Treatment Plan




You must contact the provider if there are any problems, changes or side effects. Or, if you visit a new provider for treatment. ED may indicate that there are other health issues that should be addressed, which is why we recommend routine testing of labs, and regular visits with your primary care provider. Because ED may be a sign of other medical problems such as hypertension, diabetes, or vascular disease, telling your primary care physician may lead to early treatment of problems while they may still be reversible, or before they become more harmful to your wellbeing . Your telemedicine provider and your primary care provider must be kept informed of any changes to your medication regimen. Your safety is paramount. You must disclose your health history and any health-related changes so that your provider can address your needs to help safeguard your wellbeing. 

Sildenafil and tadalafil are  prescription medications commonly used to help treat erectile dysfunction (ED) and should only be used after you’ve been diagnosed with ED. Take them as directed. Do not these medications if you’re not healthy enough for sexual activity. Sildenafil is the same medication that’s in Viagra, which has been approved for ED treatment. Tadalafil is the same medication in Cialis which can be prescribed as needed, or on a daily maintenance dosing schedule.



These are rather common, however most only last as long as the medication is still in the system. That means it's a shorter duration for sildenafil, but longer for tadalafil.

Symptom Frequency

  • Headache         16-28% vs 7% for placebo                
  • Upset stomach         10-29% vs 2% for placebo
  • Flushing           10-29% vs 2% for placebo
  • Stuffy nose         4% vs 2% for placebo
  • Dizziness.         3-4% vs 2% for placebo
  • Muscle aches          3-4% vs 2% for placebo
  • Dyspepsia (‘reflux’)        3-17% vs 2% for placebo

SIDE EFFECTS (Severe, VERY uncommon)

  • Erections that last several hours. Go to an emergency room if you have an erection that lasts more than 4 hours.
  • Decreased eyesight or loss of sight in one or both eyes.
  • Sudden decrease or loss of hearing.
  • Heart attack, stroke, irregular heartbeats, and death. Most of these happened in people who already had heart problems.
  • Seizures
  • Low blood pressure causing dizziness
  • Allergic reaction
  • Stevens-Johnson syndrome
  • Anemia

If any of these SEVERE side effects occur, seek medical care immediately.


Sildenafil does not protect against sexually transmitted diseases. If there is any concern about STDs, wear a condom to protect yourself and your sexual partner. You should inform your partner if you have any sexually transmitted infections and get their consent to engage in sexual activity.

This medication is a phosphodiesterase inhibitor, which is generally safe. There are, however, rare and serious potential side effects. Phosphodiesterase inhibitors were first developed to treat blood pressure and in some cases, they can result in dangerously low blood pressure, especially if taken with other medications that lower blood pressure, like nitrites and nitrates. These medications should never be taken simultaneously with sildenafil. Additionally, recreational use of nitrates/nitrites (such as “poppers”) should never be taken in conjunction with sildenafil. There is always a chance that the medication will not work, regardless of whether a patient is healthy and compliant with taking the medication. Phosphodiesterases have been shown to be ineffective in about 15% of patients. 

Patients with Pulmonary Veno-Occlusive Disease (PVOD) should not use this medication.

A potential side effect is an erection that can last longer than desired (priapism). In this case, a sometimes painful engorgement of the penis can persist and damage the vessels and tissue of the penis. On occasion, the damage can be permanent. It is important that you immediately seek treatment at an emergency room if such an erection lasts for longer than four hours, even if it’s not painful. Patients with penile structural abnormalities or conditions which may predispose them to priapism should also be cautious.

Changes to vision can be another potential side effect from use of the medication. It has been documented that some users see a blue tint in their vision. In rare cases, blindness can occur which can be permanent. Patients with a history of non-arteritic anterior ischemic optic neuropathy (NAION) should be cautious. It is important that you immediately seek treatment or visit an urgent care/emergency room if you are experiencing vision issues. 

For patients whose kidney/liver function is reduced, it is recommended to not exceed the maximum single dose of 25 mg sildenafil within 48 hour period. The same applies to patients who are taking erythromycin, itraconazole, ketoconazole, saquinavir, and ritonavir (common in HIV medications and Paxlovid, a treatment for COVID-19).

