Patient information: Sexual problems in men

WHAT TREATMENTS FOR IMPOTENCE ARE AVAILABLE? — The aim of treating impotence is to enable a man to get and keep an erection so that he can enjoy sexual intercourse again and again. Treatment of the impotence, depending on its cause, may include the following:

• Sildenafil, vardenafil, and tadalafil (marketed as Viagra?, Levitra, and Cialis)
• Penile self-injection with drugs that dilate the blood vessels
• Vacuum erection devices
• Penile prostheses
• Testosterone replacement therapy
• Psychotherapy with or without psychoactive drugs
• Yohimbine

Sildenafil — Sildenafil (Viagra?) was the first drug on the market approved to be an effective treatment for erectile dysfunction. The principle of this pill's work is to keep the internal chemicals which allow the penis to get and maintain the erection.

The fact is that this kind of drugs is helpful in restoring potency for 70% of men. But the effectiveness of this pill also depends on the source of the impotence. It helps best for the men with psychogenic impotency (men, having emotional conflicts as the cause of ED). And it helps less those who have some other causes, like diabetes mellitus, and the effectiveness is about 55-60% of cases. In the cases, when the cause of impotence was prostate cancer surgery, the effectiveness is about 25-30%.

It should be mentioned that a man taking sildenafil will not have a spontaneous erection. Because Sildenafil is only a facilitator, which helps to achieve and keep an erection after normal manual or oral genital sexual stimulation in the course of healthy lovemaking.

A man should understand that Sildenafil does not increase sexual desire, which means that a man with low sex drive or diminished libido will not have a sudden wave in sexual feelings while treating of this kind.

What is the dose? — take Sildenafil one hour before planned sexual intercourse. It lasts for about four hours. For most men the recommended dose is 50 mg, but starting with 65 years old men should take the minimum dose of 25 mg first. One should change the dose in the following ways:
It can be lowered if side effects occur, and it can be increased to 50 or 100 mg if the dose of 25 or 50 mg was not enough for achieving the erection or it was not satisfactory.

Side effects include:

• Headache (16 percent)
• Flushing (10 percent)
• Indigestion (7 percent)
• Dizziness (2 percent)
• Distorted (blue) vision

But we should say, that these side effects are not long-termed and they can disappear spontaneously. Thus, men responding positively to the drug and having such side effects rarely stop using Sildenafil.

What are the risks? — As far as cooperation with other drugs is concerned, a man should not use Sildenafil, if he regularly or intermittently uses nitrates (drugs used for patients with heart diseases) in any form. Otherwise, it may lead to the following problems:
A heart attack in men with heart disease Unstable blood pressure in men with hypertrophic cardiomyopathy, an enlarged heart that does not pump well.

Who should not use sildenafil? — As stated above, men taking any kind of nitrates, should not use Sildenafil. But there are some
other potentially hazardous groups of men, like:

• Those with angina (chest pain) who are not taking nitrates
• Those with congestive heart failure and low blood pressure
• Those taking a complicated blood pressure drug regimen
• Those taking drugs that can change the metabolism of sildenafil (certain antibiotics along with some other medicines)
  

Also, there are some groups of men for whom Sildenafil is not proven yet to be safe:

• Men who have had a heart attack, stroke, or life-threatening irregular heart beats (called arrhythmia) within the last six months
• Men with low or high blood pressure
• Men with retinitis pigmentosa, a progressive eye disorder that can lead to blindness

Men, who are going to take Sildenafil, should be aware that resuming sexual activity after a period of inactivity is similar to beginning a new exercise routine. And before using this drug, a doctor may ask you to undergo some kind of aerobic activity, or treadmill exercise to be sure that Sildenafil will be safe. We speak about these exercises, because it is usually equal to the energy used for sex.

There are some new drugs, which are similar to Sildenafil — Vardenafil (Levitra) and Tadalafil (Cialis). Tadalafil has a longer duration of action (up to 36 hours) than sildenafil and vardenafil. Vardenafil and tadalafil are approved in Europe, and are approved by the US Food and Drug Administration.

Recently, there was published a warning for the consumers not to use the following dietary supplements: SIGRA, STAMINA Rx and STAMINA Rx for Women, Y-Y, Spontane ES, and Uroprin, because they are used to increase sexual stamina, confidence and sexual performance and contain a dose of tadalafil. And the warning is that those who take nitrates for heart diseases may have a lowering of blood pressure after using these supplements.

Penile self-injection — Taking this kind of treatment, the patient injects a medication into the corpora cavernosa (the two chambers of the penis that are filled with spongy tissue). This causes an erection by allowing the blood vessels within the penis to expand so that the penis first swells and then stiffens to create a fully rigid erection. The erection created by penile injection occurs without sexual stimulation and differs from the erection that occurs after sildenafil.

