Purchasing medications for erectile dysfunction:  I first want to comment the issue of purchasing medication on the internet, through mail order , magazine articles or television ads that claim to sell medications such as Viagra, Cialis or Levitra or some herbal supplement for erectile dysfunction without the need for a prescription and at a low cost.  I highly recommend that you do not purchase these products this way because the sources are not known to be safe or reliable.  Would you purchase your blood pressure or diabetes medicine from someone you don’t know but who claims to be legit?  I sure wouldn’t!  It is not known if these drugs sold without prescription through ads like this are counterfeit or contain toxic chemicals which could be damaging to your health. Men often come to talk with me about medications that may help with sexual problems such as inability to acquire or maintain an erection for sexual intercourse.  Since this is a popular topic in the primary care office, I thought I might discuss male sexual dysfunction, possible causes and some treatment options. Some male sexual complaints may include:

1. Premature ejaculation
2. Delayed or inhibited ejaculation
3. Lack of interest in sex (decreased sex drive)
4. Unable to become erect or maintain an erection for satisfactory sexual intercourse (we also call this impotence or erectile dysfunction)

Erectile Dysfunction (ED):   Your doctor may diagnose erectile dysfunction if the man cannot acquire or maintain an erection during 75% of attempts to have sexual intercourse.  If a man has only occasional inability to have an erection and this improves later, they do not have erectile dysfunction (ED) as defined by the American Urological Association. Possible causes of male sexual dysfunction:

1. Limited blood flow to the penis can be caused by:
   1. Cigarette smoking
   2. Uncontrolled diabetes (high blood sugars)
   3. High blood pressure (hypertension)
   4. Alcoholism
   5. Illicit drug use
   6. Aging
   7. Depression
   8. Common medications prescribed by your doctor
2. Psychological causes: Performance anxiety, stress or decreased mood can lead to impotence.  Many patients explain that they accept a decrease in sexual function as being normal due to aging.  Often times there are reasons for decreased sexual function in men that once addressed can improve sexual function and increase the satisfaction with their sexual health.  One of the possible reasons such as performance anxiety is when the focus of the sexual act shifts from a romantic experience to one filled with anxiety about the ability to acquire or maintain an erection.  It’s also true in some men that as they mature, their interests and concerns may expand.  If he’s preoccupied with concerns about money or business matters, he may lose the sexual focus needed to maintain an erection.

How to determine the cause of male sexual dysfunction:   When a man expresses concern about sexual dysfunction, I usually start off by trying to determine the cause by asking some questions, performing an exam and then ordering some laboratory tests.  If you will be visiting your doctor and have concerns about sexual dysfunction, I recommend that you think about the following and be ready to discuss these items with your doctor:

1. Do you get erections at night or in the morning when you first wake up?
2. Are you having any personal problems with your sexual partner?
3. Did the sexual dysfunction come on gradually or all the sudden?
4. Do you have medical problems such as diabetes, high blood pressure, tobacco use, alcohol or illicit drug use or other psychological factors that could contribute to the dysfunction?

What to expect during a physical examination:  Some men may be resistant to come to their doctor to discuss sexual dysfunction because they’re not sure what to expect during the physical exam.  Your doctor may do the following:

1. Check your blood pressure – it’s very important to get your blood pressure at goal
2. Examine the penis, testicles and blood vessels in the groin
3. Examine the chest for signs of abnormal breast swelling in men

Laboratory testing:  Your medical provider will often check several lab tests that can influence a man’s sexual ability.

1. Testosterone (hormone) level – hormone
2. Blood sugar tests – a fasting blood glucose or an A1c
3. Thyroid hormone test (TSH)
4. Prolactin (hormone) level
5. Home nocturnal penile tumescence (NPT) is a test that measures how many erections the man is getting during the night when sleeping.  Men who have damage to the blood vessels or nerves involving the sexual organs usually have decreased nocturnal erections and we call this “organic” impotence.  Men with normal night-time erections are more likely to have psychologically related impotence although there may be a combination of the two factors involved.
6. If the nocturnal penile tumescence test is abnormal, your doctor may ask you to have some special tests such as a ultrasound test to examine the deep arteries of the penis and groin to make sure they are getting enough blood flow.

