Hossein Sadeghi-Nejad, MD,
associate professor of urology, New Jersey Medical School;
director, Center for Male Reproductive Medicine, Hackensack University Medical Center; and
chief of urological surgery, VA New Jersey Health Care System
What Millions of Men Fear
by Eve Jacobs
Although male sexual dysfunction came out of the closet almost a decade ago, the subject often still lands with a dull thud in "polite" conversation. The original spokesman for Viagra - former senator and presidential candidate Bob Dole - was 70 years old when he appeared before millions of television viewers to praise the virtues of the newly approved drug. But more recently, the rules of the game have undergone a metamorphosis, and younger, more robust men are touting its benefits, including athletes like 47-year-old NASCAR driver Mark Martin and 42-year-old Texas Ranger baseball player Rafael Palmeiro.
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n late 2003, two additional erectile dysfunction (ED) medicines — Levitra and Cialis — arrived on the scene, and the statistics support a steadily growing demand. In 2005, the worldwide market for drugs to treat sexual disorders was estimated at $3.8 billion and it is expected to increase to $6.6 billion by 2012. More than 32 million men in the U.S. are thought to have some degree of ED, although only one in 10 has so far pursued treatment.
Prior to Viagra, men generally assumed ED was an inevitable consequence of aging. Now they don’t, says male sexual dysfunction and male infertility specialist Hossein Sadeghi-Nejad, MD. The drug’s arrival on the scene is said to have inspired a “sexual revolution,” second only to the emergence of the birth control pill in 1960.
In fact, aging is the primary risk factor for ED. Studies indicate that 40 percent of men have some degree of ED at age 40, and almost 70 percent of men at age 70. While five percent of men report severe ED at 40 years old, that rises to 15 percent at age 70. Mild is defined as having a successful erection seven to eight out of 10 attempts, moderate means successful erection four to six times out of 10 tries, and severe is defined as zero to three successes out of 10 tries.
Men now seek medical help for this condition because there are oral medicines that are effective and safe, says Sadeghi-Nejad. As the advertising industry bombards us with the advent of each new medication, more men become comfortable with the idea of asking for ED drugs. But the physician points out that the condition is caused by many factors, including certain diseases as well as prescribed and over-the-counter medications, and treating it is often not as simple as popping the “little blue pill.”
ED can begin when a man is in his 40s and experiencing vascular (blood flow) problems —sometimes caused by diabetes, hypertension or smoking. According to the physician, it can be the first sign of more generalized vascular disease. “Collaborating with our cardiology colleagues, we’ve picked up a few cases of impending cardiac problems that first presented with ED secondary to poor blood flow,” he says. Nerve damage (from spinal cord injury, stroke or MS), low testosterone levels, surgery to remove a malignant prostate gland, radiation treatment for prostate cancer, and emotional and psychological conditions such as depression, stress and anxiety can all be the underlying problem.
A long list of medications can have ED as a side effect—for some men some of the time. These include diuretics and anti-hypertensives, anti-depressants and anti-anxiety drugs, antihistamines, non-steroidal anti-inflammatories, antiarrhythmics, muscle relaxants, prostate cancer drugs, and other chemotherapy. Substitutions can be made that will often solve the problem. Also, drinking alcohol and smoking tobacco are possible causes.
The doctor says ED is not solely a concern of those 40 and over — he also treats men in their 20s and 30s. For those with stress-related or psychogenic problems, he works with a therapist. Others may have penile blood-flow problems following a fractured pelvis from an auto or motorcycle accident, which can be surgically repaired in some cases. “The bones can shatter, affecting the main arterial blood supply,” he explains.
The specialist’s message to any man worried about ED is that “everyone can be treated, one way or another. We go through steps, starting with the least invasive method, such as adjusting existing medications or prescribing Viagra, Levitra or Cialis, all PDE5 inhibitors that relax smooth muscle and increase blood flow to the penis. They work for most cases of mild to moderate ED, and even some severe cases,” he says.
What is the difference between these drugs? “There really isn’t much,” the physician states. Because of its longer duration of action (up to 36 hours), Cialis may offer more spontaneity to some patients, but many will choose either Viagra or Levitra. He explains that it’s difficult to predict which patient will respond best to which drug. “One can be successful, and not another. Some people respond to all three, and then it can be a matter of preference due to food interactions, duration or onset of action, and less adverse events for a particular drug in an individual,” he says.
The typical starting dose for Levitra and Cialis is 10 milligrams, compared with the usual starting dose of 50 milligrams for Viagra, but these cannot be compared because they are different compounds. The onset of action for Levitra and Viagra may be somewhat faster—60 minutes—for most men as compared with two hours for Cialis, but this is rarely a factor in choosing an appropriate medication for the patient.
“But for all three, the side effects tend to be pretty minor and occur in a small percentage of patients,” he says. “We weigh all health factors before writing a prescription. None of these medications should be taken by someone on nitrates, since they can cause a sudden drop in blood pressure.” He stresses the importance of an open dialogue between the physician and the patient to remove the taboo element and help patients understand that ED, like many other illnesses, is often a physiological problem with neurologic or vascular causes that can be treated effectively.
When the drugs don’t work, “we have more involved therapies, ranging from injections to surgical repair of blood leakages in very rare cases, to implantation of a penile prosthesis,” explains Sadeghi-Nejad. The newest prostheses are safe, reliable, completely internalized, and implanted through a small surgical incision, according to the doctor, who also says that patients tend to be very happy with them and report satisfaction rates in excess of 90 percent. The fluid-filled implants are more cosmetically appealing to some men and work by transferring a saline solution stored in an internal reservoir into the penis and then reversing the transfer—both accomplished by pressing on a particular spot on the small pump that is placed inside the body. The simpler non-inflatable implants are even easier to operate.
The urologist — himself a “young boomer”— speaks to men of all ages when he says no one should suffer ED in silence. This specialty has “boomed” in the last decade, and the solutions are there for those who seek them. Sadeghi-Nejad can humbly say that most patients leave his office far happier than when they arrived.