Organic

Organic causes are causes that are a result of a physically identifiable cause such as a bodily disease, or a side effect of a drug.
The vast majority (85-90%) of erectile dysfunction is from an organic cause. The full list of causes is expansive. The most clinically relevant are: age, vascular disease, diabetes, lifestyle, neurological disease, prostate surgery/radiation, trauma and medications.

Age

Beginning at middle age, blood vessels within the penis become increasingly less pliable, making blood flow through the vessels more difficult.

Vascular disease

In men older than 50 years, nearly half of all erectile dysfunction is a result of vascular disease. Diseases include peripheral vascular disease, atherosclerosis, myocardial infarction and hypertension. Males who have had either a heart attack or open-heart surgery have a 60% chance of erectile dysfunction.

Diabetes

Diabetes is a common cause, with approximately one-half of all diabetic men experiencing erectile dysfunction at some point in their lives. Since diabetes has adverse effects on both blood vessels and nerves, the erectile dysfunction is likely a result of both. Maintaining optimal glucose control minimizes the risk of erectile dysfunction.

Lifestyle

Smoking is an independent risk factor for erectile dysfunction, accelerating atherosclerosis of penile blood vessels. Smokers are 50% more likely to get erectile dysfunction.
The MMAS study results show that men who do regular exercise are at lower risk of erectile dysfunction [Ref], likely due to positive cardiovascular effects.
Also, the MMAS study revealed that high-density lipoprotein (HDL)–the so-called “good cholesterol”–was associated with a reduced risk of erectile dysfunction.
The long-term intake of alcohol can damage conduction of nervous signals, resulting in a decreased ability to achieve satisfactory erections.

Neurological disease

Diseases of the nervous system are another cause, since intact nervous pathways are required for an erection. Disorders include stroke, Alzheimer disease, epilepsy and multiple sclerosis.

Prostate surgery/radiation

Prostate surgery can lead to erectile dysfunction, due to damage to nerves, blood vessels, or both. In surgery to reduce benign prostatic hyperplasia (BPH), the risk of erectile dysfunction is approximately 10-20%. In a radical prostatectomy, patients who are younger than 60 years have only a 20% chance of erectile dysfunction, but patients older than 70 years have a 90% chance. In radiation therapy for prostate cancer, 50% of men will experience erectile dysfunction within 5 years.

Trauma

Trauma to the vasculature or nervous pathways can lead to erectile dysfunction. Interestingly, bicycle riding is undergoing research as a possible factor causing such injury to the pelvic area, and bicycle seat manufacturers have been quick to respond with new bicycle seats designed to reduce pressure on this important area.

Medications

Both prescription and illicit medications can induce erectile dysfunction.
The commonest prescription medications which impair erections are: antihypertensives, antidepressants, antipsychotics, cholesterol-lowering agents, some anti-ulcer drugs, 5-alpha reductase inhibitors and hormonally active drugs such as finasteride.
Illicit medications include cocaine and ectasy (MDMA). Since MDMA can result in a temporary erectile dysfunction, some addicts use a concurrent Viagra tablet to counteract this effect [Ref]. This combination of MDMA and Viagra has been termed “sextasy”.

Psychogenic

Psychogenic refers to impotence from a psychological cause. Only 10-15% of all erectile dysfunction is due to psychogenic causes.
Psychogenic erectile dysfunction is characterized by good nocturnal and morning erections and negative lab investigations. Another hallmark finding is variable erections: normal one day and absent the next.
Depression is one of the best studied causes. The MMAS study found that depression was the second likeliest risk factor for erectile dysfunction (odds ratio of 1.82). Additionally, nearly 100% of men suffering from severe depression also have erectile dysfunction.
Other common psychogenic causes include anxiety (including performance anxiety), low self-esteem, stress and guilt. Even diseases such as post-traumatic stress disorder (PTSD) can be associated with erectile dysfunction.

Combination

Organic and psychogenic causes can often co-exist.
This can occur as a pure clustering of unrelated diseases, such as a diabetic patient with stress at work.
It can also occur as a clustering of risk factors. For example, the risks for vascular disease also increase the likelihood of depression. These risk factors include smoking, obesity and a sedentary lifestyle [Ref]. One study even coined the term “DEC syndrome”, referring to men suffering from depression, erectile dysfunction and coronary heart disease, since this triad of conditions is so common. Also, age increases the risk of both erectile dysfunction and the risk of depression.

Another interplay of organic and psychogenic causes is the medical treatment of a psychological disorder, such as depression. Depression is a cause of erectile dysfunction, and one of the most commonly used classes of anti-depressants are the selective serotonin reuptake inhibitors (SSRIs) which can also cause erectile dysfunction. Fortunately, one can usually readily treat the erectile dysfunction side effect of SSRIs with PDE5 inhibitors.

Psychological factors also can worsen impotence caused by a physical condition. Someone may experience anxiety about sex after a recent myocardial infarction, or low mood while adjusting to disability following a stroke.

Men who are suffering from impotence often isolate themselves from their relationships. Erectile dysfunction can be embarrassing to talk about. Partners of men with ED feel that initiating a discussion regarding the situation will cause embarrassment and humiliation. The partner may also develop a sense of inadequacy, thinking the cause of ED is their fault and that they are no longer physically attractive. In most cases, ED is a result of physical causes but it can be made much worse by psychological factors. Silence, embarrassment, and feelings of inadequacy and humiliation only lead to further withdrawal on the part of both partners, increasing the distance and tension within the relationship. The anxiety which results can easily make a case of ED worse, leading to a vicious circle of failure and anxiety about such failure.

