Updated 17/08/2006
120,000 men between the ages of 30 and 50 are impotent as a direct result of smoking
Losing weight improves erectile function
Dr Katherine Esposito of the Center for Obesity Management at the Department of Geriatrics and Metabolic Diseases at the Second University of Naples, Italy, looked at the impact of lifestyle changes on 110 obese men with erectile dysfunction (JAMA 2004;291:2978-84).
Men randomly assigned to the intervention group (n=55) received detailed advice on how to achieve a loss of 10% or more in their total body weight by reducing energy intake and increasing their level of physical activity. Men in the control group were given general information about healthy food choices and exercise.
The authors wrote, "The data demonstrate that lifestyle changes, including a reduced calorie diet and increased exercise, improve erectile function in obese men and resulted in about one third of men with erectile dysfunction regaining sexual function after treatment"
Drug firms warn of counterfeit Viagra threat
Source: The Guardian Date: 25/06/2004
It emerged yesterday that the Medicines and Healthcare Products Regulatory Agency (MHRA) seized more than ₤2m worth of fake Viagra last year. In response to the report, the Department of Health said that NHS patients who get their prescription from a pharmacy were in no danger from fake drugs. Pfizer, the world's biggest drug company, claimed that fake Viagra could pose a real risk to patient safety. Websites are a problem but the MHRA does investigate and takes action over those sites that appear to be in breach of regulations regarding advertising or sale and supply of medicines.
Smoking and impotence
120,000 men between the ages of 30 and 50 are impotent as a direct result of smoking.
20 cigarettes per day increases risk of impotence by 40%.
Sperm are damaged by smoking leading to abnormalities in babies.
Erectile dysfunction
This is the text of the information booklet regarding ED prepared by Dr Causer for his patients. (Version 026).
“My brain? It’s my second favourite organ.
Woody Allen Sleeper 1993.
What Do You Know About Erectile Dysfunction?
Test your knowledge about erectile dysfunction by answering the following questions.
1 Erectile dysfunction is defined as follows:
a Premature ejaculation
b A more precise term for impotence
c Inability to achieve or sustain an erection
d Loss of manhood
e Answers b and c
2 In the United Kingdom, erectile dysfunction affects approximately how many men over the age of 16:
a 100,000
b 500,000
c 1 million
d 5 million
e 10 million
3 Erectile dysfunction can be caused by:
a emotional conflict
b injury
c diabetes
d side effects of prescribed medication
e all of the above
4 Erectile dysfunction can be a symptom of the following health problems:
a high blood pressure
b high cholesterol
c heart disease
d all of the above
5 As many as how many percent of cases of erectile dysfunction are the result of physical conditions:
a 20%
b 50%
c 40%
d 70%
6 Treatment options for erectile dysfunction include:
a counselling
b vacuum devices
c implants in penis
d surgery
e drugs injected into penis
f pellets inserted into the opening
of the penis
g tablets taken by mouth
h all of the above
7 Successful resolution of erectile dysfunction can be achieved best by:
a Going it alone
b The man working with a knowledgeable doctor and/or nurse
c The man and his partner working with a knowledgeable and caring doctor and/or nurse
Not sure of one or more of the answers? Read on
Confronting Erectile Dysfunction as a Team
Experts agree that good communication is the foundation for an enduring relationship. However, when couples encounter sexual difficulties, communication in the best of relationships can become strained or break down entirely.
Erectile dysfunction (ED) may divide and distance couples, often causing conflict and emotional pain. Couples may intentionally, or unintentionally ignore or deny the condition, thus delaying treatment. Fortunately, many sexual difficulties can be improved through open communication and a mutual commitment to learn about the condition and treatment options.
The first step in addressing ED as partners is to understand the definition of the condition and acknowledge its existence. In 1992, the National Institute of Health in the USA defined ED as the inability to achieve and sustain an erection. This definition is more precise than impotence, a term that some associate with being sterile or lacking strength, vigour or power.
Overcoming ED is best achieved when a man and his partner openly communicate, continue to demonstrate love and affection and have a mutual desire to carry through with treatment options.
This booklet is intended to help couples learn more about ED and the treatment options available. It is hoped that this will improve communication between couples and encourage discussion of options with their doctor.
What Is Erectile Dysfunction?
As already mentioned, ED is the inability to achieve or to sustain an erection adequate for sexual intercourse. It is a common treatable condition affecting an estimated 5 million men in the UK alone. Data suggest that less than 10% of affected men actually seek and receive treatment.
