Erectile dysfunction (ED) is common, treatable, and often under-discussed. It should not be dismissed as an inevitable part of aging or treated only with a one-size-fits-all medication approach.^1,2,8 ED can significantly affect quality of life, confidence, and relationships, and it may also be an early marker of cardiovascular disease or other underlying health concerns.^1,2,7,8

We offer comprehensive ED management using both established and newer phosphodiesterase type 5 inhibitors (PDE5 inhibitors), selected around your goals, timing preferences, side-effect history, cardiovascular safety, and overall health profile.^1,2

Important safety note: PDE5 inhibitors should not be taken with nitrates because the combination can cause dangerous drops in blood pressure. Cardiovascular status, blood pressure, medication interactions, and contraindications should be reviewed before treatment.^1-6

Traditional PDE5 Inhibitors

• Sildenafil (Viagra) – Sildenafil is a widely used as-needed PDE5 inhibitor typically taken about 1 hour before sexual activity, though labeling allows use from 30 minutes to 4 hours before sex. It should not be taken more than once per day.³ Sildenafil works by enhancing nitric oxide/cGMP signaling during sexual stimulation, helping relax smooth muscle and increase blood flow into erectile tissue.³ It should not be used with nitrates because of the risk of severe hypotension.³
• Tadalafil (Cialis) – Tadalafil is available as an as-needed medication or as a once-daily low-dose option. As-needed tadalafil is taken at least 30 minutes before sexual activity and may improve erectile function for up to 36 hours, which is why it is sometimes called the “weekend pill.”⁴ Daily tadalafil is typically dosed at 2.5-5 mg once daily and does not require timing around sexual activity, which may support greater spontaneity.⁴ Daily tadalafil 5 mg is also approved for lower urinary tract symptoms related to benign prostatic hyperplasia (BPH), including in men who have both ED and BPH symptoms.⁴ Smaller studies and reviews suggest chronic tadalafil or PDE5 inhibitor use may improve endothelial-function markers and may have cardiovascular relevance, but metabolic and exercise-recovery effects remain preliminary and should not be presented as guaranteed treatment outcomes.^11-13
• Common side effects – Sildenafil and tadalafil can cause headache, flushing, indigestion or dyspepsia, nasal congestion, and dizziness.^3,4 Sildenafil can also cause transient visual changes, including color tinge or blue-tinged vision, while tadalafil is more commonly associated with back pain and muscle aches than sildenafil.^3,4 These medications are effective for many patients, but side effects can limit tolerability and may justify trying another PDE5 inhibitor.^1,2

Newer and More Selective PDE5 Inhibitors

• Avanafil (Stendra) – Avanafil is a newer PDE5 inhibitor with rapid onset; FDA labeling allows dosing as early as approximately 15 minutes before sexual activity.⁵ It is more selective for PDE5 than several older agents, particularly compared with sildenafil’s activity at PDE6, which may help reduce certain off-target effects such as visual disturbances in some patients.^9,10 Common adverse effects can still include headache, flushing, nasal congestion, nasopharyngitis, and back pain, and avanafil remains contraindicated with nitrates and guanylate cyclase stimulators.⁵ For patients who want faster as-needed dosing or who have had bothersome side effects with older PDE5 inhibitors, avanafil may be a better-tolerated option.^5,9,10
• Vardenafil (Levitra) – Vardenafil is taken as needed, typically about 60 minutes before sexual activity, with dosing adjusted based on response and tolerability. It should not be taken more than once daily.⁶ Vardenafil has a similar overall PDE5 inhibitor side-effect profile, including headache, flushing, nasal congestion, indigestion, and dizziness, though some patients may respond better to or tolerate it better than sildenafil.^6,9 Visual color changes are possible but uncommon, and vardenafil is contraindicated with nitrates and guanylate cyclase stimulators.⁶

Note: While avanafil and vardenafil have pharmacologic differences from sildenafil and tadalafil, individual response and tolerability vary. Direct head-to-head evidence is limited, so medication selection should be individualized rather than based on brand familiarity alone.^1,2,9,10

Our Approach to Choosing ED Medication

We select PDE5 inhibitors based on your preferences, medical history, side-effect profile, timing needs, and safety considerations.^1,2

• For spontaneity without planning: Daily tadalafil may be a good option because it provides continuous daily coverage without timing each dose around sexual activity.⁴
• For as-needed use with fast onset: Avanafil may be preferred because it can be taken as early as approximately 15 minutes before sexual activity.⁵
• For longer as-needed coverage: As-needed tadalafil may be preferred because it can remain effective for up to 36 hours.⁴
• For patients with bothersome side effects from sildenafil or tadalafil: Avanafil or vardenafil may be considered, depending on the specific side effects, medical history, and response to prior therapy.^5,6,9,10
• For men with both ED and urinary symptoms/BPH: Daily tadalafil 5 mg may offer the advantage of treating both erectile function and lower urinary tract symptoms related to BPH.⁴
• For patients interested in vascular or metabolic health alongside ED treatment: Daily tadalafil may be considered when clinically appropriate, but we frame non-ED and non-BPH benefits as potential rather than guaranteed, since the strongest established indications remain ED and BPH/LUTS.^4,11-13
• For cost-conscious patients: Generic sildenafil or tadalafil may be practical first-line options when clinically appropriate and tolerated.^1,3,4

