Most physicians suggest that treatments proceed from least to most invasive. Cutting back on any drugs with harmful side effects is considered first. For example, drugs for high blood pressure work in different ways. If you think a particular drug is causing problems with erection, tell your doctor and ask whether you can try a different class of blood pressure medicine.
Psychotherapy and behavior modifications in selected patients are considered next if indicated, followed by oral or locally injected drugs, vacuum devices, and surgically implanted devices. In rare cases, surgery involving veins or arteries may be considered.
Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient's partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when ED is being treated.
Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. In March 1998, the Food and Drug Administration (FDA) approved sildenafil (Viagra), the first pill to treat ED. Since that time, vardenafil (Levitra, Staxyn) and tadalafil (Cialis) have also been approved. Additional oral medicines are being tested for safety and effectiveness.
Viagra, Staxyn, Levitra, and Cialis all belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Taken before sexual activity, these drugs work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.
While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. Most PDE's should be taken 1 hour prior to intercourse to have the best effect, although Staxyn is reported to have a faster onset of action and may work more quickly. Viagra is dosed as a 25mg-100mg table taken daily as needed, and lasts approximately 3-4 hours. Levitra is dosed as a 2.5-20mg tablet taken daily as needed , and lasts approximately 4-6 hours. Staxyn comes in a 10mg dissolvable tablt taken daily as needed and lasts approximately 4-6 hours. Cialis is dosed as a 2.5mg to 20mg tablen taken daily as needed, and lasts up to 36 hours. Cialis also comes as a 5mg daily tablet designed for more consistent absorption.
None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug because the combination can cause a sudden drop in blood pressure. Also, tell your doctor if you take any drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure. Your doctor may need to adjust your ED prescription. Taking a PDE inhibitor and an alpha-blocker at the same time (within 4 hours) can cause a sudden drop in blood pressure.
Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Patients also have claimed that other oral drugs—including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone—are effective, but the results of scientific studies to substantiate these claims have been inconsistent. Improvements observed following use of these drugs may be examples of the placebo effect, that is, a change that results simply from the patient's believing that an improvement will occur.
Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.
A system for inserting a pellet of alprostadil into the urethra is marketed as MUSE. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; warmth or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.
Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.
Gone are the days of repelling Mission Impossible-like from the hospital ceiling to retrieve Charlie's medical files before the CDE entered our exam room. It's not that I don't care anymore about his A1c. Of course I care. Maybe in the past I was more consumed by it. For a very long time I so desperately wanted to see an A1c below 8. Now that we've been comfortably in the low to mid-7s for the last couple of years, there's just an expectation. It's become a little anticlimactic....
dLife's Sex & Intimacy Content is contributed & moderated by
Janis Roszler MSFT, RD, CDE, LDN
Janis Roszler, MSFT, RD, CDE, LD/N is the American Association of Diabetes Educators' 2008-2009 Diabetes Educator of the Year. She is a certified diabetes educator, marriage and family therapist, and registered dietitian. Her books include Sex and Diabetes (ADA) Diabetes on your OWN Terms (Marlowe & Co) and The Secrets of Living and Loving with Diabetes (Surrey books).
Donna Rice MSW, BSN, RN, CDE
Donna Rice MBA,RN,CDE,FAADE is the 2007 Past President of the American Association of Diabetes Educators. She is a registered nurse, diabetes educator and has developed numerous educational programs on sexual health and wellness. She is the co-author of Sex and Diabetes (ADA) and Diabetes and Erectile Dysfunction - A Quick ‘n' Easy Handbook For the Diabetes Educator (Bella Vita). Her newest publication is a children's book, The Magic is Me (Searchlight Press).