The Man's Guide to Erection Medications
Everything you need to know about Viagra, Levitra, Cialis, and Yohimbine
The world of erection impairment changed dramatically on March 27, 1998, the day the Food and Drug Administration approved the little blue pill, Viagra, for treatment of erection impairment, now medically called erectile dysfunction (ED). Viagra was not the first drug treatment for erection impairment (see yohimbine below), but it was the one that captured the public's imagination. Viagra took the U.S.--and the world--by storm. During its first month of availability, American doctors wrote more than 300,000 prescriptions, making Viagra the fastest-selling new drug in history. Within six months, repeat prescriptions were being written at the rate of 100,000 a month. Today, Viagra is one of the most successful drugs ever marketed. More than 10 million men have taken more than 125 million tablets. Annual sales approach $2 billion. And with millions of boomer men in their 50s, the future of the little blue pill--and other erection medications--looks bright.
Erection medication is not the answer to every man's erection problem. Many erection difficulties are caused by sexual anxiety, and resolve when men learn more about sex, relax about it, and adopt a less penis-centered, more whole-body-sensuality approach to lovemaking. Other erection difficulties are caused by medical problems, and resolve when the illnesses are treated. Many erection problems are caused by drugs (notably alcohol and cigarettes) and drug side effects, and can be helped by cutting back on alcohol, quitting smoking, and tinkering with prescriptions. But erection medication certainly has a place in the treatment of ED.
How Erection Medications Work
Currently there are four prescription drugs available for erection problems: Viagra, Levitra, Cialis, and yohimbine. They all work basically the same way: Sexual arousal stimulates release of a compound, nitric oxide, in the penis. Nitric oxide, in turn, triggers synthesis of cGMP, which relaxes the penis' smooth muscle tissue, and allows extra blood to flow into the organ's spongy central erectile tissues. Erection drugs enhance this smooth muscle relaxation, spurring greater blood flow into the penis.
Erection medications are not aphrodisiacs in the traditional sense of libido stimulants. These drugs do not boost sexual desire. All they do is increase the likelihood of erection. Now, for some men, lack of erection, or anxiety about raising erections is a sexual turn-off. In these men, the erection-boosting impact of erection medication can eliminate this turn-off and help the man experience his libido. But libido benefits, if any, are a bonus. These drugs don't necessarily make men want sex more. All they do is help raise and maintain erection.
Advantages
Erection drugs are pills, and Americans love pills. Depending on the drug, they are taken two to 36 hours before lovemaking, so the woman need not know you're using a drug. They help men with ED caused by both physical illness and stress/anxiety problems. Most studies show that they produce erections in 75 percent of those who use them, with even greater effectiveness among men with only mild or occasional problems. They raise erection only with normal sexual stimulation. No walking around with an embarrassing bulge in your pants that signals you've taken a drug. For most, but not all men, these drugs are also quite safe. The only significant side effects are headache (16 percent of users), flushing (10 percent), upset stomach (7 percent), nasal congestion (4 percent), and rarely, visual disturbances, mostly in men with chronic eye conditions such as macular degeneration. Some health insurers cover erection medications, but many provide only partial coverage, or none at all. However, even without insurance coverage, these drugs are quite affordable. The Viagra dose most men take, 50 mg, costs about $10, a modest price to pay for an amorous evening free from erection worries.
Disadvantages
Erection drugs also have limitations: They don't work in about 25 percent of cases. As severity of ED increases, their effectiveness decreases. For example, the drugs work well in many men with the beginnings of diabetic ED, but less well in diabetics with considerable cardiovascular and neurological damage. Even in men with mild erection balkiness, these drugs may not work in some situations, for example, if you feel particularly stressed, distracted, or alienated from the sexual experience.
