Can we just compare cash prices for the three cards and pick one this week?
Work-up before anyone prices a card
A work-up study. Not a fourth PDE5 monograph. Red flags empty the tray before a milligram is spoken.
Cost is the last line on this card, not the first. Men arrive with a screenshot of a 50 mg diamond or a 20 mg once almond and ask which window is cheaper. I want the failure named first. Sudden or slow. Morning erections present or gone. Desire present or gone. Pain, bend, or trauma. A new tablet last month.
Vasculogenic ED is treated on Princeton-style consensus as a risk-enhancing marker for atherosclerotic disease, not a lifestyle footnote. Penile arteries are small. They can declare themselves before a treadmill complaint. Skipping that thought to price a pill is the error this room exists to stop.
PDE5 cards treat a downstream enzyme. They do not explain why nitric oxide never arrived, why androgen is missing, why an SSRI flattened desire, or why the man cannot walk a flight without chest pressure. Knock those rooms. Then, maybe, chart a lock.
Red flags that stop the card tray
Chest pain, unexplained syncope, or breathlessness on modest effort stops the tray. So does a live nitrate or riociguat. So does a suspected acute coronary syndrome last week. I will not bargain those.
An erection lasting more than four hours, now or in the past on a tablet, is an emergency history, not a boast. Sudden vision or hearing loss on a prior PDE5 drug is a never-again until a specialist says otherwise. A painful erection or a traumatized penis is a urology door, not a refill.
Resting hypotension, uncontrolled hypertension, or a man who already faints on an alpha-blocker is a pressure file. Adding a PDE5 drug to win a bedroom is how we manufacture a fall. The three-card match assumes this tray is still open.
Only then do the three cards enter
If the tray is still open and the failure is compatible with a PDE5 trial, then - only then - we match locks. Tadalafil 2.5-20. Sildenafil 50 mg usual start. Vardenafil 5 or 10. Rhythm, plate, prostate, QT. Those sentences live in the match file and in the two single-molecule studies. They do not replace this room.
A first failure on a correctly taken tablet is not a reason to climb a milligram at home. It is a reason to re-check the plate, the stimulation, the alcohol, and whether the diagnosis was ever vasculogenic. Some men need injection therapy, a vacuum device, or a prosthesis conversation. Those are not failures of character.
Lifestyle is not a sermon at the end. Weight, tobacco, sleep apnea, and a walk that actually happens move endothelial function. They also move the heart file that the erection may have flagged. I will say that once. Then I will not pretend a walk replaces a needed card, or a card replaces a walk.
Referral is not a failure of the first visit. Cardiology when the chest is noisy. Endocrinology when two morning testosterone results are low. Urology when plaque, trauma, or a failed well-taken PDE5 trial sits on the desk. I would rather send one extra letter than price a lock over a missed vessel.
When the mind is the main room
Performance fear is common and not a diagnosis of exclusion you make to be kind. Intact morning erections, intact solo function, a recent humiliation, and a partner standing in the doorway with a stopwatch - that cluster is real. A PDE5 tablet can still help as a bridge. It should not be the only sentence.
Depression, heavy drink, and some antidepressants flatten both desire and erection. Stopping a needed SSRI in the car park to save a bedroom is a bad bargain. Dose, timing, and sometimes a different agent are clinic moves. So is naming the drink.
Partners hear the work-up as blame if you are clumsy. The sentence I use is that vessels, tablets, hormones, and fear can share a month. We are naming rooms, not assigning guilt. That is enough empathy. Then back to the cuff.
Sleep apnea is the room I miss when I rush. Loud snore, morning headache, a collar size that has grown, and thinning erections can travel together. Treating the airway sometimes returns mornings before any lock is swallowed. I still may offer a card. I will not skip the snore question to get to a price.
An erection that fades can be a vessel flag
Shared risk sits in plain sight: age, tobacco, diabetes, high pressure, high lipids, obesity, chronic kidney disease. ED that is mainly vascular often arrives gradually, first with weaker rigidity, then with shorter stay, while morning erections thin out. That pattern is a vascular sentence until proven otherwise.
Princeton IV still pushes a 10-year ASCVD estimate in men without known disease, and it is willing to use coronary-artery calcium when the score is borderline or the man is younger than the calculator respects. I am not ordering a CT from a blog. I am saying the erection visit is allowed to become a heart visit.
Sexual activity is a modest exertion. If he cannot climb two flights or walk a hill without symptoms, I do not open a PDE5 card to see what happens in bed. Unstable angina, decompensated heart failure, and a very recent infarction are stop signs. Stabilize the chest. Then talk about locks.
Princeton III already used exercise ability as the simple screen: if he can manage modest activity without symptoms, sex is usually in a similar band. Princeton IV added the risk-enhancing language and the calcium-score conversation. I use the older screen at the bedside and the newer language when I write the referral. Neither is a license to skip the nitrate question.
History first: sudden, slow, or never there
History patterns that change the next test
- Gradual fade, thinning mornings - think vessels and metabolic disease
- Sudden change after a new drug - think the list before the lock
- Intact mornings, failure only with a partner - think anxiety and the room, not first a 20 mg card
- Pain, bend, or trauma - think structure, not enzyme hold
Lifelong failure that was never normal is a different file from a man who was fine until 52. Sudden loss after a new SSRI, a spironolactone, a thiazide, or an opioid is a medicine-room first. Slow fade with lost morning erections is a vessel-or-androgen room. Situational failure with intact mornings and intact masturbation is often a fear or a relationship room.
Ask about bend, plaque, and pain. Peyronie's disease will not be fixed by a 50 mg diamond. Ask about pelvic surgery, radiation, and trauma. Ask about cycling numbness if it is on the history. Ask about alcohol as a regular anaesthetic, not as a moral tale.
