The drugs used to treat erectile dysfunction may be marvellous, but there are various factors that can affect whether they're effective or otherwise.
AGE WELL BY DR PETER NG
FOR the man who suffers from erectile dysfunction (ED) and is prescribed a phosphodiesterase inhibitor (sildenafil, tadalafil and so on), what happens if the pill does not work and cannot spin its magic? What can he do?
Is it back to Tongkat Ali or Chinese herbs or is it back to the prison of a sterile sexless existence?
No is the emphatic answer to this vital question. There are lots of avenues open if the blue pill or others like it do not live up to the mark. Firstly, do not assume that the failure lies with the medication alone. Sildenafil and other drugs like it are in the class of drugs called PDE5 inhibitors. Although marvellously effective, they need to be used optimally in order to be really effective.
Many patients just pop the pill and expect a volcano to spontaneously erupt between their thighs, but the fact is, just like with everything in drugs, there is a proper way of utilising any medication.
Adjust the timing and way in which the medication is taken
Timing is important and if the blood vessels feeding the penis are really narrowed by disease, they will require a high serum level of the drug. This will require attempting sex when the levels are optimal and failing if the medications are taken in less than the best conditions.
For sildenafil, the best time for the medication to be effective is an hour, and for tadalafil, it is around two hours.
The presence of food also affects the performance of sildenafil by lowering its available levels in the blood stream, so it must be taken on an empty stomach and without alcohol, but for tadalafil, this is not a factor.
The medications will have to be taken on at least eight separate occasions before it can be concluded that it is ineffective. This is because if there has been a long period of time where ED has been present, then there will be a lot of awkwardness and loss of intimacy resulting in inhibitions that will dampen excitement and the ability to attain an erection.
Once these inhibitions have passed with frequent usage, the patient will show a marked improvement in his response to medications.
The use of higher than normal doses of PDE5 medications has been shown to improve erectile function in those patients who have failed using normal doses, but the trade-off is in the side effects, which can increase to affect up to 33% of patients. Obviously this step cannot be taken unilaterally by the patient, but has to be taken under careful supervision by the doctor.
There have also been some research on the use of daily dosing of these medications, and apparently the daily dosing regimes tend to be more effective than on-demand dosing, with which these drugs have thus far been used.
More data will need to be forthcoming on this option, aside from all the issues of increased financial burden this daily dosing regime might expose the patient to.
Improve other medical conditions
It is important for medical conditions like diabetes or high blood pressure and high cholesterol, lipid levels, cardiovascular disease, depression, prostatic enlargement, smoking, drug treatment, a sedentary lifestyle, drug and alcohol misuse be treated if not under control.
Stopping cigarette smoking is also important in attempting to improve erectile function. Adding a statin to lower cholesterol has also been shown to improve erectile function and a patient's response to PDE5 inhibitors.
Up to 80% of patients can improve their erectile function once these other conditions are treated.
Switch to a different PDE5 inhibitor
There are three PDE5 inhibitors, of which the most famous is sildenafil, and if one has failed, it might be worthwhile switching to another type.
Whilst sildenafil and vardenafil are similar in the way they act, tadalafil has a much longer effective period of action. For some patients, the longer window of sexual opportunity may promote spontaneity and better sexual dynamics, which might be helpful.
However most studies looking at the comparative effectiveness of these drugs have found very little hard evidence of any significant differences.
See your doctor for psychosexual counselling
Admittedly, not all doctors are comfortable doing this, but for those who take a special interest in this field, they will be able to help patients and their partners modify negative sexual thoughts and attitudes.
Often the wife may not be ready to assume vigorous sexual activity after a prolonged period of inactivity. Discussions with the couple would identify and address these concerns.
The counselling will attempt to reduce sexual performance anxiety, especially on the part of the man, so a period of sexual therapy might be useful.
The other areas where a counsellor may help is in improving a couple's sexual skill level, the quality of their non-sexual relationship and the level of communication, which has a significant impact on sexual performance.
See your doctor to check your testosterone levels
There is increasing recognition that in older men, there is a condition called "late onset hypogonadism", where there is sub-optimal levels of the male hormone, testosterone. Most of these men will have loss of libido, difficulty attaining and maintaining an erection and a lowered intensity of orgasm. Others have difficulty concentrating at work.
Yet there are others with more vague symptoms, so they will require a blood test to see if this is an area of concern.
Sub-optimal testosterone levels will cause drugs like sildenafil to fail. Replacement therapy will be useful and this can be achieved with either injections of hormones or the use of gels.
Oral medications are an unreliable method of hormone replacement. It is important that a doctor be the one who does the assessment as well as the hormone replacement therapy as there are side-effects of hormonal therapy which must be monitored. Hormonal therapy can be given alone or in combination with medications like sildenafil.
Other modalities
There is also a whole array of other modalities which are open to these patients. These include combination therapy with other medications, injection therapies, vacuum devices and finally surgery. These will require more complex and involved management with a urologist
Conclusion
So a lack of response to PDE5 inhibitors like sildenafil is not the end of the world. There are plenty of remedial measures that one can resort to in order to restore erectile function. The solution lies in seeking help from your doctor. |