Finally, some men should absolutely never use Viagra, Levitra, or Cialis--those taking nitrate medication for heart disease, notably nitroglycerine for angina, or the party drug, amyl nitrate ("poppers"). The combination of Viagra and nitrate drugs can cause a precipitous drop in blood pressure--and possibly death. Before this problem was identified, the combination of Viagra and nitrate medication killed more than 500 men. If you take any nitrate drug, don't use Viagra, Levitra, or Cialis. However, yohimbine drugs do not have this problem, so the vast majority of men taking nitrate drugs can use them safely. (There have been a few deaths with yohimbine drugs, but they are very rare.)
In addition, Viagra, Levitra, and Cialis are associated with a small, increased risk of heart attack and stroke. They slightly increase the tendency for blood to clot. Internal blood clots trigger heart attack and most strokes. Men with histories of heart attack and stroke should consult their doctors before using these drugs, and consider taking an anticoagulant, for example, aspirin, along with them to reduce risk of internal clots.
Higher Dose, More Side Effects
Viagra comes in 50 mg pills. The typical dose is 50 to 100 mg--one or two pills. Side effects are more likely with the higher dose. The same appears to be true of Levitra and Cialis. Larger doses cause more side effects.
Over Time, Most Men Need More
The latest studies suggest that some men need to increase their dose over time. University of Alabama researchers tracked 150 men who took Viagra regularly for two years or more. During that period one-third of them had to increase their dose from 50 to 100 mg. The same is presumably true of Levitra and Cialis.
To Boost Effectiveness
For men who respond poorly to erection drugs, it may help to combine the medication with the over-the-counter supplement, ArginMax. Researchers at University of California, Davis, worked with men with ED, who did not get much benefit from Viagra. The men took Viagra plus either ArginMax or a placebo. After four weeks, erections improved significantly in 22 percent of those taking the placebo, but among men using ArginMax, the figure was 60 percent.
From ED Treatment to "Erection Insurance"
Viagra was originally approved for a medical problem, persistent ED. The original ads featured elderly Senator Bob Dole talking about how it helped his medical problem.
But once a drug is approved for any reason, doctors are free to prescribe it for other, so-called "off label" uses. Today, all erection medications are most widely used as "erection insurance" for men in their 40s to 60s who have balky erections and don't want to worry about them. Current ads for Viagra feature young, healthy, professional baseball players saying: "I take batting practice. I take fielding practice. I take Viagra." Ads for Levitra and Cialis are similar, featuring men who appear to be in their 30s or early 40s, and healthy, but just a little concerned about erection reliability.
If you're concerned about erection reliability, there are several nondrug approaches to raising an erection and keeping it firm: Don't smoke. Don't drink any alcohol for a few hours before sex, and don't drink more than 2 drinks a day. Eat lots of fruits and vegetables. Get seven hours of sleep a night. In other words, live a healthy lifestyle and you're likely to have a penis that behaves the way you want.
But if you still have balky erection--and this is perfectly natural for men over 45--then you might decide you want to use erection medication for erection insurance. If so, you may get good results with half the typical dose--25 mg. of Viagra instead of the usual 50 mg. Cut the pills in half. Low doses of Levitra and Cialis can also be taken.
Duration of Action: A Few Hours or Up to 36
Viagra and Levitra take about an hour to produce erection enhancement, and the effect lasts another 2 hours or so, longer in some men.
Cialis also takes about an hour to work, but it lasts for 24 to 36 hours, hence the claim that it's a "weekend drug." Take them on Saturday morning, and you're good to go through most of Sunday.
Many men, it seems, like the longer-lasting drug. When Cialis was approved, the pundits predicted it would not sell well because the Viagra brand was so well-established. However, Cialis has proved quite popular.
The main reason not to use Cialis is that it stays in the bloodstream longer than Viagra or Levitra, so any side effects are likely to bother you for longer, too.
Yohimbine
For centuries, the bark of the West African yohimbe tree was reputed to restore faltering erections. Scientists scoffed--until the 1980s, when several studies showed that a chemical in the bark, yohimbine, increases blood flow into the penis. More than 10 years before Viagra, the Food and Drug Administration approved yohimbine as a prescription treatment for erection problems. The herbal extract is available in Aphrodyne and Yocon.
