Valentine and Viagra

Until recently, it was a problem that few men talked about, preferring silent suffering to the shame and embarrassment associated with impotence — notably on special romantic occasions, such as Valentine’s Day. In 1992, an expert panel convened by the US National Institutes of Health tried to remove the stigma by offering the term “erectile dysfunction” (ED) to replace “impotence,” which is derived from the Latin word for “loss of power.” It was a good idea, but it didn’t help. However, everything changed in the spring of 1998, when sildenafil (Viagra) burst on the scene. Within days, male sexuality was making headlines and, within weeks, sales of the little blue pill were making history. Viagra has helped countless men with impotence since then, and it has spawned the development of two similar drugs: vardenafil (Levitra) and tadalafil (Cialis).

Who Is At Risk?

In simple terms, impotence is the failure to achieve a normal erection. But since nearly every man experiences erectile failure from time to time, doctors restrict the formal designation of impotence to cases where a man is unable to develop and sustain an erection adequate for intercourse in at least 25 percent of attempts.

Whether it’s called impotence or erectile dysfunction, it’s an extremely common problem. Age is the strongest predictor. A 2002 US survey found that only eight percent of men in their 40s reported significant erectile dysfunction, but the prevalence rose to 19 percent for men in their 50s and to 39 percent for men 60 and older. All in all, nearly a quarter of men older than 40 reported that they were frequently unable to get and keep a satisfactory erection. That means that hundreds of thousands of men need help; fortunately, most can benefit from treatment.

What Are The Causes?

So many parts of the body must work just right to produce an erection, so it’s hardly surprising that many problems can arise. The common culprits are diseases that damage blood vessels and nerves; diabetes, hypertension, and atherosclerosis are the leading examples.

Since erections depend on the arteries that supply blood to the penis, arterial disease is the most common cause of impotence. Disorders of the nervous system are also frequently responsible. Diabetes, which can damage both the blood vessels and the nerves, is a common cause of impotence. Up to 50 percent of diabetics become impotent. Many impotent men blame their hormones, but endocrine disorders account for no more than 15-20 percent of all cases of erectile dysfunction. Until recently, most impotence was blamed on anxiety or depression. Indeed, many impotent men may have psychological disorders, but it’s now clear that mental distress results from impotence rather than the other way around. Still, psychological factors are responsible for about 15 percent of all impotence.

Impotence is also a side effect of many drugs. Older men are particularly vulnerable because they often take more than one drug that might cause erectile dysfunction, and their medical problems may also cause impotence. There is no simple way to tell if a medication is to blame. Instead, it’s a trial-and-error process of removing a medication, then waiting two to six weeks to see if potency returns. Many suspect medications, however, are important for health. Only a physician should juggle prescription drugs, but the patient has an important role, too. His first task is to report the problem. Then, he should give the doctor a list of all his medications, both prescription and over-the-counter. It sounds obvious, but many men just don’t bring up the subject and some doctors neglect to ask.

It’s been estimated that up to 25 percent of all erectile dysfunction is related to drugs. So, medication should always be the first cause to consider. It is also the most easily corrected. Table 1 contains a partial list of medications that have been implicated.

How Is It Treated?

Most men with erectile dysfunction want to try a pill. It’s a good way to proceed, but before a doctor writes the prescription, he should ask himself if there are underlying problems that can be corrected and if there are, he should proceed to treat them first. In more than half the cases of impotence, however, the underlying problem cannot be corrected. Vascular and neurological impotence, diabetes, and impotence caused by prostate surgery or radiation therapy fall into this category. That’s where “the big three” come in.

Are These Pills Effective And Safe?

These pills are effective. And despite dueling ads, the three medications have similar success rates. In all, about 70 percent of men respond well to the drugs, but the rates vary according to what is responsible for the erectile dysfunction. Men with impotence of no identifiable organic cause fare best with a 90 percent success rate. In contrast, only 50 percent of men with diabetes respond well. Fortunately, many men who fail with oral drugs will respond to other treatments.

These pills are also safe. And in men without cardiovascular disease, they are very safe. The three rivals have similar side effects. The most common one is headache which occurs in up to 16 percent of men. Other reactions include facial flushing, nasal congestion, indigestion, and diarrhea. About four percent of the men who take Cialis experience backache, which is mild and self-limited. A few Viagra or Levitra users have visual disturbances, typically in the form of impaired color vision or a bluish haze. Like the other common side effects, such visual abnormalities are mild and temporary. Still, men with retinitis pigmentosa, a rare eye disease, should check with their ophthalmologists before using these medications.

Headaches and blue vision are one thing; cardiac abnormalities, quite another. Are ED pills safe for the heart? The drugs are safe for healthy hearts, but all men with cardiovascular disease should take special precautions, and some cannot use them under any circumstances. The problem is their effect on arteries. All arteries, not just those in the penis, generate nitric oxide, so any artery can widen in response to Viagra, Levitra, or Cialis. It doesn’t happen very often, but the drugs may temporarily lower the blood pressure of healthy men by a small amount, typically 5-8 mm Hg.

So, all experts agree that men who are taking nitrates cannot use the ED pills. This includes all preparations of nitroglycerine (short-acting, under-the-tongue tablets or sprays), long-acting nitrates (isosorbide dinitrate or Isordil, and others, and isosorbide mononitrate, Imdur, and others), nitroglycerine patches and pastes, and amylnitrite or amyl nitrate (so-called poppers, which some men use for sexual stimulation). Men who have taken Viagra or Levitra must not take nitrates for 24 hours; for Cialis, the ban extends to 48 hours, a disadvantage for men at risk for heart disease.

Faced with concern about ED pills and the heart, the US FDA has urged caution in patients who have suffered heart attacks, strokes, or serious disturbances of the heart’s pumping rhythm in the previous six months, in men with low blood pressure or uncontrolled angina, and in men with low blood pressure or uncontrolled high blood pressure (above 170/110 mm Hg). Because certain medications can boost the blood levels of these drugs, men taking erythromycin or certain anti-fungal or anti-HIV medications should use only a lower dose of these three ED pills. Reduced dosage is also important for men with advanced age and for those with significant kidney or liver disease.

Although you’d never know it from their ads, Viagra, Levitra, and Cialis are very similar. But they do have some differences, which are summarized in Table 2.

By itself, an ED pill will not produce an erection, but it will improve the erectile response to erotic stimulation. For best results, the drugs should be taken about an hour before sexual activity and should not be used more than once a day. These medications are not aphrodisiacs, and they should be used only to correct impotence, not to enhance sexual performance. Men who do not respond to a full dose in two or three different occasions should try other treatments.

By and large, however, these drugs are effective and safe. For those with erectile dysfunction, they are heaven-sent. And when it works, it will feel as if — as the song goes — “each day is Valentine’s Day”!