man relaxing on a bed, reading on his phoneShare on Pinterest
Nikada/Getty Images

Some people have success with “the tiny blue pill” (aka Viagra) and find that it’s enough to address their erectile dysfunction (ED). But many others discover that Viagra never works for them or gradually stops working after they’ve used it successfully.

Why does Viagra work for some but not others? We explore the reasons and share options you can try.

Becoming aroused is a complex combination of factors — from physical responses to mood and emotions — so it’s important to understand the physiology of an erection. And it can help you understand why Viagra may not be working.

“Erections occur when there is a net increase of blood flowing into, as compared to blood exiting, the erectile spongy bodies of the penis,” said S. Adam Ramin, MD, urologic surgeon and medical director of Urology Cancer Specialists.

In order to have a net increase in blood flow, Ramin said these four crucial steps must take place:

  1. First, the nerves in the pelvis must send neurotransmitters to the arteries of the penis, directing increased flow.
  2. Second, the arteries must respond to the command of the nerves by dilating and widening their diameter to allow for increased flow.
  3. Third, the erectile spongy bodies of the penis must be compliant, able to stretch out and elongate to accommodate the increased blood flow.
  4. Lastly, the veins of the penis must allow for a net increase in blood flow by closing their drainage valves to keep blood in the penis.

“Viagra works at the artery level by enhancing the command of the neurotransmitters to cause dilation and increase flow through the arteries,” Ramin said.

But if there’s a problem with any of these four steps on the way to an erection, Viagra won’t work, according to Ramin.

What causes erectile dysfunction?

The causes of ED are complex and can include mental and physical aspects. Erections happen from and are influenced by a complicated combination of:

  • physical mechanisms
  • sensations
  • your emotions
Healthline

Several factors can impact Viagra’s effectiveness. These include:

  • when you take Viagra
  • how you take it
  • what’s going on in your body when you take it

According to the American Urological Association, incorrect use of phosphodiesterase type 5 (PDE5) inhibitors accounts for 56 to 81 percent of treatment failures.

Here are common mistakes to avoid, and what you can do to make sure Viagra has the best chance to work.

1. Avoid taking Viagra with a large meal or high-fat meal

Viagra blood levels peak an hour after you swallow the tablet on an empty stomach. According to Ramin, if you eat a large or high-fat meal and then take Viagra, the medication will lose its effectiveness and may take longer to start working.

2. Avoid taking Viagra with alcohol

Drinking alcohol, especially chronic use, can contribute to ED. If Viagra is losing its effectiveness, you may want to consider decreasing or eliminating alcohol to see if that helps.

3. Don’t expect Viagra to work just minutes before sex

If you take Viagra and immediately try to have sex, Ramin said, it won’t work.

“The most optimal way to take this medication is on an empty stomach, with no alcohol in your system, one hour before sex,” Ramin explained.

4. Don’t expect Viagra to work alone

Viagra packs a punch, but it can’t produce an erection on its own. In order for it to work, you must be sexually aroused.

5. Make sure your testosterone levels get checked

Viagra and other PDE5 inhibitors won’t work well if your testosterone levels are too low.

Testosterone therapy alongside or instead of an ED medication may be a treatment to consider. Your healthcare provider should be able to test testosterone levels and evaluate this with you.

Be sure to use Viagra in several different scenarios

If you’ve taken Viagra in the most optimal situation more than five times and it hasn’t worked, then it may not be the right treatment for you, according to Ramin. Before you decide Viagra isn’t for you, though, Dr. Myles Spar recommends using it at least once when alone masturbating to make sure it isn’t a relationship issue.

You may need to try Viagra as many as 10 times, just to get comfortable with the steps of using it and how it makes you feel, as well as to understand how it may be affecting you.

Speak with a healthcare provider about your treatment so they can adjust dosing, make suggestions, and help you find what works.

Healthline

Spar, who is chief medical officer at Vault Health, said that Viagra not working could mean that the issue isn’t vascular — meaning, increasing blood flow isn’t helping.

“This can happen because of neuropathy or other issues,” he said.

