Viagra vs. Cialis vs. Levitra vs. Stendra: What's The Difference?

Dr. Constance Odom, MD

Medically reviewed by

Dr. Constance Odom, MD

Dr. Constance Odom, MD

About

Constance Tambakis Odom, MD graduated in 1987 with her Doctorate of Medicine from the New York Medical College, and was an Anesthesiologist Resident from 1988 to 1991 at the Brookdale Medical Center PGY II (CA-I)-PGY IV (CA-III). She is Board Certified by the American Board of Anesthesiology since 1998 and American Academy of Anti-Aging Medicine since 2002. Constance Odom, MD is affiliated with the American Medical Association, American Academy of Anti-Aging Medicine, American Society of Anesthesiology, Georgia Society of Anesthesiology, Hellenic Medical Society of New York, North Carolina Society of Anesthesiology, and Society of Ambulatory Anesthesia.

Credentials

Medical Director At:

• Nu Image Medical
• MetroMedispa P.A.

Staff Anesthesiologist at:

• Betsy Johnson Regional Hospital in Dunn, NC
• Onslow Memorial Hospital in Jacksonville, NC
• Duplin General Hospital in Kenansville, NC

Director of Anesthesia Services at:

• Jacksonville Surgery Center in Jacksonville, NC

Written by our editorial team.

Last Edited 1 year ago · 7 min read

According to the  Urology Care Foundation, approximately 30 million men have erectile dysfunction, more commonly known as ED. The disorder is characterized by the inability to achieve and maintain an erection following sexual stimulation and has most men feeling emotionally and physically defeated. The condition can be managed/treated using oral medications such as  Viagra, Cialis, Levitra, and Stendra. 

These FDA-approved options use a non-invasive approach to eliminate the symptoms of ED, making them safe to use for most men. They have an innate ability to manipulate the body into producing a full erection which means their high efficacy rate does not interrupt normal body processes. These treatment options have a few similarities, but what sets them apart?

Below we take a better look at each treatment option,  their capabilities, benefits, and differentiating factors to help ED patients choose an option that best suits their needs:

Basic Overview of Viagra, Cialis, Levitra, and Stendra

• Viagra

More popularly known as the 'little blue pill,' Viagra is a trademarked ED treatment created by the pharmaceutical giant Pfizer. The tablet was originally created to minimize symptoms of high blood pressure and angina but caused users to experience erections. This effect earned it a place as the first approved ED treatment on the mainstream market. Viagra uses the active ingredient sildenafil citrate to execute its function. 

The tablet has several strengths, allowing tailored and accurate dosage administration. The variance in strength also makes the tablet more adaptable to the patient's personal circumstances and health factors. A single Viagra dosage can help patients achieve and maintain an erection for standard periods. It also influences the hardness and viability of an erection, ensuring that it is adequate for satisfactory sexual intercourse.

Viagra has an impressive potency rate and effectiveness. This is because the tablet is rapidly absorbed by the gut, with maximum effects reached within 60 minutes following sexual stimulation. A PubMed study analyzing titrated doses showed this and pinpointed the most effective Viagra dose to be 50mg or 100mg. This does not mean that the lower doses are ineffective, just that a higher number of patients respond better to these doses. 

• Cialis

Gaining its official FDA stamp of approval in 2003, Cialis is an oral treatment used to manage/treat symptoms of ED and benign prostatic hyperplasia (BPH), a condition that causes an enlarged prostate. The tablet uses a single active ingredient, called tadalafil, to minimize symptoms of ED and facilitate an erection. Cialis is available in two versions—fast release (as-needed) and slow release (daily), which come in different strengths. 

Lower strength Cialis is often recommended for long-term use and ideal for those who often engage in spontaneous sexual intercourse. While higher strength Cialis is used on an as-needed basis and recommended for those who engage in planned intercourse. According to a study on Science Direct, Cialis is well tolerated in a wide range of patients and can even be taken long-term without posing any risks to users' overall health. 

Its excellent safety and tolerability profile allow it to be safely used with other treatments or polypharmacy treatment plans. This makes it an idyllic option for the elderly or patients with underlying health issues. The tablet supports a firm erection approximately 30-60 minutes after consumption, provided that adequate sexual stimulation is experienced. 

