Sexual health
This is a plumbing problemfar more often than a confidence one.
An erection is a circulatory event. When it stops working reliably, that is usually information about your blood vessels rather than about you — and it is frequently the earliest information you will get.
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- Discreet packaging
- Licensed in your state
What you are actually buying
Not performance.The end of managing around it.
The part men describe afterwards is almost never the sex. It is not having to think about it in advance.
Photographs are of models and are for illustration only. They do not depict Revani patients or treatment outcomes. These medications do not work for everybody, and whether one is appropriate for you is a clinical decision.
What it is often telling you
An erection is a circulatory event.That is why this is worth a look.
In men with no other symptoms this can show up years before anything turns up in the heart. Which makes it the earliest useful information you are likely to get.
Men over forty have some degree of this. Almost none of them have said so to anybody.
A prevalence figure rather than a diagnosis, and it says nothing about severity. Erectile difficulty becomes more common with age and is very often treatable.Blood vessels
An erection is a vascular event. The same narrowing that affects arteries elsewhere affects these first, because they are smaller.
Blood pressure
Hypertension damages vessel lining over years. Several of the drugs that treat it also contribute, which is worth untangling rather than guessing at.
Blood sugar
Diabetes affects both vessels and the nerves involved. Erectile difficulty is sometimes how undiagnosed diabetes first announces itself.
Sleep apnoea
Interrupted breathing at night drives up blood pressure and drags down testosterone. Very common, very treatable, very often missed.
Testosterone
Low testosterone affects desire more than mechanics, so it is a real cause but rarely the whole story. Worth measuring, not worth assuming.
Medications you already take
Some antidepressants, beta blockers, certain diuretics and finasteride all contribute. Sometimes the fix is a change to something you are already on.
Most places in this category will sell you the tablet without ever asking why you need it. The tablet is the easy part.
What this does and does not mean about your heart
None of this means something is wrong with your heart. It means the symptom is worth a proper look rather than only a prescription, and that the evaluation is the part with real value in it.
If everything comes back clean, you will have that in writing and a treatment that works. If something turns up, you will have found it early, which is the entire point.
What you would actually be prescribed
Four tablets exist. The differencesare practical, not clinical.
Choosing between them is mostly about how long you want it to last and whether you would rather take something occasionally or something small daily — a question about your life, not your diagnosis.
SildenafilTaken when needed
The original. An hour ahead, and a heavy meal is the usual reason a first try disappoints.
TadalafilTaken when needed
Up to a day and a half, so there is nothing to plan around. Less affected by food.
Tadalafil, daily and low doseThe option nobody mentions
No timing to think about at all. Often helps prostate symptoms at the same time.
Reviewing what you already takeSometimes the whole answer
Adjusting an antidepressant or blood pressure drug may beat adding anything new.
Treating the cause underneathThe durable route
Changes the trajectory rather than the evening. We will say so if that is your answer.
The full detail on all five, including timing and food
SildenafilTaken when needed
The original, and still the one most men start on. Taken roughly an hour ahead, useful for several hours after that. A large or fatty meal beforehand slows it down noticeably, which is the single most common reason a first attempt disappoints.
TadalafilTaken when needed
Works for considerably longer — up to a day and a half — which for most couples matters more than the raw numbers suggest, because it removes the need to plan around a tablet. Less affected by food.
Tadalafil, daily and low doseThe option nobody mentions
A small dose every day instead of a larger one occasionally, so there is no timing to think about at all. It suits men who find the scheduling itself to be part of the problem, and it can help with urinary symptoms from an enlarged prostate at the same time.
Reviewing what you already takeSometimes the whole answer
If an antidepressant, a blood pressure drug or finasteride is contributing, changing or adjusting it may do more than adding anything new. This is unglamorous and it is occasionally the entire treatment.
Treating the cause underneathThe durable route
Blood pressure, blood sugar, sleep apnoea and weight all move the needle here, and unlike a tablet they change the trajectory rather than the evening. If the weight program is the more direct answer for you, we will say so.
One expectation worth setting: these do not create desire and they do not work without arousal. They make an erection possible, not automatic. If desire is the actual problem, a tablet will disappoint you, and that is a different conversation further down this page.
The one that matters
If you take nitrates,this medication can kill you.
Not a caution and not a relative risk. Together they can drop your blood pressure far enough to be fatal, which is why a prescriber has to see your medication list before anything is sent to you.
This includes poppers.
Nitroglycerin in any form, isosorbide mononitrate or dinitrate, a nitrate spray or patch, and amyl or butyl nitrite — the recreational kind, sold as poppers. People do not think of poppers as medication, so they do not mention them, and the interaction is identical. If either is in your life, say so plainly at the evaluation. It is not a judgement and it is not a reason we cannot help you; it is a reason we would choose something different.