Underlying Contributors We Evaluate

ED is often multifactorial. We evaluate and address common contributors including cardiovascular disease, diabetes and metabolic syndrome, obesity, smoking, hypogonadism or low testosterone symptoms, psychological and relationship factors, and medication side effects.^1,2,7,8 Medication-related sexual dysfunction may occur with some antidepressants, antipsychotics, and cardiovascular medications, so a careful medication review is part of comprehensive ED care.^14,15

Addressing underlying causes alongside PDE5 inhibitor therapy often leads to better, safer, and more durable results than simply prescribing a medication without evaluating the broader health picture.^1,2,7,8

When Oral PDE5 Inhibitors Are Not Enough

For patients who do not respond to oral PDE5 inhibitors or cannot take them safely, additional options may include libido focused treatments, correcting testosterone, vacuum erection devices, intraurethral alprostadil, intracavernosal injection therapy, or referral to urology for advanced interventions such as penile prosthesis evaluation when appropriate.^1,2,8

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References

1. Burnett AL, Nehra A, Breau RH, et al. Erectile dysfunction: AUA guideline. J Urol. 2018;200(3):633-641. doi:10.1016/j.juro.2018.05.004
2. European Association of Urology. Management of erectile dysfunction. In: EAU Guidelines on Sexual and Reproductive Health. Accessed June 8, 2026. https://uroweb.org/guidelines/sexual-and-reproductive-health/chapter/management-of-erectile-dysfunction
3. DailyMed. Sildenafil citrate tablet, film coated: prescribing information. National Library of Medicine. Accessed June 8, 2026. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=30cb7d6a-ce40-c794-e063-6294a90a6861
4. DailyMed. Tadalafil tablet: prescribing information. National Library of Medicine. Revised August 2025. Accessed June 8, 2026. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=cd94158b-43fa-44fc-a858-0983770efa83
5. DailyMed. STENDRA (avanafil) tablet: prescribing information. National Library of Medicine. Revised October 2022. Accessed June 8, 2026. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=fa7d93e3-b69b-4e02-8146-89760cd8e9d6
6. DailyMed. Vardenafil hydrochloride tablet, film coated: prescribing information. National Library of Medicine. Revised November 2017. Accessed June 8, 2026. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=c70a9c8e-46b0-489d-bbda-2d7fca4b629f
7. Mostafaei H, Mori K, Hajebrahimi S, Abufaraj M, Karakiewicz PI, Shariat SF. Association of erectile dysfunction and cardiovascular disease: an umbrella review of systematic reviews and meta-analyses. BJU Int. 2021;128(1):3-11. doi:10.1111/bju.15313
8. Newman RW II, Murphy J, Pietrofesa R. Erectile dysfunction for the family physician. Osteopathic Family Physician. 2017;9(2):25-32.
9. Evans JD, Hill SR. A comparison of the available phosphodiesterase-5 inhibitors in the treatment of erectile dysfunction: a focus on avanafil. Patient Prefer Adherence. 2015;9:1159-1164. doi:10.2147/PPA.S56002
10. Katz EG, Tan RB, Rittenberg D, Hellstrom WJG. Avanafil for erectile dysfunction in elderly and younger adults: differential pharmacology and clinical utility. Ther Clin Risk Manag. 2014;10:701-711. doi:10.2147/TCRM.S57610
11. Aversa A, Greco E, Bruzziches R, Pili M, Rosano G, Spera G. Relationship between chronic tadalafil administration and improvement of endothelial function in men with erectile dysfunction: a pilot study. Int J Impot Res. 2007;19(2):200-207. doi:10.1038/sj.ijir.3901513
12. Schwartz BG, Jackson G, Stecher VJ, Campoli-Richards DM, Kloner RA. Phosphodiesterase type 5 inhibitors improve endothelial function and may benefit cardiovascular conditions. Am J Med. 2013;126(3):192-199. doi:10.1016/j.amjmed.2012.08.015
13. Aversa A, Fittipaldi S, Francomano D, et al. Tadalafil improves lean mass and endothelial function in nonobese men with mild ED/LUTS: in vivo and in vitro characterization. Endocrine. 2017;56(3):639-648. doi:10.1007/s12020-016-1208-y
14. Terentes-Printzios D, Ioakeimidis N, Rokkas K, Vlachopoulos C. Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs. Nat Rev Cardiol. 2022;19(1):59-74. doi:10.1038/s41569-021-00593-6
15. Medsafe. Sexual dysfunction associated with antidepressants and antipsychotics. Prescriber Update. March 2015. Accessed June 8, 2026. https://www.medsafe.govt.nz/profs/PUArticles/March2015SexualDysfunctionAntidepressantsAndAntipsychotics.htm