ED can ultimately lead to the break down of a relationship or family.
It is important for a man to feel as comfortable as possible discussing his condition with his partner as well as his physician, in order to consider suitable treatment options and minimize the likelihood adverse effects on the relationship.

The Discovery

Most great discoveries seem to have one thing in common: They start out innocently enough – and quite accidentally. At least that’s what the “legend” says. Researchers working on a solution to relieve angina pain with a drug call sildenifil citrate realized that it just wasn’t working. They packed up their statistics and called off the clinical trials. Chalk this one up to trial and error, they thought. Then one astute scientist noticed a side effect reported by a significant number of men: a more satisfying performance in bed.

The researchers scratched their heads and returned to the project. Certainly sildenifil citrate didn’t work on the original angina problem, but what if … no, the possibility couldn’t even be considered. But then again … maybe it could.

Sildenifil citrate, tests would bear out, did indeed seem to be that “magic pill”…. that Holy Grail for men with impotence. The unexpected – and from Pfizer’s viewpoint extremely lucrative – benefit from this drug was that it allowed men with impotence problems to perform successfully and satisfyingly in the bedroom again. Sildenifil citrate, which works by trapping the blood in the penis, it appeared, even positively affected men whose erectile dysfunction stemmed from psychological problems. The statistics were overwhelming. This medication worked for up to 72 percent of the men who tried it, regardless of the origins of their problems. It just didn’t matter, the researchers discovered, whether the cause was psychological or based on an underlying medical problem, like diabetes or cardiovascular disease.

After several years of clinical trials aimed specifically at treating impotence, Pfizer had a winner. The U.S. Food and Drug Administration approved sildenifil citrate – brand name Viagra – for the U.S. Market, March 27, 1998.

Viagra Sildenafil represents the first successful non-surgical, non-surgical treatment for impotence ever. It, indeed, represented a revolution in the treatment of male sexuality and changed forever the way men – and by necessity – their partners viewed sex.

Not much more than 40 years ago, medical school training taught would-be doctors that the cause of impotence – and yes, it was called impotence then – was all psychologically based. In other words, a man’s failure to sustain a satisfying erection was all in his head.

In fact, the 1966 edition of General Urology, a textbook used in medical schools, gave this explanation for impotence: “Various degrees of impotence in men are common, but it is rare to find definite organic cause for the complaints …The cause of almost all of these difficulties is psychogenic.”

In fact, men’s impotence wasn’t really his fault at all… it was his wife’s.

“With few exceptions,” the text continued, “the causes of sexual difficulties in the male are psychic, i.e., based on guilt, anxiety, jealousy, or frigidity on the part of the wife. Many of these men are obviously tense and nervous… Unless the patient’s difficulties are of short duration, he should be referred to a psychiatrist.”[1]

A 180-Degree Turn

Wow! What a complete turnaround in thinking in a little more than a generation. Today, with the appearance of Viagra and other prescription drugs that followed, virtually all impotence problems can be successfully treated [2]. At least, the symptoms can be successfully treated. And it certainly has given millions of men back their sense of masculinity. But, has Viagra and other drugs to treat impotence raised more questions than it answers?

Many experts think that is exactly the case. Today, more than ever, American culture proclaims a “quick fix” is absolutely necessary. And that is exactly what Viagra and similar medications give them. Viagra gives new meaning to the proverbial doctor’s phrase, “Take two and call me in the morning.”

Critics claim, though, that while Viagra may be making Supermen out of Underdogs, it is only reinforcing a culture that already relies too heavily on medications that can quickly solve any medical problem around. Can’t perform in bed? Take this pill; you’ll have the most powerful erections of your life. Never mind that your wife didn’t have a problem with your bedroom performance before this. Never mind that there just might be serious, unspoken problems, in your marriage that need to be dealt with. And, yes … don’t worry about the potential side effects which have included blindness and possibly death.
The pharmaceutical industry, intentionally or not, has finally reduced lovemaking to sexual performance. In fact, Meika Loe, author of The Rise of Viagra: How the Little Blue Pill Changed Sex in America, argues that with the appearance of Viagra, the medical community has effectively “McDonaldized” lovemaking. Pfizer did to sex, what McDonald’s did to food. Society now wants it fast, hot and
supersized. [3]

It is just one more step toward being able to “fix” any problem – including aging – with drugs. Pfizer – either intentionally or unwittingly – has turned the most intimate act between a man and woman into a performance-based sport, somewhat akin to hitting a homerun in baseball, or making a touchdown in football.

Some men view Viagra as a “magic cure,” explains Arleen Goldman, author of Secrets of Sexual Ecstasy. This makes them less likely to work on other, potentially more intricate solutions, to the problem. It also makes them less likely to deal with any underlying emotional problems in the bedroom. [4]

Viagra is only one example, albeit the most publicized, of how Americans are craving a quick fix to their problems – and their perceived problems. For more than a generation now, the American culture has reinforced the idea that life can be better … if only you take more medications. In the early 1950s, it was the advent of penicillin, the wonder antibiotic that every child received (in the form of a shot) when taken to the doctor for any reason. The flower child of the 1960s and 1970s experimented with a myriad of designer drugs – most notably LSD – and tried to “drop out of society”. Although the older generation condemned this blatant drug abuse, they were busy visiting doctors who doled out Valium and other sedatives to housewives who failed to cope with their lot in lives. Is it any wonder that the “cure” for poor performance in bed was a prescription pill, whose sales are fueled by the recent ability of the pharmaceutical industry to advertise directly to the consumer through television commercials and print ads?

