What to do if Viagra won’t do
Erectile dysfunction (ED) — impotence — is an extremely common problem that affects up to 22% of American men, mostly in the older age groups. Once considered primarily a psychological disorder, it is now clear that most cases of impotence have a physical basis. The leading causes are the chronic diseases that damage blood vessels and nerves vital for normal erectile function; diabetes, atherosclerosis, and hypertension head the list (see last month’s Harvard Men’s Health Watch). The medications used to treat these problems and other ailments can also contribute to impotence. Hormonal abnormalities are less common, but they are particularly important to detect since they can be corrected. That’s also true of the psychological problems that cause up to 15% of impotence; table 1 summarizes some of the differences between psychological and physical impotence.
For many men, the hardest thing is to admit the problem. Every man experiences erectile dysfunction from time to time, but doctors define impotence as the inability to get and keep an erection satisfactorily for penetration on at least 25% of attempts. It’s a good definition, but it should not be used to exclude men with less severe difficulties from getting treatment. A simple questionnaire can help you determine if you are having erectile dysfunction. If so, talk to a primary care doctor, urologist, or endocrinologist.
The evaluation is quite simple these days. A careful medical history, including a review of your health habits and medications, is the first step. It’s also important to be evaluated for diabetes, hypertension, atherosclerosis, and cardiac risk factors. Many doctors also check blood levels of the male hormone testosterone; it’s an important test for men who experience loss of sexual desire as well as erectile dysfunction, but it’s less likely to help men whose spirit is willing but whose flesh is weak.
Although elaborate diagnostic tests are available, they are rarely necessary. Instead, the next step is usually a trial of one of the three oral medications that have revolutionized the approach to male sexuality. About 70% of men respond well to Viagra, Levitra, or Cialis, but the success rate is lower in men with diabetes and in men who have been treated for prostate cancer. In addition, men who take nitrate medication in any form cannot use any of these drugs, and men with unstable heart disease or poorly controlled blood pressure must also avoid them. Finally, a few men abandon ED pills due to unpleasant side effects.
Many men who fail to respond to Viagra or its newer rivals experience the frustration, embarrassment, and even shame that accompanied a diagnosis of impotence in the days before Viagra. Many give up. That’s a mistake, since other treatments may be effective. First, be sure you’ve given the oral medications a full try — but never take more than the approved maximum dosage and never use the drug more than once in a 24-hour period. Men who are recovering from a nerve-sparing radical prostatectomy should try an ED pill every month or two, since sexual function may improve over 6–18 months. Next, ask your doctor if any of your other medications may be impairing your erections. Finally, consider other treatments (see table 2, page 5); although they are more cumbersome than a simple pill, they can help some men who cannot take or do not respond to Viagra, Levitra, or Cialis.
Alprostadil injections
A successful erection requires an increased flow of blood into the penis. Alprostadil (also known as prostaglandin E1) is a potent vasodilator; it widens arteries, allowing them to carry more blood. But its potency is a drawback as well as an asset. It is very effective in producing erections, but to be safe it must be administered directly to the penis by injections or pellets.
The most effective way to take alprostadil is to inject it directly into the corpus cavernosa, the shaft of the spongy tissue that brings blood to the penis (see figure 1). It sounds like a torture, not a treatment, but most men can master the technique with brief instruction from a urologist. The needle is very small and the injection is generally well tolerated. The usual dose is 5–20 micrograms (mcg) per injection; some men respond to as little as 2.5 mcg, while others require up to 60 mcg. Doctors should monitor therapy and then prescribe the lowest dose that is effective.
Alprostadil works rapidly. Since it bypasses the nervous system and produces an erection by acting directly on arteries, it does not require sexual stimulation to do its work. Without sufficient erotic stimulation, however, some men may fail to achieve orgasm despite having good erections. Some men have reported a return of spontaneous erections after longterm alprostadil use, possibly because the drug has improved the penile circulation.
Alprostadil injections are highly effective, producing an erection in up to 80% of patients. Still, many men abandon the treatment, usually because they find it unpleasant or, in 15%–20%, painful. Side effects are usually limited to the penis; in addition to pain, prolonged erections occur in about 5% of men, and 1% suffer painful prolonged erections lasting four hours or more (priapism) that ( require emergency medical treatment to prevent permanent damage. Minor bleeding may occur, but the injections are safe even for men taking warfarin (Coumadin) or other blood thinners. Al prostadil should not be used more than once a day or three times a week.
Nearly every man who has a choice between alprostadil injections and oral medication prefers an ED pill. But alprostadil is effective in many men who fail to respond to pills and, unlike the pills, it is safe for men taking nitrate medications. Some men who do not respond to an ED pill or to alprostadil may respond to a combination of the two, but since low blood pressure is a serious risk, a trial of combination therapy requires careful medical supervision. About a third of patients who try combination therapy experience significant adverse effects.
Alprostadil is most effective when taken by injection, but men who find the procedure daunting or unpleasant can consider using the drug in pellet form.
The best medicine
Doctors have made great strides in treat- ing ED over the past 10 years. Spurred by the success of Viagra, more progress is sure to follow. But prevention is always the best medicine, and ED can be prevented. The key is to preserve vascular health with a program that will protect the circulation to the penis as well as the heart, brain, and legs. That means regular check-ups to detect and correct abnormal cholesterol levels, high blood pressure, diabetes, and other risk factors. Avoiding tobacco in all its forms is essential. Prevention also requires a good diet, low in saturated fat, trans fat, and salt, but high in fiber, whole grains, fruits, vegetables, nuts, and fish. Regular exercise is just as important, and weight control will also help protect blood vessels throughout your body. Finally, men who choose to drink should keep the amount low. It’s a comprehensive program that will preserve erectile function — and vigorous good health — as men age. Not even Viagra can top that.