The small number who do receive treatment is thought to be related to the reluctance of many men to discuss the subject with their doctor.
What Causes Erectile Dysfunction?
Most men experience occasional erectile failures at some time during their lives, usually as a result of such diverse conditions as fatigue temporary stress or excessive alcohol consumption. This temporary loss of erectile capability is never something to worry about. However, when the condition persists or interferes with a man’s normal sexual activity, medical advice should be sought. It has been calculated that 15-20% of men has some sort of sexual problem.
Until recently, many in the health care professions believed ED was caused by mental or emotional conflicts. Patients were often told, “It’s all in your head.” Today, experts believe that up to 70% of all ED cases may be mainly due to physical conditions, with psychological factors accounting for the remaining 30%. However, in many cases, there are both psychological and physical reasons for the condition.
Men with ED of a physical origin often experience a gradual onset of symptoms. Physical causes of ED include:
· blockage in arteries
· sugar diabetes
· neurological nerve disorders
· spinal injury or surgery
· disease of the erectile tissue of the penis
· pelvic/genital surgery and/or trauma
· side effect of prescribed medications. (See ** later)
· chronic disease (e.g. kidney disease or liver disease)
· hormonal problems
· alcoholism or other drug abuse
· tobacco smoking
It is often said that alcohol awakens the desire and destroys the performance. Men with a high alcohol intake have an ED rate of 50-80%. Using medication to try and reverse this effect just increases the overall health risk to the man.
The effect of tobacco smoking in producing immediate and long-term effects on sexual function is surprisingly rarely publicised. Yet this effect can be dramatic and easily reversed by giving up smoking. Normal function returns as time goes by.
Men who experience a sudden loss of erectile capability usually have a psychological origin to their condition.
Just as an erection can result from thinking about sex, negative thoughts can prevent an erection from occurring.
Typically, patients whose ED is primarily psychological in nature continue to have erections while they sleep and when they wake up in the morning.
Psychological causes of impotence include:
· stress and anxiety from work or home
· worry about poor sexual performance
· marital discord
· unresolved sexual orientation
· depression
Whether physical or psychological factors or a combination of the two causes a man’s ED, it may become a source of mental, emotional and physical stress. In addition, ED may also be a symptom of more serious conditions such as heart disease or diabetes.
Can Someone Be Too Old For Treatment?
Attitude, not age, is the biggest barrier in treating ED. Some men who experience difficulty achieving an erection may see the condition as a natural, unchangeable part of ageing. Instead of seeking treatment, many men resign themselves to the condition by making excuses, such as: “I’m too old,” or “I’m not interested anymore” or “I have better things to do.” Fortunately, more and more information is becoming available to help men of any age realise that treatment options are available to treat ED. In a group of healthy people aged 80-102, 62% of men (and 30% of women) were still having sexual intercourse.
Should Couples Seek Treatment Together?
Some men prefer to deal with their erectile dysfunction with no help or assistance from their partner. Some even seek medical advice and treatment without their partner’s knowledge.
Yet most doctors acknowledge that a couple’s chances for a mutually beneficial approach to treating ED are much better when they work together.
How Are Men Affected By ED?
The ability to function sexually helps define a man’s role in the world, thus shaping his identity. It’s no wonder, then, that the loss of erectile capability can have a profound effect on a man.
Many men with ED suffer emotionally, often in silence. They may say to themselves: “If I can’t have normal sex with my partner, I’m a failure as a man and a lover.” Or they may worry, “Will she leave me if I don’t satisfy her?” Such concerns may contribute to feelings of anxiety, depression, grief, embarrassment, anger, shame and frustration.
How Are Partners Affected By ED?
Because of the emotional pain associated with ED, it’s common for men to make excuses or avoid sexual situations with their partners in an effort to forget about the condition.
Whether intentional or unintentional, these actions can make a woman feel inadequate within the relationship, often resulting in rejection, loneliness and depression.
Some women may fear they are no longer attractive to their partner, or that his attitude is the result of something she may have done. Others may worry: “Is something wrong with our relationship?” Or, “Is he having an affair?” Thus, a man’s failure to communicate his condition may contribute to feelings of anxiety or depression in his partner, or lead her to express anger and frustration.
How Can Couples Work Together?
