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

Platelet-rich plasma (PRP) therapy for ED, often sold as the P-Shot, has weaker evidence than the other main ED treatments: of the two double-blind, placebo-controlled trials published so far, one (Poulios and colleagues, 2021) found a benefit and the other (Masterson and colleagues, 2023) found no difference from placebo, and the American Urological Association (2018) classifies PRP for ED as experimental. By comparison, PDE5 inhibitors such as sildenafil and tadalafil work for about 60 to 70% of men, low-intensity shockwave therapy has more sham-controlled trials but is still considered investigational, and inflatable penile implants carry 90 to 95% satisfaction rates.

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.

The sections below set out what the evidence says about the major options and how to think about choosing between them. For the condition itself, including causes and diagnosis, see the erectile dysfunction condition page, and for a treatment-by-treatment overview, the ED treatment guide.

PRP Therapy for ED vs Other Treatments: Side-by-Side Comparison

PRP therapy for erectile dysfunction sits at the low end of the evidence ladder among ED treatments. PDE5 inhibitors, alprostadil injections, vacuum erection devices and penile implants are established, FDA approved or cleared options with large bodies of data. Low-intensity shockwave therapy has several sham-controlled trials and supportive meta-analyses. The P-Shot has two small placebo-controlled trials that disagree [8] [11].

The table below compares the treatments covered in the rest of the post. Cost ranges are the general ranges stated in the cost comparison section; prices vary by region, provider and insurance.

Is PRP better than PDE5 inhibitors for ED?

PDE5 inhibitors have far stronger evidence than PRP for ED. Sildenafil and tadalafil have been tested in many large randomized trials and work for most men, while PRP has two small placebo-controlled trials with mixed results [3] [8] [11]. PRP is marketed as restoring tissue rather than managing symptoms, but that claim has not been shown in controlled data.

How does PRP compare with shockwave therapy for ED?

Shockwave therapy has the larger evidence base of the two regenerative options. Several sham-controlled trials and meta-analyses report improved erectile function scores with Li-ESWT in mild to moderate vasculogenic ED, while PRP rests on two trials that point in opposite directions [5] [6] [8] [11]. The AUA (2018) calls shockwave investigational and PRP experimental, a weaker category [12]. Both are cash pay at most clinics.

How does PRP compare with alprostadil injections?

Both are injections into the corpus cavernosum, but they do different jobs. Alprostadil is an FDA approved drug that produces an erection within minutes of each injection, and urologists use it as a reliable second-line option when pills fail. PRP is given in a short series with the aim of improving function over months, and its effect over placebo is uncertain.

How does PRP compare with a penile implant?

A penile implant is the most reliable option for severe or refractory ED, with 90 to 95% satisfaction, but it is surgical and permanent [9]. PRP is minimally invasive and reversible in the sense that it leaves the erectile tissue intact, yet there is no evidence that it helps men with severe ED. The two serve very different patients.

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.

That limitation is the main reason men look at PRP and shockwave therapy. Both are marketed as restorative treatments that might change the underlying tissue, which is a different goal from the on-demand effect of a pill.

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

How It Works

Low-intensity extracorporeal shockwave therapy (Li-ESWT, sometimes shortened to LiSWT or acoustic wave therapy) 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. The shockwave therapy treatment guide covers its other uses.

What the Evidence Shows

The evidence for Li-ESWT is promising but still maturing. A 2017 meta-analysis by Lu and colleagues in European Urology found significant improvements in IIEF scores (the International Index of Erectile Function, the standard erectile function questionnaire) compared to sham treatment. The effect was most pronounced in men with mild to moderate vasculogenic ED [5].

A 2019 meta-analysis of randomized controlled trials by Sokolakis and Hatzichristodoulou in the International Journal of Impotence Research supported 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. Its 2018 ED guideline, led by Burnett and colleagues, classifies it as investigational, largely because the optimal treatment protocol (energy level, number of pulses, number of sessions) has not been standardized across studies [12]. This does not mean it is ineffective. It means the field is still determining best practices [6].