The five histories that mean we pause rather than prescribe
A heart attack or stroke in the last six months
Not a permanent no, but not now either. Sex itself is a cardiac workload, and the right sequence is to establish that your heart is ready for it before adding anything.
Chest pain on exertion, or angina that is not stable
This needs to be sorted out first, and it is a reason to see someone in person. If you get chest pain during sex or exercise, that is the symptom to act on rather than the erection.
Blood pressure at either extreme
Uncontrolled high blood pressure and genuinely low blood pressure both change the risk. Both are manageable, and both come before a prescription rather than after it.
Riociguat, or other pulmonary hypertension drugs
Same mechanism as the nitrate problem and the same answer. Bring your full medication list, including anything a specialist started.
Alpha blockers for your prostate
Tamsulosin and similar drugs are not a bar, but they stack with this one on blood pressure. It changes dose and timing, so it needs to be on the record.
And three reasons to stop and get seen the same day.
An erection lasting more than four hours is an emergency and can cause permanent damage — go to an emergency department, do not wait it out. Sudden loss or dimming of vision in one eye, or sudden hearing loss or ringing, both mean stop taking it and get assessed urgently. All three are rare. All three are worth knowing before the first dose rather than after.
When a tablet is the wrong answer
Two questions sort most of this out,and you can answer both yourself.
Whether this is mechanical or not changes the treatment completely, and the wrong one simply does not work.
Did it come on gradually, or all at once?
A slow slide over months or years points at a physical cause. Something that changed suddenly, or happens with one partner and not another, is usually telling a different story.
Do you still wake up with erections?
If you do, the machinery is working, and the cause is more likely anxiety, exhaustion, alcohol or the relationship. If those have stopped too, the case for a physical cause is stronger.
If the honest answer is that a prescription will not fix this, you are better off hearing it from us than finding out one tablet at a time.
Performance anxiety, and why it is a real mechanism rather than a polite explanation
It is not a soft explanation offered to spare your feelings. Anxiety triggers the same response as any other threat, and that response actively works against an erection. One bad evening becomes anticipation of the next one, and the anticipation is now the cause. This loop is extremely common and it responds well to being treated as what it is.
A tablet can genuinely help break the cycle, by removing the uncertainty long enough for the anxiety to settle. That is a legitimate use of it. What does not work is a tablet alone, indefinitely, for a problem that was never mechanical.
The four findings that mean we send you to someone else
Chest pain on exertion, sudden onset after an injury or pelvic surgery, a curvature that is painful or getting worse, or a relationship in real difficulty — all of these need someone other than us, and we will tell you that rather than prescribe around it. Being referred out is not being turned away.
Desire is a different problem
Wanting to and being able toare not the same complaint.
A tablet that improves blood flow does nothing whatsoever for desire, and prescribing one for the other is how people conclude treatment does not work for them.
For men: why testosterone is the answer less often than you expect
Low testosterone is the cause people arrive expecting, and it is sometimes right — which is why it is worth measuring properly, in the morning, more than once. But it is one cause among several, and treating it when levels are normal does not produce desire, it just produces a prescription.
The other causes are less satisfying and more common: not enough sleep, too much alcohol, an antidepressant doing exactly what antidepressants do, untreated depression, chronic stress, and a relationship where the difficulty is not really about sex. We look at those before reaching for a hormone.
If testosterone is genuinely low and symptoms match, that belongs in the men’s hormone program, where it comes with a diagnosis and monitoring rather than on its own.
For women: the reason almost nobody is told, and the treatment almost nobody is offered
The most common reason sex becomes difficult around and after menopause is not desire at all — it is that it has started to hurt. Thinning tissue causes dryness, pain and urinary symptoms, and it is treated directly and effectively with a low-dose local oestrogen that barely enters the bloodstream. Very little about this is widely explained, and a great many women are never offered it.
Desire itself is worth separating from that. It is affected by sleep, stress, medication, hormones and context, and in women it is more often responsive than spontaneous — which is normal rather than a deficiency. There is reasonable evidence for testosterone helping low desire after menopause, and no product approved for women in the United States, so it is off-label, rationed and discussed in writing.
All of this lives in the women’s hormone program rather than here, because it belongs with the rest of that assessment.
Whichever applies, the evaluation is the same and it costs nothing. If the right answer sits in one of the other programs, we will move you there rather than sell you something from this one.
What you get
A prescription, and the reasonyou needed one.
Included in the program
- A physician evaluation read by a clinician licensed in your state
- A full medication review, because the interaction that matters is in there
- Bloods where your history suggests they change the plan, and not otherwise
- Treatment from a licensed U.S. pharmacy where it is appropriate
- A different medicine, or a different dose, if the first one underperforms
- An honest answer when the cause is not mechanical and a tablet will not fix it
- Referral in person where that is genuinely the right next step
- Direct messaging with your care team, and plain unbranded packaging
What it costs
Quoted in writing after your evaluation, and before you commit to anything.
