Is Tongkat Ali effective and safe for treating erectile dysfunction?

Tongkat Ali for Erectile Dysfunction

Tongkat Ali (Eurycoma longifolia) is not recommended for treating erectile dysfunction, as it lacks sufficient evidence of efficacy and is not endorsed by established clinical guidelines—PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) remain the evidence-based first-line treatment. 1, 2

Why Tongkat Ali Is Not Guideline-Recommended

The American Urological Association's 2018 erectile dysfunction guideline does not include Tongkat Ali among recommended treatments, explicitly stating that alternatives like yohimbine and trazodone lack sufficient evidence and are not recommended. 1, 3 This absence from major clinical guidelines is significant—if Tongkat Ali had robust efficacy data, it would be included alongside FDA-approved therapies.

Limited and Contradictory Research Evidence

While some preliminary research exists on Tongkat Ali, the evidence is weak and inconsistent:

• A 2015 systematic review and meta-analysis found no statistically significant improvement in erectile function scores (IIEF-5) when comparing Tongkat Ali to placebo (WMD 0.91; 95% CI: -1.50 to 3.33), with high statistical heterogeneity between studies. 4

• The same meta-analysis identified a potential benefit only in a subgroup with lower baseline erectile function scores (WMD 2.15; 95% CI 1.03-3.27), but this was based on only 2 small studies with 139 total participants—insufficient to establish clinical efficacy. 4

• Most available studies focus on testosterone levels or general sexual health rather than erectile dysfunction specifically, and lack the rigorous methodology of FDA-approved treatments. 5, 6

The Evidence-Based Alternative: PDE5 Inhibitors

You should prescribe an FDA-approved PDE5 inhibitor as first-line treatment unless contraindicated. 1, 2

Why PDE5 Inhibitors Are Superior:

• Proven efficacy: Success rates of 69% versus 35% with placebo, with statistically significant and clinically relevant improvements in sexual function. 2

• Extensive safety data: Nearly 250,000 men evaluated in clinical trials across general and special populations. 1

• Guideline-endorsed: Strong recommendation (Grade B evidence) from the American Urological Association and American College of Physicians. 1, 2

Proper PDE5 Inhibitor Use:

• Start with conservative dosing and titrate to maximum dose if needed—an adequate trial requires at least 5 attempts at maximum dose before considering treatment failure. 2

• Provide explicit instructions on timing, food interactions, and sexual stimulation requirements to maximize efficacy. 1

• Screen for absolute contraindications: concurrent nitrate use (causes dangerous hypotension) and severe hepatic impairment. 2

Cardiovascular Risk Assessment Is Essential

Before prescribing any erectile dysfunction treatment, assess cardiovascular risk—erectile dysfunction is as strong a predictor of future cardiac events as smoking or family history of myocardial infarction. 1, 2

• Patients unable to walk 1 mile in 20 minutes or climb 2 flights of stairs without symptoms require cardiology referral before treatment. 2

• Check blood pressure, lipid panel, fasting glucose or HbA1c, and consider resting ECG. 2

• Communicate this cardiovascular risk to the patient, partner, and primary care provider for appropriate interventions. 1

When to Consider Testosterone Testing

If the patient presents with low libido in addition to erectile dysfunction, measure testosterone levels before initiating treatment. 2

• Low testosterone is present in 12.5-36% of men with erectile dysfunction and may predict treatment response. 2

• PDE5 inhibitors alone have reduced efficacy in hypogonadal men—combination therapy with testosterone supplementation may improve outcomes. 2

• However, testosterone therapy is not indicated for erectile dysfunction in men with normal testosterone levels. 2

Critical Pitfall to Avoid

Do not delay treatment while pursuing unproven herbal supplements. The opportunity cost of trying Tongkat Ali instead of evidence-based therapy means prolonged sexual dysfunction and delayed cardiovascular risk management. Erectile dysfunction provides a pivotal opportunity for early cardiovascular intervention that should not be missed. 1

Lifestyle Modifications Should Accompany Pharmacotherapy

All patients with erectile dysfunction should receive counseling on risk factor modification: 2

• Smoking cessation
• Weight loss if overweight/obese
• Increased physical activity
• Limiting alcohol consumption

These interventions address underlying vascular health and complement pharmacologic treatment.