However, since its approval, yohimbine has been attacked as ineffective. The situation is controversial--and confusing. An analysis of 208 studies published from 1979 through 1994 led the American Urological Association (AUA) to conclude that yohimbine is no better than a placebo. However, two other analyses--a 1996 review of 16 studies at Syracuse University, and a 1998 British analysis of seven studies--both showed that yohimbine is an effective treatment for ED. The British group called it "a reasonable therapeutic option."
But the naysayers may have a point, at least about the yohimbine products sold over-the-counter in supplement shops and health food stores. In 1995, the FDA analyzed 26 over-the-counter yohimbine products. The yohimbine content of yohimbe bark is 7,089 parts per million (ppm). Concentrations found in the tested products ranged from less than 0.1 ppm to 489 ppm, probably not enough to have much effect. If you want to try yohimbine, ask your physician for one of the prescription drugs. Recommended dosage ranges from 18 to 100 mg/day.
Possible side effects include: increased heart rate and blood pressure, fluid retention, nervousness, irritability, headache, dizziness, tremor, and flushing.
If you'd like to try Aphrodyne or Yocon, consult your physician.
An Important Note
Erection medication is a boon to men who need it, but the publicity surrounding it reinforces an idea that hurts both men and women sexually. It's the idea sticking an erection into erotic openings is basically all there is to sex. Wrong.
The basis of great sex is leisurely, playful, whole-body sensuality that includes the genitals, but is not fixated on them. For most men over 45 to raise erections, whole-body sensuality--kissing, hugging, massage strokes and fondling all over--are necessary prerequisites. Contrary to the all-genital sex in pornography, truly great sex is a whole-body experience. Without whole-body sensuality, many penises don't become erect--even if the man uses erection medication.
Unfortunately, erection drugs have shone a spotlight on the penis and erection, and have reinforced the false notion that sex is all about erection. If you use erection medication, incorporate it into lovemaking based on whole-body sensuality. And if you don't, your penis will work best if you let go of the idea of porn-style, all-genital sex, and embrace whole-body sensuality.
References:
Carbone, D and AD Seftel. "Erectile Dysfunction: Diagnosis and Treatment in Older Men," Geriatrics, 9-2002, p. 18.
Carey, MP and BT Johnson. "Effectiveness of Yohimbine in the Treatment of Erectile Disorder: Four Meta-Analytic Integrations," Archives of Sexual Behavior (1996) 25:341.
Carrier, S et al. "Viagra: Long-Term Eficacy and Quality of Life," presented at the World Congress of Sexology, 2005.
Ernst, E and MH Pittler. "Yohimbine for Erectile Dysfunction: A Systematic Review and Meta-Analysis of Randomized Clinical Trials," Journal of Urology (1998) 159:433.
Ishikura, F et al. "Effects of Sildenafil Citrate (Viagra) Combined with Nitrate on the Heart," Circulation (2000) 102:2516.
Ito, TY et al. "The Effects of ArginMax, A Natural Dietary Supplement, for Enhancement of Male Sexual Function," Hawaii Medical Journal (1998) 57:741.
Mika, M. "Some Men Who Take Viagra Die: Why?" Journal of the American Medical Association (2000) 283:590.
Mobley, DF and NH Baum. "What You Need to Know Before Prescribing Viagra," Hospital Medicine, 5-1999, p. 20.
Phelps, JS et al. "The PsychoPlusMed Approach to Erectile Dysfunction Treatment: The Impact of Combining a Psychoeducational Intervention with Sildenafil," Journal of Sex and Marital Therapy (2004) 30:305.
Teloken, C et al. "Therapeutic Effects of High-Dose Yohmbine Hydrochloride on Organic Erectile Dysfunction," Journal of Urology (1998) 159:122.
