how was erectile dysfunction treated before viagra

Erectile Dysfunction Health Center

Slideshow: A Visual Guide to Erectile Dysfunction

What Is Erectile Dysfunction (ED)?

Erectile dysfunction (ED) occurs when a man has consistent and repeated problems sustaining an erection. Without treatment, ED can make sexual intercourse difficult. The problem is reported by 1 in 5 men and that number increases with age.

ED vs. Poor Libido

There are several forms of male sexual dysfunction, including poor libido and problems with ejaculation. But ED refers specifically to problems achieving or maintaining an erection. Men with ED often have a healthy libido, yet the body fails to respond. In most cases, there is a physical basis for the problem.

Symptoms of ED

Symptoms of ED include:

  • Erections that are too soft for sexual intercourse.
  • Erections that are too brief for sexual intercourse.
  • An inability to achieve erections.

Men who cannot get or maintain an erection that lasts long enough or is rigid enough to complete sexual intercourse is considered to have erectile dysfunction.

Who Gets ED?

Sexual dysfunction and ED become more common as men age. The percentage of complete ED increases from 5% to 15% as age increases from 40 to 70 years. But this does not mean growing older is the end of your sex life. ED can be treated at any age. Also, ED may be more common in Hispanic men and in those with a history of diabetes, obesity, smoking, and hypertension. Research shows that African-American men sought medical care for ED twice the rate of other racial groups.

The Mechanics of ED

An erection occurs when blood fills two chambers known as the corpora cavernosa. This causes the penis to expand and stiffen, much like a balloon as it is filled with air. The process is triggered by impulses from the brain and genital nerves. Anything that blocks these impulses or restricts blood flow to the penis can result in ED.

Causes of ED: Chronic Disease

The link between chronic disease and ED is most striking for diabetes. Men who have diabetes are two to three times more likely to have erectile dysfunction than menwho do not have diabetes. Among men with erectile dysfunction, those with diabetes may experience the problem as much as 10 to 15 years earlier than men without diabetes. Yet evidence shows that good blood sugar control can minimize this risk. Other conditions that may cause ED include cardiovascular disease, atherosclerosis (hardening of the arteries), kidney disease, and multiple sclerosis. These illnesses can impair blood flow or nerve impulses throughout the body.

Causes of ED: Lifestyle

Lifestyle choices that impair blood circulation can contribute to ED. Smoking, excessive drinking, and drug abuse may damage the blood vessels and reduce blood flow to the penis. Smoking makes men with atherosclerosis particularly vulnerable to ED. Being overweight and getting too little exercise also contribute to ED. Studies indicate that men who exercise regularly have a lower risk of ED.

Causes of ED: Surgery

Surgery, including treatmentsfor prostate cancer, bladder cancer, or BPH can sometimes damage nerves and blood vessels near the penis. In some cases, the nerve damage is permanent, and the patient will require treatment to achieve an erection. In others, surgery causes temporary ED that improves on its own after 6 to 18 months.

Causes of ED: Medication

ED may be a side effect of medication, including certain blood pressure drugs, antidepressants, and tranquilizers. Men should talk with their doctor if they suspect a prescription or over-the-counter drug may be causing erectile problems. Never stop any medicine without first consulting your doctor.

Causes of ED: Psychological

ED usually has something physical behind it, particularly in older men. But psychological factors can be a factor in many cases of ED. Experts say stress, depression, poor self-esteem, and performance anxiety can short-circuit the process that leads to an erection. These factors can alsomake the problem worse in men whose ED stems from something physical.

ED and Bicycling

Research suggests avid cyclists suffer more ED than other athletes. The trouble lies in the shape of some bicycle seats that put pressure on the perineum. This area between the anus and scrotum contains arteries and nerves vital to sexual arousal. Cyclists who ride for many hours each week may benefit from seats designed to protect the perineum.

