ED treatment options beyond pills: devices, injections, implants and surgery

In short: most men hear about ED pills first, and for many men they are a reasonable place to start. They are not the whole list. The American Urological Association (AUA) guideline names five treatments men with ED should be told about: oral PDE5 inhibitors, a vacuum erection device, a urethral suppository, penile injections, and a penile implant. It adds counseling and lifestyle changes, and it sets out where testosterone, vascular surgery and newer therapies fit. This guide walks through each one in plain language, using the guideline and the National Institutes of Health as the sources, so you know what exists before you sit down with a clinician. It does not rank the options or tell you which one to choose. That choice depends on your health, your preferences and your partner, and it belongs in that conversation. This page is the starting point for our treatments beyond pills section, and each option below links to its own deeper page.

What are the treatment options for erectile dysfunction besides pills?

Besides pills, the main medical options for erectile dysfunction are a vacuum erection device, a medicine placed in the urethra, a medicine injected into the penis, and a surgically implanted penile prosthesis. The AUA guideline says men with ED should be informed about each of these, “including discussion of benefits and risks/burdens,” alongside an FDA-approved oral PDE5 inhibitor (Guideline Statements 8, 13, 14, 16 and 18 in the AUA Erectile Dysfunction Guideline).

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) gives the same list in everyday words: lifestyle changes, counseling, medicines by mouth, injectable medicines and suppositories, a vacuum erectile device, and surgery. It also makes a point worth keeping in mind from the start: health care professionals “treat the underlying cause” of ED when possible, and when the exact cause is not known, they focus on improving sexual function (NIDDK, Treatment for ED).

The labels in the last column come straight from the guideline. “Strong,” “Moderate” and “Conditional” describe how firmly the panel makes a recommendation, based on how clearly benefits outweigh risks and burdens, and the letter grade describes how solid the underlying evidence is, from A (high certainty) to C (low certainty) (AUA Erectile Dysfunction Guideline). Several of these options rest on grade C evidence, which the guideline defines as trials with serious shortcomings or very small samples, or observational studies with problems that may confound the results. That is a statement about the research, not a verdict on whether an option suits you. Our guide to how to read ED evidence explains how these grades work.

How do the ED treatment options compare?

The options differ less in whether they can work than in how they are used, what has to happen first and whether they can be undone. The table pulls those points together from the guideline, NIDDK and the product labels cited in the sections below.

Sources for the table: AUA Erectile Dysfunction Guideline; NIDDK, Treatment for ED; VIAGRA label; CAVERJECT label; MUSE label. Device classifications are from FDA’s device classification records, as set out on our vacuum erection devices and penile implant pages.

Do you have to try pills before other ED treatments?

No. The AUA guideline does not require men to move through treatments in order from least to most invasive. Its stated purpose is that, with shared decision-making as “a cornerstone for care,” all patients should be informed of all treatment options that are not contraindicated, “regardless of invasiveness or irreversibility, as potential first-line treatments” (AUA Erectile Dysfunction Guideline).

The panel says many men may choose to begin with the least invasive option, usually oral medication, but that “it is valid for men to begin with any type of treatment.” It also notes that men may choose not to treat ED at all. In every case, the clinician’s job is to make sure the man, and his partner when there is one, fully understands the benefits and the risks and burdens of each path.

The NIH frames surgery a little differently. NIDDK says most people with ED do not need surgery, and that surgery may be considered if you have tried all other options and your ED has not improved (NIDDK, Treatment for ED). The two sources are describing different things. NIDDK describes what usually happens in practice; the AUA describes which choices are legitimate. Both point to the same next step: a conversation with a clinician about all of the options that are open to you.

How do ED pills fit into the picture?

Status: FDA-approved prescription medicine for ED. Source: VIAGRA prescribing information, DailyMed, checked 2026-10-18.

ED pills are oral PDE5 inhibitors, and they work by protecting a signal the body makes during sexual arousal rather than by causing an erection on their own. The FDA-approved sildenafil label explains that during sexual stimulation, nitric oxide is released in the erectile tissue, which raises a messenger called cGMP and relaxes smooth muscle so blood can flow in. Sildenafil blocks PDE5, the enzyme that breaks cGMP down, and the label states that “sildenafil at recommended doses has no effect in the absence of sexual stimulation” (VIAGRA prescribing information, DailyMed, section 12.1).

