Not long ago, when researchers were testing a new heart drug in men, they noticed something weird. The drug did little to offset chest pain, but the guys wouldn’t give it back.
It turned out the drug, now called Viagra, had an unanticipated side effect: it enhanced erections.
Just approved last month by the FDA, Viagra is already so hot – $ 78 million worth of presciptions in its first 48 hours on the market – that it could fast become the leading treatment for impotence. At $ 7 per pill.
Technically called erectile dysfunction, impotence is the consistent inability for six months to maintain an erection sufficient for satisfactory intercourse.
That’s distinct from other types of sexual dysfunction. Low libido, or, desire is often caused by depression or low testosterone levels. Inability to reach orgasm is often a neurological problem. Failure to ejaculate sperm can be caused by antidepressant drugs like Prozac.
By contrast, impotence is a matter of sheer hydraulics: There’s not enough blood getting into or staying in the penis to make and keep it erect – a troubling problem for 20 million American men, few of whom seek treatment.
But all that could change if Viagra and other effective treatments, some still emerging, induce more men to seek help.
Impotence can have many causes. In younger men, it’s often due to athletic injuries to blood vessels, which can be fixed surgically. In older men, it’s often due to atherosclerosis, the buildup of plaque inside blood vessel walls. In fact, impotence, not coronary disease, can be the first sign of atherosclerosis.
In other cases, impotence is caused by the very drugs used to treat heart disease. Smoking contributes, too, because it makes atherosclerosis worse. (One study showed that when smokers quit, blood flow to the penis increased significantly.)
Surgery or radiation for prostate cancer also cause impotence, and diabetes has always been a problem because it damages blood vessels and interferes with production of a neurochemical called nitric oxide, the first step in the biochemical cascade that leads to erections.
In terms that are unromantic at best, that cascade goes like this, says Dr. Irwin Goldstein, a Boston University urologist:
The brain tells penile nerves to secrete nitric oxide, which triggers release of another chemical, cyclic GMP, which causes blood vessels in the penis to relax, allowing blood to rush in. As long as cGMP is being made, the penis stays erect. As soon as cGMP production begins to fall, another chemical, PDE-5, destroys the remaining cGMP.
The reason Viagra helps – it worked in 70 percent of men tested – is that it blocks PDE-5. But Viagra only works if there’s cGMP around, that is, if a man is already aroused.
Sorting out the causes of impotence can sometimes be tricky.
Men normally have three to five erections a night, says Dr. Paul Church, a urologist at Beth Israel Deaconess Medical Center. If tests show that you have erections during sleep but have trouble during sex, the problem may be psychological.
In some cases, tests made be needed, including a duplex Dopper ultrasound to “listen” to blow food in penile arteries.
Some men turn to specialized medical practices like Diagnostic Centers for Men, a national chain with 28 outlets – including one in Woburn. The chain disputes it, but critics say some for-profit outfits may do excessive testing.
Regardless of the cause of impotence, psychotherapy can often help. Though most impotence is now believed to have physical roots, it can be so upsetting that men, and couples, need emotional help. And sometimes, emotional problems really are the cause, including childhood sexual abuse, power struggles in a relationship or “performance anxiety,” says Kathleen Logan-Prince, a sex therapist and social worker in Weston.
While Viagra and psychotherapy may be the most obvious solutions, other options can also help, including vacuum pumps, which cost several hundred dollars. These devices slip over the penis and create a vacuum to draw blood in. Blood is then trapped with a band placed around the base of the penis.
Hormone supplements may also be appropriate. A simple blood test can show whether your testosterone is low, though this often shows up as low libido, not impotence. If testosterone is low, hormone patches or injections are a solution, though they can promote prostate cancer and make men more aggressive.
“If a man has a tendency to argue, he’ll argue more. If he honks the horn, he’ll honk more,” says Dr. Gregory Broderick, director of the Center for the Study of Male Sexual Dysfunction at the University of Pennsylvania.
If none of these first-line treatments work, you can turn to less user-friendly options, including injections into the base of the penis of drugs like Caverject or Edex. Unlike Viagra, these drugs, which cost $ 20 per treatment, can inititate an erection, an advantage for men who can’t get aroused, such as those who have nerve damage in the pelvis.
Another option in this category is MUSE, a pellet containing prostaglandin E-1, the same medication as the injections. The pellet is inserted into the urethra, costs $ 20 per use, and also can initiate erections in the absence of sexual stimulation.
For most men, surgery, including implants, is a last resort. With a semi-rigid implant, the man can bend the penis up or down at will. With inflatable devices, he pushes a button under the skin that triggers release of saline solution into the penis from a pouch implanted in the abdomen.
And some men try herbal remedies before they seek mainstream help. One popular option is yohimbine, a tree bark derivative available by prescription (Yocon)and as a dietary supplement (Yohimbe).
Some doctors, like Beth Israel urologist Church think yohimbine helps. Others, like Dr. Drogo Montague, a Cleveland Clinic urologist who chaired a panel on impotence treatments for the American Urological Association, say it doesn’t.
If you do try yohimbine, a word of caution. It has never been approved by the FDA. Nor is it recommended by the German commission that reviews herbal treatments, because there’s no proof it works and its side effects – agitation, tremors, anxiety and hypertension – can be serious.
Among other herbal options is NuMan, a combination of Chinese herbs. Dr. Thomas Kingston, a Salem Hospital urologist, has tried it in 20 patients and feels it’s “more effective than yohimbine.” One of his patients, a 46-year old North Shore real estate agent, has tried it and claims it’s “fabulous.”
So what should you do with so many options out there and more on the way, including a topical gel called Topiglan and a pill called Vasomax.
Given the strong evidence for Viagra and other mainstream remedies – and the weak evidence for herbals – the choice seems clear. Stick with mainstream medicine on this one, and talk things over with your partner – and your doctor.
- Medications that can cause impotence Type of Medication: Examples:
- Heart/blood pressure medications: Beta-blocker propranolol (Inderal) * * Calcium channel blocker* diltiazem (Cardizem) * * Nitrate* isosorbide dinitrate (Isordil) * * Diuretics: chlorthiazide (Diuril)
- spironolactone (Aldactone) * * Alpha-blockers:* prazosin (Minipress) * * ACE inhibitors:* catopril (Capoten) * * Cholesterol-lowering drugs:* niacin, lovastatin (Mevacor) * Anti-arrhythmia drug: Digoxin * * Other: Anti-ulcer drugs: cimetidine (Tagamet) * Antidepressants: amitriptyline (Elavil)
- fluoxetine (Prozac) * * Tranquilizers: diazepam (Valium)
- thioridazine (Mellaril) * * Antifungal: ketoconazole (Nizoral) Miscellaneous: finasteride (Proscar)
- estrogens, antiandrogens
- antihistamines
- anticholinergics
- anticancer drugs * Less likely to cause impotence * And others * *
And many others SOURCE: Harvard Men’s Health Watch, Sept., 1997 and Dr. Irwin Goldstein, Boston University Globe staff chart
2. To learn more
For more information on impotence and treatments:
- call: 800-242-2383, the American Foundation For Urological Disease.
- On the Net, you can try these sites:
- www.iiem.org
- International Impotence Education Month www.auanet.org
- American Urological Association