What it is
Sildenafil is not an aphrodisiac. It will not arouse or increase sexual desire. It is not a means to improve erections in men who do not have erectile dysfunction. It is not a chemical substitute for working on a relationship.
Sildenafil blocks an enzyme in the penis that naturally breaks down a chemical called cGMP, which is produced during sexual stimulation and plays an important role in creating and sustaining normal erections. cGMP allows smooth muscle in the penis to contract, allowing more blood to enter the penis and producing a firmer erection. The longer cGMP remains in the penis, the better the chance of reaching and maintaining an erection. Sildenafil allows more cGMP to remain in the penis, but it does not increase the body's production of the chemical. This is why sexual arousal is necessary in the first place—to produce some cGMP.
Sildenafil comes in three dosages: 25-, 50-, and 100-milligram (mg) tablets. The medication can be taken on an empty stomach about 1 hour before sexual intercourse, although it may work from 30 minutes up to 4 hours after the tablet is swallowed. Physicians usually prescribe a home trial of 50-mg tablets. If side effects develop, a lower dosage may be tried. If the response is not adequate and there are no side effects, dosage may be increased to 100 mg. Older men and those with liver or kidney failure may begin with the 25-mg tablets.
Note: Only one tablet a day should be taken. Taking more than 100 mg a day will not significantly improve the erection response and will only increase the likelihood of having side effects.
What side effects are known?
Headache is the most common side effect (about 16 percent of men taking sildenafil). A drop in blood pressure and facial flushing occur in about 10 percent of men who are using the drug. Indigestion occurs in 7 percent and nasal congestion in 4 percent. About 3 percent report some visual disturbance (blurred vision, increased light sensitivity, or seeing a bluish tinge on objects). None of these side effects is severe, and most are described as mild. Very few men stop taking the medication because of the side effects.
What medications should not be taken with sildenafil?
Men taking any type of organic nitrate medication or medications containing nitrates should not take sildenafil. Nitrate-containing medications include a number of vasodilator drugs, such as nitroglycerin. Certain street drugs, such as amyl nitrate, also will cause problems if taken with sildenafil.
How much does sildenafil cost, and will insurance cover it?
The cost at most pharmacies is about $8 to $10 a pill. Some insurance prescription drug plans cover the cost, but others do not. Some insurance plans reimburse for only a few pills a month. Contact your insurance provider directly for details on coverage.
How do I obtain sildenafil?
Because of the side effects and contraindications of sildenafil, you should see your physician for an examination. If the doctor determines that the drug is likely to help you, he or she will write a prescription.
Warning: Because of the popularity of and demand for sildenafil, some Web sites are offering prescriptions to men without obtaining sufficient medical information about them. People who order the drug directly over the Internet, without a physician's examination or a review of their medical history, are putting themselves at risk for dangerous side effects or even death. Men who have other medical problems, especially heart disease, or who have not been sexually active should check with their physician before resuming sexual activity.
156 Self-Injection Therapy Another method for treating erectile dysfunction is
The self-injection drug therapy. It requires that the man or his partner use a tiny nee dle to inject a small amount of medicine directly into the side of the penis. The injections are relatively painless and create an erection that begins about 5 to 15 minutes after the injection and lasts from 30 minutes to 2 hours. No foreplay is needed.
Drugs used for self-injection therapy include a prostaglandin (a synthetic fatty acid) called alprostadil, papaverine hydrochloride, and phentolamine in combination with papaverine. Each of these drugs creates an erection by relaxing smooth muscle tissue and widening the major artery to the penis, which enhances blood flow to the penis.
Originally, the US Food and Drug Administration (FDA) approved these drugs for other medical purposes, but only the prostaglandin drug has been approved specifically for treating erectile dysfunction. Papaverine and phento-lamine have not yet been approved for treating erectile dysfunction, even though they were the first drugs used experimentally for injection therapy. However, they are available and prescribed for medical reasons other than the FDA-approved use. Urologists have gained considerable experience with all three of these drugs, and all are considered safe for self-injection therapy.