If you are weighing shockwave therapy, the national list of clinics offering shockwave therapy shows which practices provide it, and each profile lists the clinicians and services involved.

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. The same procedure appears under several names: P-Shot, Priapus Shot, PRP injection for ED, intracavernosal PRP, and platelet-rich plasma therapy for erectile dysfunction. The PRP treatment guide explains how the plasma is prepared and where else it is used.

Current Evidence Quality

This is where clinicians who care about evidence get cautious. As of now, most of the P-Shot evidence consists of small, uncontrolled studies and case series. A 2023 systematic review by Poulios and colleagues in Sexual Medicine Reviews found that almost all clinical studies were cohort studies, and that only two double-blind randomized trials used a sham control [14].

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.

What Do the Two Placebo-Controlled PRP Trials Show?

The two trials point in opposite directions. In a Greek trial of 60 men with mild to moderate ED, Poulios and colleagues (2021) gave two PRP or saline injections one month apart; at 6 months, 69% of the PRP group reached a clinically meaningful improvement in erectile function, against 27% on placebo [8].

At the University of Miami, Masterson and colleagues (2023) ran a similar trial in 61 men and found no difference: 58.3% of the PRP group and 53.6% of the placebo group reached a meaningful improvement at one month, and penile Doppler blood flow measures did not change by 6 months [11]. Both trials reported no major adverse events, and both enrolled only men with mild to moderate ED.

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 Do Urology Societies Say About PRP for ED?

The American Urological Association guideline (Burnett and colleagues, 2018) states that PRP therapy for ED should be considered experimental and should not be offered outside an institutional review board approved research protocol [12]. The Sexual Medicine Society of North America position statement (Liu and colleagues, 2021) reached the same view for PRP, stem cells and shockwave, and advised that restorative therapies be reserved for clinical trials rather than routine practice [13].

No PRP product is FDA approved for treating ED. The centrifuge systems used to prepare PRP are cleared by the FDA for preparing the plasma, so injecting it into the penis is an off-label use that insurers do not cover. Men who want PRP within a study can look for recruiting trials on ClinicalTrials.gov, the federal registry of clinical studies.

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

Questions to Ask a Clinic That Offers the P-Shot

1. Who performs the injection, and is a urologist involved in evaluating my ED before treatment?
2. Has anyone checked my blood flow, hormones and cardiovascular risk factors first?
3. Which PRP preparation system do you use, and how many injections does your protocol include?
4. How will you measure whether it worked, for example with the IIEF questionnaire before and after?
5. What is the total cost of the full course, and what happens if I see no change?

A well run clinic answers these plainly and tells you the evidence is limited. The national list of clinics that offer PRP injections is a starting point for comparing practices, and our post on how PRP therapy works covers the procedure in more depth.

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.

Combined shockwave and PRP packages deserve the most scrutiny. Each part has its own evidence gap, and neither of the two placebo-controlled PRP trials tested PRP alongside shockwave, so a bundled price buys two unproven layers rather than one tested protocol [8] [11].

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.

Implant surgery is performed by urologists, often those with fellowship training in prosthetic or reconstructive urology. The AUA guideline lists implants among the standard treatment options men can be offered once they have been counseled on the alternatives [12].

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 2019 meta-analysis by Zhao and colleagues 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. Our post on ED and heart health explains the vascular link in more detail.

Exercise

Regular aerobic exercise improves endothelial function, nitric oxide production, and erectile quality. A 2018 systematic review by Gerbild and colleagues concluded that 160 minutes per week of moderate to vigorous aerobic exercise for 6 months reduced erectile problems in men whose ED was linked to inactivity, obesity, hypertension, metabolic syndrome or cardiovascular disease [15].

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.