The Public’s General Perception of Viagra

“For the millions of men who want to make love and can’t, we are about to make your night.” Those were the words of Hugh Downs, broadcast journalist, announcing the FDA landmark approval of Viagra.[5]

Since that night, millions of men visited their doctors to get a prescription for this little blue pill. The response of men to the first non-surgical, non-injectable treatment for impotence made Viagra the most successful drug release in history. Talk about a market for a product!

However, the approval of Viagra did more than revolutionize the way medicine treated a condition once thought nearly untreatable. It revolutionized how a nation, indeed, the world, viewed the problem of impotence (albeit now referred to as erectile dysfunction). No longer was it only spoken of behind closed doors. Viagra swung the doors wide open. Former presidential candidate, Sen. Bob Dole spoke about his own erectile dysfunction in nationwide advertisements, NASCAR driver Mark Martin raced around in front of hundreds of thousands of race fans every week with Viagra painted on his car,

Men who had nearly forgotten what satisfying sex felt like were once again enjoying the bedroom experience. The entire nation greeted the pill with an awed reverence. Science had broken through the last barrier, it seemed. Not since the FDA approved the birth control pill in 1960 did America feel so liberated sexually. Women called their family physicians to make appointments for their husbands. Men created excuses to see their doctors so they could mention their desire for a prescription.

If sales of the little blue pill, as it has been dubbed, are any indication, the initial perception by the public was overwhelmingly favorable. Pfizer’s sales in the United States for 1998 for Viagra topped $656 million. Considering that Viagra wasn’t approved until the end of March, those figures are pretty impressive. Soon after approval was received in this country, many western European countries also approved use of the medication, including France, Switzerland, France, the United Kingdom and Germany. Other nations worldwide that approved the sale of the drug included Brazil, Israel, and Australia.

Viagra: Changing the Lives of Men and the Women Who Love Them

Men, who may not have approached a doctor prior to this about their impotence, now were knocking at the office door in record numbers. And that, it seems, is a good thing, at least in some cases. One gentleman, a management consultant in California who was among the initial 1,500 men who took part in the original clinical trials for Viagra, praises the pill for transforming his marriage and in particular his love life. He scoffs at the notion that lovemaking, fueled by Viagra, is less romantic and more performance oriented. He lived with erectile dysfunction following surgery for prostate cancer more than a decade prior to his participation in the clinical trials. “What definitely isn’t romantic,” he says, “is not being able to experience sexual intimacy ever, which is where I’d be if this [prostate surgery] had happened to me 20 years ago.”

“One of the biggest myths,” he explained, “is that men are taking these medications only to have sex with younger women. I love and desire my wife … And I certainly wasn’t ready to stop having sex in my 50s.”[6]

And, indeed, for many married couples nationwide Viagra became the lifeline that saved a marriage. Sex, for many, became more intimate, just as the gentleman in the clinical trial said. Couples, in many instances, became more communicative. These were the ones who were able to “turn foreplay into a home run,” according to the co-directors of the Network for Excellence in Woman’s Sexual Health, Drs. Laura and Jennifer Berman.[7]

These doctors, while recognizing the down side of Viagra, also are able to view its full potential as one tool in a series of events to help married couples in the bedroom. “What is crucial,” the doctors, who happen to be sisters, write, “is that we address the psychological and educational aspects about how to effectively incorporate the regained erectile potential into a broader and relational context.”

In other words, Viagra is a great start, but it’s not the end-all of sexual therapy. Sex, they caution, is not performance oriented, but satisfaction oriented. “Men who are being sent home with Viagra,” they explain, “are given instructions on how and when to take it …” And that, they contend, is only a partial prescription for sexual fulfillment. These men are not being told “what to do once it works.”[8]

But for every success story, there exists a story of a failed marriage or infidelity. Soon reports were appearing in newspapers and news magazines of “Viagra divorces.” Men, with their new-found sexual powers and a brazen self confidence, were dumping their wives for younger, sexier and presumably more sexually active women.

Consider these cases, gleaned from newspaper articles across the nation following the introduction of Viagra to the American public:

A 70-year-old New York man started cheating on his wife, age 61, only two days into taking his new Viagra prescription, according to USA Today.

A wife sued her husband after he spiked her drink with Viagra in an attempt to improve their sex life.

The underlying problem, many sex therapists say, is that in many cases, women may have problems adjusting to their husband’s new found sexual prowess. “One of the things that people have forgotten about Viagra,” explains Julia Cole, a sex therapist with the relationship counseling service, Relate, “is that it can’t change the attitude of the man or the pattern of lovemaking the couple have previously had.” That means while the man, armed with his Viagra prescription, is now suddenly ready to spend the entire evening in bed, it may come as an unexpected change for a wife accustomed to a marriage practically void of lovemaking.[9]

Viagra to the Rescue: Will You Still Love Me When I’m … 84?