Diagnosing ED: Physical Exam

To diagnose ED, your doctor will ask you questions about your symptoms and medical history. The doctor will conduct a complete physical exam to uncover signs such as poor circulation or nerve trouble. And your physician will look for abnormalities of the genital area that could cause problems with erections.

Diagnosing ED: Lab Tests

Several lab tests can help diagnose male sexual problems. Measuring testosterone levels can determine whether there is a hormonal imbalance, which is often linked to decreased desire. Blood cell counts, blood sugar levels, cholesterol levels, and liver function tests can reveal medical conditions that may account for ED.

ED: A Sign of Heart Disease?

In some cases, ED can be a warning sign of more serious disease. One study suggests ED is a strong predictor of heart attack, stroke, and death from cardiovascular disease. The researchers say all men diagnosed with ED should be evaluated for cardiovascular disease. This does not mean every man with ED will develop heart disease, or that every man with heart disease has ED, but patients should be aware of the link.

Treating ED: Lifestyle Changes

Many men with ED are able to improve sexual function by making a few lifestyle changes. Giving up smoking, losing weight, and exercising more often can help by improving blood flow. If you suspect a medication could be contributing to ED, talk toyour doctor about adjusting the dosage or switching to another drug.

Treating ED: Oral Medications

You’ve probably heard of Viagra, but it’s not the only pill for ED. This class of drugs also includes Cialis, Levitra, Staxyn, and Stendra. All work by improving blood flow to the penis during arousal. They’re generally taken 30-60 minutes before sexual activity and should not be used more than once a day. Cialis can be taken up to 36 hours before sexual activity and also comes in a lower, daily dose. Staxyn dissolves in the mouth. All require an OK from your doctor first for safety.

Treating ED: Injections

While pills for ED are convenient, some men sustain stronger erections by injecting medication directly into the penis. Drugs approved for this purpose work by widening the blood vessels, causing the penis to become engorged with blood. Another option is inserting a medicated pellet into the urethra. The pellet can trigger an erection within 10 minutes.

Treating ED: Vacuum Devices (Pumps)

Vacuum devices for ED, also called pumps, offer an alternative to medication. The penis is placed inside a cylinder. A pump draws air out of the cylinder, creating a partial vacuum around the penis. This causes it to fill with blood, leading to an erection. An elastic band worn around the base of the penis maintains the erection during intercourse.

Treating ED: Surgery

If ED is caused by a blockage in an artery leading to the penis, surgery can often restore blood flow. Good candidates are typically younger men whose blockage stems from an injury to the crotch or pelvis. The procedure is not recommended for older men with widespread narrowing of the arteries.

Treating ED: Implants

In men with persistent ED, a penile implant can restore sexual function. An inflatable implant uses two cylinders that are surgically placed inside the penis. When an erection is desired, the man uses a pump to fill the cylinders with pressurized fluid. Another option is a malleable implant, which bolsters erections with surgically implanted rods.

Treating ED: Psychotherapy

Even when ED has a known physical cause, psychotherapy can be beneficial. A therapist can teach the man and his partner techniques to reduce performance anxiety and improve intimacy. Therapy can also help couples adjust to the use of vacuum devices and implants.

Treating ED: Alternative Therapies

Talk with your doctor before trying supplements for ED. They can contain 10 or more ingredients and may complicate other health conditions. Asian ginseng and ginkgo biloba (seen here) are popular, but there isn’t a lot of good research on their effectiveness. Some men find that taking a DHEA supplement improves their ability to have an erection. Unfortunately, the long-term safety of DHEA supplements is unknown. Most doctors do not recommend using it.

Treating ED: Buyer Beware

A quick web search will reveal dozens of “dietary supplements” that claim to treat ED. But the FDA warns that many of these are not what they seem. An investigation discovered the pills often contain prescription drugs not listed on the label, including the active ingredient in Viagra. This puts the man at risk for dangerous drug interactions.

ED: Reducing the Risk

Some tips to reduce the risk of ED include:

  • Exercise and maintain a healthy weight.
  • Stop smoking.
  • Avoid alcohol and substance abuse.
  • Keep diabetes under control.

