Comparative effectiveness and safety of oral phosphodiesterase type 5 inhibitors for erectile dysfunction: a systematic review and network meta-analysis

Eur Urol. 2013 May;63(5):902-12. doi: 10.1016/j.eururo.2013.01.012. Epub 2013 Jan 31.


Context: Phosphodiesterase type 5 inhibitors (PDE5-Is) are currently the first-line therapy for erectile dysfunction (ED), but available studies investigating the comparative effects of different PDE5-Is are limited.

Objective: To compare the efficacy and safety of different classes of oral PDE5-Is for ED.

Evidence acquisition: A systematic search was performed in PubMed, Cochrane Library, and Embase to identify randomized controlled trials that compared different PDE5-Is or PDE5-Is with a placebo for ED. The methodological quality of included studies was appraised with the Cochrane Collaboration bias appraisal tool, and the quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation system.

Evidence synthesis: A total of 118 trials (31 195 individuals) were included. There was no major difference in the results between the traditional meta-analysis and the network meta-analysis. Network meta-analysis demonstrated that PDE5-Is were superior to placebo to improve erectile function. Compared with tadalafil (relative risk [RR]: 0.61; 95% confidence interval [CI], 0.33-0.90) and vardenafil (RR: 0.63; 95% CI, 0.35-0.92), avanafil was less effective on Global Assessment Questionnaire question 1. Tadalafil was more effective than vardenafil (mean difference [MD]: 1.49; 95% CI, 0.50-2.50) and udenafil (MD: -1.84; 95% CI, -3.31 to -0.33) as measured by the erectile function domain of the International Index of Erectile Function. For all efficacy outcomes, the absolute effects and the rank tests indicated that tadalafil and vardenafil were the most effective agents. After adjusting for dosage, the conclusion remained the same. Safety analysis showed there was no major difference among different agents.

Conclusions: In recommended doses, oral PDE5-Is are more effective than placebo for ED, and tadalafil seems to be the most effective agent, followed by vardenafil. PDE5-Is are generally safe and well tolerated, and there is no major difference on the safety profile.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Administration, Oral
  • Carbolines / administration & dosage
  • Erectile Dysfunction / diagnosis
  • Erectile Dysfunction / drug therapy*
  • Erectile Dysfunction / physiopathology
  • Humans
  • Imidazoles / administration & dosage
  • Male
  • Odds Ratio
  • Penile Erection / drug effects*
  • Phosphodiesterase 5 Inhibitors / administration & dosage*
  • Phosphodiesterase 5 Inhibitors / adverse effects
  • Piperazines / administration & dosage
  • Purines / administration & dosage
  • Risk Assessment
  • Risk Factors
  • Sildenafil Citrate
  • Sulfones / administration & dosage
  • Tadalafil
  • Treatment Outcome
  • Triazines / administration & dosage
  • Vardenafil Dihydrochloride


  • Carbolines
  • Imidazoles
  • Phosphodiesterase 5 Inhibitors
  • Piperazines
  • Purines
  • Sulfones
  • Triazines
  • Vardenafil Dihydrochloride
  • Tadalafil
  • Sildenafil Citrate