“Is it not strange that desire should so many years outlive performance?”
–Shakespeare, Henry IV, Act 2, Scene 4

Perhaps it was strange to the great bard, Shakespeare, that desire should outlive performance. But today thanks to Viagra and other sexual enhancement prescription drugs, that no longer needs to be the case. Desire and performance can now be maintained at the same level.

Many experts thought it would be boon to the older married population, something akin to discovering the fountain of youth. And at first it appeared that Viagra just might be that. But it didn’t take long for negative reports to start flooding the news. Here again, Viagra presented complications into relationships that many times were comfortable with the status quo. One partner suddenly discovers a new-found power and the other is not quite sure how to handle it.[10]

And the consequences with older couples can be even more dramatic. With many younger married couples, it is assumed that only the man has the impotence problem. However, with elderly couples, it very well could be that both the husband and the wife experience some type of sexual dysfunction. For many post-menopausal women a reduced sexual drive and inhibited performance in the form of dryness and pain are part of the aging process.

Enter a husband, fresh from the doctor’s office, with a bottle of Viagra in hand. Popping one into his mouth, this husband believing, he is saving their marriage, is ready for sex within an hour or so. However, his wife’s physical problems are not solved. She is not so receptive. Even her libido may be under active and has really no physical urge for sex. The pair may have been relatively happy this way, adjusting to a new-found life without sex and compensating in other areas of their relationship. Suddenly sex is foisted upon her. Tensions form.

There were reports of older couples breaking up because the 84-year-old man was acting like a 25-year-old kid again, and his 80-year-old wife was acting … well, like an 80-year-old woman.

For a drug that supposedly was to put the spark back in a couple’s love life, it sure caused quite a few marriages to extinguish.

And now, a word from a certified expert on sex …

The internet abounds with message boards dedicated to men drooling over their new-found ability to make love, longer and harder. They brag in both polite and downright graphic terms about how they are able to satisfy not only their partners, but themselves. These men – average American males who had for whatever reason been unable to assert their masculinity – are now announcing to the world (granted under screen names that are not likely to reveal their real identity) their great love for Viagra. Their girlfriends, wives, lovers, they say, are also extremely satisfied with the results.[11]

Gary Schubach, Ed.D., A.C.S., an internationally known sex educator, lecturer, writer and group facilitator, decided the only way to truly understand the changes men experienced with Viagra was to take it himself. So he trudged off to his physician, who realized, by the way, Schubach’s occupation of sexologist, and received a prescription for Viagra.

Now, Schubach’s wife, Shama, also happens to be his partner in sex therapy. She has more than 10 years of experience as a hynotherapist and chemical dependency counselor in addition to her sex counseling experience. Schubach did not tell Shama he had received the prescription. He wanted her unbiased reaction. Would there be a difference in his performance with the medication?

Schubach used the medication upon Shama’s arrival home from an extended business trip. He explains, in the couple’s on line article, “The Easy Erection: Penile Panacea?”, that Shama had come home Friday night, they had made love. The counselor popped the little blue pill Saturday morning. The stage was set for a “before and after” test.

“Over the course of the day,” Schubach writes, “we made love several times, taking breaks to eat and deal with life.” Among his comments, he notes: “I was pleased to find that the effect of the drug felt very natural.”

He continued: “Not having to be concerned about losing an erection took a lot of pressure off of me. It allowed me to do a number of things during intercourse …that I could not have done without Viagra.”

The end result from Schubach’s point of view: An increased sense of pleasure and intimacy.

And Shama’s evaluation after being told of the “test”? “In retrospect, I think that because his erection was so strong, I felt it actually took some of the pressure off of me to help maintain a certain level of arousal between us.”

However successful this initial trial run of Viagra was, Part II of their test was less than memorable, Shama explains. The following day Sunday, was a long and hectic day, which included the hosting of a dinner party. Schubach took another 50 mg of Viagra. The results this time were different.

“Even though … [I was] stimulated and my desire was there, my erectile response was minimal.” Schubach said that this only confirmed his suspicion that men find great success in the product the first time they use it, but may encounter difficulties if they are tired or if there are more problems present in the relationship than just impotence.[12]

Viagra for Women?

The wild success of Viagra prompted pharmaceutical companies worldwide to search for an easy “cure” for women’s sexual problems … a Viagra for women as it were.

Women in search of a solution to their problems though are waiting. Some, inspired by their partners’ success, used Viagra to test what sexual effect, if any, it had on them. And since Viagra works by inducing blood flow to the genital area and trapping it, some females found it improved their arousal and increased lubrication.

In fact, Shama, whose husband Gary Schubach used Viagra to test its effect, experimented with it herself. “When Gary and I made love this time [while I was using Viagra], I noticed a marked increase in sensitivity in my genitals which did heighten my pleasure.”13

However, these isolated incidents have not been translated into any effective medication. The problem is that Female Sexual Dysfunction (FSD) is not a disease … and therefore not easily treated with a magic bullet. FSD is a label physicians and other health professionals use to describe a syndrome – or a set of symptoms – which includes loss of libido or desire, decreased sexual arousal, lack of orgasm, pain during sex and lubrications problems.

