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. 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 below 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 (see below). If so, talk to a primary care doctor, urologist, or endocrinologist.

The evaluation is quite simple. 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 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 below); 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.

Figure 1: Alprostadil injections   Figure 1: Alprostadil injections   This simple and highly effective method produces an erection within 5 to 20 minutes after a man injects the medication into the base of the penis, causing the smooth muscle tissue of the penis to relax and allowing blood to flow into the corpora cavernosa.

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 long-term 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. Alprostadil 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.

Alprostadil pellets

Alprostadil injections were approved by the FDA in 1995, alprostadil pellets two years later — but both have been eclipsed since 1998, when Viagra burst onto the scene. Still, both forms of alprostadil merit consideration by men who cannot take Viagra and its rivals.

Tiny pellets of alprostadil can be inserted directly into the urethra using the Medicated Urethral System for Erection (MUSE). A man inserts a slender tube containing a pellet into his urethra, advancing it about an inch from the tip of the penis (see figure 2). When he presses a button, the pellet is propelled into the urethra. Alprostadil is rapidly absorbed from the pellet and enters the corpora cavernosa, where it dilates arteries.

Figure 2: Alprostadil pellets   Figure 2: Alprostadil pellets   Using a slim applicator, a man inserts a tiny pellet containing the same medication used for injection therapy about an inch inside the tip of his penis to produce an erection.

About 50% of men respond to MUSE. The major complication is penile pain, which occurs in 30% of patients, but it is usually mild. Prolonged painful erections are much less common with MUSE than with injection therapy. However, about 3% of MUSE users develop low blood pressure and dizziness.

MUSE is available in four strengths, from 125 to 1,000 mcg. Physicians must determine the minimum effective dose and check for low blood pressure before prescribing it for home use. Each application costs about $25; men should not use more than two pellets in 24 hours.

All the medications used for erectile dysfunction are expensive, and each has drawbacks and potential side effects. But there is a highly effective, safe alternative, and it requires only a one-time expense. That’s the good news. The bad news is that the vacuum pump is cumbersome.

The vacuum pump

Most men with ED can use a vacuum constriction device to achieve erections without medication (see figure 3). The penis is placed in an airtight plastic cylinder attached to a hand pump. Air is pumped out of the cylinder to create a vacuum, which increases penile blood flow. When the penis is erect, a special band is secured around its base to retain the blood after the cylinder is removed. When intercourse is complete, the band is removed and the penis becomes flaccid. Vacuum devices are up to 90% effective in producing satisfactory erections within 5 minutes. They are cumbersome, however, and require some manual dexterity. About 10% of men experience adverse effects, including penile bruising, numbness, pain, and impaired ejaculation. The side effects are almost always mild; and the device does not produce excessive bleeding in men taking anticoagulants (blood thinners). Vacuum devices cost between $150 and $450 and are available without a prescription.

Figure 3: Vacuum pump   Figure 3: Vacuum pump   This less invasive, but somewhat awkward, technique creates an erection by way of a vacuum pump placed over the penis. A man lubricates his penis and puts it into an airtight plastic cylinder that is attached to a hand-held pump. Some pumps are manual, while others operate on a battery. In either case, air is pumped out of the cylinder to create a vacuum, which increases blood flow to the penis. Once an erection occurs, which should take about five minutes, the man removes his penis from the cylinder and fits a rubber ring around the base of the penis to prevent blood from draining away.

Surgery

Surgical implants are another option for erectile dysfunction. Two approaches are available. One implants silicone rods that produce a permanent erection; because the rods can be bent up and down, the erect penis can be concealed under clothing. The alternative is an inflatable device that produces an erection when it is filled with fluid pumped from a reservoir placed in the abdomen. Inflatable implants function more naturally, but they have a higher rate of complications and failure than rigid implants. More than 200,000 American men have had penile implants, but fewer men are choosing this method now that less invasive treatments are available.

Vascular surgery may be able to correct problems in penile circulation, restoring erectile function to some men. It’s a logical approach, but the results have been very poor in typical ED patients and in older men. Still, some young men with hereditary or traumatic causes of impotence may wish to consult a specially trained urologist to discuss this possibility.

Counseling and sex therapy

About 90% of men with ED of no identifiable organic cause respond well to ED pills, and most of the others can benefit from alprostadil or the pump. Still, if the cause of impotence is psychological, psychotherapy is the only way to correct the basic problem. Therapists who specialize in sexual dysfunction can also help a man and his partner cope with a broad range of sexual problems that even a good erection won’t resolve.

Experimental therapies

Despite the medical success of Viagra (and because of its brilliant financial success), manufacturers are racing to develop other treatments for ED. The most likely to succeed are the pills that are similar to Viagra; only time will tell if they offer important advantages.

A cream or ointment that could be applied to the penis has obvious appeal. Researchers have tested preparations containing nitroglycerin, alprostadil, and a combination of aminophylline, isosorbide dinitrate, and codergocrine mesylate with mixed results. A cream containing alprostadil and SEPA, a chemical that enhances drug penetration through the skin, appears promising but is still experimental.

Phentolamine tablets (Vasomax) are also being studied. In the early trials, 37%–45% of men responded favorably. Side effects include headaches, facial flushing, and nasal congestion.

Apomorphine (Spontane) is a tablet that is placed under the tongue. It produced erections in about half the men who tested it. Nausea, which can be severe, is the most common side effect, but at high doses apomorphine can also lower the blood pressure and cause fainting.

Ineffective therapy

Despite the understandable appeal of pills and powders promoted as aphrodisiacs, men should be discouraged from experimenting with unapproved folk remedies or herbs. One traditional folk drug can be prescribed by doctors; yohimbine (Yohimex, Yocon) is an alpha blocker derived from certain trees. Although it is widely prescribed for impotence, it appears to help only men with psychological impotence. Caveat emptor — buyer beware.

The best medicine

Doctors have made great strides in treating ED since the mid-1990s. 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.