• Levitra 

Released to the mainstream market in 2003, Levitra is a treatment that aims to minimize and eliminate symptoms of ED. Levitra uses the active ingredient, vardenafil, to improve processes involved in achieving and sustaining a penile erection. When paired with sexual stimulation, Levitra causes an erection adequate enough for successful penetrative intercourse. 

The treatment is available in multiple strengths, accommodating the needs of a wide range of users. Levitra has quite a large patient following and comprehensive studies proving its efficacy and safety. PubMed study evidence shows that various strengths of the medication are well-tolerated, with users reporting relevant improvements in erectile function. 

The tablet is more aptly suited for short-term use but can be used long-term if a professional's approval is gained. It can safely be used in treatment plans that contain other medicines and takes approximately 30 minutes after administration to produce effects.

• Stendra

Stendra is a second-generation treatment that was developed in the 2000s. The FDA officially approved the product in 2012, making it a newcomer in the ED treatment industry. Stendra is similar to other popular ED treatments on the market and uses the same non-invasive approach to support a firm erection. Stendra uses the active ingredient avanafil, which comes in different strengths to support a wide range of patient needs and varying severities of ED. 

The product has excellent efficacy, safety, and tolerability rate supported by clinical evidence from NCBI. The evidence shows that Stendra has a fast onset of action time frame of 15 minutes, favoring spontaneous and planned sexual encounters. Moreover, the active ingredient, avanafil, in the formula has a low chance of interacting with other medications and a low chance of side effects. Stendra can be taken in small doses daily or large doses as needed. 

This means that it can be used long or short-term. The treatment can also be taken in conjunction with other medications. The cumulative data also suggested that Stendra is suitable for patients with ED and comorbid cardiovascular diseases who are on nitrates. This is a huge benefit as nitrates are one of the primary substances that cannot be taken with ED medicines. 

Do These Treatments Work Differently?

After reading the overviews above, I'm sure you've noticed quite a few differences between these treatments. However, the mechanism of action is not one of them. The way these treatments work are identical because they all belong to the PDE5  inhibitor class of medication. This means that Viagra, Cialis, Levitra, and Stendra stop the PDE5 enzyme from doing its job. 

The PDE5 enzyme is created naturally by the body to disable an erection. By inhibiting or stopping this enzyme from carrying out its function, the treatment options above support a sustained erection. They also induce blood vessel dilation (widening of blood vessels), relax muscles, and allow larger volumes of blood to enter the penile region, facilitating a fuller, more rigid erection. 

This mechanism of action also supports a faster sexual response. Although Viagra, Cialis, Levitra, and Stendra work similarly, they have different durational effects. This is primarily because they each use a different active ingredient to perform their function. Below we look at the differences at onset times (how long treatment takes to work once consumed) and durational effects (how long a treatment's effects last).

Dosage and Usage Instructions 

Dosage and usage guidelines are an expert-designed strategy that helps patients appropriately utilize

therapeutic compounds (active ingredients) in treatments such as Viagra, Cialis, Levitra, and Stendra. Due to the different composition/formula used to create each of these treatments, the dosage/usage guidelines and strength variation slightly differ. 

Below we take a look at the differences:

Side Effects and Efficacy 

Because these treatment options have the same effect on body processes, the possible side effects that come with them are similar as well. The most common side effects are mild congestion, headaches, nausea, and flushing. Although the adverse effects are similar, the side effect rates (possibility of side effects) when using each treatment differ. The efficacy rates (how well a medication works) of these treatments differ as well.

A large-scale study published by the Europen Association of Urology presented the evidence below regarding these ED treatments: 

• Viagra had the greatest efficacy but also had the highest overall side effect rate

• Cialis had intermediate efficacy but had the lowest overall side effect rate 

• Levitra and Stendra had similar overall side effect rates, which were lower than Viagra but higher than Cialis. The efficacy rate of Levitra and Stendra was lower than Viagra but higher than Cialis. 

Those who want to prioritize efficacy can opt for Viagra. However, Cialis is a better choice for tolerability. If Cialis is not potent enough to meet treatment goals, Levitra or Stendra should be the next option due to its balanced efficacy and side effect profile.  

Interactions and Contraindications 

Viagra, Cialis, Levitra, and Stendra are all first-line medical treatments for ED, which means it's the best option for managing symptoms of the condition. Although they are the first preference, there are some instances where they cannot be used due to the possibility of interactions and contraindications. In essence, interactions refer to the negative effects produced when contrasting medicines are taken together. 

