ED Treatments Compared: PDE5 Inhibitors vs P-Shot vs Shockwave

Why Comparing ED Treatments Matters

Erectile dysfunction affects roughly 30 million men in the United States alone. The prevalence increases with age, but this is not purely an aging problem. About 26% of men under 40 presenting to sexual health clinics meet criteria for ED [1]. And the treatment options have expanded well beyond the blue pill.

The challenge is that men now face a confusing mix of options: prescription medications, regenerative procedures, shockwave devices, supplements, and surgical implants. Each has a different mechanism, different evidence quality, and different cost profile. Some treat symptoms. Others claim to restore function. A few actually do.

Here is what the evidence says about the major options and how to think about choosing between them.

PDE5 Inhibitors: The Standard First-Line Treatment

How They Work

Phosphodiesterase type 5 (PDE5) inhibitors block the enzyme that breaks down cyclic GMP in penile smooth muscle. Cyclic GMP is the molecule that relaxes blood vessel walls and allows blood to flow into the corpora cavernosa during arousal. By blocking its breakdown, PDE5 inhibitors amplify your body’s natural erectile response [2].

The key point: these drugs require sexual stimulation to work. They do not cause spontaneous erections. They make the existing arousal pathway more efficient.

The Options

• Sildenafil (Viagra): Take 30-60 minutes before activity. Lasts 4-6 hours. Available in 25, 50, and 100 mg doses. Generic versions are widely available and affordable.
• Tadalafil (Cialis): Can be taken as-needed (10-20 mg, lasts up to 36 hours) or daily (2.5-5 mg for continuous coverage). The daily dose also treats benign prostatic hyperplasia (BPH).
• Vardenafil (Levitra) and Avanafil (Stendra): Similar mechanism with slightly different pharmacokinetics. Avanafil has the fastest onset at about 15 minutes.

Efficacy and Limitations

PDE5 inhibitors work for about 60-70% of men across clinical trials. That number drops in specific populations: men with diabetes (about 50-55%), post-prostatectomy patients (about 15-40% depending on nerve-sparing technique), and men with severe vascular disease [3].

Common side effects include headache, flushing, nasal congestion, and visual changes (sildenafil specifically). These are generally mild and dose-dependent. The serious contraindication is concurrent nitrate use, which can cause dangerous drops in blood pressure.

The fundamental limitation of PDE5 inhibitors: they are symptom management. When you stop taking them, nothing has changed structurally. For many men, this is perfectly fine. For others, especially younger men or those who want to address the root cause, this matters.

Shockwave Therapy (Li-ESWT): Treating the Vascular Cause

How It Works

Low-intensity extracorporeal shockwave therapy (Li-ESWT) delivers acoustic energy pulses to penile tissue. The proposed mechanism involves three processes: stimulating angiogenesis (new blood vessel formation), recruiting endogenous stem cells, and activating local growth factors. The goal is to improve penile blood flow at the structural level rather than pharmacologically [4].

This is the same general technology used in orthopedics for tendinopathy and wound healing, adapted for sexual medicine with lower energy settings.

What the Evidence Shows

The evidence for Li-ESWT is promising but still maturing. A 2019 meta-analysis of 7 randomized controlled trials found statistically significant improvements in IIEF scores (the standard erectile function questionnaire) compared to sham treatment. The effect was most pronounced in men with mild to moderate vasculogenic ED [5].

A 2021 systematic review published in the Journal of Sexual Medicine confirmed these findings and noted that treatment effects appeared durable at 6 and 12 month follow-ups in several trials, though longer-term data remains limited [6].

The men who respond best are those with vasculogenic ED (blood flow problems) who still have some residual erectile function. Men with severe neurogenic ED or complete vascular occlusion are less likely to benefit.