Even if you’ve had success getting or keeping erections while using Viagra, you may notice it doesn’t work as well anymore. But before you ditch the Viagra prescription, it’s important to consider why it might not be as effective anymore.

Viagra can lose its efficacy over time, due to changes in your body or changes in your health. If that happens, Spar said, you can try switching to another medication in the same class (meaning, another PDE5 inhibitor).

Yes, if Viagra isn’t cutting it, you can try another PDE5 inhibitor — but don’t expect rock-star results.

While a change to a different medication may do the trick, it’s not always a guarantee. A doctor can help you decide if another PDE5 is worth trying.

In addition to Viagra, the other oral medications that are considered the first-line treatment for ED, according to a 2016 review, include:

  • tadalafil (Cialis),
  • vardenafil HCL (Levitra)
  • avanafil (Stendra)

The four PDE5 inhibitors are the only oral medications approved in the United States by the Food and Drug Administration to treat ED.

In this case, tadalafil may be a good bet.

A reason that this PDE5 inhibitor is preferred by many people, including healthcare providers treating ED, is that tadalafil has a longer window of activity, meaning you can take it in a daily dose.

This can remove some of the psychological aspects and uncertainty of timing a pill before sex. Plus, it can help to see how effective PDE5 inhibitors are for you.

Viagra may not be the most effective for everyone, either because of its dosing schedule, how it works, or health conditions it’s not right with.

Here are some of the more common physical and emotional reasons why Viagra may not work.

Malfunction of nerves

According to Ramin, people with diabetes who have neuropathy or people who’ve had prostate surgery and injury to their nerves may find that Viagra doesn’t work.

Atherosclerotic heart disease

Viagra not working could mean there’s significant obstruction to the blood flow in the penile artery. This can be a sign of general atherosclerosis or plaque in the arterial system, Spar said, which is a risk factor for heart attack and stroke.

People with atherosclerotic heart disease have arteries that are plugged with cholesterol plaques or have lost their elasticity, said Ramin. In this situation, the arteries won’t respond to Viagra because it’s a vasodilator. This means it’s a chemical that causes dilation, or widening, of the artery.

Penile erectile body disease

In people with an injury to the body of the penis or Peyronie’s disease, the erectile body may not be able to accommodate increased blood flow, Ramin said.

Venous leak

If you have leaky valves, Ramin said, the blood may flow at an increased rate to your penis, but it will all leak out and not stay long enough to cause an erection.

It’s also possible that you can get an erection, but the venous leak means you’re unable to maintain it.

One cause of venous leak ED is Peyronie’s disease, which affects the connective tissue of the penis.

Anxiety, depression, stress, or relationship issues

Spar said another reason Viagra does not work for everyone has to do with anxiety and emotional health. This can make it difficult to get sexually excited from a neurotransmitter perspective.

The good news is that some of the things that can have the biggest positive impact on ED symptoms involve actions you can take without a prescription.

Make lifestyle changes a priority

In addition to medical interventions, it’s important to address lifestyle factors that play a role in ED. Some common factors that can lead to conditions affecting blood circulation include:

  • lack of activity
  • smoking habits
  • stress
  • drinking alcohol

To help improve your overall health and improve ED symptoms such as circulation, consider these changes:

  • Quit smoking.
  • Minimize daily stress.
  • Manage your weight through a healthy diet and regular activities.
  • Participate in daily exercise and physical activity.
  • Reduce or eliminate alcohol intake.

Work with a urologist

There are several options to treat erectile dysfunction aside from oral medications like Viagra, including:

Work with a therapist

No matter what treatment or medication you may be trying for ED, talking with a licensed counselor can help you get the most out of your treatment and help you work on reducing stress, pressure, or anxiety — in general and in the bedroom.

Sex therapists, for example, focus on intimacy, communication, relationships, and yes, sex.

Online search tools, like Healthline’s FindCare tool, can help you find general physicians and specialists in your location.

If you’re dealing with ED, you’re not alone. The inability to get or keep an erection firm enough for sex may affect as many as 30 million men, according to the Urology Care Foundation.

If Viagra isn’t working for you, there are things you can try that increase the chances of it working. You can also try lifestyle changes or consulting with a urologist or therapist instead.