Erectile dysfunction: Viagra and other oral medications

Wondering about drugs to treat erectile dysfunction? Find out how Viagra, Levitra and Cialis compare with each other.

Viagra, Levitra and Cialis are often the first treatment tried for erectile dysfunction — the inability to achieve or sustain an adequate erection for sexual activity. For most men with erectile problems, they work well and have few side effects. All three medications improve erectile function in the same basic way, but the effects of tadalafil (Cialis) last longer. This and a few other minor differences among these medications may make one a better choice over another for some men.

Viagra, Levitra and Cialis: How they work

Viagra, Levitra and Cialis increase levels of nitric oxide, a chemical produced by your body during sexual stimulation that causes blood vessels in the penis to relax and open. This allows you to achieve and maintain an erection. These medications don't automatically trigger an erection; sexual arousal is needed to start the whole process.

Which is best for you?

Viagra, Levitra and Cialis each have a slightly different chemical make up. These minor differences affect the way they work, such as how quickly they take effect and wear off; how they interact with other medications; and side effects. Your doctor will consider these factors when deciding if one of these medications is a good choice for you. Your doctor will also consider any other health problems you have and whether any of your current medications could cause problems when taken with Viagra, Levitra or Cialis.

	Viagra (sildenafil)	Levitra (vardenafil)	Cialis (tadalafil)
How to take	Without food, no more than once a day	Without food, no more than once a day	With or without food, no more than once a day
When to take	30 to 60 minutes before sex	30 to 60 minutes before sex	30 minutes before sex
Time an erection is possible	Up to four hours	Up to four hours	Up to 36 hours

Not safe for everyone

Although these erectile dysfunction medications can help many people, not all men can safely take them. Viagra, Levitra and Cialis may not be a good choice if you have:

• Heart problems, including a recent heart attack, heart pain (angina) during sex, heart failure, heart rhythm problems (arrhythmias)
• High or low blood pressure (hypertension or hypotension) that isn't controlled
• A history of stroke within the last six months
• Relatives with retina disorders, including retinitis pigmentosa
• Sickle cell anemia, leukemia or other health conditions that can cause an erection that won't subside (priapism)

Interactions with other medications

Tell your doctor about all medications you take, including herbal remedies. A number of other drugs, including certain antibiotics, anti-seizure medications, blood thinners and anti-arrhythmic heart medications can affect how well Viagra, Levitra or Cialis work and cause other side effects.

A few medications should never be taken with Viagra, Levitra or Cialis, or should be used with caution:

Never take Viagra, Levitra or Cialis if you take nitrate drugs to treat chest pain due to heart problems (angina). Like Viagra, Levitra and Cialis, nitrates dilate blood vessels. Their combined effects can cause dangerous low blood pressure and loss of consciousness. Medications that contain nitrates include:

• Nitroglycerin (Nitro-Bid, Minitran, others)
• Isosorbide dinitrate (Dilatrate-SR, Isordil, others)
• Isosorbide mononitrate (Imdur, Monoket, others)
• Recreational drugs such as amyl nitrite or nitrite ("poppers")

Talk to your doctor if you take alpha blockers, medications often used to treat an enlarged prostate. Alpha blockers can cause dangerously low blood pressure when combined with drugs for erectile dysfunction. Examples of alpha blockers include: tamsulosin (Flomax), terazosin (Hytrin) and doxazosin (Cardura).

• Don't use Viagra, Levitra or Cialis within four hours of taking an alpha blocker.
• If you do use an alpha blocker, never take sildenafil (Viagra) in doses above 25 milligrams.
• There's one exception to the rule about not taking alpha blockers with medications for erectile dysfunction: Tadalafil (Cialis) has been approved for use with the alpha blocker tamulosin (Flomax).

Erectile dysfunction medications for other health problems

Viagra, Levitra and Cialis all belong to a type of medications called phosphodiesterase-5 (PDE-5) inhibitors, which improve erectile function by affecting blood pressure. Experts are investigating whether these drugs may be useful to treat certain heart or blood flow problems. Revatio, the same medication as sildenafil (Viagra) was recently approved by the Food and Drug Administration as a treatment for pulmonary hypertension, a rare condition affecting blood flow to the lungs.

Common side effects

Viagra, Levitra and Cialis don't usually cause severe side effects. Some men have reported headache, flushing, indigestion, and a stuffy or runny nose after taking Viagra, Cialis or Levitra. Men taking Levitra have also reported back pain and muscle aches. In some men, Viagra caused temporary vision changes, such as "blue" vision.

Rare but serious side effects

In a small number of cases, men taking Viagra, Levitra or Cialis have reported:

• Vision loss. A few men using Viagra, Levitra and Cialis have had permanent vision loss due to a condition called nonarteritic anterior ischemic optic neuropathy (NAION). However, it's unclear whether the drug — or an underlying condition — caused blindness. If you have a retinal disorder, such as diabetic retinopathy, see your eye doctor before taking any medication for erectile dysfunction.
• Sudden hearing loss. Some men have reported hearing loss after taking Viagra, Levitra and Cialis. However, it isn't clear whether the hearing loss was directly caused by taking these medications. If you're taking one of these medications for erectile dysfunction and have sudden loss of hearing, don't take any more of the medication and seek medical help right away.
• An erection that doesn't subside 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, see your doctor.

