Erectile Dysfunction

Introduced in 1998, Viagra, one of a drug in the family called phosphodiesterase 5 inhibitors, has become one of the blockbuster drugs of the 21st century. And it’s not just older men with erection problems using the pills. An unknown number of younger men are using Viagra or one of the phosphodiesterase 5 inhibitors, to enhance their normal erections, reduce performance anxiety, or simply to experiment.

What is Erectile Dysfunction?

All men experience times when erections fail, whether because of stress, tiredness, one drink too many, or just the unpredictable nature of sexual arousal itself. But aging—the male biological clock—definitely takes a toll on erections. That’s because, fundamentally, an erection is a matter of plumbing, hydraulics, chemistry, and nerve impulses, all of which depend on physical structures that wear out, to one degree or another, as a man ages.

In most cases, an erection begins when the brain registers a physical or mental stimulation— such as physical touch or a sexually arousing visual or mental image. This arousal produces electro-chemical signals that travel along nerve fibers down the spinal cord to the penis. When the signals reach the penis, they trigger the release of a gas called nitric oxide, which, in turn, causes the arteries feeding the penis to relax and open up. Blood can then pump into three cylinders of sponge-like tissue inside the penis. When the chambers are fully saturated, the penis is erect. The erection is maintained because the swelling tissue squeezes shut the many small veins draining blood out of the penis. Normally, an erection lasts as long as sexual stimulation continues or until orgasm. Following orgasm, nerve signals reverse the effect on penile arteries—squeezing them shut again, which allows blood to drain out of the penis causing it to return to the flaccid state.

Erectile dysfunction usually begins as a purely physical problem with blood vessels, nerves, or other parts of the male reproductive machinery. But very rapidly a complicated psychological dimension is layered onto the physical problem—which almost always makes things worse. For example, men often become increasingly anxious that they’ll lose their erection. Anxiety releases hormones such as adrenaline that clamp down on blood vessels, including those feeding the penis, thereby making an erection that much harder to obtain. Men sometimes misinterpret the reason for erectile failure (“I must not find her sexually attractive anymore”)—and women sometimes blame themselves (“I must not be sexy enough”). 

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The nature of the plumbing supporting erections means that anything interrupting the initial opening of the penile arteries (such as cholesterol deposits inside the arteries, damage to the nerves associated with the arteries, or interruption of the nitric oxide signal in the penis) will hurt erections. Likewise, if the penile veins don’t close fully, blood can’t remain trapped in the penis long enough to sustain an erection. It’s here that aging takes its toll—nerve fibers degrade, arteries clog, and the enzymes that create nitric oxide become less robust. It’s here, too, that a wide range of prescription medications exert side effects that can interfere with erections. For example, antidepressants belonging to the family of serotonin reuptake inhibitors—of which Prozac is the most familiar—can interfere with both erectile function and the ability to achieve orgasm. In addition, some classes of high blood pressure medications (such as the thiazide diuretics and beta-blockers) also can impair male sexual functioning. Recognizing the role that common prescription medications can play in sexual dysfunction is important because alternative medications are usually available that can produce similar clinical benefits with less risk of sexual problems. If you are taking an antidepressant or beta blockers, and your sex life is affected, talk to your doctor. You might be much happier with a different prescription. Although we’ve just seen that erections can fail for many reasons, many treatments and interventions are available today to restore erections and reverse this aspect of the male biological clock. 
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How the Little Blue Pill can Help

Phosphodiesterase 5 inhibitors such as Viagra, Levitra, Cialis, and Stendra work by blocking an enzyme that normally controls the constriction of penile arteries after the release of nitric oxide. With the enzyme blocked, the relaxation triggered by nitric oxide lasts longer and is harder to shut down. The result? Erections that are easier to create and easier to maintain.

It’s important to point out, too, that a man has to want to get an erection as well as have the ability to get an erection. Studies show that Viagra and other erection-enhancing drugs don’t work very well in men with low testosterone and, hence, low sexual desire. For these men, testosterone needs to be boosted to normal levels using any of the available strategies and then, if they still have erectile problems, an erection-enhancing medication is likely to be effective.

A Viagra Success Story

Norm had a great life: wife, two kids, dog, nice home in a small town, and satisfying work. The only thing he didn’t have, it seemed, was sex.