The AUA lists four FDA-approved PDE5 inhibitors in the U.S.: sildenafil, tadalafil, vardenafil and avanafil. It also states the most important safety rule for the class: combining a PDE5 inhibitor with nitrate medicines can cause a precipitous drop in blood pressure, and men taking nitrates regularly should not use these drugs (AUA Erectile Dysfunction Guideline).

Pills are covered in depth elsewhere on this site. Our guide to how ED medications work explains the mechanism, the four ED pills compared sets them side by side, and ED medication side effects covers what to expect. The rest of this page is about the options that are not pills, because those are the ones most men have never had explained.

How does a vacuum erection device work?

Status: FDA Class II medical device (external penile rigidity device). Source: FDA Product Classification database and 21 CFR 876.5020, checked 2026-10-17.

A vacuum erection device, often shortened to VED, uses suction to draw blood into the penis and an elastic ring to help keep it there. NIDDK describes three parts: a plastic tube that goes around the penis, a pump that creates a vacuum, and an elastic ring that helps you keep an erection (NIDDK, Treatment for ED).

NIDDK is direct about what to expect. You may need to practice with the device or adjust it. It can make the penis feel cold or numb, and the penis can look purple or bruised; the bruises are usually painless and fade within a few days. A VED may also weaken ejaculation, which NIDDK says does not affect the pleasure of climax.

The AUA guideline says men with ED should be informed about this option, including its benefits and burdens (Statement 13). Its discussion adds three practical points (AUA Erectile Dysfunction Guideline):

• Only devices with a vacuum limiter, a feature that caps the suction pressure to reduce the chance of injury, should be used, whether the device is bought over the counter or by prescription.
• Men who take blood thinners, have a bleeding disorder, or have a history of priapism should use a VED with caution.
• The panel describes the VED as a low-cost option for select men, and notes that most of the research on it is observational and predates modern questionnaires.

Because a VED is a device rather than a drug, it is one of the few options that does not depend on how a medicine is processed in the body. Whether it fits your situation, including any blood-thinning medicine you take, is a question for your clinician. Our guide to vacuum erection devices covers how to tell a medical device from a novelty pump and what the studies found.

How are ED injections different from ED pills?

Status: FDA-approved prescription medicine for ED (alprostadil injection). Source: CAVERJECT prescribing information, DailyMed, checked 2026-10-18.

The key difference is where each one starts. A pill strengthens the response to arousal and needs sexual stimulation to have an effect, while an injected medicine acts directly on blood flow in the penis. NIDDK describes an injectable medicine as one that “causes a quick, automatic erection by increasing blood flow to the penis,” and says your health care professional will teach you how to give the injection yourself (NIDDK, Treatment for ED). That contrasts with the sildenafil label’s statement that the pill has no effect without sexual stimulation (VIAGRA prescribing information, DailyMed).

The AUA calls this option intracavernosal injection, or ICI, and says men with ED should be informed about it, including its benefits and burdens (Statement 16). According to the guideline, it can suit men who have a reason they cannot take a PDE5 inhibitor, men who prefer not to take an oral medicine, and men who find pills inadequate. The panel cites research suggesting PDE5 inhibitors do not work for about 40% of men, and notes that some men who respond at first stop responding as ED progresses (AUA Erectile Dysfunction Guideline).

A few facts about the medicines themselves are worth knowing:

• Only one injected medicine is FDA-approved for ED. The AUA guideline says alprostadil is the only medicine FDA-approved in the U.S. for injection into the penis. Mixtures of other drugs are also used, but the guideline notes that no standardized mixture is FDA-approved and that these combinations are compounded by a pharmacy on a physician’s instructions.
• The first dose happens in the office. The AUA says an in-office injection test should be performed before a man starts (Statement 17), and that finding the right medicine and dose can take several visits. The CAVERJECT (alprostadil) prescribing information likewise says the first injections are given in the health care provider’s office, and that patients should be well trained in self-injection before using it at home (CAVERJECT label, DailyMed).
• Pain and scarring are the main burdens. The CAVERJECT patient information lists penile pain as its most common side effect and warns about penile fibrosis, a change in the shape of the penis, which the provider should check for regularly. The AUA also reports pain and fibrosis across studies and advises regular monitoring.

This page deliberately leaves out doses, drug mixtures and injection technique. Those are set in the clinic, for one person, after the office test. Our guide to ED injections and suppositories covers the in-office test, the compounded mixtures and the priapism risk in more depth.