Practical Details

• Protocol: Typically 6-12 sessions over 3-6 weeks, with each session lasting about 15-20 minutes
• Experience: Minimal discomfort. No anesthesia needed. Most men describe a tingling or tapping sensation.
• Results timeline: Improvements typically become noticeable 1-3 months after completing the treatment course
• Devices matter: Clinical-grade focused and radial shockwave devices used in urology practices differ significantly from at-home consumer devices, which lack sufficient evidence

Limitations

Li-ESWT is not yet endorsed by the American Urological Association as a standard treatment. It is classified as investigational, largely because the optimal treatment protocol (energy level, number of pulses, number of sessions) has not been standardized across studies. This does not mean it is ineffective. It means the field is still determining best practices [6].

The P-Shot (PRP Injection): Regenerative Promise, Limited Proof

How It Works

The Priapus Shot (P-Shot) involves drawing a patient’s blood, centrifuging it to concentrate platelets, and injecting the resulting platelet-rich plasma (PRP) directly into the corpus cavernosum of the penis. Platelets release growth factors (PDGF, VEGF, TGF-beta) that theoretically stimulate tissue regeneration, new blood vessel formation, and improved nerve function [7].

PRP has been used in orthopedic medicine, dermatology, and wound care for years. Its application to ED is newer and considerably less studied.

Current Evidence Quality

This is where clinicians who care about evidence get cautious. As of now, the P-Shot evidence consists primarily of small, uncontrolled studies and case series. A 2021 systematic review identified only a handful of studies, most with small sample sizes, no sham controls, and short follow-up periods [8].

Some of these studies do show improvements in IIEF scores and patient satisfaction. But without adequate placebo controls, it is impossible to separate the PRP effect from the injection procedure itself (the needle stick and fluid volume can temporarily improve blood flow) and the placebo response, which is substantial in sexual medicine research.

Bottom line: PRP for ED is biologically plausible and some men report meaningful improvement. But we cannot confidently say it works better than a sham injection based on the current data. If you pursue this option, go in with calibrated expectations.

What to Expect

• Procedure: About 30-45 minutes total. A topical anesthetic or nerve block is applied before injection. Most men report minimal pain.
• Recovery: Return to normal activity the same day. Mild bruising or swelling for 24-48 hours is common.
• Repeat treatments: Providers typically recommend 2-3 sessions spaced 4-6 weeks apart

Combination Approaches

In clinical practice, many providers are combining treatments rather than relying on a single modality. Common combinations include:

• Shockwave + PDE5 inhibitor: Using Li-ESWT to improve underlying vascular health while using medication for immediate function. Some data suggest shockwave therapy can improve PDE5 inhibitor responsiveness in men who were previously non-responders [5].
• Shockwave + PRP: The rationale is that shockwave creates a pro-regenerative environment that PRP growth factors can act on. This combination is common in regenerative clinics but has minimal controlled data.
• PDE5 inhibitor + vacuum device: Using a vacuum erection device for rehabilitation alongside medication, particularly after prostatectomy.

The combination approach makes biological sense but adds cost. Discuss what the evidence supports with your provider rather than defaulting to the most expensive package a clinic offers.

Penile Implants: The Last Resort That Actually Works Best

When medications, shockwave therapy, and injections have all failed, penile prostheses remain the treatment with the highest satisfaction rates. This sounds paradoxical, but the data are clear: 90-95% of men with inflatable penile prostheses report satisfaction, as do their partners [9].

An inflatable three-piece implant allows the patient to manually control erections by squeezing a pump placed in the scrotum. The procedure is surgical and irreversible (it destroys the natural erectile tissue), which is why it is reserved for men who have exhausted other options.

Modern implants last 15-20 years on average, and infection rates have dropped below 2% with antibiotic-coated devices.

The Lifestyle Foundation: What Affects Every Treatment

No ED treatment works optimally in a body that is metabolically unhealthy. The following factors directly impact treatment outcomes across every category:

Cardiovascular Health

Erectile function is a vascular event. The penile arteries are 1-2 mm in diameter compared to 3-4 mm for coronary arteries, so they develop plaque buildup earlier. This is why ED often precedes a heart attack by 3-5 years. A 2018 meta-analysis found that ED was associated with a 43% increased risk of cardiovascular events and a 33% increase in all-cause mortality [10].

Any man under 50 with new-onset ED and no obvious cause should get cardiovascular risk factors assessed: lipid panel, fasting glucose, blood pressure, and possibly coronary calcium scoring.

