End Erectile Dysfunction
Treatment recommendations for erection problems
The European Association of Urology issued updated guidelines on erectile dysfunction in 2006. These can be found in European Urology, 49, pages 806 to 815. The introduction to the article below can be found here.
Other pages on this website about the causes of erectile dysfunction and impotence
Other sections on erectile dysfunction
First-line therapy for ED
Nowadays, phosphodiesterase type 5 (PDE5) inhibitors such as Viagra are the treatment of choice. (Phosphodiesterase type 5 is an enzyme which has a role in the erection mechanism in the cavernosal tissue of the penis. Inhibition of PDE5 causes an increase in the blood flow in the arterial vessels of the penis, smooth muscle relaxation, and penile erection. (Read about it here: www.male-questions.com.)
Since Viagra was launched on the market in the year 2000, 20 to 30 million men have used the drug, and of this total, around 80% will have found it produces satisfactory erections up to one hour after ingestion.
Common observations about Viagra: its absorption into the bloodstream is reduced after a large meal heavy in fat; the tablets are available in 25, 50, and 100 mg forms, and the usual recommended starting dose is 50 mg; the dose may later be adjusted according to a man's response and the level of side-effects that he experiences.
Viagra maintains its efficiency for about 12 hours after ingestion; side-effects are mild and tend to decrease the more the drug is used, although it may be necessary to take a series of doses before man's body has fully acclimatized to the drug and he's getting maximum benefit from it.
In one study, improved erections were reported after six months of treatment by 56%, 77%, and 84% of men who were given doses of 25, 50, and 100 mg of Viagra respectively.
Although it's been rightly said that it's necessary to look at the social and relationship context in which Viagra is administered to deal with erectile dysfunction, there is a large body of men for whom the simple achievement of an erection is all that is required for successful therapy, and it is among these men where Viagra has perhaps been most useful.
Tadalafil (Cialis) is a similar compound to Viagra but has a slightly more rapid effect, usually working within 30 minutes after administration, although its maximum impact is felt after about two hours. It's also rather longer lasting than Viagra, having a longer half life, so that it is still effective up to 36 hours after it's been ingested.
Even better, its efficiency is not influenced by the food that a man has eaten before he takes the drug. In one study, after only three months of treatment, improved erections were reported by 67% and 81% of men taking 10 mg and 20 mg of Cialis respectively. It may be effective where Viagra is not.
The third well-known compound that is Vardenafil, marketed as Levitra. Again, this is effective after about 30 minutes, but it is markedly less efficient when taken after a heavy meal rich in fat. Although it has greater potency than Viagra, this does not necessarily translate into greater clinical efficiency.
Once again, adverse effects are rather mild in nature and may fade with time. In one study, after three months of treatment, improved erections were gained by 66%, 76%, and 80% of men, taking 5, 10, and 20 mg of Levitra respectively.
So one of the obvious questions is: which drug should a man choose to deal with his erection problems?
There are few if any comparative studies of the three, and it is therefore up to a doctor to advise a man, based on his experience of these drugs, as to which is most likely to be successful, and best tolerated.
This is why it's important for you to get at least an initial prescription from a doctor, so that you can be sure you're taking the right medication, even if you subsequently renew your prescription by means of online services.
There are some safety issues with PDE5 inhibitors: these centre around cardiovascular safety. Organic nitrates such as nitroglycerin, or isosorbide dinitrate, and other nitrate preparations including amyl nitrite and ayml nitrate (the latter two being used as recreational drugs) are absolutely prohibited for a man taking any of the three drugs for erectile dysfunction, because they interact in a way that causes rapid and unpredictable drops in blood pressure and hypotension: indeed, they can be fatal.
PDE5 inhibitors also seem to have some kind of interaction with alpha-blockers, and it's probably not a good idea to take them together.
One of the more recently reported side-effects of PDE5 inhibitors is non-arteritic anterior ischaemic optic neuropathy, which has been reported as occurring after ingestion of PDE5 inhibitors. This is serious condition which causes visual problems and possibly the entire loss of vision in one eye.
Although it's extremely rare, no effective treatment is available, and any man who has ever had vision problems after taking PDE5 inhibitors should speak to a doctor immediately. Also, if you've ever had severe loss of vision, at any time, for any reason, you absolutely must talk to a doctor before taking these compounds.
Needless to say, these three drugs will have interactions with other drugs, some of which increase metabolic breakdown of PDE5 inhibitors and some of which, unsurprisingly, accelerate their breakdown.
There is an alternative to Viagra and its counterparts, called apomorphine. This is administered sublingually, i.e. under the tongue, but it has a much lower rate effectiveness than Viagra, and is not licensed for use in the United States.
It can be used in cases of mild or moderate erectile dysfunction, or when the cause of erectile dysfunction appears to be psychological or emotional. It may also be useful in men who cannot take Viagra because they're taking nitrates for heart conditions.
Vacuum constriction devices
These devices are an old standby treatment for erectile dysfunction. They overcome a man's inability to achieve an erection by providing passive engorgement of the corporate cavernosa, which is then maintained by a constriction ring placed around the base of the shaft of the penis so that blood is trapped within the shaft.
Although these erections are not natural, they can provide a satisfying means of sexual intercourse for some couples although it has to be said that the satisfaction rate varies widely, between 30% and 90%, in the couples using them.
Intracavernosal injections were one of the first successful medical therapies for erectile dysfunction. They can still be useful for men who do not respond to oral drugs.
An erection will appear between 5 and 15 minutes after the injection has been made, and will last for a period of time that depends on the dose injected. It is necessary that a man is trained by a doctor, so that either he or his partner can administer the injection in the correct way.
The satisfaction rate for this treatment is very high: between 87 and 94%, although this may be because only patients and partners who are willing to undertake the therapy in the first place will ever make the injection, and they must therefore be highly motivated to achieve success.
Unfortunately, there is a high rate of penile pain associated with continued injection, and fibrosis may develop in about 2% of men who use this method.
Another danger that has been well documented is that of prolonged erections or priapism; an erection which lasts for longer than three hours needs medical attention.
All in all, it is clear that there has been much progress in the pharmacology of treating erectile dysfunction in the last ten years. Even men with diabetes and men who've had a radical prostatectomy may find benefit from using these drugs.
In some cases it's appropriate for a man to try all three of the drugs and make his own choice about which works best, selecting the one which he perceives to have the highest efficiency, as well as being the most convenient in terms of duration of action and opportunity for sexual intercourse.