMC13458603
  2. Burnett AL, Nehra A, Breau RH, et al. Erectile dysfunction: AUA guideline. J Urol. 2018;200(3):633–641. doi:10.1016/j.juro.2018.05.004 (PubMed record only; see the AUA for the full guideline text). https://pubmed.ncbi.nlm.nih.gov/29746858/
  3. Gupta BP, Murad MH, Clifton MM, Prokop L, Nehra A, Kopecky SL. The effect of lifestyle modification and cardiovascular risk factor reduction on erectile dysfunction: a systematic review and meta-analysis. Arch Intern Med. 2011;171(20):1797–1803. https://pubmed.ncbi.nlm.nih.gov/21911624/
  4. Pyrgidis N, Mykoniatis I, Haidich AB, et al. The effect of phosphodiesterase-type 5 inhibitors on erectile function: an overview of systematic reviews. Front Pharmacol. 2021;12:735708. https://pmc.ncbi.nlm.nih.gov/articles/PMC8452927
  5. Snyder PJ, Bhasin S, Cunningham GR, et al; Testosterone Trials Investigators. Effects of testosterone treatment in older men. N Engl J Med. 2016;374(7):611–624. https://pubmed.ncbi.nlm.nih.gov/26886521/
  6. Yao H, Wang X, Liu H, et al. Systematic review and meta-analysis of 16 randomized controlled trials of clinical outcomes of low-intensity extracorporeal shock wave therapy in treating erectile dysfunction. Am J Mens Health. 2022;16(2):15579883221087532. https://pmc.ncbi.nlm.nih.gov/articles/PMC8949743
  7. Weinberger JM, Shahinyan GK, Yang SC, Shahinyan RH, Mills JN, Eleswarapu SV. Shock wave therapy for erectile dysfunction: marketing and practice trends in major metropolitan areas in the United States. Urol Pract. 2022;9(3):212–219. https://pmc.ncbi.nlm.nih.gov/articles/PMC12721601
  8. Asmundo MG, Durukan E, von Rohden E, Thy SA, Jensen CFS, Fode M. Platelet-rich plasma therapy in erectile dysfunction and Peyronie’s disease: a systematic review of the literature. World J Urol. 2024;42(1):359. https://pmc.ncbi.nlm.nih.gov/articles/PMC11136842
  9. Patel J, Zakkar B, Polchert M, Tannenbaum J, Dick B, Raheem O. Recent technological development of penile prosthesis: a literature review. Transl Androl Urol. 2024;13(1):165–184. https://pmc.ncbi.nlm.nih.gov/articles/PMC10891389
  10. CIALIS (tadalafil) tablets, prescribing information, sections 4.1 and 5.3 (repackager label revised 2/2010; confirm against the current label). DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=6a8621eb-7415-42a6-9432-630751d34c6b&type=display
  11. Centers for Medicare & Medicaid Services. National Coverage Determination 230.4, Diagnosis and Treatment of Impotence (Medicare NCD Manual, Pub. 100-3). https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=32

Cost figures are ranges and editorial estimates unless a source above states otherwise. This article is educational and is not medical advice.