Erectile dysfunction: Don't ignore underlying cause

Taking Viagra, Levitra or Cialis without treating the original problem may improve sexual performance, but don't ignore an underlying issue by just taking pills to treat the symptom of another health issue. Getting proper treatment for the underlying cause of erectile dysfunction may help you prevent related health problems and improve sexual performance. A number of conditions can cause or worsen erectile dysfunction:

• Heart disease. In some cases, erectile dysfunction is the first sign of serious heart or blood vessel problems such as hardened arteries (atherosclerosis).
• Diabetes. Over time, uncontrolled diabetes can damage blood vessels and nerves, making it more difficult to get or keep an erection.
• Psychological issues. Depression or anxiety can cause sexual problems and often requires psychological counseling or medications to get better.
• Being overweight. Being overweight or obese can cause or worsen erectile dysfunction because of hormonal changes and related cardiovascular issues. Increased physical activity and losing weight can improve your overall health and sexual function.
• Low testosterone. Men who have low testosterone levels (hypogonadism) may need testosterone replacement therapy to increase sex drive and sexual performance.
• Lifestyle choices. Unhealthy habits such as drinking too much alcohol, smoking, using illegal drugs and a sedentary lifestyle can all worsen erectile dysfunction.

http://www.mayoclinic.com

Infidelity: Mending your marriage after an affair

Infidelity causes intense emotional pain — anger, disbelief, fear, guilt, shame. But an affair doesn't have to mean the end of your marriage. Understand how a marriage can be rebuilt after an affair.

When an affair is first discovered, both partners feel as if the world has collapsed — you're left wondering whether your marriage can survive.

Few marital problems cause as much heartache and devastation as infidelity. Money worries, disagreements about children or a serious illness can strain a relationship. But because of the deep sense of betrayal, infidelity undermines the foundation of marriage itself.

Divorce doesn't have to be the inevitable resolution to infidelity. With counseling, time to heal and the mutual goal of rebuilding the relationship, some couples emerge from infidelity with a stronger and more honest relationship than before.

When an affair is discovered

The initial discovery of an extramarital affair can trigger a range of powerful emotions for both partners — shock, rage, shame, depression, guilt, remorse. Both members of the couple may cycle through all of these emotions many times in a single day — one minute vowing to end the marriage and the next wanting desperately to save it. At this point, it's important to take one step at a time:

• Get support. For your own well-being, seek support from family, friends, a pastor or counselor — people you trust and feel comfortable with. Talking about your feelings with those you love can help you cope with the intensity of the situation. Objective support can help you clarify what you're feeling and put the affair into perspective. However, avoid confiding in people who you know will take sides — this tends to increase the emotional intensity of the situation.
• Give each other some space. Both partners need a break from the emotional stress generated by the discovery of an affair. Although difficult, experts advise taking a "timeout" when emotions are running high.
• Take time. Avoid delving into the intimate details of the affair with your partner at first. Postpone such discussions until you can talk without being overly accusatory or destructive. Take time to absorb the situation. You may need to air out your feelings with someone who is a good listener before you can have a constructive conversation with your spouse.

http://www.mayoclinic.com

Erectile dysfunction

Definition

Erectile dysfunction (ED) is the inability of a man to maintain a firm erection long enough to have sex. Although erectile dysfunction is more common in older men, this common problem can occur at any age. Having trouble maintaining an erection from time to time isn't necessarily a cause for concern. But if the problem is ongoing, it can cause stress and relationship problems and affect self-esteem.

Formerly called impotence, erectile dysfunction was once a taboo subject. It was considered a psychological issue or a natural consequence of growing older. These attitudes have changed in recent years. It's now known that erectile dysfunction is more often caused by physical problems than by psychological ones, and that many men have normal erections into their 80s.

Although it can be embarrassing to talk with your doctor about sexual issues, seeking help for erectile dysfunction can be worth the effort. Erectile dysfunction treatments ranging from medications to surgery can help restore sexual function for most men. Sometimes erectile dysfunction is caused by an underlying condition such as heart disease. So it's important to take erectile trouble seriously because it can be a sign of a more serious health problem.

Treatments and drugs

A variety of options exist for treating erectile dysfunction. They range from medications and simple mechanical devices to surgery and psychological counseling. The cause and severity of your condition are important factors in determining the best treatment or combination of treatments for you.

Cost
You and your partner may want to talk with your doctor about how much money you're willing to spend and your preferences. Treatment for erectile dysfunction can be costly and insurance coverage varies. Because erectile dysfunction can by a sign of a number of underlying health conditions, initial evaluation of the problem is covered by most insurance policies. Medications or other treatments for erectile dysfunction may or may not be covered by your policy — check with your insurance provider to find out. Many policies have a limit on how many pills or injections are covered per month. Standard Medicare prescription drug coverage doesn't cover medications for erectile dysfunction.

