The Top Five Evidence-Based Alternatives to Viagra
The introduction of phosphodiesterase type 5 (PDE5) inhibitors, commonly known as Viagra, Cialis, and Levitra, revolutionized the treatment landscape for erectile dysfunction (ED). However, these oral medications are not universally effective or appropriate for all patients.
Epidemiological data indicates that erectile dysfunction affects over 50% of men at some point in their lives, with prevalence increasing significantly with age: approximately 40% of men between 35-45 years experience ED symptoms, rising to nearly 70% by age 65.
While Viagra and Cialis demonstrate efficacy in many cases, they do not work perfectly for every patient population. Limitations can include side effects including nasal and sinus congestion, headaches, body aches, flushing, and general malaise in a minority of patients.
Also, some men fail to respond to these medications, with aging and worsening erectile dysfunction. Whether the medications have become less effective, are contraindicated, or a patient is interested in a more root-cause approach, we discuss some alternative options in the blog below.
While many of the therapies discussed are supported by scientific literature, several remain outside of established American Urological Association protocols. Patients are encouraged to review the available research and discuss these options with their providers or a urologist to make informed decisions about care. Many of our patients have previously explored conventional treatments and choose Kass Precision Medicine for a more innovative, precision-guided approach. Results vary among individuals and cannot be guaranteed.
1. Shockwave Therapy for Erectile Dysfunction (AKA Low-Intensity Extracorporeal Shockwave Therapy <Li-ESWT> or GAINSWave® Therapy)
Low-intensity extracorporeal shockwave therapy (Li-ESWT) is one of the most scientifically studied non-pharmacologic treatments for ED. Using high-frequency acoustic pulses, Li-ESWT stimulates angiogenesis, the formation of new microvascular networks within penile tissue, and improves the function of existing blood vessels. These effects enhance oxygenation, nitric oxide signaling, and nerve regeneration, all essential components of healthy erectile function.
Unlike oral medications that provide temporary symptomatic relief, shockwave therapy aims to restore erectile function by addressing age-related vascular decline.
Clinical studies published in European Urology and other peer-reviewed journals demonstrate that Li-ESWT can significantly improve erectile rigidity and satisfaction, particularly in men with vasculogenic ED. Treatments are non-invasive, painless, and performed in-office, with benefits that may persist for months or even years as vascular remodeling continues.
Treatment protocols typically involve 6-12 sessions delivered over several weeks, with no significant adverse effects reported in clinical trials.
At Kass Precision Medicine, we implement evidence-based shockwave protocols and frequencies using our FDA - cleared shockwave (both Focused and Radial) medical devices. For more information, please visit our Shockwave Therapy page.
2. Platelet-Rich Plasma (PRP) Therapy - The P-Shot®
Platelet-rich plasma therapy, commercially known as the Priapus Shot or P-Shot, represents an autologous biological treatment approach for erectile dysfunction. This regenerative medicine technique harnesses growth factors and cytokines concentrated in the patient's own platelets to stimulate tissue repair and revascularization within the penis.
The procedure involves drawing a small volume of the patient's blood, processing it through centrifugation to concentrate platelets 5-7 times concentration above baseline levels, and then injecting the PRP into target areas of the penis including the corpus cavernosum and frenulum. The concentrated growth factors, including platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF-β), vascular endothelial growth factor (VEGF), and fibroblast growth factor (FGF), promote angiogenesis, recruit stem cells, and enhance tissue regeneration.
Clinical outcomes suggest that PRP therapy can improve erectile rigidity, enhance penile sensitivity, and potentially increase both length and girth through tissue expansion and improved vascular supply. Benefits typically manifest gradually over 3-12 weeks as vascular remodeling occurs, with optimal results often requiring 2-3 treatment sessions spaced 4-8 weeks apart.
Because PRP utilizes autologous tissue, the risk of adverse reactions or immune responses is negligible. This treatment appeals particularly to patients seeking to enhance the vascular function of the penis and address underlying changes that come about with age and chronic conditions. PRP therapy can be effectively combined with other modalities, including shockwave therapy, for synergistic effects. For more information, please visit our P-Shot for ED page.
3. Trimix Intracavernosal Injections
Intracavernosal injections represent one of the most effective second-line treatments for erectile dysfunction, with reported success rates exceeding 85%. Trimix, a compounded formulation containing alprostadil (prostaglandin E1), papaverine, and phentolamine, works through complementary vasodilatory mechanisms to induce penile tumescence (rigidity) independent of stimulation. This is unlike Viagra or Cialis which still require sexual stimulation to achieve an erection.
The three vaso-active agents in Trimix act synergistically to relax smooth muscle and increase blood flow to the penis.
The injection is self-administered near the base of the penis using an ultra-fine needle, making the procedure relatively painless for most patients. Onset of action occurs within 5-20 minutes, with erections lasting 30-60 minutes on average. Dosing is individually titrated to achieve optimal response. Caution is required using this medication due to the risk of priapism (prolonged erection exceeding four hours).
Patient satisfaction rates with this medication are fairly high. However, side effects can include priapism, lumps, bumps, or scar tissue at injection sites, and rarely, Peyronie’s Disease.
4. Therapeutic Botox® for Erectile dysFunction
An emerging therapeutic approach to erectile dysfunction involves the intracavernosal injection of botulinum toxin type A (Botox). While traditionally associated with aesthetic applications, Botox has demonstrated potential in treating ED through its effects on smooth muscle relaxation and neurotransmitter modulation.
Research suggests that Botox injections enhance erectile function by inhibiting sympathetic tone, allowing blood vessels to dilate, fill and trap blood more effectively. Botox facilitates the relaxation of blood vessel walls, facilitates nitric oxide production, promoting the vasodilatory cascade necessary for good erections.
Preliminary clinical studies suggest that a single intracavernosal injection of Botox (100 units) can improve erectile function for 3-6 months. Unlike Trimix, which requires injection before each sexual encounter, Botox provides sustained effects from a single treatment session.
Current research continues to refine optimal dosing protocols and patient selection criteria, but early results indicate favorable safety profiles with minimal adverse effects. For more information, please visit our Therapeutic Botox for ED page.
5. Vacuum Erection Device (VED) / Penis Pump
Before the advent of oral ED medications, vacuum erection devices were among the earliest mechanical treatments for erectile dysfunction, and they remain a valuable option for many men. The device uses negative pressure to draw blood into the penile tissue, creating an erection that is maintained and can be accompanied by a constriction ring placed at the base of the penis.
This mechanical mechanism bypasses normal erectile pathways, making VEDs effective regardless of the underlying etiology of ED, whether vascular, neurogenic, hormonal, or psychogenic. This universal applicability makes vacuum devices particularly valuable for men with complex medical conditions or those who cannot tolerate medications or for those for whom medications are not creating a substantial enough erection for sex.
VEDs can help men achieve functional erections with and without medication and can also serve as a rehabilitation tool after prostate surgery to maintain tissue oxygenation and elasticity. Consistent use may even improve spontaneous erectile function over time by preserving cavernosal blood flow.
However, improper or excessive use can lead to bruising or curvature (Peyronie’s disease), so medical guidance and training are essential for safe use.
A Comprehensive, Precision-Based Approach to Men’s Sexual Health
KPM helps patients navigate the diversity of available ED treatments, both traditional standard of care treatments and promising investigational treatments when appropriate.
Underpinning KPM’s ethos is a dedication to addressing the underlying pathophysiology of sexual changes and a commitment to prevention. View our Longevity Screening Program and Men’s Sexual Health and Erectile Dysfunction pages to explore our comprehensive approach.
Call our office AT 425-209-1060 for scheduling.
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