A consumer guide to understanding and treating erectile dysfunction
A consumer guide to understanding and treating erectile dysfunction Contents
3 Authors 3 Introduction 4 ED: What is it? 4 Oral medications: Cialis, Levitra, Viagra 6 Injections: Caverject 6 Other options: Rings and vacuums 7 Surgery 7 Counselling and relationships 7 Important things to consider 8 Things to consider if your treatment isn’t working 8 References
Disclosure Costs associated with the development of this resource have been funded by Eli Lilly Australia. Eli Lilly Australia did not have any involvement in the development of the content in this resource, however the company has reviewed the document to ensure it complies with the guidelines for communicating health information to consumers, outlined in the Medicines Australia Code of Conduct, and required by law under the Therapeutic Goods Act.
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Authors
Introduction
The content of this document has been developed by the following experts using available medical evidence, and should be used as a guide only. Treatment advice specific to your situation should be sought from your doctor. A thorough medical assessment should be conducted before any treatment is commenced.
In recent years, erectile dysfunction (ED) has been increasingly discussed, encouraging men and their partners to seek advice about the condition. Because ED can be an indicator of other health problems, it’s important to seek treatment as soon as possible. It’s also important to remember when seeking treatment for ED that there is a lot of information out there - not all of it correct - from a variety of sources, and that your best source of information is a healthcare professional such as a doctor, pharmacist or sexual health counsellor.
Professor Doug Lording Endocrinologist/Andrologist Cabrini Health, Victoria Dr Michael Lowy Sexual Health Physician Sydney Men’s Health New South Wales Dr Andrew Pattison General Practitioner Victoria
This resource has been developed to provide up-to-date, factual information on the main, proven treatments that are approved by the Australian health regulatory authorities. All products covered in this guide (except for the external devices) are available on prescription from a doctor. The guide has been developed by a team of doctors with expertise in treating a range of ED patients. It has also been reviewed by a number of men who have ED, to provide important information in easily understood terms. IMPORTANT: This resource is intended as a guide only. Advice on your specific situation should be sought from a medical doctor.
The content of this resource has been reviewed and approved by Impotence Australia (IA), an independent not-for-profit consumer organisation, which provides counselling and information on ED (impotence) and sexual health. IA supports the development of this type of resource to achieve ongoing improvements in treatment and care for men and their partners.
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ED: What is it? Erectile dysfunction (ED) is the inability to achieve or maintain an erection of sufficient quality for sexual activity. Several studies have estimated that about 40% of males aged 40 years have some degree of ED, increasing to 70% of men aged 70 years (1). While ageing is the most common cause, ED can be associated with a number of health problems such as high blood pressure, diabetes and cardiovascular disease. It is believed that around 80 per cent of ED has a physical cause (2). It’s a good idea to get a medical check up if you are experiencing problems, as it can be an indicator of other health conditions. Couples can then choose whether or not to pursue treatment. Don’t be embarrassed to talk to a doctor about ED – they can help you. It is recognised that having a satisfying sexual experience has positive health benefits – it’s good for your health and good for your relationship. Follow-up appointments with your doctor are very important to answer your questions and to check that any treatment is working as intended. For more information on ED visit: www.impotenceaustralia.com.au www.andrologyaustralia.org
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Tablets for ED: Cialis®, Levitra®, Viagra® Doctors will often start your treatment with tablets (oral medications): °
There are three tablets approved for use in Australia: Cialis (see-ah-liss), Levitra (le-veetrah) and Viagra (vy-ag-rah). These treatments are generally well tolerated, and work in the majority of men with mild to moderate ED. Remember that you should always talk to a doctor before commencing medical treatment to assess your individual suitability for taking these tablets or other treatments
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IMPORTANT: These medicines should not be used by patients also taking medicines known as “nitrates”, which are used for the treatment of angina (“chest pain”) or other heart conditions. A sudden and serious drop in blood pressure can occur in this situation
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You should obtain these tablets on prescription from your doctor and purchase through your pharmacist for personal use only
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The tablets work by enhancing the normal sexual response, allowing greater blood flow to the penis
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A common misconception is that men will have a permanent erection while the medication is working – this is not the case. They require sexual stimulation to work
How do I use the tablets? °
Many men may need to use oral treatments several times before feeling confident and gaining maximum benefit from them
