Oral ED Meds: “Youth Serum”

Andrew Siegel MD    9/19/2020

September is PROSTATE CANCER awareness month. Nearly 200,000 American men will be diagnosed in 2020. 1 in 9 men over the course of their lifetimes will be diagnosed. The disease prevalence is highest in African-American men: 1 in 6 men. Prostate cancer causes NO symptoms in its earliest stages so please consider seeing your physician once yearly for a prostate exam and PSA blood test, the means of early detection. When diagnosed early, prostate cancer is eminently treatable.

ERECTILE DYSFUNCTION MEDS

In 1998, Pfizer released Viagra, revolutionizing the treatment of male erectile issues, allowing for a simple and discreet solution to “erectile insecurity” for many men. In a moment of pure serendipity, Pfizer scientists’ experimental medicine that had failed to control high blood pressure and chest pain, curiously and dramatically improved erections of participants. At the termination of the study, the participants were profoundly distressed that this magic potion was no longer available.  The rest is history!

4 HOUR ERECTIONS: FACT OR FANTASY? 

Let’s get one thing straight once and for all– The oral ED meds have been available in the USA for more than 20 years and I have NEVER encountered any patient with a prolonged erection due to these pills.  “4-hour erection” is nothing short of brilliantly clever advertising hype!  Prolonged erections can and do occur, but for other reasons.  Documented cases of prolonged erections from oral ED meds are extremely few and far between with a total of 400 or so cases reported to the FDA since 1998 out of a denominator of tens of millions of men benefiting from the use of these pills. 

THE CHEMISTRY OF ERECTIONS & FLACCIDITY

Skip this section if not interested in the science underlying erections.

Erections

1. In an erotic situation, cavernous nerves release nitric oxide (NO) –>
2. NO causes release of cyclic guanosine monophosphate (cGMP) –>
3. cGMP relaxes penile arterial and erectile chamber smooth muscle –>
4. Smooth muscle relaxation causes blood to flood erectile chambers–>
5. Venous outflow pinched off and further rigidity induced by pelvic floor muscle engagement –> rigid erection
6. The rest is your business!

Flaccidity

1. After ejaculation, the enzyme phosphodiesterase5 (PDE5) is released –>
2. PDE5 decreases levels of cGMP –>
3. Low levels of cGMP cause penile arterial and erectile chamber smooth muscle constriction->
4. Constriction–>flaccid penis

THE 4 MEDS AVAILABLE FOR ED

1. Viagra (Sildenafil)
2. Cialis (Tadalafil)
3. Levitra (Vardenafil)
4. Stendra (Avanafil)

HOW THEY WORK

These meds work by inhibiting PDE5, the chemical mediator of flaccidity, and are known as PDE5 inhibitors. They are taken by mouth and require anywhere from 15-60 minutes to start working. Because their absorption can be slowed down by a meal, they are generally best taken on an empty stomach.

UPSIDE

Obvious. Better rigidity, better durability, shortened refractory period, improved confidence, happy partner…I’ll stop at that. 

DOWNSIDE

Although effective for many, they will not work for everyone.  If there is significant penile nerve or blood vessel compromise, they will likely be ineffective.

Men who are taking any of the nitrate class of drugs (cardiac medications of the nitroglycerine family that are used for angina) should never use these meds or serious consequences may result, including a dramatic drop in blood pressure. Perhaps you remember Jack Nicholson’s situation in the movie Something’s Gotta Give.

Side effects have everything to do with increased blood flow to the sinuses of the body–sinus “congestion.”  Sinuses are present in the penis and in the face; sinus congestion in the penis causes an erection, whereas facial sinus congestion causes a stuffed nose, facial flushing, and headache, common side effects of these medications.

These drugs originally were costly to the tune of about $50/pill. Fortunately, Viagra, Levitra and Cialis are available in generic, much less costly forms.  An erection should not have to cost you an arm and a leg!  Stendra generic is not yet available in the USA.

VIAGRA

This was the first of the group, available in 1998. The name Viagra is an amalgam of the word “vigor” (physical strength) and “Niagara” (the most powerful waterfall in North America). Dosed at 25, 50 or 100 mg, the half-life (the period of time required for its concentration in the blood to be reduced by one-half) is about 4 hours. It is taken on demand with an onset of 15-60 minutes and remains active for 12 or so hours.  Viagra is not only used for ED; a 20 mg dose is effective for children with pulmonary hypertension, a condition in which the blood vessels in the lungs have abnormally high blood pressures.

The most common side effects of Viagra are headache, facial flushing, upset stomach, and nasal and sinus congestion. Less frequent side effects are temporary changes in color vision, sensitivity to light and blurry vision.

