PDE5 inhibitors like sildenafil (Viagra) and tadalafil (Cialis) are the world’s most prescribed ED medications — and for good reason. They work reliably in the moment for many men. But they don’t change the underlying condition, and for a growing number of men, a treatment that addresses the root vascular cause is a more attractive long-term option.

How PDE5 Inhibitors Work

PDE5 inhibitors work by blocking the enzyme (phosphodiesterase type 5) that breaks down cGMP — a signalling molecule that relaxes smooth muscle and dilates blood vessels. The result is enhanced blood flow to the penis when sexually aroused. The effect lasts for the duration of the drug’s half-life and then reverses completely. No cumulative improvement in underlying vascular health occurs.

How Focused Shockwave Therapy Works Differently

Rather than temporarily enhancing blood flow chemistry, focused shockwave therapy stimulates the physical growth of new blood vessels (angiogenesis) in penile tissue. This means the improvement is structural — when the treatment works well, the penis can achieve better natural erections without any pharmacological assistance, not just during a drug’s window of action.

A full explanation of the mechanism is in our guide to what focused shockwave therapy involves.

Can They Be Used Together?

Yes — and for some men this is the optimal approach. Men who currently rely on PDE5 inhibitors can continue using them during and after a shockwave therapy course, with the goal of eventually achieving sufficient natural function to reduce or eliminate medication dependence. Some clinicians also find that PDE5 inhibitors enhance blood flow during the active treatment period, potentially improving shockwave efficacy.

The Decision Framework

The choice between approaches comes down to goals and context:

• If erections on-demand are the primary need — PDE5 inhibitors are fast, predictable, and reliable
• If the goal is reducing medication dependency — shockwave therapy is the more appropriate route
• If ED is primarily vascular — shockwave therapy addresses the cause; PDE5 inhibitors do not
• If hormonal factors are also present — address these alongside (see our page on testosterone and sexual performance)