Nerve damage from surgery, trauma or radiation therapy can interfere with the body’s ability to get and maintain an erection. Men with a history of prostate cancer surgery may have great issues with maintaining an erection. 

On occasion, sexual activity comes with cardiac risk. Patients must communicate with their provider about any history of chest pain, heart disease, high/low blood pressure, irregular heartbeats, coronary artery disease, aortic stenosis, idiopathic hypertrophic subaortic stenosis, coronary ischemia, heart attacks, strokes, heart defects or heart failure. It is also recommended that doses of sildenafil >25 mg not be given to patients within 4 hours of taking an alpha-blocker medication.  If you are not sure about the medications which you are taking and if they are safe, please make sure to ask your doctor, telemedicine provider, or pharmacist.

Pilots and air traffic controllers should not take sildenafil within six hours of aviation related duties, due to the potential vision changes that can happen when taking this medication for ED. Additionally, pilots and air traffic controllers should not take Cialis (tadalafil) within 36 hours of aviation related duties. 


Do not take the medicine on an empty stomach and avoid fatty foods for at least two hours before taking the pill. Fat interferes with its absorption. Avoid alcohol while taking this medication. Grapefruit juice can possibly affect the absorption of this medication since it increases the blood level after an initial delay in absorption. 

For your first experience with this medication, it is recommended to take it alone (without engaging in sexual acts) in case there are any side effects. 

This medication can aid the patient in getting an erection but it does not always persist during intercourse. On occasion, erections may persist but it may be challenging to orgasm. Some patients may experience premature ejaculation, especially after periods of abstaining from sexual activity. It is best to communicate with your provider and sexual partner to address any issues.

Do not take more than the prescribed dose within a 24 hour-period.

If you are taking an alpha blocker (usually for high blood pressure or enlarged prostate) be sure that you are stable on the alpha blocker before lowering the dose of the alpha blocker. If you are already taking this medication and begin the use of an alpha blocker, start on the lowest dose of the alpha blocker. Do not take this medication within four hours of taking alpha blockers.

It is not recommended to take different types of ED medications simultaneously. They should not be taken within 48 hours of each other. Do not take sildenafil or tadalafil together, or within 48 hours of one another.


Penile tissue releases Nitric Oxide (NO) when the brain processes erotic stimulation. This release of NO increases a chemical known as Guanosine MonoPhosphate (cyclic-GMP) which causes the relaxation of the muscles in the penis, in a process known as tumescence. The swelling causes the veins in the penis to collapse, which restricts blood from leaving the penis. This is what causes a persistent erection. Eventually, the penis will become flaccid again as the blood is released, in a process known as detumescence. It is caused by chemicals known as phosphodiesterases which break down the cyclic-GMP in a reversal of how the erection started. Sildenafil is a phosphodiesterase inhibitor, meaning it blocks your body’s phosphodiesterases which inhibits the breakdown of cyclic-GMP, so the blood stays in the penis for longer, resulting in a longer erection.

Certain phosphodiesterase inhibitors can react differently in the body. This medication can be effective in as little as one hour and will be out of the bloodstream in up to eight hours, whereas tadalafil may not take effect for two hours and can work for up to 36 hours. 


There are other ways to treat ED. Below are some options that should be carefully discussed with your provider before treatment. 

A vacuum-tube device is an option. It creates a vacuum suction around the penis, which forces blood to fill the penis and results in an erection. A ring device that is placed at the base of the shaft can also restrict blood from leaving the penis, but should be removed 30 minutes later so there is no risk of tissue damage. Discuss with a provider before use. 

Alprostadil is another option that can be used as a penile suppository or as a penile injection. Alprostadil acts as a vasodilator, which causes blood to fill the penis. Discuss with a provider before use. 

Surgery is another option. Surgical options include the placement of a rod, inflatable implant or a semi-rigid implant. Discuss these options with your provider. 

Healthy lifestyle choices and alterations are also encouraged for improvement in a patient’s ability to get and maintain an erection. Healthy eating, exercise, adequate sleep, managing stress and limited alcohol/nicotine consumption are some of the ways to improve overall sexual performance. Alcohol acts as a depressant in the nervous system which can inhibit messaging between the brain and the body. Smoking can damage blood vessels and impede the body’s ability to achieve an erection. 

Contact your provider with any and all concerns. If you are experiencing a medical emergency, seek treatment immediately. 