Desire belongs in the first ten minutes. Low desire plus low morning erections pulls toward testosterone and toward depression or sleep apnea. High desire plus a soft erection pulls toward vessels, nerves, or a performance loop. Mixing those two stories is how men get an unnecessary PDE5 trial and a missed hormone.
Medicines I actually hunt on the list: SSRIs and SNRIs, spironolactone, thiazides, beta-blockers that already flatten a tired man, 5-alpha-reductase inhibitors, opioids, and some antipsychotics. Recreational stimulants and daily heavy drink belong in the same hunt. A new start two months ago is more useful than a childhood allergy.
Bloods and a pulse before a prescription
Blood pressure in both arms if the story is vascular. Pulse and a look at femoral and foot pulses when the history is claudication. Genital exam for plaque, meatus, testes. A waist and a glucose conversation belong in the same ten minutes as the embarrassment.
Labs I actually use: A1c or fasting glucose, a lipid panel, and a morning total testosterone if desire is low, mornings are gone, or the body looks androgen-deficient. Repeat a low testosterone before you treat it. TSH and a blood count when the story is tired and global, not when the story is a single soft night after a wedding.
I do not start with nocturnal penile tumescence or a duplex as a greeting. Those have jobs after the simple file is messy. Most men need honesty, a cuff, and bloods more than they need a specialised cartoon of flow.
Neuropathy, pelvic radiation, and radical prostatectomy change the odds that a first PDE5 trial will feel like a miracle. I still may offer a card after the chest is cleared, but I warn that nerve-injury ED is a harder room. Failure there is information, not a reason to stack two brands at home.
Sign-out: work-up first, cost last
Sign-out the failure before the window. Pattern, red flags, cuff, bloods, list. Vasculogenic ED can be the first quiet coronary mark. PDE5 locks are downstream tools with their own holds.
Ask a clinician who can examine you before anyone prices a strip, a diamond, or a mid card. This floor teaches the order. It does not sell the tablet.
Last Updated
From the postbag
Questions this study raised
Answered by Dr. Saoirse Byrne, MD · Internal medicine & clinical pharmacology
Work-up letters often arrive as price letters. I send them back to the pattern and the red flags. The cash window can wait.
Not as a first move. I want to know whether this is a vessel fade, a new tablet, a hormone, or a fear loop, and whether your chest is fit for the exertion of sex. A cheap 50 mg diamond is the wrong cheap if a nitrate is in the drawer or if you get pressure on a hill. Price after the tray is open. Bring the list and the pattern to a clinician who can examine you.
He still has morning erections but fails with me. Is that still a heart problem?
Intact mornings and intact solo function lean away from a purely vasculogenic story and toward anxiety, a rushed room, or a relationship strain. Heart disease is not excluded forever - men can have two rooms at once - but I would not open with a coronary panic or with a 20 mg once card as the only plan. Name the humiliation if there was one. Slow the first attempts. A PDE5 tablet can be a bridge after that talk, not a substitute for it.
Which blood tests are actually worth paying for before a first tablet?
Glucose or A1c, a lipid panel, and a morning testosterone if desire is low or mornings have gone. Repeat a low testosterone before anyone treats it. I do not reflex a full endocrine basket after one awkward night. Thyroid and a blood count when fatigue is global. Specialised flow studies wait until the simple file is messy. Your own clinician picks the panel. This is the usual first pass, not a menu you order online.
He started sertraline two months ago and the erection went. Do we add Viagra 50 mg or stop the antidepressant?
Do not stop a needed SSRI in the car park. Sexual side effects are common and sometimes dose-linked. The moves are a review of dose and timing, sometimes a different agent, and sometimes a PDE5 trial if the depression is stable and the chest is fit. Adding a diamond without telling the prescriber who owns the sertraline is how lists drift. Bring both problems to the same visit.
I get a tight chest on stairs. Is that a red flag or just fitness?
Treat it as a red flag until a clinician says otherwise. Sex is modest work. If stairs already produce pressure, a PDE5 card is not the next experiment. You need a chest review - and a nitrate question, because some men already carry a spray they forgot to mention. Do not swallow a lock to see whether bed is easier than the staircase.
Does a normal testosterone mean we skip the heart talk?
No. A normal morning testosterone tells you the fade is less likely to be a simple androgen door. It does not clear the arteries. Gradual ED with thinning mornings can still be vasculogenic with a perfect testosterone. Keep the metabolic and pressure file. The hormone result answers one room. It does not close the floor.
He had a four-hour erection on a tablet years ago. Can he try a lower milligram now?
A priapism history is a specialist conversation, not a home re-challenge at half the count. Four hours is an emergency when it happens. Recurrence risk is not a thing I bargain from a study page. See urology before anyone prices a new card, even 5 mg. Painful or prolonged erections belong in urgent care, not in a wait-and-see.
Is Peyronie's something a PDE5 card can straighten?
No. Bend, plaque, and pain are a structural room. A PDE5 tablet may still help rigidity if vessels and nerves allow, but it will not flatten a plaque. He needs an examination, not a stronger lock. Some men get both problems. Treat them as both. Do not buy a 20 mg once card to straighten a curve.
If the work-up is clean, which lock do you reach for first?
I reach for the match, not a favourite. Nightly or unplanned sex, or real prostate symptoms, pull toward tadalafil's daily 5 mg door. A dated evening and a lighter plate can use sildenafil 50 mg. Older, alpha-blocked, or QT-clean short-card needs can use vardenafil 5 or 10. Nitrates empty all three. That sentence lives in the comparison study. This room only decides that the tray may open.
Read these as teaching on a general point, not as a care plan for whoever asked. Anything specific to you belongs with a prescriber who can see your notes, bloods and full medicine list at once.