Like many couples, Norm’s sex life with his wife Margaret had evolved from the passion-filled, playful, and lusty days of courtship, to the regular and satisfying sex of early marriage, through long sex-less stretches in the aftermath of children. Now, as he was approaching 50, sex was so infrequent he usually couldn’t remember the last time he and his wife made love. 

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Age and the sheer familiarity of sex with his wife played a role in Norm’s situation, but he also suspected another cause: his unpredictability as a lover.

Even in the early days of his marriage, Norm would occasionally lose his erection, usually during foreplay as he was helping his wife get aroused and lubricated. Often, by the time she was ready, he was limp.

“It’s just awful to have my wife lying there, ready and willing, and not be able to get an erection,” he says. “She said she understood, but I’m not sure she did and she was probably as frustrated by it as I was.”

The problem would come and go. Sometimes (often after he’d had a drink or two) he wouldn’t worry about his erection and sex would be, if not wild, at least mutually satisfying. But equally often, it seemed, his fear of losing his erection made it impossible to achieve one. Over the years, he initiated sex less and less often—and with the addition of children the excuses for doing so were easy to find.

“When you have kids you’re often both so exhausted that it’s really just easier not to have sex,” Norm says. “The thing is, I really wanted to have sex. Hell, when I masturbated I had no problems with erections then. But when it came to sex with Maggie…I just wasn’t confident. I’m sure she felt that, and I’m also sure it’s not exactly attractive.”

When Viagra became available, Norm didn’t consider trying it. He figured he wouldn’t be a candidate since he could, after all, get erections on his own. He didn’t see himself as having erectile dysfunction even though his history suggested a less-than-robust erectile capacity. But one day a fight with Maggie over who did more housework escalated and suddenly veered into her dissatisfaction with their sex life.

“She said, at one point, ‘I’m just not attracted to you sometimes, and the fact that you can’t make love to me doesn’t help.’ That’s when I decided to give the pill a try. I think we’d both been pretending that sex wasn’t really very important to us. We’d been married for 16 years, we snuggled together in bed, and we basically had a good relationship. But underneath, we were obviously both angry and frustrated.”

The first time he popped the little blue pill, Norm was skeptical.

“I really didn’t think it was going to work,” he says. “And also it had been so long since Maggie and I made love that the whole thing felt a little strange.”

But it did work.

“I got an erection very easily,” Norm says. “I started to go too fast for Maggie…I was so used to feeling like I had to penetrate her or I’d lose my erection. So I slowed down, and relaxed, and I was amazed that the erection just stayed there. It was great. Like the old days…maybe better.”

In the year since that first trial with Viagra, Norm says he and Maggie have made love roughly once a week, using the pill every time.

“That may not sound like much to some guys,” he says, “but it’s just right for me…and I think for Maggie too. I’ve been struggling for years with a self-image that I’m not a very good lover. I may still not be Casanova, but I’m a helluva lot more confident now than in the past.” 

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Are There Any Disadvantages?

Men are sometimes prescribed Viagra and its cousins without a proper analysis of medical conditions such as diabetes and heart disease that may be causing the erectile problems. Failing erections can be like the canary in the coal mine—an early sign of a significant medical problem. Several studies have shown a very high correlation, for example, between erectile dysfunction and risk for heart attacks or stroke. Fixing a failing erection without checking for potentially important underlying problems is like taking a painkiller for a toothache. The solution is to take care of the tooth, not just mask the pain with drugs.

It’s also vital to remember that all of these drugs can be dangerous—even lethal—if used by men who are also using certain drugs called nitrates for heart problems. In addition, if used by otherwise healthy men, the drugs can cause an excessively prolonged and painful erection, called priapism. Fortunately this is extremely rare. Because of these and other, much less common risks, none of these drugs should be taken without a doctor’s permission.

What if Viagra Doesn't Work?

Sometimes erectile dysfunction arises from relatively severe damage to either blood vessels or nerves. Older men with diabetes, for instance, often have difficulties with erections because of nerve damage caused by long-term high blood sugar levels. Also, men who have had prostate surgery (even those who undergo so-called “nerve-sparing surgery”) often have erectile problems because of damage to nerves during the operation. In such cases, erection-enhancing pills may not be enough.

The remaining options include: penile-self injection; intra-urethral suppositories; vacuum devices; and penile implants. If a man is found to have abnormally low testosterone levels, he may benefit from testosterone therapy as well.