Low testosterone is a separate problem from ED, though the two often overlap. Testosterone replacement can help libido in men with confirmed deficiency, but it is not a stand-alone ED treatment; the TRT treatment guide covers testing and monitoring.

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)

Cost and evidence run in opposite directions for the regenerative options. A full P-Shot course can cost as much as several years of generic tadalafil, while resting on far thinner data, so it is worth asking any clinic for the total price of the whole protocol before the first session.

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.

Other clinicians play a part too. Primary care physicians often make the first diagnosis and order the cardiovascular workup, endocrinologists manage diabetes and hormone problems, cardiologists follow up on vascular risk, and sex therapists or psychologists help when anxiety or relationship stress is part of the picture.

How to Find an ED Treatment Clinic in the Directory

The national list of ED treatment clinics on Regenerated.com includes urology practices, men's health clinics and regenerative clinics, and each profile shows which treatments the practice offers. Filter for PRP or shockwave if those are what you want to compare, then check who performs the treatment and whether a diagnostic workup comes first.

Listing order on Regenerated.com is not paid ranking. Featured slots are clearly labeled and capped. A Verified badge means the clinic completed our credential checks, not that it paid for placement, and the directory is free for patients. Inclusion is not an endorsement; the guide to featured, verified and organic listings explains each label.

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.
• Interested in PRP: Treat it as an optional add-on for mild to moderate ED after a proper workup, ideally within a clinical trial, and keep an established first-line option in place while you try it.
• 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
• Natural ED Treatment: What Lifestyle Changes Can and Cannot Do

Frequently Asked Questions

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

PDE5 inhibitors such as sildenafil and tadalafil work for about 60 to 70 percent of men across clinical trials, according to a review by Carson and Lue. Success rates are lower in specific groups, roughly 50 to 55 percent for men with diabetes and about 15 to 40 percent after prostatectomy, depending on nerve-sparing technique. They need sexual stimulation to work and manage symptoms rather than changing the underlying blood vessels or nerves.

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

Low-intensity shockwave therapy usually costs $400 to $600 per session across 6 to 12 sessions over 3 to 6 weeks, roughly $2,400 to $7,200 in total, and is rarely covered by insurance. Sessions take 15 to 20 minutes, and improvements usually appear 1 to 3 months after the course ends. Benefits are clearest in mild to moderate vasculogenic ED, and the AUA still classifies it as investigational.

Does the P-Shot (PRP injection) work for ED?

The P-Shot has not been shown to work reliably better than placebo. Of two double-blind trials, Poulios and colleagues (2021) found 69 percent of men improved meaningfully on PRP against 27 percent on saline, while Masterson and colleagues (2023) found no difference between PRP and placebo. The AUA classifies PRP for ED as experimental. A course usually costs $1,200 to $2,500 per treatment across 2 to 3 treatments, without insurance coverage.

Which ED treatment has the highest success rate?

Inflatable penile implants have the highest reported satisfaction of any ED treatment, with 90 to 95 percent of men and their partners satisfied in published studies. They cost $15,000 to $25,000, are often partly covered by insurance, and are irreversible because the surgery replaces the natural erectile tissue. That makes implants a later option for men whose ED has not responded to pills, injections or other treatments.

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

Common side effects of PDE5 inhibitors include headache, flushing, nasal congestion and, with sildenafil, visual changes; these are usually mild and dose dependent. The serious risk is combining them with nitrate medications, which can cause a dangerous drop in blood pressure. Onset varies by drug: sildenafil is taken 30 to 60 minutes before sex and lasts 4 to 6 hours, while avanafil works in about 15 minutes.

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

Yes, on both counts. A 2018 systematic review by Gerbild and colleagues linked 160 minutes of moderate to vigorous aerobic exercise a week, kept up for 6 months, to fewer erectile problems. ED is also an early cardiovascular warning sign: Zhao and colleagues (2019) tied it to a 43 percent higher risk of cardiovascular events, so men under 50 with new ED should have their heart risk checked.

Sources

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