Are most men comfortable talking to their doctors about erection problems?
A: The Viagra era has certainly changed the embarrassment level. But many men still feel embarrassed, which is why I think it’s important for doctors to ask men over 40 about their sexual health as part of the routine “review of systems.” It’s especially important since erectile dysfunction can be an early sign of cardiovascular problems.
Q: What’s the connection between erectile dysfunction and cardiovascular disease?
A: When a man gets sexually aroused, the brain sends signals to the penis, where the release of certain chemicals causes blood vessels to dilate — turning a straw into a hose, if you will. The penis fills with blood, and you have an erection. A problem that affects the vascular system means that those blood vessels don’t dilate adequately. Problems with the vascular system often show up first as an inability to get or maintain erections.
Q: What percentage of men with erection problems turn out to have cardiovascular disease?
A: About 70 percent of men who have a cardiovascular event such as a heart attack or angina, when asked later, say that they were experiencing erectile dysfunction. When they’re asked how long they’d been experiencing erection problems, the average answer is about four years. Among men diagnosed with diabetes, almost 100 percent have been experiencing erectile problems. So erectile dysfunction can be a very useful warning sign.
Q: Can lifestyle changes recommended for preventing heart disease help improve erectile function?
A: That depends on the severity of the problem, how long it’s been a problem and a man’s age. A recent study in France looked at men who stopped smoking. After a year, 25 percent showed spontaneous improvement in their erections. Another recent study looked at obese men. It found that when they lost weight through a carefully monitored program of exercise and reduced calories, about one-third were having spontaneous erections after two years. That means they were getting erections without having to take drugs like Viagra.
Q: Can lowering blood pressure or cholesterol with medication improve erectile function?
A: The story here is a little less clear. We don’t have good evidence that lowering blood pressure improves erectile function. What it probably does is prevent progression. With diabetes, it’s very important to control blood sugar levels, because the diabetic process is known to cause vascular damage. Cholesterol-lowering drugs may help some men get spontaneous erections, but the stronger evidence relates to how well men with erectile dysfunction respond to Viagra, Levitra or Cialis. We did a study looking at men with elevated cholesterol who didn’t respond to Viagra. After we put them on Lipitor, a cholesterol-lowering drug, 60 percent were able to get erections.
Q: How do erectile dysfunction drugs work?
A: All three of the drugs on the market work to prevent the breakdown of the chemical that causes blood vessels in the penis to dilate. That allows more of the chemical to hang around and build up, so erections are better and last longer. After orgasm, blood vessels actually contract and the erection goes down. For men using these drugs, the refractory period, or bounce-back time — how long it takes before you can have an erection again — is also significantly shorter.
Q: Are there important differences among these drugs?
A: Viagra, Levitra and Cialis are each slightly different molecules, with slightly different effects and side effects. Viagra and Levitra usually last four to six hours, for instance, although there’s some evidence that they may last longer than that. Cialis can last as long as 36 hours. So you have a longer window of opportunity. Some men prefer that. Which drug is best? The answer is the one that works for you, with the fewest side effects.
Q: Are there dangers to overusing these drugs?
A: Despite early concerns, there is no evidence of a higher risk of heart attacks or blindness or acute hearing loss. In fact, erectile dysfunction drugs have actually been shown to lower heart attack rates in men taking them on a regular basis. That’s not surprising. Viagra was originally developed to treat angina, chest pain caused by cardiovascular disease. It didn’t prove to be particularly effective, so the study was stopped. But when the researchers asked the volunteers to give back the leftover drugs, they balked. The reason: their erections were so good. By dilating blood vessels, these drugs probably improve blood flow to the heart, which would protect heart muscle.
Q: Can men become dependent on erection drugs?
A: No. There is no evidence that people come to need more and more of them to get an erection, and no evidence of physical dependence. In fact, I often prescribe them to men with psychogenic erection problems, as a way to build confidence. After they become confident that they can have a normal erection, they don’t need the drugs any longer.
Q: Do erectile dysfunction drugs work for most men?
A: About 70 percent of the men in my practice respond. But if the vascular damage is too serious, even these drugs can’t help. In men who smoke, have elevated cholesterol, hypertension and diabetes — vasculopaths, I sometimes call them — the blood vessels in their penises are like lead pipes. They can’t dilate to cause an erection.
Q: What happens, then, if erectile dysfunction drugs fail?
A: Erection-inducing drugs can be injected directly into the penis, which creates higher levels and sometimes works when pills don’t. We train men to do this at home. For men who are uneasy about giving themselves a shot, there’s another approach that involves placing a tiny medication-containing pellet into the urethra. As the drug passes through the walls of the urethra, it causes blood vessels in the erectile tissue to dilate.
Another approach is the use of vacuum tubes, which have been around for more than a century. You put the penis inside a plastic tube, and a small pump draws the air out, pulling blood into the erectile tissue. Once the penis is erect, you slip a constriction band around the base of the penis and remove the tube and you’re ready for action. Clearly this is the least natural alternative, but it’s also the least expensive.
For highly motivated men, there’s the option of a penile prosthesis. Most of these are inflatable tubes implanted in the shaft of the penis, connected to a pump placed in the scrotal sack. With a squeeze of the pump, the prosthesis inflates and you have an erection. The penis looks normal in a flaccid state. The prosthesis doesn’t interfere with urination, sexual pleasure or orgasm. And our surveys of men and their partners say they’re very happy with the results. One downside is that you can have mechanical failures, which means having to replace the device. And there’s a very small risk of infection. Also, once you have a prosthesis implanted, you can never have an erection again without it.
Q: Can erectile dysfunction be prevented?
A: Men can certainly reduce the risk by maintaining good vascular health. The usual advice applies. Don’t become obese. And get lots of exercise. Exercise increases blood flow throughout the body, and what’s good for vascular health is good for the penis.
Here’s something most men are happy to hear: Sex is also good for your penis. In fact, men normally get two to seven spontaneous erections during the night — not because they’re having an erotic dream or their bladders are full. It’s a reflex. We’re designed to get erections so that blood flows into the erectile tissue to nourish it. Sometimes after prostate surgery, men stop having nocturnal erections, at least temporarily. The longer you don’t have them, studies show, the more likely you are to begin to lose length, girth and vascular tissue in the penis. For most men, that’s a pretty strong case for use it or lose it.
According to nytimes.