Exercise

Regular aerobic exercise improves endothelial function, nitric oxide production, and erectile quality. A meta-analysis showed that 160 minutes per week of moderate exercise for 6 months significantly improved IIEF scores in men with ED. The effect size was comparable to PDE5 inhibitors in men with mild dysfunction [10].

Smoking

Smoking damages the endothelium that lines blood vessels, directly impairing the nitric oxide pathway required for erections. Cessation improves erectile function measurably within 6-12 months.

Blood Sugar Control

Diabetes is one of the strongest risk factors for ED, affecting both vascular and nerve function. Men with poorly controlled diabetes (HbA1c above 8%) have significantly worse outcomes with PDE5 inhibitors. Improving glycemic control independently improves erectile function.

Sleep and Stress

Testosterone production depends on adequate sleep. Men sleeping fewer than 5 hours per night show testosterone levels equivalent to men 10-15 years older. Chronic stress elevates cortisol, which suppresses the HPG axis and reduces both testosterone and libido.

Cost Comparison

Pricing varies by region, provider, and insurance coverage, but here are general ranges:

• Generic sildenafil: $2-15 per dose (widely covered by insurance)
• Generic tadalafil (daily): $15-40 per month
• Shockwave therapy: $400-600 per session, typically 6-12 sessions ($2,400-7,200 total). Rarely covered by insurance.
• P-Shot (PRP): $1,200-2,500 per treatment, typically 2-3 treatments ($2,400-7,500 total). Not covered by insurance.
• Penile implant: $15,000-25,000 (often partially covered by insurance)

When to See a Urologist vs Starting Online

Online telehealth platforms have made PDE5 inhibitors easy to access. For a generally healthy man with intermittent ED and no red flags, this is a reasonable starting point.

See a urologist if:

• PDE5 inhibitors are not working after trying adequate doses of at least two different medications
• You are under 40 with no clear cause for ED
• ED onset was sudden (suggests psychogenic or neurological cause rather than gradual vascular decline)
• You have Peyronie’s disease (penile curvature or plaque)
• You have a history of pelvic surgery, radiation, or spinal cord injury
• You want to explore shockwave therapy, PRP, or surgical options

A urologist can perform duplex Doppler ultrasound to directly assess penile blood flow and determine whether the issue is arterial inflow, venous leak, or neurogenic. This changes the treatment approach significantly.

Choosing the Right Treatment

There is no single best ED treatment. The right choice depends on the underlying cause, severity, your health status, tolerance for ongoing medication, and budget. Here is a practical framework:

• Mild ED, generally healthy: Start with lifestyle changes and PDE5 inhibitors. This resolves the majority of cases.
• Moderate ED, wanting to address root cause: Consider shockwave therapy as an adjunct to medication. The evidence is strongest for vasculogenic ED in this group.
• PDE5 inhibitor non-responder: Get a urological workup. Penile injection therapy (alprostadil) is an effective second-line option often overlooked in favor of trendier treatments.
• Refractory ED after multiple treatments: Penile implant consultation. Do not wait years if nothing else is working. The satisfaction data are excellent.

Whatever you choose, address the lifestyle factors simultaneously. A treatment that works in a healthy body works even better. A treatment used instead of fixing underlying problems often disappoints.

Related Reading

• Sexual Wellness: The Evidence-Based Guide (Pillar)
• ED and Heart Health: What the Vascular Connection Means
• Shockwave Therapy for ED: How It Works and Who It Helps
• Low Libido in Women: Hormonal and Non-Hormonal Approaches
• TRT Side Effects: What to Expect and How to Manage Them

Frequently Asked Questions

How well do PDE5 inhibitors like Viagra and Cialis actually work?

Across clinical trials, PDE5 inhibitors work for about 60 to 70 percent of men. Success rates are lower in specific groups, dropping to roughly 50 to 55 percent for diabetic men and about 15 to 40 percent for men after prostatectomy. They treat the symptoms rather than the underlying causes of ED.

What does shockwave therapy (Li-ESWT) cost and how long until it works?