In order to appropriately treat ED and strengthen a healthy and nurturing relationship, couples need to communicate openly and honestly with each other. Most importantly, couples need to confront any concerns they may have about ED by discussing their feelings and reassuring each other that they still care. Couples need to maintain this communication throughout the treatment process.
What ED Treatments Are Available?
Currently, there are a number of lifestyle changes obvious from the information above and several treatment options available for men with ED. A physician can explain the best course of treatment.
In some cases, the first course of treatment satisfies the patient and his partner. For other patients a number of steps may be taken before one is found satisfactory.
Among the proven treatment options are:
¨ Hormone medications:
Abnormal levels of sex hormones cause a small percentage of ED cases. Fortunately, for men who experience ED as a result of unbalanced hormone levels, there are medications that can restore this balance.
¨ Professional counselling:
Because ED can often result from a combination of psychological and physical factors, counselling can lessen anxiety, which in turn may reduce the impact and duration of the condition. This therapy is often used in combination with other treatments directed by a physician.
¨ Vacuum devices:
This treatment involves the use of an external vacuum device and one or more tension rings (basically rubber bands). The device works by inserting the penis into a plastic cylinder, which is then pumped to create a controlled vacuum. Once an adequate erection is produced, a tension ring is slipped around the base of the penis to maintain erection; the vacuum device is then removed. The erection-like state generally lasts long enough for a couple to have intercourse.
¨ Injection and pellet therapy:
This involves the self-injection of medication into the side of the penis or inserting a pellet into the urethra. Both methods deliver a drug that causes an erection.
¨ Penile prostheses (implants):
This treatment involves the surgical placement of a stationary or moveable device into the two sides of the penis, allowing erections as often as desired. These implants come in two forms: an inflatable device and semi-rigid rods. This treatment is not recommended until other methods have been considered or tried first.
¨ Drug therapy by mouth:
Yohimbine occurs naturally in the bark of evergreen trees and has been used as an aphrodisiac for centuries by Indians and Africans. It is believed the drug works by enhancing nerve sensitivity in the penis. While there have been no large-scale studies to prove the drug’s effectiveness, a small percentage of men report it to be helpful for impotence.
Viagra (sildenafil) is the latest treatment and is covered in more detail later.
¨ Surgical treatment:
This treatment is usually reserved for those patients whose blood flow has been blocked by an injury to the penis or pelvic area. Surgery is also used to correct ED caused by vascular blockages. The goal of this treatment is to correct a blockage of blood flow to the penis so that erections will occur naturally.
Regaining Sexual Function
The good news for many men and their partners is that ED can usually be treated reasonably safely and effectively.
In light of recent medical advances, men no longer need to suffer from ED in silence, nor must their impotency be a dividing force in their relationships. Most importantly, couples can fully enjoy the enriching and exhilarating experience of intimate sexual contact.
The key to regaining long term sexual function is trust and open communication between the motivated man and his supportive partner. Success also requires a knowledgeable and caring health care professional, one who understands the physical and psychological impact of the condition on both the patient and his partner. With teamwork, communication and a mutual commitment to regaining sexual function, many couples can experience renewed passion and excitement in their physical and emotional relationship.
**Medications associated with ED include:
¨ Some blood pressure drugs
¨ Some antidepressants and other drugs for mental illness
¨ Some epilepsy drugs
¨ Some drugs for ulcers, cholesterol lowering, morphine type painkilling, cancer treatment, and also digoxin for the heart.
Many will be absolutely necessary but ask if any of the following may help: delaying dose until after intercourse, having occasional “drug holidays”, adding another drug to counteract the problem, reducing doses, stopping the drug or changing to a different drug treatment.
Viagra (sildenafil)
861 men, average age 58, with ED lasting 6 months or more who were in a stable relationship with a female partner of 6 months or more duration, received either Viagra or placebo.
Men with the following conditions were specifically excluded from the study:
problems with the shape of the penis, another sexual disorder, injury of spinal cord, major psychiatric disorder, poorly controlled diabetes, peptic ulcer disease, history of alcohol or substance abuse, major illnesses, recent stroke or heart attack or taking nitrate treatment. Studies were of short duration (not more than 36 weeks). If one of these situations that lead to exclusion of men from the study applies to you then the results of the study may not apply to you. So neither your doctor nor you know whether this is a safe effective necessary medication for you.
Viagra may help millions of men but it is not a sexual cure-all. It is not an aphrodisiac. It will not work in the absence of desire and absence of appropriate stimulation. Nor will it make a normal erection harder or make one last longer. It will not, in itself, save a marriage. In fact, there are some risks to taking Viagra that everyone, whether sexually dysfunctional or merely dissatisfied, should consider before rushing to use the drug.
