MALE PATIENTS

Erectile dysfunction is a common clinical entity that affects mainly men older than 40 years. In addition to the classical causes of erectile dysfunction, such as diabetes mellitus and hypertension, several common lifestyle factors, such as obesity, limited or an absence of physical exercise, and lower urinary tract symptoms, have been linked to the development of erectile dysfunction. Substantial steps have been taken in the study of the association between erectile dysfunction and cardiovascular disease.

Erectile dysfunction is a strong predictor for coronary artery disease, and cardiovascular assessment of a non-cardiac patient presenting with erectile dysfunction is now recommended. Substantial advances have occurred in the understanding of the pathophysiology of erectile dysfunction that ultimately led to the development of successful oral therapies, namely the phosphodiesterase type 5 inhibitors. However, oral phosphodiesterase type 5 inhibitors have limitations, and present research is thus investigating cutting-edge therapeutic strategies including gene and cell-based technologies with the aim of discovering a cure for erectile dysfunction.

Treatment of underlying causes

• Education and counseling

• Oral phosphodiesterase inhibitors

• Sometimes other drugs, mechanical devices, or surgery

Any underlying disorder is treated, and doctors often stop drugs that may be causing erectile dysfunction (ED) or switch the man to a different drug. However, men should talk with their doctor before they stop taking any drug.

Excess weight is a risk factor for many disorders that may cause ED, so weight loss may improve erectile function. Smoking is a risk factor for atherosclerosis, so stopping smoking may also improve erectile function. Stopping or decreasing alcohol use, if excessive, can also help.

Even ED caused by a physical disorder usually has a psychologic component, so doctors offer reassurance and education (including of the man's partner whenever possible). Couples counseling by a qualified sex therapist can help improve partner communication, reduce performance pressure, and resolve interpersonal conflicts that contribute to ED.

Supplemental testosterone can help restore erections in men with low testosterone levels. These testosterone preparations can be applied daily as a patch or a gel. Testosterone nasal products and below-the-skin implants are also sometimes recommended. Men with very low testosterone levels may need testosterone injections twice per month.

Noninvasive methods (mechanical devices and drugs) are tried first. Sometimes men must try the method a few times before doctors can determine whether it is effective. Usually, oral drugs are tried first. Drugs injected into the penis just before intercourse are effective and often tried second. Although most men prefer drugs to other methods of treating ED, mechanical devices have the advantages of being highly effective and, because they are free of drug side effects, usually very safe. Penile implant surgery with an inflatable prosthesis is the last used, but most effective, way to achieve intercourse.

Drugs

The primary drugs for ED are oral phosphodiesterase inhibitors. Other drugs include prostaglandins that are injected into the penis or inserted into the urethra. Oral phosphodiesterase inhibitors are used much more often than other drugs because they are simple to use and allow spontaneity in intercourse. Over-the-counter herbal remedies are sold for ED, but they are usually ineffective, contain hidden doses of a phosphodiesterase inhibitor, or both. The hidden phosphodiesterase inhibitor may expose the man to a drug with possible side effects.

Oral phosphodiesterase inhibitors (sildenafil, vardenafil, avanafil, and tadalafil) increase blood flow to the penis. These drugs work in the same way, but differ as to how long the effect lasts, their side effects, and their interactions with food. The effect of tadalafil lasts longer than those of the other drugs (up to 36 hours), which some men prefer.

Most phosphodiesterase inhibitors work best when taken on an empty stomach and at least 1 hour before sexual intercourse. Men who are taking nitrates (most often nitroglycerin for the treatment of angina but also recreational amyl nitrate ["poppers"]) should not take phosphodiesterase inhibitors because the combination can cause blood pressure to drop to unsafe levels. Other temporary side effects of phosphodiesterase inhibitors include flushing, vision abnormalities (including abnormal color perception), and headache. Priapism (prolonged erection) develops very rarely and may require emergency medical treatment. In rare instances, men have reported blindness or hearing loss after taking phosphodiesterase inhibitors, but it is not clear whether the phosphodiesterase inhibitors have been the cause.

