Let’s Talk Sex: ED Treatments and Advice

In my expert opinion, treating the factors that cause and perpetuate ED is at least as important as treating the erectile symptoms. All men with ED should be medically assessed, even if the symptoms have been treated medically. Why? Well decades of medical research has confirmed that ED is often the first presentation of heart disease and occurs 3-5 years before the heart condition would otherwise be diagnosed.

Experts suggest that “a man with ED should be considered a cardiac patient until proved otherwise” and that ED is a risk factor for heart disease, increasing the risk by nearly 50%, especially in younger men.

The arteries that supply the penis are 2/3 of the diameter of the coronary arteries in the heart. Therefore the same level of cholesterol deposit will cause symptoms much earlier in the penis. This makes heart disease easier to spot, especially as a man over forty still expects the same level of performance from his penis as he had at twenty.

Treating the factors that cause and perpetuate ED is at least as important as treating the erectile symptoms. All men with ED should be medically assessed, even if the symptoms have been treated medically.

Professor Geoffrey Hackett

The takeaway?

All men with ED should have an assessment by a doctor, including blood pressure measurement and blood taken for cholesterol, diabetes check and a morning testosterone, and sometimes thyroid evaluation.

This is because it’s relatively common to pick up an underlying cause in ED patients. Undiagnosed diabetes is found in 15%, and low testosterone in 20% overall and in 10% of men under 40. In older men, prostate enlargement can cause ED and in men of all ages, depression and certain prescription drugs can lead to ED.

Without a doubt, lifestyle changes should be attempted in all men with ED.

• Smoking is an important cause of ED and continuing with smoking will undermine all interventions.
• Being overweight or obese is associated with diabetes, heart disease and low testosterone. In men with mild ED and no known heart disease, weight loss has been shown to improve ED after 2 years, meaning that lifestyle change alone will usually need to be combined with medication. In men with known diabetes and heart disease, weight loss alone resulted in minimal improvement, meaning that medication will almost always be required.
• Reducing alcohol consumption to safe levels of 14 units per week or less has been shown to improve ED.
• Moderate exercise for 20-30 minutes, five or more times per week will help reduce ED as well as reducing the risk of heart disease and improving the response to medication.
• Recreational drugs such as cannabis and opiates should be avoided as these may affect erection, desire and orgasm, usually through alterations of testosterone levels.
• Reducing levels of (or ideally avoiding) pornography has been shown to improve erections, orgasm and sexual function in previous high-level users.
• Dietary Supplements can be effective in mild cases or can be used to enhance the effect of other medications in severe cases. L-Arginine is an enhancer of the natural erection process but a dose of 2-3 grams is required. Folic Acid 5mg daily has been shown to enhance the effect of oral medications, especially in diabetes. Yohimbine, a natural plant extract, has been used for over fifty years to enhance erections. Saw Palmetto can improve ED and urinary symptoms. Many commercial preparations are available that combine some of these supplements.
• Vitamin E has been shown to be beneficial for fertility both with and without ED medication.

Dietary Supplements can be effective in mild cases or can be used to enhance the effect of other medications in severe cases. L-Arginine is an enhancer of the natural erection process but a dose of 2-3 grams is required. Folic Acid 5mg daily has been shown to enhance the effect of oral medications, especially in diabetes.

Professor Geoffrey Hackett

The licence of Sildenafil (the active ingredient in Viagra), the first in a class of drugs known as PDE5 inhibitors in 1998, changed the management of ED forever. Viagra was developed to treat heart disease but the men in the clinical trials refused to return their unused medication because of the frequent erections experienced! The developers won the Nobel prize for medicine.

Sildenafil acts by opening up the blood vessels, especially in the penis, resulting in increased flow and erection. It is recommended to be taken around 1 hour before anticipated sex. In older men or when accompanied by a heavy meal, better results are obtained after 2-3 hours.

Sildenafil, at doses of 25-100mg can work for 8-10 hours meaning that an element of planning is required, which some couples find less acceptable. It is vital that the man has direct physical stimulation for the drug to be effective and this is the most common reason for failure. Side effects are usually short lived and include headache, flushing, indigestion and transient blue vision in less than 10% of patients.

Sildenafil has been shown to be effective in around 85% of men.

Vardenafil (Levitra) at 10-20mg has a similar duration of action, is almost as effective with a similar side effect profile.

Tadalafil (Cialis) is a long-acting PDE5 inhibitor which is effective within 1 hour but remains active for up to 36 hours, potentially allowing for greater spontaneity. Tadalafil at 10-20mg has lower rates of headache and flushing but more indigestion and persistent back pain in around 5% of men. At a lower dose of 5mg, Tadalafil can be effective when “on-demand” dosing has failed and is also licenced to treat urinary symptoms.

Avanafil (Spedra) is the newest of the PDE5 inhibitors and is currently more expensive as it is still under patent. The major benefits are potentially the fastest onset of action and the lowest rate of side effects.

How safe are these medications?

PDE5 inhibitors have an incredible safety record and initial concerns about safety have largely been dispelled. As sex involves physical activity equivalent to walking a mile in 20 minutes and climbing a flight of stairs, it should not be surprising that men with severe heart disease run into difficulties attempting inappropriate effort. In fact, recent research suggests that these drugs are good for the heart, which should not be surprising as they increase blood flow to important organs and were developed to treat heart disease.

Sildenafil (the active ingredient in Viagra) is effective in around 85% of men.

How can I get the best results with ED medications?

• Take medication on an empty stomach with no alcohol and do not attempt intercourse for at least 1 hour with Sildenafil and Vardenafil or 2-3 hours with Tadalafil.

• Maximise direct genital stimulation before having sex.

• For men in new relationships, try it first with self-stimulation to build confidence before attempting sex with a new partner.

• Be patient, as it may take up to 7 attempts to be effective. But in the vast majority of cases it works much quicker than that.

• Attempt sex in the morning, as this is when testosterone levels are normally highest.

• Consider taking medication on a more frequent basis, even daily for 1-2 weeks.

• If still unsuccessful, then arrange to see a health care professional for morning testosterone to be checked, as correcting testosterone levels – through supplements – may be successful if sildenafil is reintroduced after 2-4 weeks.

Remember: medication will not solve relationship problems. Significant relationship conflicts need to be discussed with a partner and addressed, if necessary, by seeking the help of a sex therapist. If in doubt, chat with your GP to ascertain if the cause of your ED is physical, psychological or a combination of the two.

PDE5 inhibitors have an incredible safety record and initial concerns about safety have largely been dispelled. In fact, recent research suggests that these drugs are good for the heart, which should not be surprising as they increase blood flow to important organs and were developed to treat heart disease.

Professor Geoffrey Hackett