Posts Tagged ‘pulmonary hypertension’

Viagra, Levitra, Cialis or Stendra: Which ED Med Is Right For You?

July 1, 2016

Andrew Siegel MD  7/1/2016


Cartoon by my patient/artist Ben Blank given to me shortly after  Viagra became available in 1998.  It says it all!

There are lots of options available if you are having erection problems. In my humble opinion, healthy lifestyle measures should always be considered first-line: weight management, healthy eating, exercise (including cardio, strength, core and pelvic floor), sufficient sleep, avoidance of tobacco, excessive alcohol and excessive stress, etc. With respect to ED medications, there are now many choices. Today’s entry will discuss which of the ED meds is best for you.

How the Penis Erects

In an erotic situation, nerves to the penis release nitric oxide that then causes the release of cGMP, resulting in blood flooding into the erectile chambers of the penis, the basis of an erection. As the erection gets fuller, penile veins become compressed, limiting the exit of blood and ultimately the pelvic floor/perineal muscles engage to cause maximal erectile rigidity.

How the Penis Becomes Flaccid

After ejaculation, the enzyme PDE-5 (phosphodiesterase) is released, the chemical mediator of flaccidity. It results in decreased levels of cGMP, resulting in a loss of the erection and a return to flaccid status.

ED Meds

The ED medications include Viagra, Cialis, Levitra and Stendra. They work by inhibiting PDE-5 and are known as PDE-5 inhibitors. Effective for many men with ED, they result in enhanced erectile function, sexual satisfaction and quality of life.

They are taken orally, require some time to get absorbed and necessitate sexual stimulation to work effectively. Although they can result in some increase in penile fullness (tumescence) without sexual stimulation, sexual stimulation is a must in order to induce a fully rigid erection.

Although effective for many men, they will not work for everyone.  If there is significant nerve or vascular compromise to the penis, they will likely be ineffective. It is important to know that the same ED drug at the same dose may work variably depending on the particular time and situation, sometimes more effectively than at other times since there are so many factors that determine erectile rigidity.

Men who are taking nitrates of any kind should never use the ED meds or serious consequences may result, including a dramatic drop in blood pressure (Remember Jack Nicholson in “Something’s Gotta Give”?). All of these ED drugs are metabolized in the liver for breakdown by the body.

Viagra (Sildenefil) This was the first of the group, released in 1998. Dosed at 25, 50 or 100 mg, the half-life (the amount of time it takes for the blood level of the drug to drop by 50%) is about 4 hours. It is taken on demand and kicks in in 15-60 minutes and remains active for 4 or more hours.

Viagra trivia:  Viagra was discovered by chance. Pfizer scientists conducted a clinical trial with an experimental medicine that causes blood vessels to dilate in an effort to treat high blood pressure and chest pain. The medication did not work particularly well for the intended purposes, but had a side effect in that it dramatically improved erections. When the study ended, the participants were profoundly disturbed that the drug was no longer available. The rest is history.

More Viagra trivia: The name Viagra was born as a fusion of the words “vigor” (physical strength) and “Niagara” (the most powerful waterfall in North America).

Even more Viagra trivia: Viagra is not only used for ED. A 20 mg dose is effective for children with pulmonary hypertension, a condition in which the blood vessels in the lungs have abnormally high blood pressures.

The most common side effects of Viagra are headache, facial flushing, upset stomach, and nasal stuffiness. Less frequent side effects are temporary changes in color vision, sensitivity to light, and blurry vision.

Levitra (Vardenefil) This drug came to market in 2003 and is very similar to Viagra, available in 10 mg and 20 mg doses. The effectiveness and side effect profile is similar to Viagra; however, there are no reports of visual distortions as side effects. It is taken on demand and has an onset of about 25 minutes and has a half-life of about 4 hours and remains active for 4 or more hours.

Levitra trivia: The name Levitra derives from “elevate”; in French “le” indicates masculinity and “vitra” suggests vitality.

More Levitra trivia: Levitra is also formulated in a minty, dissolves-in-your-mouth 10mg formulation called Staxyn.

Cialis (Tadalafil) This was FDA approved in 2003 and is available in 2.5, 5, 10, and 20 mg doses. The effectiveness and side effect profile is similar to Viagra. Uniquely, Cialis has a long duration of action that has earned it the nickname “the weekender” as it can be taken on Friday evening and remain effective for the remainder of the weekend without the need for an additional dose. This affords a considerable advantage in terms of spontaneity. Cialis is either taken on demand (usually 10 or 20 mg, although 5 mg can be effective as well) or on a daily basis (2.5 or 5 mg) and has an onset of 15-45 minutes and remains active for 36 or more hours.

Cialis trivia: Cialis is also approved to treat children with pulmonary hypertension.

In 2012, daily Cialis (2.5 and 5 mg) was FDA approved for the management of urinary symptoms due to benign prostate enlargement.

Cialis, on occasion, can cause backaches and other muscle aches. Cialis is not affected by eating fatty meals, which can slow the absorption of the alternative ED meds.

Stendra (Avanafril) This was FDA approved in 2012. Available in 50, 100 and 200 mg doses, it has the advantage of a rapid onset of action. It is taken on demand and has an onset of about 10 minutes and remains active for 6 or more hours. It seems to have lower rates of hypotension when nitrates are co-administered.

Stendra trivia:  The name Stendra probably is a derivative of the word “extends.”

My Take

I have been in urology practice since 1988 and have plenty of clinical experience managing ED with these meds. In my opinion, Viagra 100 mg is the most potent of the group, but will also incur the most side effects, particularly facial flushing and potentially a nasty headache. Levitra is very similar in most respects to Viagra. Cialis is overall the best of the bunch because of its long duration, the spontaneity factor, the ability to take it with a fatty meal and its dual utility of helping urination as well as sexual function. The downside to Cialis is the occasional muscle aches. Stendra’s rapid onset gives it a small advantage.

Many men are capable of functioning satisfactorily without any of these medications, but find that taking a “recreational dose” of Cialis 5 mg enhances erectile capability and takes 20 years or more off the functional age of the penis. It is particularly useful for those with performance anxiety.


These drugs have gradually increased in price to the point where they are ridiculously expensive, unaffordable for many. None of the ED meds are yet generic. They typically retail for $40 or more per pill.

Tip of the Day: Viagra 20 mg (for pulmonary hypertension in children) is now generic and significantly less expensive than the branded variety and can be used for ED (taking up to 5 pills) at significant savings.

Bottom Line: The arrival of this class of medication in 1998 revolutionized the management of erectile dysfunction. Each of the available ED medications in this class is effective in improving erectile dysfunction issues for most men. There are subtle differences among the four that provide potential advantages and disadvantages. Trial and error will determine what works best for your needs.

Wishing you the best of health and a wonderful Independence Day weekend,

2014-04-23 20:16:29

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