Contraindications, on the other hand, refer to health conditions/symptoms that a person might have which prevent treatment use. Interactions and contraindications can either decrease or increase the effects produced by a treatment or induce serious side effects. Viagra, Cialis, Levitra, and Stendra cannot be used with the following or in the below circumstance: 

Interactions:

• Other PDE5 inhibitors

• Blood pressure tablets

• Alpha-blockers and nitrates 

• Guanylate cyclase stimulators

• Anti-fungal medication/treatment

• Herbal and pharmaceutical ED treatments

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Medications used the manage/prevent HIV/AIDS

• Grapefruit or products that contain extracts of grapefruit 

• Heart medications to treat conditions such as angina attacks

Contraindications:

• Penis abnormalities or penis injuries

• Blood vessel issues, pulmonary veno

• Hyperlipidemia (high fats in the blood)

• Diabetes, stroke, or severe stomach ulcers

• Irregular heartbeat or severe chest pain (angina)

• High/low blood pressure (hypertension or hypotension)

• Eye issues–retinal disorders, retinitis pigmentosa (an inherited eye disorder)

• Blood or bleeding disorders– leukemia, multiple myeloma (blood-related cancer)

These interactions and contraindications apply to all four of these treatments. However, there is an exception regarding Levitra and Stendra. Instead of completely ruling out Levitra and Stendra's use in the above circumstances, adjustments can be made to accommodate their use. We expand on this below:

When using Levitra, dose adjustments can be made to accommodate the following treatments/circumstances:

• Patients with liver issues

• Those using antiretroviral drugs used to manage or prevent HIV (indinavir, ritonavir, saquinavir, or atazanavir) 

• Individuals on antifungal medications ketoconazole or itraconazole

• Patients on antibiotics clarithromycin or erythromycin

When using Stendra, dose adjustments can be made to accommodate the use of the following treatments/circumstances:

• Diabetes patients 

• Moderate CYP3A4 inhibitors, such as erythromycin, amprenavir, or diltiazem

• Alpha-blockers and nitrates 

These exceptions are definitely differences of note as older ED treatments can not be used in these circumstances. Evidence from a study on DovePress shows that this may be due to the rapid onset time and shorter durational effects of Stendra and Levitra. Their short stay in the body means they don't have enough time in the bloodstream to cause interactions or contraindications.

Pros and Cons Weighed Up

Comparing treatments such as Viagra, Cialis, Levitra, and Stendra, can be hard considering that they share quite a few commonalities. However, it is very necessary when choosing an ideal aid for short or long-term use. Below we've tabulated the pros and cons of each of these treatments to help patients easily identify the treatment that best suits their needs.

Viagra, Cialis, Levitra, and Stendra, Which is the Best Choice?

Viagra, Cialis, Levitra, and Stendra are four of the most popular ED treatments on the market. Their large consumer following can be attributed to their many features and benefits. These agents have become the first-line therapy for ED and are preferred by health care practitioners and patients alike. They stand firm as safe, convenient, and effective methods for improving ED. Given the lack of adequate head-to-head trials that include all of these treatments, it is difficult to determine which is better than the other. 

However, considering that each ED patient is different and symptoms vary in intensity, we would say, selecting an overall ideal choice would be pointless as it depends on the user and their needs. This is the primary reasons we suggest taking a close look at the differences between these treatments, as it can ensure the decision made fosters positive results. 

8 Sources

Nu Image Medical has strict sourcing guidelines to ensure our content is accurate and current. We rely on peer-reviewed studies, academic research institutions, and medical associations. We strive to use primary sources and refrain from using tertiary references. 

https://www.urologyhealth.org/urology-a-z/e/erectile-dysfunction-(ed)

https://pubmed.ncbi.nlm.nih.gov/10400408/

https://www.sciencedirect.com/science/article/abs/pii/S0302283803005852

https://pubmed.ncbi.nlm.nih.gov/15082207/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547533/

https://www.sciencedirect.com/science/article/pii/S0025619612006684

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4155803/

https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.942.9905&rep=rep1&type=pdf

This article is for informational purposes only and does not constitute medical advice. The information contained herein is not a substitute for and should never be relied upon for professional medical advice. Always talk to your physician about the risks and benefits of any treatment. Nu Image Medical may not offer the medications or services mentioned in this article.