Treatments for male sexual dysfunction:  Men often come in to the clinic and ask for medication without understanding that medication may not help if the cause of the problem is not discovered.  It’s very important to determine the cause of the sexual dysfunction because the improper use of medications can have serious side effects and may not actually cure or help the problem. Medications to treat erectile dysfunction: Testosterone therapy:  If your testosterone level is too low, correcting this by taking testosterone medication can improve sex drive, erectile dysfunction, increase muscle mass and reduce the risk of osteoporosis.  Men who do not have low testosterone levels do not benefit from additional testosterone and may actually have unhealthy side effects if they take testosterone inappropriately.  Treatment options may include testosterone injections that may be given every 1-2 weeks, testosterone gels (Androgel is a commonly prescribed example), a testosterone skin patch (Andoderm is a popular example) or a testosterone lozenge that remains in the mouth for 12 hours are the most common treatment options for low testosterone. Counseling:  We realize that depression, anxiety and increased social stresses can cause erectile dysfunction. Sexual therapy is often helpful in these cases.  The great thing about counseling is that there are no medical side effects because this does not involve taking a medication.  Counseling can actually fix the problem which is often more desirable than relying on a medication which must be used repeatedly.  Some examples of where psychotherapy can be useful are:

1. Performance anxiety, when a man suddenly experiences one or more failures during sex.   Often this is not due to the inability to perform but more related to anxiety about failure.
2. Men who have depression or anxiety often have a lowered sex drive.  Counseling can help improve both while improving sex drive and function without the need for medication.
3. Couples where one partner has a serious medical condition might be worried about possible the safety of sexual activity.  It is often helpful to discuss this with a medical professional or counselor who can help with these concerns.

Phosphodiesterase-5 inhibitors (PDE-5) – Viagra, Levitra and Cialis:  These medications work by increasing the natural chemicals in the body that allow the penis to become erect.  The do not increase sexual desire.  These medications are effective in restoring the ability to have an erection in about 70% of men and work best in men with psychological erectile dysfunction problems (in combination with treating the underlying psychological component).  In men with damage to the blood vessels or nerves of the pelvis/penis due to high blood pressure or diabetes, these medications help about 55-60% of the time.  For men who have sexual dysfunction after prostate surgery, these medications help in only 25%.   The main difference between Viagra, Levitra and Cialis is the cost of the medication and amount of time that the medication takes to begin working and how long the effects last.  Some people may find the one particular medication works better for them than another but all three work in a medically similar way. Possible side effects:  PDE-5 medications such as Viagra can cause headache, dizziness, indigestion and flushed (red colored) skin or blurred vision.  Most side effects only last a short time, but because Cialis has a longer duration than the others, the side effects may also last longer.  There is also a possibility of drug interaction with nitroglycerin if a patient uses that for chest pain or blood pressure.  Using PDE-5 medications and nitroglycerin can cause dangerously low blood pressure.  If a man is taking nitrate medications we generally do not recommend Viagra, Levitra or Cialis. Drug interactions:  In addition to nitroglycerin, patients who take doxazosin or terazosin (which are used to treat enlarged prostate and hypertension) should not take PDE-5 medications because the combination can cause a dangerously low blood pressure.   Other medications such as erythromycin, ketoconazole, rifampin, phenytoin and grapefruit juice can alter the time that these erectile dysfunction drugs remain in the body and subsequently can cause more side effects. Safety:  We are unsure if Viagra is safe for patients who have had a heart attack, stroke or life-threatening heartbeats (arrhythmia) within 6 months.  We are also not sure if it is safe for men who have had untreated high or low blood pressure or a condition called retinitis pigmentosa which is a medical condition of the eye that can lead to blindness. Penile self-injection:  Patients may inject a medication into an area of the penis called the corpora cavernosa and this causes an erection by allowing the blood vessels within the penis to expand.  No sexual stimulation is needed to create the erection.  The common medications used are alprostadil or papaverine. Possible side effects:  many men stop doing penile self-injections because of pain at the injection site.  There is also a risk that the penis may remain erect after intercourse.  Prolonged erection is called priapism.  If it lasts longer than 4-6 hours it may be a medical emergency and those patients should be seen in an emergency room.  If blood stays inside the penis for more than 48 hours permant scarring of the tissue inside of the penis may result. Insertion of a pellet into the urethra:  MUSE (Intraurethral alprostadil):  The same medication used for penile self-injection can be inserted into the urethra (opening where the urine comes out) and the medicine is absorbed and causes an erection. Possible side effects:  There can be some pain in the penis as the blood vessels enlarge to create the erection.  There is less chance of prolonged erection with this than with self-injection. Vacuum-assisted erection devices:  A rigid ring is placed at the base of the penis (near the body) to hold the blood in the penis and then vacuum pressure is used to draw blood into the penis to create an erection.  About 67% of patients are able to achieve and erection with a vacuum assisted device but only about 25-50% of people who use them are satisfied with them. Possible side effects:  Although the man will be able to have an orgasm, he is usually not able to ejaculate with a vacuum-assisted device because the ring that holds blood in the penis also compresses the urethra and that prevents semen from exiting. Inflatable implant:  With an inflatable implant, an erection is produced by squeezing a small pump that has been implanted surgically in the scrotum.  The pump causes fluid to flow from a reservoir (also implanted surgically) in the lower pelvis to two cylinders residing inside the penis.  The cylinders expand to create the erection. As you can see, there any many possible reasons that can lead to male sexual dysfunction and multiple treatment options. For more information, you may check out the web resources below: American Urological Association The Hormone Foundation   I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, D.O.
Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.