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Thank heavens for “the little blue pill.” Not only did the introduction of Viagra mean men finally had a safe and tolerable option for erectile dysfunction (ED), but it also got people talking about a condition that we were previously too embarrassed to discuss. I’m pleased when men ask me about ED. It’s an opportunity to review safer sex and can actually be a good barometer for overall health.

Getting an erection is a surprisingly complex event requiring the interplay between neurologic, hormonal, vascular and psychologic systems of the body. If something is out of balance—let’s say too much alcohol use—then perhaps ED will be the red flag that clues us in to a problem.

One of the biggest risk factors for ED is age. About 40 percent of men will have experienced significant sexual dysfunction by age 40. Yet I regularly see men in their 20s with concerns about the quality of their erections. In young men, ED is often psychologic in nature—performance anxiety, if you will. These guys typically have normal erections on their own or during REM sleep, and things often improve once they’re in a trusting relationship.

That said, ED can be triggered at any age by lifestyle factors such as obesity, smoking and insufficient exercise.

(Believe it or not, a third of obese men at any age will notice an improvement in erectile function simply by increasing activity and losing some weight.)

Medical problems like diabetes, high blood pressure and high cholesterol can cause hardening of arteries serving the penis and interfere with sexual function. It’s the same process that damages blood vessels around the heart causing heart disease. Sometimes ED can be the first sign of blood-vessel damage and an increased risk of having a heart attack. ED can also signal testosterone or other hormone imbalances.  Your doctor may want to evaluate your risk of heart disease as well as hormone levels if there are symptoms suggesting that there is a deficiency.

Regardless of the underlying reason for ED, medications called PDE5 inhibitors are often the first step for treatment.

These medications work by encouraging penile blood vessels to open—improving blood flow.  PDE5 inhibitors like Viagra and Levitra need to be taken on an empty stomach about one hour before sex, and last for four hours. Cialis has a daily formulation and a larger “as needed” pill that lasts for 36 hours.  Some guys prefer the flexibility that the longer duration of action offers, though this means that side effects might linger as well.

Typical side effects from any of these medications include flushing, headaches and heart­burn. Viagra sometimes causes a blue haze to the vision. You have to be very careful not to take poppers or nitroglycerine for chest pain while using PDE5 inhibitors—these can cause a dangerous drop in blood pressure.

Perhaps the greatest limiting factor for these medications is their cost.  Most private plans don’t cover them, and they are extremely expensive.  While it’s pretty easy to order cheap Viagra online, I don’t recommend it, as the amount of active medication can be unreliable.

For men in whom PDE5 inhibitors aren’t effective, the next steps are vacuum devices and penile injections. Vacuum devices are a bit cumbersome to use, but some find them perfectly acceptable. With penile injections, a prescription solution like alprostadil is self-injected into one side of the penis with a tiny needle. It’s very important to get proper training on how to do this safely. This method of ED treatment sounds dramatic but is actually quite safe, effective and painless. I’m seeing more and more men who prefer this method over tablets, because the dose can be individualized and we don’t often see systemic side effects.    Typically, after a proper evaluation, ED can be treated well with one of the above measures. It’s surprising how a short period of consistently good erectile function can increase one’s confidence and help rebuild a satisfying sex life.

But instead of borrowing ED meds from your friends, make sure that you get checked by your doctor to rule out any heart disease or an easily treated medical condition.


Dr. Malcolm Hedgcock is a Toronto-trained family doctor living and working in Vancouver. He has a special interest in gay men’s health issues, including the primary care of those living with HIV and AIDS.