Try It, You’ll Like It?

Paul Turek, MD — Mon, 07 May 2012 15:00:09 +0000

The pill that started it all in 1998.

As if it’s not top of mind anyway, here’s an update on the state of erection pills. Another one was just approved by the FDA and will hit the streets soon. Its name: Stendra (avanfil). Who names these drugs anyway?

The PDE5i Drugs

This new pill works similarly to the holy triumvirate of Viagra, Levitra and Cialis; it is a full-fledged member of the phosphodiesterase inhibitor (PDE5i) family. In essence, they are like taking coffee for the penis. Stendra is the first such pill to be approved in the last decade and it will certainly be interesting to see how it fares in this field of household giants.

What These Pills Do for You

You may be curious to try one of these pills, even if you don’t need it. You may even have thought to open that email spam folder that says “Bigger, Better, Badder” for quite some time. What can expect when you take these pills? Well, it depends on why you are taking it.

Goal: Trying it for Kicks

All pharmaceutical grade, FDA-approved pills share benefit and risk. The same is true for the PDE5i’s. If you don’t really need any help with your erection, this is termed “recreational use.” In fact, this is more common than you might think. It is estimated that 1 in 5 men ages 18-30 years have tried one of these erection pills for fun. But we know even more. Men claim that the pills prevent sexual failure and improve sexual performance and stamina. And, these pills tend to be used with other recreational drugs and alcohol that can decrease erections. More concerning however, is the well-defined association between illicit drugs, PDE5is and an increase in unsafe sexual behavior and increased HIV transmission.

In the simplest scenario, when they are taken in isolation by healthy young men, there may be a shorter latency period (“down time”) between ejaculation and the next erection. Others observe that the time to ejaculation can be extended.

But, for the most part, a normal erection is a normal erection and these pills would not be expected to offer much benefit to men who don’t really need them. In such cases, the common side effects of these medications such as headaches, facial flushing, nasal stuffiness, upset stomach may be more evident.

Goal: Trying it for Special Situations

Some men need a little help with erections. They may have normal erections at times but at other times, it’s not quite up to speed. This is termed situational erectile dysfunction. Whether it’s early in the relationship, associated with condom use or because of scheduled sex needed to conceive, the associated stress can be a killjoy. For these men, the PDE5is can be man’s best friend since 90-95% of men will recover normal, on-demand erections. Again, if the PDE5is are not really “needed” the side effect profile of these agents can be bothersome and limit their use.

Goal: Trying it Because You Need it

It is for men with true erectile dysfunction that these pills are intended. For those unable to achieve or maintain an erection, these pills are a holy grail. In fact, from 60-85% of men with erectile dysfunction will respond to the PDE5is as first line therapy, a great achievement for any pill. Unfortunately, men in this category may also have associated medical conditions such as diabetes, cholesterol imbalance or heart disease that make medical supervision of patients mandatory. In addition, other medications, including statins (cholesterol lowering) drugs, diltiazem, Zoloft and protease inhibitors to name a few, can interact with PDE5is and affect drug metabolism and produce, at times, life-threatening side effects. Clearly, doctors need to be involved in determining whether or not a patient should consider PDE5is for erectile dysfunction.

The reason these drugs are so popular is obvious. In the words of the self-help author Wayne Dyer, men fully realize that “miracles come in moments. Be ready and willing.”

Getting There Early or On Time: Which is Better?

Paul Turek, MD — Mon, 25 Jan 2010 00:05:32 +0000

Is faster better? Not always.

What is the most common sexual health problem affecting men? That’s easy, it’s erectile dysfunction, right? Nope. Try premature ejaculation. Hands down more common than erection issues, affecting 25-40% of men in the U.S.

Variably called early ejaculation, or early or rapid climax, it is defined as male ejaculation earlier than the subject or his partner desires. It used to be defined as ejaculation within 2 minutes of sexual intercourse, until it was realized that 75% of men ejaculate within 2 minutes in over half of their sexual encounters. What the definition really implies is that is some element of poor control over ejaculation that is stressful and may result in interpersonal difficulty.

Is this a medical disorder? In some cases, yes. Think of ejaculation as a reflex, like sneezing. There is a point of no return and this is what comes too soon in men with early ejaculation. The problem has two forms: lifelong and recent. The former is believed to result from low levels of the neurotransmitter serotonin (5HT) that normally modulates the ejaculation reflex. The recent form does not have as clear a biological basis, but may occur from psychological stress or from the need to overcome an erection problem.

The good news is that there are treatments available, and more treatments being reviewed by the FDA. Currently, the most effective treatments are pills called SSRIs, which elevate 5-HT levels and include anti-depressants such as Prozac, Zoloft, Celexa, and Lexapro. A newer form of SSRI drug, called Priligy, is now available in nine countries but has still not been FDA approved in the states. Also, a metered-dose aerosol spray has been developed to increase time to ejaculation by numbing the skin on the penis and decreasing sensation. Maybe this will help. Unfortunately, with all drug treatments for this condition, when the drugs are stopped, the issue generally returns.

What I find interesting is that companies are vigorously trying to drum up sympathy and attention for premature ejaculation as a widespread medical disorder, when in many cases it may be only an occasional annoyance that does not need constant treatment. Treatment might be perfect for a few men with debilitating disease, but it appears that they are trying to create and market a whole new category of disease. Good idea: create a “huge unmet need,” an epidemic that is perfect for a blockbuster, quality of life drug. Well what about a pill for shyness, or talking too fast? Where does it end? The larger issue here might be the “medicalization” of our daily lives in which there is a healthy and wide variation of normal.

Do I believe that some men have debilitating early ejaculation? You bet, and I see them every day. Do I think that a pill will treat this issue? Sure, for many, but only while you take it. Will blockbuster pills be the cure-all for early ejaculation? No way. The cure will come with more holistic treatment, by empowering men through behavioral changes that teach them to control and “own” the problem. Works superbly for my patients, pill or no pill.