Please see your PCP and notify them that you have started taking medications for erectile dysfunction.

ED may be a early sign of the following conditions: heart disease, atherosclerosis, high cholesterol, high blood pressure, diabetes, obesity, metabolic syndrome, Parkinson’s disease, multiple sclerosis, sleep apnea, prostate disease, other genitourinary diseases, low testosterone, psychological conditions, certain medications, smoking, drug and alcohol use.

If you do not have a PCP, please click on the following link:


While your prescribing physician has reviewed the medications you have reported, it is important for you to be aware of the many drug interactions which can occur with phosphodiesterases. The following list is long, but not complete.  Please review the PDR (Physicians Desk Reference) for a complete list.


  • Alfuzosin (Uroxatral) (Treats High Blood Pressure or Enlarged Prostate)
  • Aliskiren (Tekturna, Rasilez) (Treats High Blood Pressure)
  • Alpha-blockers (e.g., Cardura, Coreg Flomax, Hytrin, Minipress, Oravase, Rapaflo, Regitine,Trandate) (Treats High Blood Pressure or Enlarged Prostate)
  • Ambrisentan (Letairis) (Treats PAH–High Blood Pressure in the Arteries of the Lungs)
  • Amlodipine (Norvasc) (Treats High Blood Pressure)
  • Amprenavir (Agenerase) (Treats HIV)
  • Amyl Nitrite (Amyl nitrite Systemic, Poppers, Rush) (Recreational Drug)
  • Aprepitant (Emend) (Treats Nausea)
  • Atazanavir (Reyataz) (Treats HIV)
  • Atropine (Isopto Atropine) (Treats Eye Conditions)
  • Boceprevir (Pegasys, Pegintron) (Treats PAH and Hepatitis C)
  • Butyl Nitrate (Poppers, Rush, Liquid Gold) (It is a recreational drug)
  • Brigatinib (Alunbrig) (Cancer)
  • Capecitabine (Xeloda) (Cancer)
  • Cariprazine (Vraylar) (Psychiatric Disorders)
  • Ceritinib (Zykadia) (Cancer)
  • Cimetidine (Tagamet) (Stomach Ulcers)
  • Ciprofloxacin (Proquin, Cipro) (Antibiotic)
  • Clarithromycin (Biaxin) (Antibiotic)
  • Clopidogrel (Plavix) (Blood Thinner)
  • Cobicistat (Stribild, Tybost) (Treats HIV)
  • Conivaptan (Vaprisol) (Treats Low Sodium in the blood)
  • Crizotinib (Xalkori) (Cancer)
  • Darunavir (Prezista) (Treats HIV)
  • Dasabuvir (Viekira XR, Viekira Pak–contains Ritonavir*) (Treats Hepatitis C)
  • Delavirdine (Treats HIV)
  • Dihydroergotamine (Migranal) (Treats Migraines)
  • Diltiazem (e.g., Cartia, Cardizem, Dilacor XR, Tiazac,) (Treats High Blood Pressure)
  • Doxazosin (Cardura, Carduran) (Treats High Blood Pressure or Enlarged Prostate)
  • Dronedarone (Multaq) (Irregular Heartbeats)
  • Duloxetine (Cymbalta) (Treats Depression and certain nerve pain disorders)
  • Erythromycin (Erythrocin, Ery-Tab, E-Mycin, Eryc) (Antibiotic)
  • Fluconazole (Diflucan) (Treats Fungal and Yeast Infections)
  • Fluoxetine (e.g., Prozac, Sarafem) (Treats Psychiatric disorders like depression)
  • Fluvoxamine (Faverin, Fevarin, Floxyfral, Dumyrox, Luvox) (Treats OCD)
  • Fosamprenavir (Lexiva) (Treats HIV)
  • Grapefruit juice
  • Idelalisib (Zydelig) (Treats Cancer–Leukemia)
  • Imatinib (Gleevec) (Treats Cancer–Leukemia)
  • Indinavir (Crixivan) (Treats HIV)
  • Isavuconazonium (Cresemba) (Treats Fungal Infections)