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Some men will stop taking tablets after only one or two doses, thinking that it just doesn’t work for them. You may have more success if you keep trying, and talk through any problems with your doctor
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Studies have shown that between 40-55% of men who have tried tablets unsuccessfully in the past subsequently found them effective when taken again at the correct dose and for the recommended number of attempts (3,4)
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These days doctors don’t consider these medications to be ineffective until you have tried them at least six to eight times at the right strength of the medication (4), and have also tried at least one other medication from the same group
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There may be slight differences between tablets – your doctor will discuss these with you. You may also need to discuss taking these tablets with food and alcohol
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Clinical studies show that, typically, Levitra (5) and Viagra (6) last between 4 to 6 hours, while Cialis can work for up to 36 hours (7). That is, these are the time frames during which an erection can be achieved with sexual stimulation. This time frame can vary from man to man. The tablets usually begin to work 20 to 30 minutes after taking them (8)
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It is important to follow the manufacturers’ guidelines when using these medicines
How much do they cost? This can vary slightly between pharmacies. For a prescription of four tablets, the cost is generally between $65 and $80. In most cases, the Government does not reimburse you for ED medications. Some private health insurance funds may cover some of the cost of prescription medications. Holders of Repatriation Health Cards may also be reimbursed. Are there any side effects?* Common side effects you may experience are: °
Headaches
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Facial flushing
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Blocked nose
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Indigestion
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Muscular pain
For most men, side effects are rarely troublesome enough to stop treatment. There may be a misconception that there is an increased risk of heart attack with these medications. There is no evidence to support this claim, provided your doctor conducts a thorough medical examination before prescribing medication to make sure the oral treatments are appropriate in your specific case. For further information on other, less common side effects, you can refer to consumer medical information provided by the manufacturer of each medication. * You may have seen some recent media stories linking damage to the optic nerve (a condition called NAION) with oral ED medications. NAION is extremely rare and has only been seen to occur in men with multiple risk factors including being over 50 years old, having high blood pressure or diabetes, or an anatomical variance in the eye. There is no direct proven link to any of the three ED medications. Your doctor should assess these risk factors in you before prescribing a PDE5 inhibitor. 5
Injections: Caverject Impulse® If you have not found oral medications effective, don’t give up hope. There are several other effective treatment options that you can discuss with your doctor. °
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Men with ED at the more severe end of the spectrum tend to find injections into the penis a more effective treatment than the tablets. Injections have been used in Australia since the mid-90s. The most widely used injection is called Caverject (other mixtures are available and may be recommended by your doctor) Injections are only available on prescription and are usually recommended when the tablets haven’t worked or you aren’t able to use them for medical reasons The injections work by directly opening up the penile blood vessels. It may take between 5 and 10 attempts to master the technique
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After injecting, the drug will usually work within 5 to 10 minutes (with or without sexual stimulation) and ideally will last 30 minutes (9)
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You should discuss any treatment involving injections in detail with your doctor. A followup appointment is important to ensure you are correctly using the injection
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It is recommended to start injections at a lower dose, then work your way up to minimise the chance of a prolonged erection (called priapism), which can cause permanent damage. By working with your doctor, this risk can be minimised
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Some men will experience pain in the penis and sometimes scarring may occur
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A pack of two injections costs between $30 to $40
External devices (rings and vacuums) °
There are two external devices your doctor may suggest – penile rings and vacuum pumps
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Penile rings are made of rubber and tend to be used when a man can get an erection initially but can’t sustain it
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Rings are placed around the base of the penis to make it rigid enough for intercourse
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It is recommended that its use is limited to 30 minutes. The ring must be removed when this time has elapsed or there is a risk of permanent damage to the penis (i.e. it’s important not to go to sleep with it on)