Forty three percent of women ages 18 to 59 suffer from some type of FSD. At least, that’s the results of a 1999 national survey published in the Journal of the American Medical Association. FSD occurs most frequently in premenopausal women ages 18 to 50.14

As with male erectile dysfunction, medical experts initially believed that FSD origins lie purely within the realm of psychological conditions. However, professional opinion is now shifting on this. They now believe some sexual issues stem from physical or organic origins.[15]

“Pharmaceutical products that could treat FSD could be a significant medical advance.” These are the words of Leland Wilson, president and CEO of Vivus, Inc., a California based company specializing in products to “improve the quality of life for men and women with a focus on sexual dysfunction.” His company is testing a topical medicated cream called Alista. This cream is aimed at helping women overcome problems with arousal. Alista’s active ingredient is alprostadil, a synthetic version of a naturally occurring vasodilating agent of the body.[16]

Industry giant Proctor & Gamble is examining the role testosterone plays in the female during the sex. It hopes to market a testosterone patch. Low levels of this hormone, typically associated with men, plays a role in a lowered sexual desire in women. Some gynecologists are already prescribing this male hormone for their patients who suffer from decreased desire.

Pfizer, buoyed by its profitable development and marketing of Viagra, spent nearly a decade looking for a Viagra equivalent for women. Finally in February 2004, the company abandoned the project. The pharmaceutical researchers discovered what every woman probably could have told them from the start: Women do not have the same relationship between sexual arousal and desire that men do.

In men, arousal almost always leads to desire. Viagra works on men because it improves his ability to have an erection and in turn affects his sexual function. But in women arousal and desire are not as intricately intertwined.

“Men consistently get erections in the presence of naked women and want to have sex. With women, things depend on a myriad of factors,” explains Dr. Mitra Boolel,, a leading member of Pfizer’s sex research team. So, instead of focusing on Viagra, Dr. Boolel and his team are changing their focus from a Viagra-like medication that would affect blood flow to the crucial sexual organ of women, the brain. 17

Viagra in American culture … where does it all lead?

In less than ten years, Viagra has become a household word. You would be hard pressed to find a person who hasn’t heard about the drug or what it does. It’s been the subject of jokes, ridicule and praise. In fact, it’s been so commonplace, that up until June 2005 Medicaid paid for Viagra prescriptions.

You can thank the power of direct-to-consumer advertising of prescription drugs for a large dose of that recognition. And if trends are any indication, you’re bound to see a lot more of it for medications that are now being classified as “smart” drugs. These are drugs that affect your “quality of life” more than your physical well-being. Basically, it can be described as drug use by otherwise healthy individuals whose sole desire for the medication is to manipulate mood, memory or perhaps concentration. It’s already a phenomenon on many college campuses, with students asking the campus doctors for a prescription for Ritalin so they can stay up late and study.18

Scientists are learning more about the brain everyday and it’s not unreasonable to assume that the past success of direct-to-consumer advertising will join forces with the nation’s desire to perform better – not just in bed – but on the job and in school as well.

There exists a trend – the pros and cons of which are being argued in scientific circles – of branding such normal mood swings .. depression, sadness, anxiety and the like .. as medical disorders. Combine this trend with the track rate of the direct-to-consumer advertising of drugs and you’ve just created a market that otherwise has not existed in the past.

If you tell someone often enough and long enough that his occasional sadness is a serious condition that needs medicating, he’s bound to believe you. His next step is to go to his doctor and tell him about his symptoms. He’ll even mention he saw an ad on television for a medication that might help him. What do you think, doc?

And the doctor, through no fault of his own, is busy and believes that if the patient believes the symptoms are serious enough to see a doctor, then perhaps the medication just might work for him. The patient walks out of the doctor’s office with a prescription for a drug he really doesn’t need and the doctor goes on to his next patient.

If taken to extremes, people won’t have to tolerate any type of mood swings or any lack of concentration or any other variation in their personalities. Watch television long enough and you’re bound to hear an advertisement for a condition similar to yours.

After all, up until this point, hasn’t our society told us that we shouldn’t want for anything. Everything we want is at our fingertips. If we don’t have enough money for it, don’t worry, we’ll charge it. Our heart isn’t functioning well? Don’t bother with that pesky exercise and trying to eat properly. Why that takes just way too long. Here’s a pill that can help bring down your cholesterol. After all it isn’t your fault anyway that your cholesterol level is sky high? You inherited that from Aunt Pauline.

And, oh, by the way, are you having a difficult time pleasing your partner and you in bed? Here’s another pill to take care of that. Welcome to Viagra country!

Background

Levitra (generic name vardenafil) was the second of the PDE5 drugs to be introduced, with FDA approval in August 2003. Approved five years after Viagra had begun to help men with erectile dysfunction, Levitra attempted to help even more.

Manufacturers Bayer and GlaxoSmithKline launched the drug with a heavy advertising campaign. Sports celebrity Mike Ditka stood by the product, and the bold-print slogan read “When you’re in the zone, it’s all good.”

Levitra Dosage and usage

Levitra’s unique status among PDE5 agents is its biochemical potency, meaning that very few milligrams are needed to produce the desired effect. The drug is supplied as round orange tablets, with the dose stamped on one side. Levitra is available in strengths of 5mg, 10mg and 20mg.