Discussing ED With Your Partner

It’s natural to feel angry or embarrassed when dealing with ED. But don’t forget that your partner is also affected. Talking openly about ED will help your partner understand the diagnosis and treatment options. This can reassure a partner that you haven’t lost interest.

Reviewed by Jennifer Robinson, MD on July 01, 2016

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Beth Israel Deaconess Medical Center: “Impotence.”

Bohm, M. Circulation. 2010.

Boston University School of Medicine: “Erectile Dysfunction and Bicycling.”

FDA: “Hidden Risks of Erectile Dysfunction ‘Treatments’ Sold Online.”

Feldman, H.A. Journal of Urology, January 1994.

Food and Drug Administration: “FDA Approves Stendra for Erectile Dysfunction.”

John Hopkins Bloomberg School of Public Health: “18 Million Men in the United States Affected by Erectile Dysfunction.”

Memorial Sloan-Kettering Cancer Center: “ArginMax.”

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health: “Erectile Dysfunction.”

Penn State Hershey: “The Medical Minute: Why smoking is such a bad idea.”

Shamloul, R. Journal of Sexual Medicine. 2010.

The Cleveland Clinic: “Erectile Dysfunction.”

The Harvard Medical School: “Heart Disease and Erectile Function.”

UCLA Health System: “Erectile Dysfunction.”

UptoDate: “Evaluation of Male Sexual Dysfunction.”

This tool does not provide medical advice. See additional information:

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Erectile Dysfunction Health Center

13 Common Sex-Drive Killers

What Are the Differences Between These Drugs?

Cialis, Levitra, Staxyn, Stendra, and Viagra work similarly. There are subtle differences in how long the drug works and how quickly it works.

Levitra works a little longer than Viagra. They both take effect in about 30 minutes. With Levitra, the effects last for about 5 hours. With Viagra, they last about 4 hours.

Cialis works much longer — up to 36 hours in some cases. Stendra can start doing its thing in as little as 15 minutes, and its effects last up to 6 hours.

Staxyndissolves in your mouth. It contains the same active ingredient as Levitra, but it should not replace Levitra. It also can begin working in about 15 minutes.

If One of These Doesn’t Help Me, Can I Try Another?

Yes. But because these drugs work the same way, you’re likely to have similar results.

What Precautions Should I Take Before Trying One of These Drugs?

There are situations where these drugs may not be safe. Before you take them, tell your doctor:

  • If you are allergic to any drugs, including other ED medications.
  • About any prescription or nonprescription medications you take and any herbal and dietary supplements .
  • If you are scheduled for surgery, even dental surgery.
  • If you take nitroglycerin or a similar medicine for chest pain. The combination of ED medication and these drugs can cause dangerously low blood pressure.
  • If you take alpha-blockers for blood pressure or prostate problems. These can lower your blood pressure when taken with ED pills. You should not start on Staxyn unless your doctor has prescribed you Levitra before.

Always follow the directions on your prescription label carefully. Also make sure to ask your doctor or pharmacist to explain anything you don’t understand. Take these drugs exactly as directed.

ED Medications: Cialis, Levitra, Viagra

How do these drugs work?

Cialis, Levitra (Vardenafil) and Viagraв„ў (Sildenafil) work by selectively inhibiting an enzyme in the penis called Phosphodiesterase V (PDE V), a chemical that takes away the erection. By blocking PDE V temporarily, these medications empower the chemical, Nitric Oxide (NO) that occurs naturally with arousal to initiate, produce and maintain an erection. Patients need sexual stimulation and foreplay to release NO initiate an erection in order for these medications to be effective. They are called phosphodiesterase inhibitors.

