Way back in the 1990's, a new drug being tested in England was an utter failure at treating high blood pressure and angina. It did, however, have quite an unusual side effect - it caused male erections. That drug is now known as Viagra, and the rest, as they say, is history.Today, Viagra, Levitra, and Cialis are the only drugs approved by the FDA for Erectile Dysfunction (E.D.), a condition that affects as many as 30 million men in the United States. These drugs work by increasing the flow of blood into the penis so that, upon arousal, an erection is more likely to occur. They belong to a class of drugs called PDE5 (phosphodiesterase 5) inhibitors. They work by dilating the smooth muscles in the blood vessels that provide blood flow to the male genitalia. For the most part, those helped by the PDE5 drugs are older and have a clear cause for erectile dysfunction that is not reversible. The immediate cause is inadequate rigidity of the corpora cavernosa, a chamber in the core of the male penis. This in turn can be the result of a lack of nerve signals initiating blood flow, impairment of the arteries filling the penis, ineffective closure of veins required for appropriate storage of blood within the erect penis, hormonal deficiencies, or psychological factors. Often the cause of E.D. involves both physical and the psychological factors. Issues related to E.D. also include loss of sexual desire, premature ejaculation, or inability to reach orgasm. Many common diseases and conditions are associated with atherosclerosis and thus poor blood flow (note that one of the early indicators of heart disease is E.D.), including high blood pressure, high cholesterol, diabetes, vascular disease, cigarette smoking, depression, and aging. For a younger healthy man where there is no obvious cause of E.D., a full work-up should be undertaken to find a potentially treatable cause before beginning any of the PDE5 medications. In young men, sexual dysfunction is often caused by emotional problems, particularly if there are relationship issues. Drugs and alcohol interfere with sexual performance, and stress, anxiety and fatigue may also play a role. While E.D. is certainly not a fatal condition, it does result in a withdrawal from sexual intimacy and a reduced quality of life, and even decreased work productivity and increased health care utilization. These three drugs are now considered first-line treatment for the medical treatment of erectile dysfunction. So, which one may be right for you? Viagra is the first and most famous of the PDE5 drugs. Because food decreases its absorption, it should be taken on an empty stomach, at least 30 minutes after dining. Cialis seems to be the clear choice for spontaneity, since it lasts for 36 to 100 hours and taking two to three pills per week is now an acceptable treatment. For patients with difficult to treat erectile dysfunction, Levitra may be the best choice as it has the highest potency. It can last up to 24 hours, and onset is very rapid. `Viagra, however, remains the "gold standard" of PDE5 drugs. It has the longest safety record, though they all appear quite safe. I tend to let my patients try all three, and choose the one that works best and is right for their needs. Side effects from Cialis, Levitra and Viagra are unusual. They do include headaches, recent reports of sudden hearing loss (which is still under investigation), facial flushing, upset stomach, and unusual visual disturbances including bright vision or a blue-green halo. Which men should NOT be taking any of these medications? Anyone who has exhibited an allergy to any one of these three drugs should avoid all of them; Those with any surgery pending, including dental surgery; Those taking any nitroglycerin products, either in the short-acting or long-acting form, or any "alpha blockers" for prostate problems. The combination of these with Viagra, Levitra, or Cialis could lead to dangerously low blood pressure; Anyone who has suffered a heart attack, a stroke or a life threatening heart rhythm problem in the past six months. Discuss these medications with your doctor. Incidentally…a Viagra-type drug is coming soon for women…stay tuned. Good health to you all!

Dr. Alan Frischer is former chief of staff and current chief of medicine at Downey Regional Medical Center. Write to him in care of this newspaper at 8301 E. Florence Ave., Suite 100, Downey, CA 90240.

********** Published: April 10, 2009 - Volume 7 - Issue 51