But men need some time to get used to this kind of therapy. Urologists help the men by showing how to make the skin on the penis sterile and how to inject the medicines in the proper way. But there are cases when men stop using this therapy because they feel uncomfortable because of injections despite the achieved erection.

What drugs are used? — Doctors prescribe one of these:

• Papaverine
• Alprostadil
• Alprostadil with papaverine and phentolamine

What are the side effects? — The most common one is pain. And that is why men often stop using this kind of therapy.

There is also another risk that penis will still remain erect after sexual intercourse, though this risk is small enough. This takes place in 6% of men taking alprostadil and in 11% of men taking papaverine. Prolonged erection is called priapism and it lasts for about 4-6 hours. It is a medical emergency. The procedure to empty the blood in the penis should be done right away after this occurs, and if the erection lasts longer than 48 hours, a man usually needs scarring of the tissue inside the penis. After this most men discontinue using self-injection.

Intraurethral alprostadil (MUSE) — This kind of treatment is similar to the previous one, but here a man inserts the same drug into the opening in the centre of the penis from which urine flows, the opening being called urethra.

What are the side effects? — The most common side effect here is pain, because the blood vessels in penis widen and swell to create the erection. As far as such side effects as prolonged erection and scarring the penis are concerned, they are less common than in the self-injection therapy.

Vacuum-assisted erection devices — these devices are used to force blood into the penis by vacuum pressure and there are rings to hold the blood in.

What are the side effects? — These products require manual dexterity. Usually it takes about one week to get used to its working principle and make it work effectively. But as soon as the man gets used to it, he can create the erection very easily and it will be rough enough for the sexual intercourse. But here is the warning that a man will not ejaculate because of the rings holding the blood into the penis and compressing the urethra. Thus, semen does not leave the penis.

Penile prostheses — This kind of treatment is using a device, penile prosthesis, which is surgically implanted into the penis and helps him to become erect. Due to the popularity of Sildenafil and Penile injections therapy, Penile prostheses are not used so often any more as in the past. But it is a good alternative for those men who don't like vacuum therapy and do not respond positively to the injections.

What are the side effects? — Side effects include those related to the anesthesia used during surgery, local wound infections, and mechanical failure. In the case of mechanical failure, a man may need removing the old prosthesis and implanting a new one. Testosterone replacement therapy — When a man's testes do not make enough of the hormone testosterone and therefore he has permanent low blood testosterone level, he will need this kind of therapy. Thus, there will be no use for those men who have a normal level of the hormone testosterone.

There are two ways of using this therapy. The first one is to make testosterone injections every one to two weeks, or to apply a
testosterone patch or gel to the skin surface daily. Nowadays there exist three kinds of testosterone patches. One patch
(Testoderm?) is applied once a day to the scrotum, and the other two (Androderm? and Testoderm TTS?) are applied daily to the torso
or extremities. Testosterone gel (Androgel) is applied to the skin and left to dry. Because all these kinds have their advantages
and disadvantages, you should consult the doctor and choose the most suitable one.

Psychotherapy and psychoactive medications — In some cases ED may be caused by depression, anxiety, and distractions. They can be effectively treated using psychological counseling, antidepressant drugs, or both. Sometimes sexual therapy is needed as well.

What are psychoactive medications? — The drugs, treating these diseases, are very effective but causing side effects sometimes. Some newer medicines, like those of serotonin reuptake inhibitor class, may call such side effects as decreased sex drive and erectile dysfunction. On the other hand, the problem of rapid ejaculation can be treated by some antidepressant drugs, which cause delayed ejaculation.

What is psychotherapy? — Psychotherapy involves consulting the doctor and discussing all the points with him. For example, some serious concerns and beliefs about sexual function may be treated with the help of education or reassurance. Psychotherapy may be helpful for:
Those couples in which one or both partners have serious medical condition, Anxiety over the safety of sexual activity may be present in both the medically ill patient and his or her partner. Men who suddenly experience one or more erectile failures during attempted intercourse. This is called performance anxiety. Men who are depressed (in this case psychotherapy is combined with antidepressant drugs)

What is sexual therapy? — This type of therapy is often helpful for men who lack focus. This takes place with some middle-aged men and reflects in waning sexual function. As a man matures, his interests and concerns expand. And he may distract his mind during sexual intercourse, because he has more responsibilities in life, like work, family. Treatment usually focuses on encouraging both sexual partners to work together and participate in a set of structured at-home exercises.

Some sexual problems require longer, more in-depth therapy. If this occurs, your doctor will refer you to the specialist.

Yohimbine — Yohimbine is a drug claimed to treat sexual dysfunction in the cases when it is caused by psychological factors. Yohimbine causes blood to engorge the penis and prevents it from flowing out. This creates an erection.

What are the side effects? —They are as follows: dizziness, flushing, nausea, and headache.