This class of medication is a safe and effective oral treatment for men with erectile dysfunction of physical, psychological or mixed cause. However, it is important that patients should be aware of the low probability (less than 50%) that intercourse will be possible after the first dose – particularly in severe or advanced cases and especially when using Viagra or Levitra. The majority of men who stop Viagra because of apparent lack of effect will in fact respond and achieve intercourse if they continue to try again, progress from 50 mg to 100 mg, or take the pill without food on an empty stomach (3 hours after eating). Taking Viagra or Levitra on a full stomach will not only reduce their peak concentration in the body by 30 to 50% but in addition will delay their peak concentration by one hour. In other words one may have to wait after intake before initiating sexual activity. Cialis peak concentration and time before reaching maximum absorption is not affected by a full stomach. Because of this it remains my drug of choice for the treatment of ED and I always prescribe it first. In addition many of my patients experience fewer side effects with Cialis then with the other two. Finally Cialis has a long period of activity and patients are successful at intercourse up to 36 hours after taking this pill. This represents a distinct advantage from the patient’s perspective as it diminishes the need for planning. Sex can be more spontaneous and natural. Planning kills the mood. Having sex long after taking the pill makes men feel more normal! For these reasons I will first try Cialis on all my Patients and reserve Viagra and Levitra for those men who do not tolerate Cialis.

The steps illustrated in Reference #4 below will help optimize the chances of success of Levitra and Viagra 4.

Reliable safety data gathered in the 10 years since these PDE % inhibitors were launched confirm that side effects such as Priapism (prolonged erection), red eyes, painful eyes, syncope(fainting), tachycardia (rapid heart rate), and nausea do occur, but are rare. Back pain and muscle aches occur rarely with Cialis. HIV medications (protease inhibitors) have been shown to raise their blood levels. Certain patient groups are more susceptible to a decrease of their blood pressure, including those with aortic stenosis, hypertrophic obstructive cardiomyopathy, and multiple system atrophy. Finally, all PDE 5 inhibitors remain contraindicated in patients taking nitrates.

A few new safety concerns such as visual and hearing loss have emerged in the past year, however these remain extremely rare reinforcing that these medications are very safe. Indeed, we now know that many patients with cardiovascular disease (CVD) and ED benefit from it.

Erectile Dysfunction: Oral Therapy Treatment Options

Dr. J. Francois Eid discusses the oral therapy options, or “pills”, available to treat erectile dysfunction.

The following can be prescribed a PDE 5 inhibitor (Cialis, Levitra, Viagra) safely without the need for extensive Cardiovascular investigationВІ:

  • men who are a symptomatic and have fewer than three risk factors for coronary artery disease
  • those with controlled hypertension
  • those with mild stable angina
  • patients who have undergone successful coronary revascularisation (bypass or stent placement)
  • men with a history of uncomplicated heart attack that happened greater than 6-8 weeks ago
  • those with mild valvular disease of the heart
  • patients with mild left ventricular disease and congestive heart failure (NYHA Class I)

    Cialis (Tadalafil)

    Oral medications such as Cialis, Levitra and Viagra are available for the treatment of erectile dysfunction. They are in a class called PDE 5 inhibitors. They work to restore a normal system of blood flow in the penis so that an erection can occur with sexual stimulation.

    Highlights of Cialis:

    Only ED medicine clinically proven to work up to 36 hours.

    Works as fast as 30 minutes in some men.

    Gives you the freedom to choose the moment that is right for you.

    The most common side effects include headache, upset stomach, back pain and muscle aches. The side effects usually go away after a few hours. In the rare event of Priapism seek immediate medical help to avoid long term injury. Another uncommon side effect reported was a suddendecrease or loss of vision.

    Who should not take Cialis:

    Cialis is contraindicated in patients using nitrates. If you use recreational drugs called “poppers” like amyl nitrate and buty nitrite do not take Cialis. If Cialis is taken with certain Alpha Blockers, it can result in a sudden drop of blood pressure, which could lead to dizziness or faintness. It can however be used with Flomax 0.4mg.

    Tell your doctor if you take any other medications including prescription and non-prescription medicines, vitamins or any health supplements as Cialis and these may affect each other adversely.