Oral medications
Oral medications available to treat ED include:

• Sildenafil (Viagra)
• Tadalafil (Cialis)
• Vardenafil (Levitra)

All three medications work in much the same way. Chemically known as phosphodiesterase inhibitors, these drugs enhance the effects of nitric oxide, a chemical that relaxes muscles in the penis. This increases the amount of blood flow and allows a natural sequence to occur — an erection in response to sexual stimulation.

These medications don't automatically produce an erection. Instead they allow an erection to occur after physical and psychological stimulation. Many men experience improvement in erectile function after taking these medications regardless of the cause of their impotence.

These medications share many similarities, but they have differences as well. They vary in dosage, duration of effectiveness and possible side effects. Other distinctions — for example, which drug is best for certain types of men — aren't yet known. No study has directly compared these three medications.

Not all men benefit
Although these medications can help many people, not all men can or should take them to treat erectile dysfunction. You should not take these medications if:

• You take nitrate drugs for angina, such as nitroglycerin (Nitro-Bid, others), isosorbide mononitrate (Imdur) and isosorbide dinitrate (Isordil)
• You take a blood-thinning (anticoagulant) medication
• You take certain types of alpha blockers for enlarged prostate (benign prostatic hyperplasia) or high blood pressure

Viagra, Levitra or Cialis may not be a good choice for you if:

• You have severe heart disease or heart failure
• You've had a stroke
• You have very low blood pressure (hypotension)
• You have uncontrolled high blood pressure (hypertension)
• You have uncontrolled diabetes

Don't expect these medications to fix your erectile dysfunction immediately.

Work with your doctor to find the right treatment and dose for you. Dosages may need adjusting. Or you may need to alter when you take the medication.

Before taking any medication — including Viagra, Levitra or Cialis — make sure to discuss with your doctor:

• Potential benefits and side effects of the medication you are considering
• Any illnesses or serious health problems you have now or have had in the past
• Any prescription or over-the-counter medications you take (including herbal remedies)

Prostaglandin E (alprostadil)
Two treatments involve using a drug called alprostadil. Alprostadil is a synthetic version of the hormone prostaglandin E. The hormone helps relax muscle tissue in the penis, which enhances the blood flow needed for an erection. There are two ways to use alprostadil:

• Needle-injection therapy. With this method, you use a fine needle to inject alprostadil (Caverject, Edex) into the base or side of your penis. This generally produces an erection in five to 20 minutes that lasts about an hour. Because the injection goes directly into the spongy cylinders that fill with blood, alprostadil is an effective treatment for many men. And because the needle used is so fine, pain from the injection site is usually minor. Other side effects may include bleeding from the injection, prolonged erection and formation of fibrous tissue at the injection site. The cost per injection can be expensive. Injecting a mixture of alprostadil and other prescribed drugs may be a less expensive and more effective option. These other drugs may include papaverine and phentolamine.
• Self-administered intraurethral therapy (Muse). This treatment involves using a disposable applicator to insert a tiny alprostadil suppository, about half the size of a grain of rice, into the tip of your penis. The suppository, placed about two inches into your urethra, is absorbed by erectile tissue in your penis, increasing the blood flow that causes an erection. Although needles aren't involved, you may still find this method painful or uncomfortable. Side effects may include pain, minor bleeding in the urethra, dizziness and formation of fibrous tissue.

Hormone replacement therapy
For the small number of men who have testosterone deficiency, testosterone replacement therapy may be an option.

Penis pumps
This treatment involves the use of a hollow tube with a hand-powered or battery-powered pump. The tube is placed over the penis, and then the pump is used to suck out the air. This creates a vacuum that pulls blood into the penis. Once you achieve an adequate erection, you slip a tension ring around the base of your penis to maintain the erection. You then remove the vacuum device. The erection typically lasts long enough for a couple to have sex. You remove the tension ring after intercourse.

Vascular surgery
This treatment is usually reserved for men whose blood flow has been blocked by an injury to the penis or pelvic area. Surgery may also be used to correct erectile dysfunction caused by vascular blockages. The goal of this treatment is to correct a blockage of blood flow to the penis so that erections can occur naturally. But the long-term success of this surgery is unclear.

Penile implants
This treatment involves surgically placing a device into the two sides of the penis, allowing erection to occur as often and for as long as desired. The inflatable device allows you to control when and how long you have an erection, the semirigid rods keep the penis in a rigid state all the time. These implants consist of either an inflatable device or semirigid rods made from silicone or polyurethane. This treatment is often expensive and is usually not recommended until other methods have been considered or tried first. As with any surgery, there is a small risk of complications such as infection.

Psychological counseling and sex therapy
If stress, anxiety or depression is the cause of your erectile dysfunction, your doctor may suggest that you, or you and your partner, visit a psychologist or counselor with experience in treating sexual problems (sex therapist). Even if it is caused by something physical, erectile dysfunction can create stress and relationship tension. Counseling can help, especially when your partner participates.

http://www.mayoclinic.com