  • Isocarboxazid (Marplan) (Treats Depression)
  • Isosorbide Dinitrate or Monohydrate (Isordil Titradose, Dilatrate-SR, Imdur, Imdur ER, Ismo, Monoket, IsoDitrate) (Treats Heart Disease and Chest Pain)
  • Itraconazole (Sporanox, Onmel) (Treats Fungus and Yeast)
  • Ivacaftor (Kalydeco) (Treats Cystic Fibrosis)
  • Ketoconazole (Nizoral, Extina, Ketodan Kit, Kuric, Nizoral A-D, Xolegel) (Treats Fungal Infections)
  • Lopinavir; Ritonavir (Kaletra) (Contains Ritonavir and Treats HIV)
  • Lorcaserin (Belviq) (Weight Control)
  • Lurasidone (Latuda) (Treats Depression)
  • Mifepristone, RU-486 (Korlym, Mifeprex) (Treats Cushing’s Syndrome and Ends Pregnancy)
  • Mitotane (Lysodren) (Treats Cancer and Cushing‘s Syndrome)
  • Monoamine oxidase inhibitors (e.g., Azilect, Marplan, Nardil, Parnate) (Treats Depression)
  • Nebivolol (Bystolic) (Treats High Blood Pressure)
  • Nelfinavir (Viracept) (Treats HIV)
  • Nesiritide (Natrecor) (Treats Heart Failure but is an IV drug)
  • Netupitant (Akynzeo) (Prevents Nausea and Vomiting)
  • Nifedipine (Procardia, Nifedical XL, Adalat, Procardia XL) (Heart Disease among others)
  • Nilotinib (Tasigna) (Treats Cancer–Leukemia)
  • Nitrates (Isordil Titradose, Dilatrate-SR, Imdur, Imdur ER, Ismo, Monoket, IsoDitrate) (Treats Heart Disease and Chest Pain)
  • Nitroglycerin (Nitro-bid, Nitrocot SA Capsule, Nitro-dur, Nitrostat, Nitrodisc, Nitrek transdermal, Minitran, Nitrol ointment, Transderm-Nitro, Nitro-Time, Nitrotab, NitroMist, Nitro-Par, Nitrolingual, Nitroquick, Transderm-Nitro, Nitrogard, Nitroglyn, Nitrong) (Treats Chest Pain and Heart Conditions)
  • Nitroprusside (Nipride RTU, Nitropress) (Heart Failure and High Blood Pressure)
  • Ombitasvir; Paritaprevir; Ritonavir (Technivie, Viekira Pak) (Treat Hepatitis C)
  • Phenoxybenzamine (Dibenzyline) (Treat High Blood Pressure and Pheochromocytoma)
  • Phentolamine (Regitine, Oraverse) (Erectile Dysfunction, High Blood Pressure)
  • Phenylephrine (e.g.,Sudafed) (Decongestant)
  • Posaconazole (Noxafil) (Treats Fungal Infections)
  • Prazosin (e.g., Minipress, Vasoflex, Lentopres, Hypovase) (Treats High Blood Pressure, PTSD, and Anxiety)
  • Ribociclib (Kisqali) (Treats Cancer)
  • Riociguat (Adempas) (Treats High Blood Pressure in the Arteries of the Lung)
  • Ritonavir (Norvir) (Also found in Technivie and Viekira Pak) (Treats HIV and Hepatitis C)
  • Sapropterin (Kuvan) (Treats a disorder that causes amino acid buildup in the brain)
  • Saquinavir (Invirase, Fortovase) (Treats HIV)
  • Silodosin (Rapaflo) (Treats an Enlarged Prostate)
  • Tacrolimus (Prograft, Advagraf XL, Protopic, Hecoria) (Treats Organ Transplants)
  • Tamsulosin (Flomax) (Treats an Enlarged Prostate)
  • Telaprevir (Incivek, Incivo) (Treats Hepatitis C)
  • Telithromycin (Ketek, Ketek Pak) (Antibiotic)
  • Telotristat Ethyl (Xermelo) (Treats diarrhea in cancer patients)
  • Terazosin (Hytrin) (Treats High Blood Pressure)
  • Tipranavir (Aptivus) (Treats HIV)
  • Verapamil (Calan, Isoptin) (Treats High Blood Pressure, Angina, Irregular Heart Beats)
  • Vigabatrin (Sabril) (Treats Seizure Disorders)
  • Voriconazole (Vfend) (Treats Fungal Infection)