    How to use Cialis:

    Cialis is available by prescription only. It is taken orally before sexual activity, not more than once daily. It may be taken with or without food. In some patients, the dose strength and maximum frequency of use may be adjusted.

    Levitra (Vardenafil)

    Levitra is also an FDA approved medication for the treatment of Erectile Dysfunction.

    How Levitra works:

    Levitra is an oral medicine, available by prescription only, and should be taken approximately 60 minutes prior to sexual activity. It should be taken no more than once daily. It can be taken with or without food.

    The side effects are generally mild and do not last very long. The most common side effects are headache, flushing, stuffy or runny nose. In rare cases Priapism and vision changes have been observed.

    Levitra is contraindicated in patients who take any form of medication known as nitrates or recreational drugs called “poppers” like amyl nitra or butyl nitrate. If you are taking any alpha blockers, Levitra is not the right medication for you.

    First effective FDA-approved oral medication for the treatment erectile dysfunction

    Boosts natural process of erection during arousal

    Works across broad range of Erectile Dysfunction causes

    Over 6 million patients have tried it

    Approximately 250,000 doctors have prescribed it

    Over 14 million prescriptions written

    Over 100 million tablets dispensed

    Unlike placebo-like drugs, Viagraв„ў has high refill rate

    How to Use Viagraв„ў

    If taken on an empty stomach, it takes about 85 minutes for Viagraв„ў to be absorbed into the circulation and reach the penis. Some patients (younger men) may experience benefits from the medication as early as 30 minutes after taking it. A high fat meal will delay the absorption of Viagraв„ў, and therefore it is recommended that Viagraв„ў is taken on an empty stomach or after a lowfat meal. Furthermore, once absorbed, Viagraв„ў will stay inthe circulation for approximately four to six hours, which represents the window of sexual opportunity. If initially not successful, patients should try Viagraв„ў at 100mg on 3 different occasions before concluding that the medication is ineffective.

    Viagraв„ў is effective in two-thirds of men with erectile dysfunction regardless of age and the severity of Erectile Dysfunction. However, certain groups of men using the drug do better than others. For example, spinal cord injured males have better results than patients suffering from cardiovascular disease (e.g. hypertension, high serum fat levels), and patients who have undergone treatment for prostate cancer (e.g. removal of the prostate or radiation therapy) seem to benefit the least.

    Viagraв„ў Side Effects

    Most side effects are mild and well-tolerated. The following are the most common reported side effects: headache, flushing of the face, heartburn, and nasal congestion. A small percentage (3%) of people may develop visual disturbance; it may take the form of a blue haze or tinge as well as increased perception of brightness. This effect is very mild, transient, and reversible.

    Who Should Not Take Viagraв„ў

    Viagraв„ў is CONTRAINDICATED for patients who take any medications that contain nitrates. This includes patients who need nitrates (including nitroglycerine) on an intermittent basis for the treatment of angina.

    In patients used to regular exertion, sexual activity poses no special cardiovascular risk. Even in patients who have a history of myocardial infarction (MI), there is little risk of MI during intercourse for those who exercise regularly. However, there is insufficient information on the cardiovascular risk in previously sexually inactive men who become sexually active. Stress test and/or referral to a cardiologist may be appropriate, and variables such as patient’s age, medicalhistory and existing medical conditions may be relevant.

    Stendra

    Alternative medication therapies

    Alternative oral therapies for Erectile Dysfunction (availability may vary geographically) are Uprima (apomorphine), and phentolamine. Both Uprima and phentolamine have very low or no efficacies and therefore for present purposes will not be addressed.

    Uprima is approved for the treatment of Erectile Dysfunction in Europe and initial sales have not been very impressive (less than 20% of ED market). Refill rates are dismal supporting lack of efficacy.

    Phentolamine’s application to the FDA was withdrawn and the drug is not available.