What is a urethral suppository for ED?

Status: FDA-approved prescription medicine for ED (MUSE, alprostadil). Source: MUSE prescribing information, FDA, checked 2026-10-18.

A urethral suppository is a tiny pellet of medicine placed in the opening of the urethra, the tube that carries urine, where it is absorbed into the surrounding tissue. NIDDK describes it as “a solid piece of medicine that you insert into the urethra” and says some people with ED prefer it; a clinician teaches you how to insert it (NIDDK, Treatment for ED).

The medicine is alprostadil, the same drug used in the approved injection, delivered by a different route. The FDA-approved MUSE label states that it “is indicated for the treatment of erectile dysfunction” (MUSE prescribing information, FDA).

The AUA says men with ED should be informed about intraurethral alprostadil, including its benefits and burdens, as a conditional recommendation (Statement 14). The guideline describes it as an option for men who cannot take PDE5 inhibitors, for men or partners who prefer to avoid oral medication, and for those who prefer not to use the needles that injections require (AUA Erectile Dysfunction Guideline).

As with injections, the first use happens under supervision. The AUA says an in-office test should be performed (Statement 15), and the MUSE label says dose titration should be done under medical supervision because of the potential for low blood pressure and fainting. The label lists pain in the penis, urethra or testes as the most frequently reported reactions during in-clinic titration, and also reports dizziness. The MUSE label puts numbers on that caution: low blood pressure with symptoms occurred in 3% of men and fainting in 0.4% during in-clinic dosing. The AUA adds a caution about expectations: a positive result in the office does not always carry over to home use.

What is a penile implant and what types are there?

Status: Inflatable penile implants are Class III medical devices that need FDA premarket approval; semi-rigid rod implants are Class II medical devices. Source: FDA device classification rules, 21 CFR 876.3350 and 876.3630, checked 2026-10-17.

A penile implant, or prosthesis, is a device placed inside the penis during surgery. NIDDK describes it as a device that makes the penis erect “either using a pump in the scrotum or a rod that you can control on your own” (NIDDK, Treatment for ED).

The AUA guideline names the types more precisely: malleable (non-inflatable) models, and two-piece or three-piece inflatable models. It says men with ED should be informed about implants, including the benefits and burdens, as a strong recommendation (Statement 18). The main points from its discussion (AUA Erectile Dysfunction Guideline):

• Malleable rods bend but do not deflate. The guideline says these models “can be bent to lay flat against the groin” but “cannot be ‘deflated.’” Two-piece inflatable models may be considered for men for whom an abdominal reservoir poses a risk, and they are easier to work than three-piece models for men with limited hand dexterity.
• It is best thought of as permanent. The AUA says the choice “is best conceptualized as irreversible”: an implant can be removed, but the penis is unlikely to respond reliably to other ED treatments afterward.
• It changes rigidity, not desire. The guideline says an implant has no direct effect on libido and does not generally firm the head of the penis or improve orgasm and ejaculation.
• Expectations are part of the treatment. Statement 19 says men who decide on an implant should be counseled about recovery, including pain after surgery and how long before the device can be used, and about possible changes in appearance, including a perceived loss of length.
• Infection is the serious risk. The guideline describes infection as a serious complication that usually requires removing the device, and Statement 20 says the surgery should not be done while a man has a body-wide, skin or urinary tract infection.

NIDDK notes that surgery is usually considered after other options have been tried, while the AUA says a man may start with any option that is not ruled out for him. If an implant is on your list, a urologist who performs the surgery can walk through the device types, the recovery and the risks in detail. Our guides to penile implants, implant surgery and recovery and penile implant cost cover each of those in turn.

Is surgery on the penile arteries or veins a treatment for ED?

Rarely. The AUA treats the two vascular surgeries very differently: artery repair may be considered for a narrow group of men, and vein surgery is not recommended for men with ED (AUA Erectile Dysfunction Guideline).

Penile arterial reconstruction (Statement 21, a conditional recommendation on grade C evidence) may be considered for young men with a focal blockage in a pelvic or penile artery who have no documented generalized vascular disease and no venous leak. The panel says men and their partners must be counseled that the long-term success of the procedure is not well established, and that it should be done only by highly experienced surgeons. It also notes that proper diagnosis takes a thorough workup. NIDDK similarly says artery repair “works best for younger men” (NIDDK, Treatment for ED).

