Sildenafil
Helps you get and keep an erection.
Sildenafil helps more blood enter the penis during sexual stimulation. It blocks PDE5, an enzyme that breaks down a natural signal that keeps blood vessels relaxed.
About sildenafilVital Step Men · Meet 4th Gear
An oral-liquid
option for ED.
Meet 4th Gear, a compounded prescription oral liquid for erectile dysfunction. Four active ingredients in one formula, with private online evaluation and discreet delivery if prescribed.
From $1295-pack · per refill
Subscription renews monthly. Prescription required. A clinician determines if treatment is right for you.
- Taken by mouth
- Online evaluation
- Discreet delivery
Your next step, made easy
Private care. Made simple.
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Start online
Share your health history and goals in a private online evaluation.
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Get expert guidance
A licensed clinician reviews your health and prescribes if appropriate.
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Delivered discreetly
Medication ships discreetly to your door, if prescribed.
LegitScript certificationVerify vitalstep.com
What is 4th Gear?
Four active ingredients.
One prescription liquid.
4th Gear combines sildenafil, tadalafil, vardenafil and apomorphine in one compounded oral liquid. Here’s what each ingredient does, and how it relates to the erection response.
Tadalafil
Blood-flow support with longer action.
Tadalafil blocks the same PDE5 enzyme. Its longer action in approved tadalafil tablets can allow more flexibility around intimacy. Those tablet studies do not establish how long 4th Gear’s compounded liquid will work.
About tadalafilVardenafil
Supports the physical erection response.
Vardenafil also helps blood flow into the penis during sexual stimulation by blocking PDE5. It shares the same blood-flow pathway as sildenafil and tadalafil.
About vardenafilApomorphine
Acts on the brain’s erection signals.
Apomorphine stimulates dopamine receptors involved in erection signaling. It acts through the nervous system, while the other three ingredients act on the blood-flow pathway. It has been studied as a sublingual ED treatment.
About apomorphine researchThese descriptions explain the individual ingredients. Benefits, onset and duration studied for other formulations cannot be assumed for this compounded combination.
One formulation. 5-pack, 10-pack and 20-pack options.
Pack size changes the supply quantity, not the strength of your prescription.
How the ingredients relate to the erection response
The science, in plain English
Erections start with signals.
Blood flow makes them possible.
During sexual stimulation, nerve signals help muscles in the penis relax. Blood then fills the erectile tissue. These ingredients act on signaling and blood flow, two parts of that response.
Sexual stimulation
Starts the body’s erection response.
Nerve signals
Help the muscles in the penis relax.
Blood flow
Fills erectile tissue to create firmness.
Sildenafil · Tadalafil · Vardenafil
Help the blood-flow signal last.
The body uses a chemical messenger called cGMP to relax muscle in the penis. PDE5 breaks that messenger down. These three medicines block PDE5, helping preserve the relaxation signal so blood can flow in during sexual stimulation.
Apomorphine
Act on erection signaling.
Dopamine is one of the brain’s chemical messengers. Apomorphine stimulates dopamine receptors involved in erection responses. That is a different mechanism from the PDE5 ingredients; it does not establish a guaranteed increase in desire.
What does combining them mean?
This formulation brings ingredients acting on the blood-flow pathway and dopamine signaling into one oral liquid. That explains the different mechanisms present; it does not prove that the combination is more effective than a single medicine.
Three ingredients share the same drug class, so the combination needs an individual benefits-and-risks review. Your clinician considers your health, medications and previous ED treatment before prescribing.
How PDE5 medicines work · Apomorphine clinical trial. Research on individual medicines is not a clinical trial of 4th Gear.
Explore your treatment options.
Let’s talk about
what you want next.
More connection starts with an honest conversation. Tell us what you want from treatment, what you’ve tried and what matters to you. We’ll guide you through the next step.
- New to ED treatment?Share your symptoms and health history. A clinician can help you understand your options.
- Tried a pill before?Tell your clinician what you used, what helped and what didn’t.
- Prefer a liquid?4th Gear offers an oral liquid format, with instructions tailored to your prescription.
Know what you’re choosing
How 4th Gear
differs from a standard pill.
A different formulation and format. Your clinician helps decide which approach fits your health and treatment history.
| Treatment detail | 4th Gear | Single-ingredient ED pill |
|---|---|---|
| Active ingredients | Sildenafil, tadalafil, vardenafil & apomorphine | One active ingredient |
| Format | Oral liquid | Tablet |
| Formulation | Compounded combination | Depends on the product prescribed |
| Prescription | Clinician review required | Clinician review required |
4th Gear is not an approved generic equivalent of Viagra, Cialis or Levitra. More ingredients do not guarantee a better result. Discuss the right treatment with your clinician.
Your 4th Gear plan
Choose your pack.