The normal starting dose is 10mg. A starting dose of 5mg is appropriate for men older than 65 years, or who have moderate hepatic impairment. No dose adjustment is needed for renal impairment, or mild hepatic impairment [Ref]. If Levitra is not working at the starting dose, higher doses may be needed to achieve results. Difficult-to-treat erectile dysfunction should be titrated more rapidly.

Like Viagra, Levitra is taken 25 to 60 minutes before anticipated sexual intercourse. Also, sexual stimulation is required for Levitra to produce a satisfactory erection.

Levitra is vaunted to reach its maximum plasma concentration within a relatively short time, and for some people, the first clinical effect may be seen as soon as 10 minutes after ingesting Levitra. Maximum plasma concentrations vary among individuals from 30 minutes to 120 minutes. Review of the product monograph shows the median time to maximum concentration to be 60 minutes, which is similar to Viagra.

Levitra has a mildly delayed absorption following a high-fat meal. A meal with greater than 30% fat will reduce maximum plasma concentration by 18-50% and delay the time at which maximum concentration occurs by 1 extra hour [Ref]. This delay is somewhat less than with Viagra. Users of Levitra should avoid meals with over 30% fat within 2 hours prior to taking Levitra. There is no noted negative effect on absorption with low-fat meals.

Levitra is usually recommended not to be taken more than once a day.

Levitra Side-effects

Levitra, like other PDE5 inhibitor medications in its class, is well tolerated overall.

Many of the side-effects are ones that also occur with other PDE5 inhibitor drugs. These include headache (13%), flushing (12%), rhinitis (9%) and dyspepsia (3%). Rare side-effects of accidental injury, flu syndrome and increased creatine kinase were all 2%, and similar to rates seen in placebo.

Notably, Levitra has a reduced incidence of blue-tinted vision versus Viagra, likely due to its reduced affinity to the PDE6 enzyme in the retina. In the commonly cited studies, only 0.7% of patients reported any type of visual abnormality with Levitra.

Virtually all adverse events diminish with discontinuation with the medication.

The PDE5 class of medications has had case reports of priapism, and erections over 4 hours in duration should be treated medically to avoid damage to the penis.

The mildness of adverse events with Levitra is quantified by the fact that only 3.5% of patients stop taking Levitra as a result of the side-effects (versus 1.2% for placebo)

Levitra Contraindications, drug interactions and cautions

Levitra should not be used by men who are taking any form of nitrates or nitric oxide donors. Nitrates are medications that have an effect of lowering blood pressure. Levitra causes a drop in blood pressure when taken in isolation, but when used together with nitrates, that drop in blood pressure can be enough to endanger life.

The FDA approval mandates that Levitra is also contraindicated in patients taking an alpha-adrenergic blocker medication. Alpha-blocker medications include such agents as Uroxatral (alfuzosin), Cardura (doxazosin), Flomax (tamsulosin), Hytrin (terazosin), and prazosin. They are used in the treatment of benign prostate hypertrophy (BPH) and, less commonly, for reducing blood pressure. Similar to nitrates, the combination of Levitra and an alpha-blocker can lead to dangerous hypotension, as well as priapism or other adverse events.

Levitra is metabolized in the liver, primarily by an enzyme called P450 34A. Other drugs, including anti-infection agents erythromycin, ketoconazole, itraconazole, saquinavir and ritonavir inhibit this liver enzyme. With the liver enzyme inhibited, less Levitra is broken down, and the levels in the plasma can rise unwantedly high. Thus, Levitra is either contraindicated with concurrent use of these drugs, or else the dose of Levitra is adjusted downward accordingly.

Levitra is not recommended to be used together with other erectile dysfunction drugs, such as penile injections, since it may increase the likelihood of priapism.

Since there are not clinically controlled trials to prove otherwise, warnings should be considered in certain groups of patients. These warning groups include patients with: unstable angina, acute myocardial infarction, blood pressure less than 90/50, blood pressure over 170/110, or a stroke/myocardial infarction/symptomatic postural hypertension within 6 months.

Similar to the studies on Viagra, Levitra does not significantly alter cardiac status nor increase the exercise time on a stress test, as compared to placebo.

Strengths and weaknesses

Levitra has advocates that describe a faster onset of action as compared to Viagra, though comprehensive comparator trials are still pending.

There is an increased selectivity versus Viagra for some PDE enzymes in the body, including the retina, so there is lessened visual side-effects.

Another advantage is that some men with erectile dysfunction that is not responding to Viagra may have some effect with Levitra. One such trial shown that, among men who were nonresponders to Viagra, Levitra was effective in over 60% of these patients. It is important to note that men with the most severe forms of erectile dysfunction are less likely to respond to any type of PDE5 inhibitor medication.

There is still the inconvenience of avoiding high-fat meals before using Levitra, although the effect is not as bad as with Viagra.

The duration of action of Levitra is much less than that of Cialis.

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Cialis (generic name Tadalafil) is the most modern of the three PDE5 drugs, with the medication receiving FDA approval in November 2003.

Manufacturer Lilly launched Cialis into the pop culture vocabulary with a nickname of “The Weekender”, due to its unique property of having an effect that lasts up to 36 hours. More conservative advertising used the slogan, “When the moment is right, will you be ready?”

Cialis is shown to be effective, both in the short term and in the long term, with the original clinical trials still showing results at 24 weeks when the study was completed [Ref]. Among five randomized control trials with 1,112 erectile dysfunction patients, intercourse was successful with 10mg (61% success rate) and 20mg (75% success rate) of Cialis, compared to only a 32% success rate with placebo.