Not all men respond to this type of treatment. Apart from the fact that most men have trouble injecting a needle into their penis, self-injection therapy cannot be used by men with certain heart or liver diseases. Of those who can take the injections, some do not respond by developing good erections, while others may get erections that do not go away and require a counterinjection to soften them. Still, about 70 percent of men find that they achieve satisfactory erections after self-injections. Generally, a doctor can teach a person to do the injections in one or two office visits. The men are asked to return for follow-up visits, particularly at the beginning of the treatment process, to see if changes are needed in the type of drug used or its dosage.
All medications used in self-injection therapy have both potential risks and side effects. Some men have experienced dizziness, heart palpitations, or a flushed feeling when using these medications. And there is a small chance of infection and the possibility of bleeding or bruising during injection.
One of the risks of self-injection therapy is prolonged erection or priapism— an erection that lasts more than 4 hours. Priapism occurs in only a small percentage of men, but it requires a trip to a hospital emergency department to receive medication to counteract the self-injection and relieve the erection. Men should know that any erection that lasts more than 2 hours needs to be treated by a physician to prevent damage to the penis.
Another potential risk, particularly for those who use self-injected drugs often, is the possibility of permanent scarring inside the penis. For this reason, doctors advise that self-injection therapy be limited to once every 4 to 7 days, 157
depending on what medication is used and how a man responds to the initial Sexuality treatment.
Self-injection therapy has the following advantages:
• It can be used anytime and involves only a small amount of preparation.
• It creates an erection that is very similar to a natural erection.
• The erection generally lasts long enough for successful and satisfying intercourse.
• It does not involve surgery and is only minimally painful.
• The drug costs $8 to $10 per injection, which is much less than surgery. (Sildenafil currently costs about $8 to $10 per pill; see page 154.)
Urethral Suppositories In 1997 the FDA approved an alternative form of the drug alprostadil. The product is a single-use applicator filled with the drug. The user inserts the applicator about an inch into the urethral opening of the penis, where the drug is released, absorbed by the urethra, and transported to the surrounding tissues. An erection begins within 8 to 10 minutes and may last as long as 30 to 60 minutes. These times vary from one person to another.
The most common side effects associated with urethral suppositories are aching in the penis, testicles, legs, and the area between the scrotum and the rectum; a warm or burning sensation in the urethra; redness of the penis due to increased blood flow; and minor urethral bleeding or spotting, usually caused by improper application.
Vacuum Devices Vacuum devices are simple mechanical tools that allow a man to develop an erection suitable for sexual intercourse. The devices available work best for men who are able to achieve partial erections on their own. They can be harmful to men who have blood-clotting problems or who use blood-thinning medication.
Vacuum devices work by pulling blood into the penis and then trapping it. The man inserts his penis into the hollow plastic tube that is closed at one end and presses the tube against his body to form a seal. A vacuum is created in the tube using a small hand- or battery-driven pump, and this, in turn, draws blood into the penis, causing the penis to engorge, enlarge, and become rigid. After 1 to 3 minutes in the vacuum, an adequate erection develops and a soft rubber O-ring is then placed around the base of the penis to trap blood and maintain the erection. Sexual intercourse can occur anytime after the tube is removed. The rubber O-ring maintains the erection until removed. It can be left in place for 30 minutes only, or blood supply to the penis is compromised. It takes practice to use this device skillfully.
The vacuum device has the following advantages: It can be used anytime, at the user's convenience.
It is safe—it has no side effects (unless left on longer than 30 minutes) and does not involve surgery or injections. It works for most types of erectile dysfunction. It costs less than surgery or ongoing self-injection therapy.
The vacuum device has the following disadvantages:
Setup time can interfere with a couple's mood or foreplay. Devices may not fit all body shapes.
Once the O-ring is applied, there is no erection between the rubber band and the body, making the penis somewhat floppy, so guidance is needed for insertion.
In some men the O-ring inhibits ejaculation.
Some men complain of a coldness or numbness of the penis after the O-ring has been put in place.
