Men who have erectile dysfunction (ED) after cancer have several options to treat the problem. This guide explains the most common treatments including how they work, the men who succeed best with each, and pros and cons of each. Insurance coverage and cost for these treatments vary a lot. Most are not covered by Medicare or Medicaid. Sometimes a brand name treatment is not covered, but a generic version is included in your plan. If you need to pay out-of-pocket, check out online sites like GoodRX, Blink Health, or Pharmacy Checker to find the best prices.

PDE5-INHIBITOR PILLS: What is it? 

Phosphodiesterase 5-inhibitors (PDE5-inhibitors) are pills that help men get erections more easily. Viagra(sildenafil) was the first PDE5-inhibitor to be approved in the United States in 1998. Since that time, three other PDE5-inhibitors have come to the market, Levitra (vardenafil), Cialis (tadalafil), and Stendra (avanafil). All work the same way. If one pill does not give you good erections, it is unlikely that another will succeed. However, some men switch from one brand to another because the pill come in different doses and have slightly different side effects. Some act faster or stay longer in the bloodstream. Cialis is available in daily dose.

Comparing the PDE5 Inhibitor Pills

How does it work? 

PDE5 inhibitors are prescription drug and should only be taken after consulting your doctor. PDE5 inhibitors work in the tissue of the penis, not in the brain. When a man's penis is soft, the tissue inside the shaft is tight, like a dry sponge. When a man begins to get an erection, the tissue inside the relaxes, so that blood can flow in. The PDE5 inhibitors help a man get erections more easily by increasing a chemical called cyclic guanosine monophosphate (cGMP) involved in relaxing the tissue inside the penis. 

These pills do not increase a man’s desire for sex or make his orgasm more intense. Some men find that their confidence in keeping an erection while on the pills helps them delay orgasm however, if they were coming too quickly. Taking a PDE5 inhibitor does not create an automatic erection. After taking the pill, a man needs mental sexual excitement and physical caressing to develop the best possible erection. 

Sildenafil and vardenafil do not work well if you take them close in time to eating a fatty meal. It is best to avoid alcohol when taking any PDE5 inhibitor, since even a small drink can interfere with erections. These pills also need time to build up in the body. With sildenafil and vardenafil, take your pill at least an hour before sex to give the medication time to have its strongest effect. The benefit can last 8 to 12 hours, so some men take a pill about 2 hours before dinner time and then plan sex later in the evening. Staxyn is a 10 mg dose of vardenafil in a tablet that melts on your tongue, without using extra liquid. The newest PDE5 inhibitor, avanafil, acts the most quickly of the four. 

Tadalafil takes somewhat longer to work but also stays in the bloodstream for a longer time. You may want to take tadalafil at least 2 hours before trying sex, although the manufacturer says it works within 30 minutes. Some people call it the weekend pill, because one dose can last for up to 3 days. Men who have sex several times a week and want to be ready at any time can take a smaller, daily dose of tadalafil instead of using it only when planning to have sex. If you tend to have sex less often, however, a daily dose may not be worth the cost and side effects. 

What are the common side effects? 

The comparison table lists the common side effects of each pill. The most common side effects include: 

• Headaches 

• Stuffy nose 

• Facial flushing 

• Upset stomach 

• Temporary vision changes (increased light sensitivity, blurry or double vision, or objects appear bluish) 

• Muscle aches 

The stuffy nose and indigestion are the ones that men complain of most often. Tadalafil does not cause blurry vision or loss of color vision like the other two pills, but it is more likely to cause backaches or other muscle aches. 

What are the health risks? 

Men who take nitroglycerin (nitrates) for chest pain caused by heart disease should not use PDE5 inhibitors. Combining these two medicines can cause a sudden, rapid fall in blood pressure. A few men have died from this drug interaction. Trade names for common nitrates include Deponit, Minitran, Nitrek, Nitrodisc, Nitro-Dur, Nitroglyn, Nitrostat, Nitrolingual spray, Imdur, Monoket, ISMO, Dilatrate, Isordil, Sorbitrate, Duotrate, Peritrate, Tetraneed, Nipride, and Nitropress. This list does not include every nitrate, so be sure to check with your doctor. For the same reason, men should never use the street drugs called "poppers" (amyl nitrite) when using a PDE5 inhibitor. 

When sildenafil first was approved in the United States, some heart attacks were blamed on the medication. We now know that PDE5 inhibitors improve blood flow to the heart muscles and arteries, increasing men’s ability to tolerate exercise. Men with heart failure or a history of heart attacks can usually take PDE5 inhibitors safely, unless they are using nitrates. Always consult your doctor, but a guideline is that a man is fit enough to have sex if he can walk briskly up two flights of stairs without chest pain or getting out of breath. 

Men taking pills called protease inhibitors to treat the human immunodeficiency virus (HIV) should be very careful in using PDE5 inhibitors. The amount of medication available in their bloodstream can build up, increasing the side effects. Men and their doctors should discuss safety issues. 

Pilots need to be able to tell blue from green landing lights. Since sildenafil and vardenafil can temporarily affect color vision, pilots should not take these pills within 24 hours of flying. 

Several years ago, it was reported that PDE5 inhibitors might increase the risk of a rare type of sudden blindness, called non-arteritic ischemic optic neuropathy or NAION for short. NAION affects less than 11 people out of 100,000 (so far less than one percent), but risks are highest in men in their 50s who are diabetic, have high blood pressure, and have problems with lipids (bad cholesterol). Since these men also are at high risk to have ED, it is not clear if NAION was caused by taking PDE5 inhibitors, or if it would have happened anyway. The blindness comes on suddenly, usually on waking from sleep, so it is easy to link it with taking a medication the night before. Unfortunately, blindness can be permanent, so more studies are needed. 

Another rare problem that is more likely to be linked to taking a PDE5 inhibitor is having a sudden loss of hearing, almost always just on one side, within 24 hours of taking the medication. The hearing loss may be related to a buildup of cGMP in the cochlea, an important structure in the inner ear. About half of men recover their hearing, sometimes after treatment with steroids (medications that reduce inflammation). 

Pro Tip: If you notice loss of hearing or vision, contact your doctor immediately. 

Who succeeds with it? 

PDE5 inhibitors are most effective in men with mild erection problems. If a man can feel sexually excited without getting any swelling of his penis, these medications may not be strong enough to produce a firm, lasting erection. 

Men whose erectile tissue no longer make nitric oxide (NO) also may not benefit from a PDE5 inhibitor. Severe damage to the nerves inside the penis and the blood vessels can limit NO production. The chance of having a good response to these pills after pelvic surgery (radical cystectomy, radical prostatectomy, or surgery for rectal cancer) is best if nerves were spared on both the left and right sides of the prostate (bilateral nerve-sparing). Even when both nerves are spared, the nerves get bruised and stretched during surgery and take months to recover. Diabetic men are also less likely to get a good erection with these pills. 

Men with mild erection problems in the first few months after pelvic radiation therapy often have a very good response to PDE5 inhibitors. However, from one to five years after radiation, as scarring continues to damage the blood vessels and nerves involved in erection, the PDE5 inhibitors may no longer work. 

Good to know: If you want to use a PDE5 inhibitor, get a prescription from your doctor and buy your pills from a pharmacy. The pills offered for sale on the internet are almost always forgeries, with the exception of those from large, online companies such as HIMS or Roman. 

PROS AND CONS