Cialis Dosage and usage

Cialis is packaged as yellow, almond-shaped coated tablets in 5mg, 10mg or 20mg strengths.

Men should be advised that a starting dose allows them to evaluate the drug for both side-effects and efficacy. The starting dose varies by clinical indication and other comorbid conditions. Normally, the starting dose of Cialis is 10mg, though for certain cases, a starting dose of 5mg is recommended. If the starting dose is well-tolerated, but insufficient to achieve results, a subsequent dose increase can be considered. A patient should try the drug at least four times before considering a higher dose.

Ingestion of food neither impacts the absorption rate nor impacts the absorption extent of Cialis. In contrast to the other PDE5 inhibitor medications, fatty-meals are not an issue in planning when to take the drug [Ref]. There is no difference whether the pill is taken in the morning or in the evening.

Cialis is taken as needed prior to anticipated sexual activity. It is effective as soon as 30 minutes within taking the tablet. The medication’s effect lasts as long as 36 hours after ingestion.

A male with erectile dysfunction requires sexual stimulation in order to produce an erection after taking Cialis. Taking Cialis without the accompanying sensual and/or physical arousal will not achieve the expected results.

The maximum recommended frequency of Cialis is one dose per 24 hour period.

Cialis Side-effects

The side-effects of Cialis are usually mild. The commonest ones reported are: headache (11%), dyspepsia (7%), back pain (4%), myalgia (4%), nasal congestion (4%) and flushing (4%) [Ref]. Most of these side-effects are similar to other PDE5 inhibitor medications.

All side-effects are PDE5 class-related, except for the back pain [Ref]. This back pain is only rarely severe enough to cause discontinuation.

There are other rare side-effects including priapism, due to the length of time that the drug stays in the body. Rare possible side-effects in which causality is unclear include: dizziness (1.7%), swollen eyelids (0.3%) and ocular discomfort (0.3%).

Cialis has good selectivity for PDE5 versus other PDE enzymes around the body. The drug is 700-fold more selective for PDE5 in the penis than the PDE6 in the retina, which likely accounts for its very low numbers of visual side-effects. Among all clinical trials of Cialis at doses of 10-20mg, reports of colour vision abnormalities were under 0.1%.

Cialis Contraindications, drug interactions and cautions

Contraindications and cautions are mostly similar to other PDE5 inhibitor agents.

Men who use nitrates should not take Cialis. This includes nitrates in any form: inhaled, oral, sublingual or transdermal. Coadministration of the two medications can lead to a dangerous hypotension.

Patients taking many alpha-blocker medications (such as prazosin) should also be aware that Cialis can cause an additive hypotension [Ref]. However, the manufacturer reports that Cialis can be safely used with some selective alpha-1 blocker medications including tamsulosin.

Cialis is not recommended to be combined with other oral erectile dysfunction medications, since the risk of priapism increases.

Since it is metabolized in the liver, caution should be used when using other drugs which slow down the metabolism, such as some antivirals, some antibiotics or some antifungals. Specific drugs include ketoconazole and ritonavir. This slowed metabolism can result in higher levels of Cialis in the bloodstream. Conversely, some drugs such as rifampicin speed up the liver metabolism, dropping the plasma levels of Cialis to an ineffective dose.

The clinical trials for Cialis did not include some groups of patients, and thus caution is required if using the drug in those patients. These include men with unstable angina, severe renal insufficiency, severe hepatic insufficiency, hypotension below 90/50 mmHg, hypertension greater than 170/100, uncontrolled arrhythmias, a myocardial infarction within the last 3 months, a stroke in the last 6 months, or heart failure worse than New York Heart Association Class 2 in the last 6 months

Cialis has neither an impact on cardiac exercise tolerance nor on reproductive abilities [Ref]. Cialis can be used safely in stable cardiac patients without other contraindications. For some cardiac patients, sexual activity–with or without Cialis–may be inappropriate [Ref]. Patients with renal impairment should not use Cialis on a daily basis.

Finally, caution should be used in patients with conditions which predispose to priapism, or with an anatomical deformity of the penis.

Strengths and weaknesses

One of the most prominent strengths of Cialis is the relatively long half-life. A 36 hours, Cialis lasts significantly longer, as compared to the 4 hour half-life or either Viagra or Levitra. This extended half-life can allow the patient to have increased spontaneity of intercourse, especially those less likely to predict when they will have intercourse. There is some evidence in comparison studies that Cialis may be preferred to Viagra, perhaps because of this extended length of action.

With regards to flexibility with meals, Cialis does hold the advantage versus the other PDE5 inhibitor medications. Viagra and Levitra can’t be taken effectively following a high fat meal, but Cialis still has the expected effect regardless of whether or not a fatty meal was recently consumed.

Among the PDE5 inhibitor medications, Cialis has the least effect on PDE6 in the eye. Whereas Viagra has only a 10-fold specificity for PDE5 in the penis versus PDE6 in the retina, Cialis has a 700-fold specificity. Current case reports of retinal problems from Viagra are very uncommon, though the long-term effects are unknown.

The long-term effects of the extended 36 hours of systemic exposure to Cialis are unknown, though there is no evidence to show that it more harmful versus other agents.