LEVITRA

This was the second ED drug to come to market, available in 2003. The name Levitra derives from “elevate”; in French “le” indicates masculinity and “vitra” suggests vitality.  It is available in 10 mg and 20 mg doses. The effectiveness and side effect profiles are similar to Viagra; however, there are no reports of visual distortions as side effects. It is taken on demand and has an onset of 15-60 minutes and a half-life of about 4 hours, remaining active for 12 or so hours.

Levitra is also formulated in a minty, dissolves-in-your-mouth 10 mg formulation called Staxyn.  Staxyn dissolves on the tongue and is absorbed directly through the oral mucosa, so slower absorption because of taking the medication at the time of a meal is not an issue.

CIALIS

FDA approved in 2003, it is available in 2.5, 5, 10 and 20 mg doses. The effectiveness and side effect profiles are similar to Viagra. Uniquely, Cialis has the longest duration of action that has earned it the nickname “the weekender” as it can be taken on Friday evening and remain effective for most of the weekend without the need for an additional dose. This affords a considerable advantage in terms of spontaneity. Cialis is either taken on demand (usually 10 or 20 mg, although 5 mg can be effective as well) or on a daily basis (2.5 or 5 mg) and has an onset of 15-60 minutes and remains active for 36 or so hours.

Cialis is also approved to treat children with pulmonary hypertension.   In 2012, daily Cialis (2.5 and 5 mg) was FDA approved for the management of urinary symptoms due to benign prostate enlargement.

Cialis can occasionally cause backaches and other muscle aches. Cialis is not affected by eating fatty meals, which can slow the absorption of the alternative ED meds (with the exception of Staxyn).

STENDRA

FDA approved in 2012, it is available in 50, 100 and 200 mg doses. It has the advantage of a rapid onset of action. It is taken on demand and has an onset of about 15 minutes and remains active for 12 or so hours. The name Stendra probably is a derivative of the word “extends.”

TIPS TO OPTIMIZE EFFECTIVENESS OF ED MEDS

1. Take on an empty stomach or after a low-fat meal.
2. Take 45-60 minutes before anticipated sexual activity.
3. Although they result in some increase in penile fullness (tumescence) without sexual stimulation, sexual stimulation is a must in order to induce a fully rigid erection.
4. Increase to a higher dose if initial dose is ineffective, up to Viagra 100 mg, Levitra 20 mg, Cialis 20 mg, Stendra 200 mg.
5. Using daily dosing as opposed to on-demand dosing may improve effectiveness.
6. In prostate cancer patients recovering from treatment, continue to use periodically even if ineffective initially because of expected gradual recovery of erections.
7. The same ED drug at the same dose may work variably depending on the particular time and circumstances, sometimes more effectively than at other times since there are so many factors that determine erectile rigidity, so continue to trial before deeming ineffective.
8. Although each of the available meds in this class is effective in improving erection issues for most men, there are subtle differences among the four that provide potential advantages and disadvantages. Trial and error may be required to determine which drug best suits an individual’s needs.
9. If you encounter side effects, e.g., headache and nasal stuffiness, they can be counteracted using Tylenol/Aspirin and nasal spray, respectively.
10. It is highly unlikely that you will encounter a “longer than 4-hour erection” on these meds, this phrase being brilliant advertising spin!  You are far more likely to encounter prolonged erections with penile injection therapy, a topic for another day.  There are numerous other causes for priapism, the medical term for a prolonged and unwanted erection that is a urological emergency. In the super-rare chance that you do encounter a prolonged erection on these meds, contact your doctor.

IMHO

Viagra 100 mg is the most potent of the group, but will also incur the most side effects, particularly facial flushing and potentially a nasty headache. Levitra is very similar in most respects to Viagra in terms of effectiveness and side effects.  Rarely, Viagra can cause an alteration in color perception.  Cialis is overall the best of the bunch because of its long duration, the spontaneity factor, the ability to take it with a fatty meal and its dual utility of helping urination as well as erections. The downside to Cialis is occasional muscle aches and longer lasting side effects. The rapid onset of Stendra confers a small advantage.

Many men are capable of functioning satisfactorily without any of these medications but find that taking a “recreational” (low dose) enhances erectile capability and takes years off the functional age of the penis. These meds are particularly useful for men with performance anxiety (“stagefright”).

Many men who undergo nerve-sparing prostatectomy or radiation therapy will be able to have good quality erections with the use of these meds. It is common practice after prostatectomy to start daily Cialis 5 mg or alternative ED medications to accelerate the erection recovery process. More about erection recovery after prostatectomy in a future entry.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.  Today’s entry is excerpted from his latest book, Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Video on THE KEGEL FIX 

Tags: Andrew Siegel MD, Cialis, Levitra, oral erectile dysfunction medications, PDE5 inhibitors, Stendra, Viagra