The figure depends on which medicine is prescribed, whether it is taken daily or as needed, and whether anything else turns up that needs treating. The evaluation costs nothing to complete and no insurance is required at any point.
Start my evaluationWe prescribe FDA-approved medicines for this wherever possible. Where anything compounded is used, it is prepared by a licensed U.S. pharmacy, it is not FDA-approved, and your clinician will tell you so and explain why it was chosen.
Before you compare us to anyone
Six things this industry sellsthat you will not find here.
Embarrassment is the most profitable feeling in medicine, because it makes people buy quickly and ask nothing. Most of what is sold in this category is built on that.
Anything sold without asking about nitrates
This is the whole test. Apply it to every other site you have open.
Novelty blends and custom troches
No evidence they beat the approved tablets, and blending defeats price comparison.
Testosterone prescribed for an erection
Treats a number nobody measured, and commits you to therapy you may not need.
Shockwave, PRP and the priapus shot
Considerable cost, immature or absent evidence.
Bigger doses as a first move
Usually it is timing, a heavy meal or alcohol. Escalating first is simply more profitable.
Refills without a conversation
Chest pain on exertion is a new fact a repeat order will never surface.
Why, on each of the six
Anything sold without asking about nitrates
This is the whole test. If a site will take your money without establishing what else you take, it is not practising medicine, and the interaction it did not ask about is the one that can kill you.
Novelty blends and custom troches
Compounded mixtures marketed as stronger, faster or more potent than the approved tablets. There is no evidence they outperform what already exists, they are not FDA-approved, and the blending mainly serves to make price comparison impossible.
Testosterone prescribed for an erection
Testosterone drives desire far more than mechanics. Handing it out for erectile difficulty without confirmed low levels and matching symptoms treats a number nobody measured, and commits you to ongoing therapy you may not need.
Shockwave, PRP and the priapus shot
Sold at considerable cost on evidence that is still immature or absent. We would rather tell you it is unproven than take the money and let you find out.
Bigger doses as a first move
When a tablet underperforms, the usual reason is timing, a heavy meal or alcohol — not dose. Working through those costs nothing. Escalating first is simply more profitable.
Refills without a conversation
Blood pressure changes, medications change, and chest pain on exertion is a new fact that a repeat order will never surface. Ongoing treatment means ongoing contact with someone accountable for it.
Straight answers
The questions men askonce the door is shut.
If yours is not here, a clinician answers it during your consultation rather than after you have paid for something.
Safety and side effectsWill I become dependent on it?
Not physically. These medicines are not habit-forming and there is no withdrawal. What does happen is psychological reliance — some men become reluctant to try without one after a good run. That is worth naming early, and it is a reason we would rather also treat what is causing the problem than leave you on a tablet forever.
Can I drink?
A drink or two is fine and will not stop it working. More than that works against you — alcohol is a depressant and it suppresses the response directly, so a heavy evening can defeat a dose entirely. This is the most common reason a tablet appears not to work.
How long until I know whether it works?
Give any one medicine several separate attempts before deciding. Roughly a quarter of men who conclude a tablet failed them had the timing wrong, ate a heavy meal beforehand, drank too much, or expected it to create desire. If it genuinely has not worked across several fair attempts, we change the drug or look harder at the cause.
Is my partner going to know?
That is entirely your decision and we have no view on it. Packaging is plain and unbranded, and nothing on the outside indicates what is inside or who sent it. Worth saying, though: most partners find the silence harder than the problem.
I am on an antidepressant and it started after that. What now?
Very likely connected, and worth raising properly rather than working around. Some antidepressants affect this far more than others, and timing changes or a switch can resolve it. What we will not do is tell you to stop a medication that is working for your mental health — that decision belongs with whoever prescribed it, and we will coordinate rather than override.
Can I take it with my blood pressure medication?
Usually yes, with two exceptions that matter. Nitrates are an absolute no. Alpha blockers for the prostate stack with this one on blood pressure and need dose and timing adjusted rather than avoided. Bring the full list, including anything a specialist started and anything you buy yourself.
Do I need a blood test?
Sometimes. If your history suggests undiagnosed diabetes, cholesterol worth knowing about or low testosterone, then bloods change what we would do and we will arrange them. If your history is clean and the picture is straightforwardly mechanical, we will not order tests to look thorough.
Is this covered by my insurance?
We do not require insurance at any point, and nothing is charged to complete the evaluation. Coverage for this category is patchy even with insurance, which is part of why the price is quoted to you in writing up front.
You have been putting this off
The embarrassing part takes about three minutes and happens in a form,and nobody says the words out loud.
About three minutes. Nothing is prescribed at this step and nothing is charged.