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Erectile Dysfunction
By Dr. Shafiq Qaadri, MD

What is erectile dysfunction (ED)?
Erectile dysfunction occurs when a man is unable to get a hard enough erection for what he and his partner want to do sexually. In heterosexual couple, usually that means not being able to penetrate the vagina. For a gay man who would like to have anal intercourse…he may have to get a firmer erection.
But you don’t actually have to have an erection in order to be sexual: Many men can enjoy full sexual pleasure, ejaculate, and have the sensation of orgasm without a full erection.

How should one screen for ED?
ED screening is something that both physicians and patients have been anxious about…With the limited time in primary care, we must find direct ways of asking. I tend to say, “Many patients have sexual concerns. I wonder what concerns you might have.” This is wide open, and allows patients—both men and women—to elaborate.

What is the prevalence of ED?
The prevalence of ED increases as men age due to the presence of other diseases, notably hypertension, hyperlipidemia, diabetes…as well as changes in hormone status, such as declining testosterone levels. One of the best epidemiological studies was conducted in Boston in the early 1990s, the Massachusetts Male Aging Study...Looking at men age 40 to 70, they found overall a prevalence of about 50% of at least some degree of erectile dysfunction, ranging from mild to severe.

Looking at the men age 40, 5% of them had complete erectile dysfunction…being unable to perform sexually at any time. That number increases to about 15% of men having complete erectile dysfunction by age 70.

Is ED an illness, a lifestyle illness, or a manufactured illness?
We know that when men are in a supportive relationship, they tend to stay healthy, and they tend to live longer…Being sexual is part of emotional and physical intimacy…so I would argue that this isn’t a manufactured illness. I don’t think it’s a lifestyle illness.

What’s the breakdown between the legitmate medical use and the recreational use of Viagra?
I can’t quote direct numbers…but it’s my belief that most of the use of Viagra is medical. I think there are some isolated niches where Viagra may be used to enhance sexual function.

My point would be that if men have concerns of sexual function, and if Viagra can help them with that function, I think that is a safe medication for them.

When I work with couples, and get a sense of the partner’s experience, I think that may be the most successful measure of sexual function, and a treatment success or failure.

Is it important to involve couples, and treat ED as a couples’ disease?
That depends on the individual man. Many men are uncomfortable talking about sexual concerns, and will want to be seen on their own. Some will say, “Doc, just give me the pill please.”
Some studies, however, do suggest that the treatment outcomes will be better in men who come in with their partners.

Couples need to be reassured: There’s an urban myth out there that taking Viagra may cause a man to die of a heart attack…Viagra is really an extraordinarily safe medication, and that the contraindication to taking Viagra is is taking nitrates.

What is the mechanism of action of Viagra, and why don’t things stand at attention if you’re just there? Why is sexual stimulation required?
Viagra gives a very natural erection, as an amplifier for the sexual signals from the brain to the penis. When a man has sexual stimulation, his brain will send nerve impulses down to the penis.
With aging and various diseases, even certain medications, these signals get muted and damped down. So the penis can’t react as much.

What Viagra does is block the breakdown of intracellular nitrous oxide, which is an intracellular messenger. This allows the inflow of blood to the penis, through the afferent arteriole.

So if a man isn’t having sexual thoughts, or takes Viagra and slips into bed wanting to surprise her, and they both don’t do anything, then they’ll both wake up with a refreshed night’s sleep.

In contrast, with some of the other technologies, for example the injections of prostaglandins, that will give him an erection whether he wants one or not. A lot of men will describe that erection as feeling wooden.

Why are nitrates an absolute contraindication?
Nitroglycerin for angina, for example, will also increase intracellular nitrous oxide levels. When a man takes nitroglycerin, the nitric oxide is degraded and broken down by the phospodiesterases. When you take Viagra, you block the breakdown of these products, so the concentration of nitric oxide is greatly increased.

In what clinical situations for ED do you resort to implants, injectables, or vacuum tubes?
Until Viagra was released in the Canadian market, these other options were all that we had.

When I used to mention the word injection and penis in the same sentence, men would tend to blanch and run from the room…I do still have some men using the injectable treatments. The other modalities are still excellent treatment options in appropriate patients.

Viagra has totally revolutionized the approach to sexual dysfunction…it has forced the issue into mainstream medicine…Studies have shown that about 72% of men taking Viagra will benefit. However, that still leaves almost one out of four men who did not significantly respond to the Viagra. For these men, the other treatment options remain viable.

For example, this includes Muse, which is an intraurethral prostaglandin. The advantage is that it doesn’t involve a needle. The downside is that it can cause some aching in the penis.

Injections such as Caverject can give very satisfactory erections, and I do keep these as second-line medications.

Vacuum tumescence devices have been around for a long time. They are effective for many couples, and do not involve any medications.

When considering ED, how do you decide if a man is suffering from pure ED, and thus require Viagra, or Andropause, and thus require Testosterone. Do you occasionally give both?
I occasionally give both.

The standard sexual response cycle involves having sexual desire, arousal—for women to get lubricated, for men, to get an erection—and then to have an orgasmic release.

Viagra works primarily in the area of arousal…It’s not a direct desire medication; it’s not an aphrodesiac.
In contrast, Andropause, or decreased testosterone levels, can result in decreased desire and decreased intensity of orgasmic sensation.

There are a number of ED drugs in the Canadian market: Cialis (Eli Lilly) and Levitra (GSK-Bayer). Are there additional benefits?
The first two are phosphodiesterase inhibitors that work in a similar way to Viagra.
Regarding Cialis and Levitra, as when any medication is released, competitors will try to improve on the current standard. Given the huge market in this area, other companies are looking to meet those needs.
Viagra does have an onset of action that takes a number of minutes to work—it’s not immediate. Some of the new molecules being discussed are different. One of them is going to last longer, so that you can uncouple taking the sexual drug from being sexual. For example, if you are looking to be sexual on a weekend, you can take the medication on a Friday evening, and have an effect Saturday and Sunday.
The other is being touted as having a more rapid response than Viagra.

It remains to be seen if these differences are significant in clinical practice.

What is this idea that if men take Viagra, and it doesn’t work the first time, than they can continue to try it until in works? Is this a loading-dose effect?
It’s not a loading dose. Men often have a large anxiety component, which causes them to release adrenaline, which is erectolytic. When men get anxious, they lose more of their erection. When they first take Viagra, they may be psyching themselves out…as they get more relaxed, they get improvement.
When I first prescribe Viagra, I tend to suggest that they take the first dose alone, without their partner, and to self-pleasure, just to get used the effect.

Is ED a marker for coronary artery disease?
There is data to suggest this. There’s an Canadian study underway to see if ED is a better marker for heart disease than the traditional coronary risk factors…There’s evidence that suggests that erectile dysfunction is linked to coronary artery disease—the caliber of the penile artery is the same diameter as the coronary arteries.

What is your final message for family physicians regarding ED?
Sexual function is a normal part of being human. Being able to treat illnesses that impact sexual function is part of treating the whole patient and improves the quality of life.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

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