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A vacuum device, consisting of a cylinder that extracts air, is also used when a man can’t achieve or sustain an erection
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The vacuum is placed over the penis and, as air is pumped out of the cylinder, blood is drawn into the penis making it enlarge. A ring is then placed around the base of the penis to maintain the erection
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Your doctor will recommend where to purchase these devices
Surgery °
Surgery requires a referral to a urologist, who will assess whether your erection problem is suitable for surgery and discuss details of the operation
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Penile implants are suitable for a small number of men. Some types require pressure to be applied to a small reservoir at the base of the scrotum. This pumps fluid into the implant tubes and makes them go firm to create an erection
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A surgical implant would only be likely to be considered when all other treatments have failed or are unsatisfactory for you
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Severe curvature of the penis (called Peyronie’s Disease) may interfere with intercourse and this condition can also be surgically corrected
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Rarely, there may be surgery on the blood vessels in the penis. This is called vascular surgery and is not performed very often for ED. It is a highly specialised procedure and is often not successful
Counselling and relationships
There is, of course, more to a sexual relationship than the ability to get and maintain an erection. ED does not always require treatment, and some men choose not to be treated. However, as ED may be a sign of an underlying health condition, it’s important to see your doctor for a thorough check up.
Important things to consider You may have heard of other products for treating ED, but these may not have been approved by the Commonwealth Department of Health’s medicines agency, the Therapeutic Goods Administration (TGA). If you are in doubt about a treatment, discuss it with your healthcare professional or phone Impotence Australia on 1800 800 614. It is very important that a qualified doctor is involved with your diagnosis and treatment, because they will be able to undertake a full medical assessment and explore health factors that may contribute to ED. They will also carefully prescribe appropriate and safe medications that will not interact or impact on other medication or treatments being used.
While ED usually has a physical cause, it often has emotional impacts. Talk to your doctor and your partner if you need support and advice. Sometimes ED is the direct result of an emotional situation without a physical cause. You might find it useful to talk to a sexual health or relationship counsellor, or contact Impotence Australia on 1800 800 614. Useful websites www.impotenceaustralia.com.au www.relationships.com.au www.relationshiphelponline.com.au
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Additional things to consider if your treatment isn’t working °
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Have you had a follow-up appointment?
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Do you have the correct information about your treatment?
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Is your partner involved in the discussions?
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Is there some stress issue you need to address?
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Do you feel you need counselling?
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You may need to have your testosterone level checked particularly if your interest in sex is low – ask your doctor Have you taken the correct dose of your medication an adequate number of times?
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Did you wait long enough after taking the tablet before attempting sex?
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Did you obtain your treatment with a prescription from a legitimate source that provided adequate medical supervision?
Feldman HA, et al. ‘Impotence and its medical and psychosocial correlates: Results of the Massachusetts
Have you had a full medical assessment by your doctor?
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References
male aging study’, Journal of Urology 1994, vol 151; pp. 54-61 2
Lue TF. ‘Erectile dysfunction’, N Engl J Med 2000, vol 342; pp. 1802-13
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Sklar GN et al. ‘Salvage of sildenafil failures referred from primary care physicians’, Journal of Urology 2003, vol 170; pp. 2356-2358
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McCullough A., Barada J. et al. ‘Achieving treatment optimization with sildenafil citrate (Viagra) in patients with erectile dysfunction’, Urology Aug 2002, vol. 60; Supplement 2B, pp. 28-38
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Levitra Product Information
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Viagra Product Information
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Cialis Product Information
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Levitra, Viagra Product Information; Brock, GB et al. ‘Efficacy and safety of tadalafil for the treatment of erectile dysfunction: Results of integrated analyses’, Journal of Urology 2002, vol 168; no. 4; pp. 1332-1336
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Heaton JPW et al. ‘Intracavernosal alprostadil is effective for the treatment of erectile dysfunction in diabetic men’, International Journal of Impotence Research 2002, vol 13; pp. 317-321
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