Low-intensity shockwave therapy typically runs 6 to 12 sessions over 3 to 6 weeks, at $400 to $600 per session, for a total of roughly $2,400 to $7,200. Each session takes about 15 to 20 minutes, and improvements usually become noticeable 1 to 3 months after completing the course. Studies showed statistically significant improvements for mild to moderate vasculogenic ED that were durable at 6 and 12 month follow-ups.

Is the P-Shot (PRP injection) proven to work?

The page is cautious here. There is limited high-quality data despite the P-Shot’s growing popularity, with evidence coming primarily from small, uncontrolled studies and case series. As it states, we cannot confidently say it works better than a sham injection based on current data. Treatment costs $1,200 to $2,500 each, usually across 2 to 3 treatments ($2,400 to $7,500 total).

Which ED treatment has the highest success rate?

Penile implants have the highest reported satisfaction, with 90 to 95 percent of men reporting satisfaction. However, they cost $15,000 to $25,000 (often partially covered by insurance) and are irreversible, since the procedure destroys the natural erectile tissue. That makes them generally a later option rather than a first step.

What are the side effects and safety concerns with ED pills?

Common side effects of PDE5 inhibitors include headache, flushing, nasal congestion, and visual changes. They are contraindicated with nitrates, so they should not be combined with those medications. Onset varies by drug: sildenafil is taken 30 to 60 minutes before activity and lasts 4 to 6 hours, while avanafil has the fastest onset at about 15 minutes.

Can lifestyle changes improve ED, and is ED a warning sign for other problems?

Yes. The page notes that 160 minutes per week of moderate exercise for 6 months significantly improved IIEF scores. ED can also be an early cardiac warning sign, associated with a 43 percent increased risk of cardiovascular events, and men under 50 with new ED should receive a cardiac evaluation.

References

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2. Goldstein I, Burnett AL, Balon R, et al. Erectile dysfunction. Nat Rev Dis Primers. 2017;3:17026. doi:10.1038/nrdp.2017.26
3. Carson CC, Lue TF. Phosphodiesterase type 5 inhibitors for erectile dysfunction. BJU Int. 2005;96(3):257-280. doi:10.1111/j.1464-410X.2005.05614.x
4. Vardi Y, Appel B, Kilchevsky A, Gruenwald I. Does low intensity extracorporeal shock wave therapy have a physiological effect on erectile function? Short-term results of a randomized, double-blind, sham controlled study. J Urol. 2012;187(5):1769-1775. doi:10.1016/j.juro.2011.12.117
5. Lu Z, Lin G, Reed-Maldonado A, et al. Low-intensity extracorporeal shock wave treatment improves erectile function: a systematic review and meta-analysis. Eur Urol. 2017;71(2):223-233. doi:10.1016/j.eururo.2016.05.050
6. Sokolakis I, Hatzichristodoulou G. Clinical studies on low intensity extracorporeal shockwave therapy for erectile dysfunction: a systematic review and meta-analysis of randomised controlled trials. Int J Impot Res. 2019;31(3):177-194. doi:10.1038/s41443-019-0117-z
7. Matz EL, Pearlman AM, Terlecki RP. Safety and feasibility of platelet rich fibrin matrix injections for treatment of common urologic conditions. Investig Clin Urol. 2018;59(1):61-65. doi:10.4111/icu.2018.59.1.61
8. Poulios E, Mykoniatis I, Pyrgidis N, et al. Platelet-rich plasma (PRP) improves erectile function: a double-blind, randomized, placebo-controlled clinical trial. J Sex Med. 2021;18(5):926-935. doi:10.1016/j.jsxm.2021.03.008
9. Bettocchi C, Palumbo F, Spilotros M, et al. Patient and partner satisfaction after AMS inflatable penile prosthesis implant. J Sex Med. 2010;7(1):304-309. doi:10.1111/j.1743-6109.2009.01499.x
10. Zhao B, Hong Z, Wei Y, et al. Erectile dysfunction predicts cardiovascular events as an independent risk factor: a systematic review and meta-analysis. J Sex Med. 2019;16(7):1005-1017. doi:10.1016/j.jsxm.2019.04.004