Penile venous surgery (Statement 22, a moderate recommendation on grade C evidence) is not recommended. The panel reviewed study arms covering about 3,000 men and found that short-term high response rates “generally declined rapidly over time.”

Both verdicts rest on observational studies, most of them retrospective. For almost everyone with ED, the vascular surgeries are not part of the conversation; the panel limits even artery repair to a small group of men who meet strict criteria.

Are there creams or gels for ED?

Status: Not FDA-approved for ED in the US (any alprostadil, sildenafil or tadalafil cream or gel); Eroxon gel is a device whose De Novo request FDA granted. Source: FDA Drugs@FDA and FDA De Novo database (DEN220078), checked 2026-10-17.

No cream or gel is an FDA-approved drug for ED in the US. The one topical product FDA has authorized for ED is Eroxon, a drug-free gel whose De Novo request FDA granted in June 2023, which makes it a medical device rather than a medicine (FDA De Novo database, DEN220078). Products sold as sildenafil or tadalafil creams are not approved medicines. The AUA guideline also lists topical products among the options it found lacking in evidence. Our guide to ED creams and gels covers what is sold where, including the alprostadil cream available in some other countries.

Which ED treatments are still experimental?

Status: Investigational: not approved for ED (low-intensity shock wave therapy, stem cell therapy and platelet-rich plasma). Source: AUA Erectile Dysfunction Guideline, Statements 23 to 25, checked 2026-10-18.

Three newer therapies are not established ED treatments, according to the AUA guideline. It says low-intensity shock wave therapy and stem cell injections should be considered investigational (Statements 23 and 24), and platelet-rich plasma (PRP) should be considered experimental (Statement 25) (AUA Erectile Dysfunction Guideline).

The reasons differ slightly for each. For shock wave therapy, the panel says sham-controlled trials do not clearly show that benefits reliably outweigh the burdens, that the treatment is not FDA-approved, and that it should be used only within an IRB-approved clinical trial. For stem cells, it says the ability to restore normal erectile function has not been convincingly demonstrated and the risks are not well established. For PRP, it says there were no full-text peer-reviewed publications to form an evidence base, so it should not be offered outside an approved research protocol.

The panel also lists oral and topical products it judged ineffective, unsafe, or lacking enough evidence, including yohimbine, ginseng and L-arginine, and warns that using them “may preclude the use of other treatments known to be effective.” NIDDK advises talking with a health care professional before taking any dietary supplement for ED (NIDDK, Treatment for ED). Our comparison of natural remedies for ED vs medication goes through the supplement evidence in more detail, and our page on FDA tainted supplement warnings tracks the “natural” products FDA has found with hidden drugs in them. For the newer therapies, including what the trials of shock wave therapy found, see experimental ED therapies.

Where do counseling, lifestyle changes and testosterone fit?

Counseling, lifestyle changes and testosterone are not alternatives to the options above so much as parts of care that sit alongside them. The AUA guideline addresses each one directly (AUA Erectile Dysfunction Guideline).

Counseling. Statement 6 says referral to a mental health professional should be considered for men being treated for ED, to help with sticking to treatment, to reduce performance anxiety, and to fit treatment into a sexual relationship. NIDDK says counseling can help lower anxiety and stress about sex, and that a counselor may invite your partner to sessions (NIDDK, Treatment for ED). If anxiety is part of your picture, our guide to ED vs performance anxiety covers how the two overlap, and counseling and sex therapy for ED explains what sessions involve.

Lifestyle changes. Statement 7 says clinicians should counsel men with ED who have related health conditions that changes in diet and more physical activity “improve overall health and may improve erectile function.” The panel describes the measured effect on erections as small overall, adding that it may be clinically meaningful in a subset of men. NIDDK’s list of lifestyle changes includes quitting smoking, limiting or stopping alcohol, increasing physical activity, keeping a healthy weight, following a healthy eating plan, and stopping recreational drug use.

Testosterone. In the guideline, testosterone comes up for men who have both ED and testosterone deficiency, not as a treatment for ED on its own. Statement 12 says those men should be told that a PDE5 inhibitor may be more effective when combined with testosterone therapy, and the panel adds that testosterone therapy “is not an effective mono-therapy for ED.” Our guide to ED and low testosterone explains how the two are evaluated together.