Alprostadil (the prostaglandin PGE1) alone or in combination with papaverine and phentolamine may be directly injected into the side of the penis using a very thin needle, causing a suitable erection in most men. Alprostadil suppository may be inserted into the urethra using a straw-like applicator. These therapies may cause priapism and penile pain. Usually, the doctor guides the man to administer the drug himself during an office visit. After this, men may give themselves these drugs at home. Alprostadil suppository may be combined with an oral phosphodiesterase inhibitor for men in whom oral drugs are not effective.

Oral medications are often the first line of treatment for erectile dysfunction. For most men who have trouble keeping an erection firm enough for sex (erectile dysfunction), these medications work well and cause few side effects.

Sildenafil (Viagra), vardenafil (Levitra, Staxyn), tadalafil (Cialis) and avanafil (Stendra) are oral medications that reverse erectile dysfunction by enhancing the effects of nitric oxide, a natural chemical your body produces that relaxes muscles in the penis. This increases blood flow and allows you to get an erection in response to sexual stimulation.

How oral medications differ
Although they work in similar ways, each oral medication has a slightly different chemical makeup. These minor differences affect the way each medication works, such as how quickly it takes effect and wears off, and the potential side effects. Your doctor will consider these factors as well as other conditions you have and possible interactions with other medications you take.

• Sildenafil (Viagra). This medication is most effective when taken on an empty stomach one hour before sex. It's effective for four to five hours or more if you have mild to moderate erectile dysfunction.

• Vardenafil (Levitra, Staxyn). This medication also is most effective when taken one hour before sex and can be taken with or without food. A high-fat meal might keep it from absorbing as quickly.

• Vardenafil is effective for four to five hours or more if you have mild to moderate erectile dysfunction. A newer form of the drug that dissolves on the tongue might work faster than the pill that you swallow.

• Tadalafil (Cialis). This medication is taken with or without food about one to two hours before sex. It's effective for up to 36 hours. It can be taken in a small dose daily or in a larger dose as needed.

• Avanafil (Stendra). This medication is taken with or without food 30 minutes before sex, depending on the dose. It lasts up to six hours.

Because these drugs are similarly effective, it is recommended that the choice be based on your preferences, including cost, ease of use, how long the drug's effects last and side effects. There are generic versions of sildenafil, verdenafil and tadalafil available.

When oral medications might not be safe
Before taking any medication for erectile dysfunction, get your doctor's OK. Medications for erectile dysfunction might not work or might be dangerous if you:

• Take nitrate drugs

• • commonly prescribed for chest pain (angina)

  • such as nitroglycerin (Nitro-Dur, Nitrostat, others), isosorbide mononitrate (Monoket) and isosorbide dinitrate (Dilatrate-SR, Isordil)

• Have very low blood pressure (hypotension) or uncontrolled high blood pressure (hypertension)

• Have severe liver disease

• Have kidney disease that requires dialysis

Side effects
Most men who take oral erectile dysfunction medications aren't bothered by side effects. When side effects do occur, they can include:

• Flushing

• Headache

• Indigestion

• Visual changes, such as blue tinge to vision, sensitivity to light or blurred vision

• Stuffy or runny nose

• Back pain

Rarely, more-serious side effects can occur, including:

• Hearing loss or vision loss. Some men have had sudden loss of hearing or loss of vision after taking one of these medications. However, it isn't clear whether vision or hearing loss was directly caused by taking the medication or by a preexisting condition. If you're taking an oral erectile dysfunction medication and have sudden loss of hearing or vision, seek prompt medical attention.

• An erection that doesn't go away on its own. Called priapism, this rare condition can be painful and requires medical treatment to avoid damage to your penis. If you have an erection that lasts more than four hours, seek immediate medical attention.

Ireland spends approximately €9.5 million per year on ED treatment.
Figures show that the HSE spent nearly €57m on Viaga between 2009 and 2015 — that’s around 167m pills. 

Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist if you are not sure.