    Discussion

    Although Viagra, Levitra and Cialis differ in their biochemical potency and selectivity, and in onset and duration of action, it is important not to extrapolate those findings inappropriately to the clinical setting. For example, greater biochemical potency does not necessarily translate into enhanced clinical efficacy. The same is true of selectivity. In short, there appears to be little biochemical or clinical differences between the three agents except for the lack of food interaction and the duration of activity for Cialis. All three medications are contraindicated in patients who take nitrates.

    A recent survey looking at what patients with ED really want from their treatment found that efficacy and a favorable side-effect profile were the highest prioritiesВі Fast onset was desirable, but there were major differences in what was considered fast. Duration was important only in terms of lasting long enough to complete intercourse. Few men (or their partners) felt that multiple erections, or the ability to achieve them over time, were critical as long as one dose was enough for a successful encounter. Most complaints were about high cost or lackof insurance coverage.

    An underlying desire was reported by most couples for initiation of sex to be normal (spontaneous and natural). Few patients fully understood the duration of activity that Viagra can provide, and its advantages. Cialis may indeed fulfill the desire that couples and patients with ED have for the initiation of sex to be normal (spontaneous and natural). Although Viagra, Levitra and Cialis are safe and effective they do, like all medications, have disadvantages. They essentially enhance partial (sexual) erections, rather than initiating them. At best, the response rate among men with advanced ED (for example following radical prostatectomy) is 30%. Fewer than 505 of men with Diabetes will respond. Correct administration of Viagra and Levitra is critical, and if one does not work when taken correctly, no other oral “Viagra like drug” (PDE5 inhibitor like Levitra or Cialis) will either.

    In conclusion, the potencies of Viagra, Levitra and Cialis are broadly similar, but each has unique pharmacological properties related to its molecular structure. Viagra is an exemplary PDE-5 inhibitor that, after 10 years of widespread clinical use, is acknowledged to be effective and particularly well tolerated. Cialis and Levitra are the newer medications and are similar to Viagra in their efficacy and contraindications. The only new attributes of clinical significance are the lack of food interaction and the long duration of action of Cialis. This may translate into greater efficacy of the first dose as well as a return to more spontaneous (normal) initiation of sexual activity (broader window of opportunity).

    Question: Is it possible to identify potential non-responders to oral therapy?

    Answer: No, it is not possible to identify potential non-responders to a PDE 5 inhibitor such as Cialis, Levitra or Viagra, other than by a trial of these medications in the setting of sexual activity. Patients, who appear to be non-responders to Viagra or Levitra, need to repeat a trial on an empty stomach a few different times before giving up. Cialis absorption and onset of action is not affected by food. The 20-30% who still do not respond generally have ED related to an irreversible physical abnormality due to chronic poor blood flow (often smoking-related) or damaged penile tissue (often diabetes, high cholesterol and after prostate cancer surgery). The best option for these patients remains an inflatable penile prosthesis.

    Question: You said that the PDE5 inhibitors were comparable in efficacy. What about reports that Levitra is more effective than Viagra in treating ED among men with diabetes?

    Answer: Clinical trial reveals that all three medications have the same success regardless of patient age, underlying medical condition or severity of erectile dysfunction. There is no head-to-head evidence of that, and what literature there is may be misleading. My belief is that clinical experience will show them to be similar.

    References

    McCullough AR, et al. J Urol 2001. In press.

  • DeBusk R, et al. Am J Cardiol 2000; 86: 175-81.
  • Data from Six Degrees Survey, October 2001.
  • Optimizing Viagra and Levitra therapy:
    • men who require fast onset or better absorption should avoid fatty meals or take these pills on an empty stomach;
    • maximize sexual stimulation and arousal;
    • start foreplay later in older patients (who may need up to 2 hours to absorb the medicicne);
    • consider partner issues;
    • do not give up before making at least 3 attempts at intercourse having at the maximum dose: Viagra 100 mg, Levitra 20mg.
  • Erectile Dysfunction (ED)

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