Quote a tablet after you name the failure
Nobody on Keizersgracht quotes a tablet until the failure has a name. An erection is a coordinated event: arterial inflow, trapped venous outflow, intact nerves, a usable testosterone backdrop, and a brain that will allow the spark. Break any one piece and a PDE5 slip looks 'dead.'
Men arrive with a price in their mouth. I ask for a timeline instead. Sudden after prostate surgery is not the same file as a slow fade beside rising glucose. Lifelong difficulty with a new partner is not the same file as a man who still wakes with a firm morning erection. Those details sort vascular, nerve, hormone, and mood before anyone says 20, 100, or 10.
This page is the workup slip. It is not a shop. It is not a fourth PDE5 monograph. If you already know the cause and want a clock, use the three-clock comparison. If you do not know the cause, stay here.
Blood that never arrives is a vessel story
Blood that never arrives is a vessel story. The penis is a vascular organ. Atherosclerosis, diabetes, smoking, and high blood pressure steal inflow the same way they steal it from a heart. ED can show up years before a coronary event. That is why I treat a new erection complaint in a man over forty as a cardiovascular hint, not as a joke.
Endothelial lining releases nitric oxide. If that lining is sick, a PDE5 inhibitor has less spark to amplify. Tablets still help many vascular men - the class was built for this plumbing - but a tablet without blood pressure, lipids, and glucose on the parchment is a skipped peel.
Venous leak is the other plumbing miss: blood arrives and will not stay. A PDE5 slip may still assist. When it does not, the next tools are not a bigger milligram from a search title. They are a specialist exam and, sometimes, injection or implant talk. Do not stack three INNs hoping one will cork a leak the enzyme cannot cork.
The workup this desk asks before any milligram
Peel order before a price is spoken
- Holds first: nitrates, riociguat, unstable heart symptoms.
- Vessel clues: BP, glucose, lipids, smoking, claudication.
- Nerve clues: surgery, spine, neuropathy, pelvic radiation.
- Hormone clues: desire, mornings, two morning T draws if low.
- Mood clues: new partner, new SSRI, alcohol, a tablet-as-test ritual.
The workup this desk asks before any milligram is short and unfashionable. Blood pressure. Glucose or A1c. A lipid glance. Morning testosterone when desire or mornings are off. A medicine list that includes nitrates, antiandrogens, spironolactone, and the QT agents if vardenafil is even in the room.
Sexual history is the cheap test everyone skips. Sudden versus slow. Partner-specific versus all settings. Pain, bend, or a plaque - Peyronie is a different file. Ejaculation and orgasm still present? That split matters. A man who climaxes with a soft penis is not the same man who has no climax at all.
I do not order a nocturnal penile tumescence gadget on every chart. I do listen for morning erections. I do not skip a genital exam when the story suggests anatomy. And I do not quote Cialis 20, Viagra 100, or Levitra 10 until the nitrate drawer is empty.
Testosterone is a chapter, not the whole chart
Hormone card - peel before any milligram slogan
Testosterone is a chapter, not the whole chart. Desire, energy, and morning erections can sag when morning total testosterone is truly low on more than one draw. Replacing a normal level because a tablet failed is how people buy acne and a thicker blood without an erection.
I want a morning sample, then a repeat, plus LH to see if the problem is testicular or pituitary. Thyroid and prolactin belong on the same bench when the story is odd - headaches, visual fields, milk, or a sudden desire crash. Those are not PDE5 questions.
Lowish testosterone plus vascular disease is common in the same decade. Fixing one number does not crown the file. A man may still need a slip after hormones are honest. He may need no slip if desire was the only missing piece and replacement restores it. Score the chapter. Do not let it eat the book.
When the tablet fails, the diagnosis was often wrong
When the tablet fails, the diagnosis was often wrong - or the trial was not a trial. No stimulation. Heavy plate on sildenafil or vardenafil. One attempt on daily tadalafil before day five. A 100 mg diamond on top of a nitrate the man forgot to mention. Those are process failures.
True class failure after several attempts, right plate, real arousal, and a fair dose means we reopen vessels, nerves, hormones, and mood. We do not add a second INN the same night. We do not invent a 20 mg Levitra trophy because 10 mg 'felt weak' after a steak.
Partners belong in the room when the man agrees. A lot of 'dead pills' are two people waiting for the drug to create desire that neither of them brought. I would rather have that awkward conversation than sell another clock.
A cord or a nerve can mute the nitric spark
A cord or a nerve can mute the nitric spark. Prostatectomy, pelvic radiation, spinal injury, multiple sclerosis, and some neuropathies interrupt the message that tells the vessels to open. No message, no cyclic GMP rise, no substrate for a PDE5 tablet to protect.
Nerve-sparing surgery leaves a window where function can return over months. Early PDE5 use in that window is a rehabilitation conversation with the surgeon, not a 100 mg diamond from a drawer. Non-nerve-sparing stories need a different honesty: tablets may do little, and vacuum or injection files deserve an earlier seat.
Diabetes sits on both lists - vessels and nerves. A man with long-standing glucose chaos who 'failed Viagra' often failed a combined file. I still offer a PDE5 trial. I also score feet, reflexes, and A1c before I call the class useless.
Anxiety writes its own loop
Anxiety writes its own loop. One failure, then a watchful third party in the room - the man's own attention - and the nitric spark never arrives. Morning erections that are still firm are a clue the plumbing can work. Situational failure with a new partner is another.
PDE5 tablets can break the loop by giving a first success. They can also feed it if the tablet becomes a test. Daily tadalafil's quiet background sometimes helps here because the countdown leaves the bed. That is a mood reason to open the chip lane, not a proof that 5 mg is 'stronger' than 100 mg.
Depression, alcohol, and some SSRIs write parallel files. I ask about new medicines before I raise a diamond. A man who started a serotonin agent last month and lost both desire and firmness is not a Levitra selectivity problem. He is a side-effect problem.
A PDE5 slip is one tool on a longer bench
A PDE5 slip is one tool on a longer bench. It needs arousal. It needs enough endothelial spark. It needs a hold list that is clean. After that, the clock choice is almost administrative: long almond, late diamond, cautious 2.5-or-10.
Lifestyle is a tool people treat as a lecture. Weight, walking, sleep apnoea, and stopping tobacco move erections without a milligram. I say that once, plainly, then I still offer a slip if the man wants one and the holds are clear. Preaching without a tool is how clinics lose people.
Vacuum devices, intraurethral pellets, injection therapy, and implants sit further down the bench. They are not moral failures. They are what we reach for when the enzyme trick has no substrate left. A man after non-nerve-sparing surgery deserves that map early, not after six random internet tablets.
File the cause, then decide if a slip even belongs
File the cause, then decide if a slip even belongs. Vascular hints go to a heart-risk look. Nerve stories go to the surgeon or neurologist who owns the injury. Hormone chapters get two morning draws. Mood loops get time and sometimes a quiet daily chip.
Only then do the three locks mean anything: Cialis 20 mg once, Viagra 100 mg, Levitra 2.5 or 10. They are clocks on a parchment, not prices and not crowns. Read their labels. Read their deep-dives. Hold the nitrates.
A tablet quoted before a name is jewellery. This desk files jewellery in a drawer. Bring the failure. Then we can talk about a tool.
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