Choose a 5, 10 or 20 pack. Each is a recurring subscription. Your clinician determines how and when to use your medication.
Subscription renews monthly. Dispensing and refills follow your prescription.
Review the subscription and cancellation terms at checkout.
The people behind your care
A team in your corner.
A plan built around you.
Bring your goals, your questions and your health history. A licensed provider reviews your information and helps you understand which treatment is right for you.
- Medical review before prescribing
- Medication and dose chosen for your needs
- A care team for treatment questions
How Vital Step works
From online evaluation
to your door.
Tell us about you.
Complete your online health form with your symptoms, medications and previous ED treatments.
Choose your 4th Gear pack.
Select a 5, 10 or 20 pack. Review the full charge and subscription terms at checkout, then submit your request for clinical review.
Your clinician takes it from here.
A licensed clinician reviews your information and decides whether treatment is right for you. Follow any requests for more information or consultation steps before a prescribing decision.
Start care with clear instructions.
If prescribed, the pharmacy prepares and ships your medication. Follow your pharmacy label, and contact your care team with treatment or refill questions.
After you submit, check your patient portal for review and delivery updates. Your treatment choice is a preference for your clinician to review, not a confirmed prescription.
Start my private evaluationWho’s behind your care?
Online care.
Licensed clinicians.
Vital Step Men
Your online starting point for ED treatment, plan selection and access to care.
A licensed clinician
Reviews your health history, medications and treatment options before making a prescribing decision.
A dispensing pharmacy
Prepares your prescribed medication and provides the label with your specific instructions.
About this medication. 4th Gear is a compounded prescription medication and is not FDA-approved. The FDA does not review compounded drugs for safety, effectiveness or quality before marketing. Important safety information · About compounding.
Questions about 4th Gear.
What happens after I submit my request?
Your request moves to clinical review. Check your patient portal for updates and follow any requests for more information or consultation steps. Your clinician confirms whether treatment is appropriate. If prescribed, the pharmacy prepares your medication, with tracking available in your portal when it ships.
Does choosing a treatment mean I have a prescription?
Your selection tells the clinician what you would like to explore. The clinical review is a separate step: your clinician considers your health history, medicines and any follow-up information before making the prescribing decision.
How does the online consultation work?
Start by completing the health questions online. A licensed clinician reviews the information you submit. If further information or consultation is needed, follow your care team’s instructions; submitting the form does not mean the review is complete.
When is my first payment taken?
Checkout authorizes your payment method; you are charged only if a clinician prescribes treatment. A temporary authorization hold may appear on your card. Review the full charge, renewal schedule and cancellation terms at checkout.
Is 4th Gear the same as Viagra or Cialis?
No. 4th Gear is a compounded combination, not an FDA-approved brand or an approved generic equivalent of either medicine.
How do I take it?
Follow the amount, method and timing on your pharmacy label. This is an oral medication; do not inject it. Ask your pharmacist if any instruction is unclear.
How quickly will it work?
Ask your clinician or pharmacist about expectations for your prescription. Timing varies, and claims about other ED products do not establish how this combination will work for you. Do not take extra medication because you have not noticed an effect.
Can I use it with another ED medication?
Do not add other ED medication. Share all medicines, supplements and recreational substances with your clinician so they can check for interactions. Read the important safety information below.
Does a larger pack mean a stronger treatment?
No. Pack size describes supply quantity. Your prescribed formulation, strength and instructions are separate. The number in a pack does not tell you how much or how often to take it.
How does billing work?
Choose your pack size. Your subscription renews monthly, with refills subject to your prescription. Your selected pack size does not tell you how often to take the medication. Review the subscription and cancellation terms at checkout.
What if I have tried ED treatment before?
Tell your clinician which medication you used, your response and any side effects. Do not change the amount or frequency yourself. Your care team can reassess the next step; results are not guaranteed.
4th Gear · Vital Step Men
Make your
next move.
Curious about 4th Gear? Start a private online evaluation and find out whether it’s right for you.
From $129 for a 5-pack per refill. Subscription renews monthly.
Prescription required. Treatment depends on clinical suitability.
Read before considering treatment
Important safety
information.
This overview does not replace your prescription information or a clinician’s advice.
Review your health and medications.
Do not use with nitrates, recreational nitrites (poppers) or riociguat. Do not add other ED medication. Share all medications and health conditions with your clinician so they can check interactions and whether sexual activity is appropriate for you.
Know when to seek help.
ED medicines can cause side effects such as headache, flushing and upset stomach. Seek urgent medical care for an erection lasting more than four hours or sudden vision or hearing loss. This is not a complete list of possible effects or interactions.
General medicine information: sildenafil, tadalafil, vardenafil and apomorphine (injection reference). These references do not establish the safety or effectiveness of the 4th Gear combination.