Your other medicines. NIDDK says a clinician may review the medicines you already take, because a medicine for another condition can contribute to ED, and may suggest a different dose or drug. It is explicit: do not stop taking any medicine on your own; talk with your health care professional first.

Can erectile dysfunction be cured?

No treatment on this page is described by the guideline or NIDDK as a cure for ED in general, but some causes can improve when they are treated. NIDDK says health care professionals treat the underlying cause of ED when possible, and that when the exact cause is not known, they focus on improving sexual function (NIDDK, Treatment for ED). The AUA guideline adds that men should be strongly advised to address underlying medical issues that may contribute to ED, whatever they decide about treating the ED itself (AUA Erectile Dysfunction Guideline). Pills, devices, injections and suppositories work while they are used; an implant gives a lasting mechanical option but, as the guideline says, is best thought of as irreversible. Our guide to whether ED can be reversed sorts the causes that tend to improve from the ones that usually do not.

What is the best treatment for erectile dysfunction?

There is no single best treatment for every man, and the guideline does not rank one. It says all options that are not ruled out for a man are potential first-line treatments, and that the most effective approach for a particular man is best decided by him, with his partner when there is one, together with the clinician (AUA Erectile Dysfunction Guideline). For pills specifically, our guides to the four ED pills compared and the safest ED medication explain what the labels and pooled trials show by group, which is not the same as a verdict for one person.

How do you choose between ED treatment options?

You choose with a clinician, through what the AUA calls shared decision-making: the clinician explains the evidence for each option, and you weigh it against your own priorities, values and health. The guideline says the most effective approach for a particular man is “best determined by that man (in consultation with his partner, when applicable) in collaboration with the clinician” (AUA Erectile Dysfunction Guideline). NIDDK puts it simply: choosing an ED treatment is a personal decision, and if you have a partner, you may want to talk about it together (NIDDK, Treatment for ED).

Questions that tend to shape the decision include whether you have a reason you cannot take a PDE5 inhibitor, such as nitrate heart medicine; whether you prefer to avoid pills, needles or surgery; how you feel about a permanent option; what your partner thinks; and what an evaluation shows about the cause. The AUA also says that, whatever a man decides about treating ED, he should be strongly advised to address any underlying medical issues that may contribute to it.

That evaluation is the natural first step. Our guide on when to see a doctor about ED covers the red flags and what a visit involves, which doctor treats ED explains when a urologist is the right person, and what your ED may be telling you about your health explains why the workup matters beyond the bedroom. The point of knowing the full list is not to pick an option from a web page. It is to walk into that appointment knowing that pills are one choice among several, and that every choice is yours to discuss.

Sources

Every clinical statement on this page traces to a primary or guideline source:

• American Urological Association, Erectile Dysfunction: AUA Guideline (Burnett AL, et al.). Purpose and treatment framework (all non-contraindicated options as potential first-line treatments, shared decision-making), Statements 6 to 8 and 12 to 25 with their discussion text (PDE5 inhibitors, vacuum erection devices, intraurethral alprostadil, intracavernosal injections, penile prostheses, arterial and venous surgery, investigational and experimental therapies), and Other Treatments: auanet.org, erectile dysfunction guideline
• NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases), Treatment for Erectile Dysfunction, last reviewed October 2024. Lifestyle changes, counseling, medicine review, PDE5 inhibitors, testosterone, injectable medicines and suppositories, vacuum erectile devices, surgery, and when to seek care right away: niddk.nih.gov, ED treatment
• VIAGRA (sildenafil citrate) prescribing information, DailyMed, section 12.1 (Mechanism of Action). Role of sexual stimulation and no effect without it: dailymed.nlm.nih.gov, VIAGRA label
• CAVERJECT (alprostadil) for intracavernosal injection, prescribing and patient information, DailyMed. First injections in the provider’s office, priapism, penile fibrosis and penile pain: dailymed.nlm.nih.gov, CAVERJECT label
• MUSE (alprostadil) urethral suppository prescribing information, FDA (2024). Indication for erectile dysfunction, supervised titration because of symptomatic low blood pressure (3%) and fainting (0.4%) during in-clinic dosing, most frequent reactions during in-clinic titration: accessdata.fda.gov, MUSE label
• FDA De Novo database, DEN220078 (Eroxon). De Novo request granted June 9, 2023: accessdata.fda.gov, DEN220078