“Male enhancement” is a very vague term.
One website promises a firmer erection, while another claims to increase size, testosterone levels, orgasm intensity and stamina to the point of requiring a complete garage cleaning.
Few FDA-approved products do all of the above.
There are FDA-approved medications for treating erectile dysfunction, hormone replacement for low testosterone and medical treatments for premature ejaculation.
There are also devices to help achieve an erection, each targeting a specific area of concern.
The attractive looking capsules that offer an all-in-one male enhancement are a completely different category.
Dietary supplements aren’t FDA-approved to treat erectile dysfunction and some have even been found to contain illicit prescription-drug ingredients.
It is important to distinguish what it is a man is actually looking to treat.
A man who loses his erection needs a different treatment option than a man with low sexual desire but normal erections.
For problems related to erection, prescription drugs are the first line of defense.
Erectile dysfunction medications most commonly belong to a class called PDE5 inhibitors.
Four drugs have been approved in the United States: sildenafil, tadalafil, vardenafil and avanafil.
Each of these medications follow a similar mechanism of action, although individuals sometimes find they respond better to one than another.
The drugs function to prolong the natural erection process when sexually stimulated by inhibiting PDE5 enzymes.
A tablet has no power to create desire or enlarge a penis permanently.
Sildenafil: popular and short-acting
Sildenafil is the generic name for Viagra and it’s usually taken an hour before sex, with the medication lasting about four hours.
Sildenafil’s major advantages are the drug’s popularity and affordability as a generic drug.
There may be a delay if a heavy meal is eaten shortly before taking the drug, and headache, flushing of the skin, indigestion and nasal congestion are common side effects.
Men sometimes report a temporary slight sensitivity to light and a bluish tint to their vision.
Viagra often fits well with planned sex: one takes the dose, waits for it to kick in and enjoys the sexual response in the evening before fading away.
Tadalafil: the long-acting option
Tadalafil is sold under the brand name Cialis and can last up to 36 hours, depending on the dose.
It isn’t necessarily stronger than sildenafil, but lasts much longer.
This offers more flexibility for sex without having to time things out precisely.
Food has less of an effect on tadalafil, meaning restaurant dinners can be easier.
A lower dose of tadalafil can also be taken every day, which is helpful for men who have sex often or who prefer not to think about a medication for sex in advance.
It might also help symptoms of an enlarged prostate.
Headache and indigestion are possible with this drug, but back and muscle pain are particularly common with tadalafil, likely due to its longer duration.
The appeal of Cialis for many couples isn’t a more dramatic erection, but less rigid scheduling.
Vardenafil and avanafil
Vardenafil functions in a way that’s very similar to sildenafil, but it has its own unique place in treatment.
It’s another PDE5 inhibitor with a similar treatment window to sildenafil, except that some men who didn’t have good results with sildenafil find that vardenafil works better, even though the drugs are related.
Vardenafil has an extra heart rhythm precaution and is generally avoided in men with congenital long QT syndrome and those taking certain heart rhythm medications.
Avanafil is the newest of the PDE5 inhibitors and it may start working faster for some men, while being slightly more selective for the PDE5 enzyme.
Insurance coverage can be an obstacle for both vardenafil and avanafil, although they don’t appear to be significantly more expensive than sildenafil overall.
It can be difficult to distinguish between the drugs based on strength, but personal response, side effects and timing usually determine a winner.
The nitrate rule applies to all ED tablets.
PDE5 inhibitors shouldn’t be combined with nitrates like nitroglycerin or isosorbide.
Recreational drugs called poppers that contain nitrites are also contraindicated.
Taking these drugs with a PDE5 inhibitor can cause a dangerous drop in blood pressure that could lead to fainting, heart attack or stroke.
Riociguat should also be avoided with these medications.
Alpha blockers, blood pressure drugs and certain antibiotics, antifungals or HIV medications may also affect the dose of a PDE5 inhibitor.
If a man experiences chest pain after taking an ED drug, he should call emergency services and tell them specifically what medication he took.
He shouldn’t take nitroglycerin unless he’s directed to by medical professionals.
An erection that lasts four hours or more requires emergency medical attention.
When tablets aren’t enough
One way to achieve an erection without tablets is with a vacuum erection device that draws blood into the penis using suction.
A tension ring at the base of the penis helps keep blood in the penis.
Vacuum devices aren’t as convenient as a pill, but there’s no reliance on the same physiological pathway and they can be useful after prostate surgery, in cases of severe nerve damage or when a man can’t take an ED medication.
It’s important to use a medically-approved device rather than an enlargement pump, and the tension ring shouldn’t be left on for longer than recommended, typically no more than 30 minutes.
Another injectable medication called alprostadil is also a known ED treatment.
It can be injected into the side of the penis or delivered through the urethra in specific formulations. The thought of an injection might put some men off, but the needle is small and the medication can be very effective for men who don’t respond to oral drugs.
Dose titration is important with this medication since an excessively high dose can cause a prolonged erection.
Penile implants are typically reserved for men with severe erectile dysfunction who haven’t responded to less invasive treatment.
The surgery is permanent but overall satisfaction is high among appropriate candidates and their partners.
Vacuum devices and injectable drugs are part of the full range of treatment options for erectile dysfunction, not products to make a healthy penis perform more than normal.
Testosterone isn’t an erection booster for everyone
Testosterone treatment is only recommended for men with confirmed hypogonadism due to a specific medical condition.
A man will need to have symptoms of low testosterone as well as consistently low morning testosterone levels before treatment is considered.
A man who has been diagnosed with testosterone deficiency should see an improvement in sexual desire and erections if his testosterone is low.
A man whose testosterone is normal shouldn’t expect testosterone replacement therapy to behave like a stronger version of Viagra. Testosterone can decrease sperm production, shrink testicles and is a medical treatment with other potential health concerns.
“Testosterone boosters” sold as supplements should not be confused with prescription testosterone.
What about pills sold without a prescription?
This is where the word “approved” goes out the window.
Herbal erection pills, honey packs and gas station capsules may boast terms like “laboratory tested,” “GMP manufactured” or “FDA-registered facility.” None of that means the FDA approved the product for ED.
The FDA has taken numerous actions against sexual enhancement supplements that were found to contain illicit sildenafil, tadalafil or related chemicals. An undocumented ED drug is especially dangerous for someone taking nitrates since neither he nor his doctor knows about the interaction.
Products that promise permanent enlargement deserve the same level of scrutiny.
No pill, cream or oil has been approved to create permanent inches on an adult penis.
The best FDA-approved drug is therefore not a universal pill, but an option for a short planned window. Sildenafil may be the drug of choice in that situation, while tadalafil wins out for flexibility. If oral treatment isn’t an option, then a vacuum device or alprostadil may be an appropriate choice.
This answer is less exciting than “one capsule transforms everything,” but has the advantage of being real.