25% of the men receiving placebo reported improved function. Of those receiving Viagra, improvements were 56% on 25mg, 77% on 50mg and 84% on 100mg. Side effects were said to be mild and included headache, flushing, indigestion, and disturbance of vision.
However, drug studies nowadays involve a surprisingly small number of people. Often major safety problems only appear when large numbers of patients use the drug. Once these problems are identified, the drug is then withdrawn.
ED may be associated with a reduced blood supply to the heart. As there is no reliable method of detecting this before ED treatment two problems arise. One is that the ED treatment itself may make the heart circulation worse. The other is that having an erection to enable intercourse does not mean that the heart can stand the exertion involved. By July 1999, there had been 77 deaths in America. It could not be proved that Viagra was responsible in any way. As this was a tiny number compared to the number of tablets dispensed the American drug watchdog has not withdrawn the drug’s licence.
Side effects in the study included:
Headaches
One out of 10 men developed blinding headaches that grew more severe at higher doses.
Seeing Blue
Because the eyes contain an enzyme similar to the one on which Viagra works in the penis, about 3% of users develop temporary vision problems, ranging from blurred vision to a blue or green halo effect. This can last from a few minutes to a few hours. Later studies found no evidence of permanent damage to vision.
Blackouts
Viagra can trigger sudden drops in blood pressure leading to fainting or shock. This effect may be worse in men on some blood pressure treatments.
Nitrates such as glyceryl trinitrate (used in angina) or amyl nitrate (poppers) must never be taken with Viagra as the effect on blood pressure is very marked. This combination can produce a fatal reaction.
Priapism (defined as an erection that lasts four hours or more).
Although it never happened in the trials, there is a theoretical risk that men with sickle-cell anaemia, leukaemia or urethral inflammation could, when taking Viagra, develop priapism which can lead to tissue damage and permanent impotence.
Heart attack during intercourse
Sometimes ED is an early indicator of heart disease, diabetes and also some types of cancer. Taking Viagra could therefore mask these conditions.
Men with known coronary problems who have not had sex for a long time should consult their doctors before putting too much strain on a weakened heart.
Studies suggest that intercourse between those in a stable relationship leads to an increase in heart rate equivalent to walking up 2 flights of stairs. Extramarital relationships seem to place more stress on the heart; particularly when a middle-aged man is in unfamiliar surroundings with a younger partner.
Abuse
Nobody knows the long-term effects of large doses of Viagra, especially on men who take it for the wrong reason. Although it seems to be a relatively safe drug, there is a possibility that users will become psychologically dependent on it and unable to achieve an erection without Viagra.
Never give any prescribed medications to others. They may have conditions that make the use of such medications dangerous.
In particular, women should not take Viagra.
Availability at NHS expense
The Government ruling is that men in the following categories may receive Viagra at NHS expense:.
· Diabetics
· After treatment for prostate cancer
· Men with kidney failure
· Multiple sclerosis
· After spinal cord or severe pelvic injury
· Spina bifida
· Parkinson’s disease
· Single gene neurological disease
· After radical pelvic surgery
· Polio
· Men receiving drug treatment for ED on 14th September 1998
The final category relates to severe distress. This requires consultant assessment probably from the mental health services. The prescription would have to be provided by the consultant either for collection from the hospital pharmacy or a community pharmacist depending on the hospital’s arrangements. Regular consultant review would be necessary to ensure circumstances had not changed. The suggested frequency is one tablet per week based on the average frequency of intercourse in men aged 40 to 60.
Private prescriptions
In other cases, a private prescription can be issued. There is no charge for the prescription form itself but you do have to pay the pharmacist for the tablets.
References
Hirshkowitz M et al. Nocturnal penile tumescence in cigarette smokers with dysfunction. Urology 1992:39:101-7.
Bretschneider JG, McCoy NL. Sexual interest and behaviour in healthy 80-102 year olds. Arch Sex Behav 1988;17:100-29.
Gregoire Alain. Male sexual problems. BMJ 1999;318:245
Goldstein L et al for the Sildenafil Study Group. Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 1998;338:1397-404.
Johnson A, Wadsworth J et al. Sexual attitudes and lifestyle survey UK 1990-91. Published 1994.
The Minster Practice, Lichfield