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Viagra is a medication used to treat erectile dysfunction in males. For men who are over the age of eighteen, and in general good health, Viagra is the ultimate medication that will permit you to once again over come erectile problems for sexual pleasure. Some women have used Viagra to increase their own ability for an orgasm.

Viagra is a medication that releases slowly into your body using your hormones to allow the blood flow to the penis to resume, causing an erection to happen naturally when a male hormones are changing and becoming aroused.

A generic form of Viagra is Sildenafil, which is the same medication and is used in the same manner as Viagra is.

How to Use Viagra

Viagra is a pill, taken orally, that can be cut in half or can be taken all in one dosage. Viagra is known as a phosphodiesterase inhibitor, which is another word to describe its ability to treat erectile dysfunction. Erectile dysfunction is also abbreviated as ED in some medical writings.

Viagra can be used by men who are over the age of eighteen and in general good health. Erectile dysfunction can be a problem for weeks or years, with Viagra still producing the same results when taken properly. Viagra will not cause an erection when taken without the cause and effect of hormone reactions that occur during sexual relations.

For males who are elderly but want to attain an erection, Viagra can be safely used if your profile fits that of those males who are in general good health, meaning you do not have diabetes, heart problems, heart disease, high or low blood pressure and you want to have sexual relations once again. For males who are over the age of sixty, a lower dosage of Viagra is suggested and this can be increased if your body tolerates this medication.

Viagra Precautions

Additional conditions and people who should not be using Viagra for treatment of erectile dysfunction include those who have heart disease, heart problems, which have had a stroke, high blood pressure, low blood pressure, kidney or liver problems, and those who have history of stroke and those who have diabetes.

Women who are pregnant or those who are nursing should not use or experiment with Viagra.

Viagra Drug Iteractions

Viagra should not be taken in conjunction with some other types of medications. Do not mix Viagra with the use of Tagament, Erythromycin, Sporanox, Nizoral, Norvir, Invirase, or any type of medication that includes the ingredient of nitrates or nitrogen.

History of viagra is very interesting. Viagra has been manufacatured since 1998 and available to the public since 1999. Millions of men have been using Viagra so the studies of Viagra on other portions and effects of the body have been looked at for a few years now. Studies on the effects of increased blood flow to the eyes have been a particular area of interest to those in the optomitry field.

Most of the risks have been studied and ruled out by the University of Irvine Colllege who has taken this overall study very seriously. Nerve damage to the eye was considered very small for males who were continually using Viagra, even for those who are taking Viagra in larger dosages to treat their erectile dysfucntion.

Increaseing the blood flow to other areas of the body did not decrease the blood flow to the eye, and at the same time did not increase the blood flow to the eye. The bodies natual ability to limit the blood flow to the eye gave Viagra uses no problem while using this medication. No effects on the eye is a great benefit for those who are using Viagra so they don’t have the worry about losign their eye sight as a side effect of using Viagra. Avoiding eye damage for the long term is what all Viagra users should be aware of.

Studies on men using Viagra have been completed at both Stanford, and at University of Irvine, finding that Viagra did not affect the eye, or the thickness of the layers of the eye, which the blood flow contributes to. The vascular portions of the eye remain in tact enabling those men who took part in the study no underlying problems associated with the use of Viagra.

What should be noted is that while there are studies that show men do not suffer long term problems with the eye, or the pressures to the eye with the use of Viagra, there continues to be some males who while using Viagra medications continue to report problems with distinquishing small changes in colors, or in shades of colors while using Viagra. This is a rare occurance not noticed in the males who were invovled in the studies of the affects of Viagra on the eye.

Viagra does give men some type of ability to want more sexual relations because they now have this ability where they were not able before. Women who are not wanting sexual relations are looking to medications such as Viagra to increase their ‘want’ for sex and intimate relationships, but the real answer is not just in taking the pill.

Women who are using and taking the male sexual enhancing medication Viagra are realizing that the increase in blood flow does not balance their needs for increasing sexual desire. There are a number of large drug manufacturers that are working on a treatment for women and their needs for increasing their sexual desires and abilities but yet there are no companies who are making great strides in their research to find the women’s sexual aid medication but none are approved by the FDA at this time.

What the are percentages that drug manufacturers are looking at? There are roughly forty percent of women who suffer from some type of sexual problem and this include a huge majority of women who really don’t have a desire to have sexual relations. If a woman doesn’t have the desire or the need to have sexual relations they are said to be suffering from a problem with their libido, which is an internal feeling or want.

There is another amount of the forty percent of women suffering from sexual problems who feel they are not achieving an orgasm; they are not feeling the true overall feelings of heightened sexual awareness. As manufacturers are finding out, these types of sexual problems are very different from the male problems in not being able to get an erection.

The use of Viagra serves to focus on the blood flow problem that in general males have when they are not able to have an erection. Viagra does not change how they feel, or their real ability to perform with an erection. Focusing on changing the feelings of a woman to want sexual relations or in how they are feeling during sexual relations is a much more challenging situation for drug companies.
Viagra does seem to help some women in their needs to overcome how they feel during and before sexual relations. Viagra for the most part is not helping the overwhelming numbers of women who find they have a need for a sexual aid. Often times the best treatment for women who are suffering from these feelings are found to be an antidepressant and these types of medications change how a person feels.

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