O-rings must be removed after 30 minutes to allow return of normal blood flow to the penis.
Vacuum erection devices range in price from $300 to $500 and require a physician's prescription. Some insurance companies reimburse all or part of the costs associated with this type of treatment. This can be a useful treatment for some men who take nitrate medications for chest pain or high blood pressure and are therefore unable to use sildenafil.
Penile Implants An implantable penile prosthesis (artificial device) is another treatment option that has improved in design in recent years. All penile implants place prosthetic tubes inside the penis to mimic the engorgement process and create an erection. Since the 1950s, thousands of men have been treated successfully with implants. These devices work best for men who can ejaculate and have orgasms even if they cannot achieve erections.
Implants are effective in treating most types of erectile dysfunction. They have a 90 percent success rate when both partners are informed about how they work and what their limitations are. Men with penile implants do not require intensive follow-up treatment after implantation, and no medications or injections are required. In addition, once the implant is in place and functioning, there are no additional costs. The newer prostheses are very reliable, with a chance of mechanical failure in the range of only 2 to 4 percent per year.
One drawback of the implantable penile prostheses is that their placement permanently changes the internal structure of the penis. If the prosthesis is ever removed, normal erections do not return. There is also a small (3 to 5 percent) chance of infection that could require removal of the implant. Some men develop
Reproductive System surgical or anesthetic complications or experience numbness at the head of the 159
penis and uncomfortable intercourse. Also, because the erection is not caused by S exuality increased blood flow to the penis, the head of the penis is not part of the erection, and this softness may bother some men.
There are three types of penile prostheses currently available:
• Inflatable penile prostheses are the most natural-feeling of the penile implants, because the penis can be either erect or flaccid. These two-piece or three-piece implants are made of soft tubes of silicone or similar material. The tubes are filled with a sterile liquid that comes from a small reservoir placed either under the muscles of the abdomen (three-piece implant) or in the scrotum (two-piece implant). A tiny pump in the scrotum is used to move the fluid from the reservoir to the tubes. The more fluid that is pumped into the tubes, the firmer and larger the erection. When the erection is no longer desired, the pump is deactivated and the fluid returns to the reservoir, leaving the penis soft again. The major advantage of an inflatable penile implant is that it provides a more natural erection that the user can control. One major disadvantage is that this type of device is slightly more complicated to implant and, because it has more mechanical parts, there is an increased risk of leaks, twisting of the tubes, or mechanical failure.
• Self-contained inflatable implants use paired silicone cylinders that have a pump at the tip of the prosthesis. A reservoir within the shaft of the device allows fluid to transfer in such a way that the cylinder becomes firm. The advantage of this device is that surgery is slightly simpler than that for a two-or three-piece inflatable prosthesis. The major disadvantage is that the inflatable portion does not significantly increase the girth of the penis. The penis is also not as soft or as easily concealed when deflated.
Semirigid prostheses are made from silicone-covered bendable metal rods. They allow the penis to be rigid enough for penetration but flexible enough to be concealed in a curved position. They are the simplest and least expensive of all implants and have the least chance of mechanical failure. The major problem with semirigid implants is that the penis is always semierect. Even with bendable implants, concealment can be a problem with certain types of clothing. Another disadvantage is that the erection depends on the size and rigidity of the prosthesis. This type of prosthesis is not routinely used.
Vascular Reconstructive Surgery A very small percentage of men may be candidates for reconstructive surgery to improve penile blood flow. Techniques being used on an experimental basis include revascularization (rerouting blood vessels to allow new, greater blood flow to the penis) and venous ligation (sealing off veins in the penis that leak blood during attempted erection).
Overall, the long-term experience with this type of surgery has been disappointing. Even the best results show that only one of 20 men can be helped with these procedures. Vascular reconstructive surgery is a very technical and expensive procedure. Complications include nerve damage, thrombosis (clotting of blood inside deep-lying veins, usually in the legs), and scar tissue formation. It is rarely used to treat men who do not have a specific vascular abnormality causing the erectile dysfunction.
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