The hardness factor

One of the most famous drugs in recent history and the only one credited with saving millions of marriages turned 15 last week and while no parties were held to mark the occasion, sufferers of erectile dysfunction were probably silently thanking the little blue pill for restoring their manhood.

 Initially studied for use in hypertension (high blood pressure) and angina pectoris (a symptom of ischaemic heart disease), the drug sildenafile, marketed by Pzifer as Viagra, has revived the love lives of millions of couples since being approved by the US Food and Drug Administration on March 27, 1998.

But while Viagra may fix the problems in bed, specialists are quick to point out that erectile dysfunction is on the rise, especially amongst the ageing population. They estimate that by 2025, erectile dysfunction prevalence around the world will double, going from including 152 million men in 1995 to 322 million.

And that’s alarming because of the relationship between erectile dysfunction and heart disease.

Professor Dr John P Mulhall, as associate professor at the department of urology at Memorial Sloan Kettering Cancer Centre and director of the Male Sexual and Reproductive Medicine programme, regards erectile dysfunction as a public health concern. He points to a study revealing that 49 per cent of males in a sample of 300 patients with coronary artery disease suffered from erectile dysfunction and that the erectile dysfunction symptoms started before they developed any symptoms or heart pain. The time frame between erectile dysfunction starting and the onset of angina chest pain was about 3.2 years.

“You may not be overly worried about erectile dysfunction problem, but once you have symptoms, it’s essential you have a health check,” says urologist Assoc Prof Dr Somboon Leungwattanakij of Bangkok Hospital’s section for male sexual dysfunction.

Mulhall says that when the patient has problems with erectile dysfunction, the first concern should be whether there are any signs of underlying vascular problems. The erectile dysfunction, he adds, could be covering for cardio and brain vascular diseases that may lead to a severe heart attack, a stroke and paralysis.

In the past, erectile dysfunction was regarded as mainly psychogenic. Research has however shown that it is more likely to stem from a physical health problem.

“Around 40 per cent of erectile dysfunction comes from vasoconstriction and 30 per cent from diabetes,” says Mullhall.

Dr Somboon, who also hosts Channel 3’s “Choo Rak Choo Ros” programme on sexual health, says that erectile dysfunction is not a disease but a symptom of vasoconstriction. 

When a man is aroused, chemicals are released to relax muscles in the penis. Normally, these muscles are constricted so that blood cannot flow into the penis. When these muscles relax, large amounts of blood are able to enter the penis, causing an erection. At the same time, the enzyme phosphodiesterase type 5 (PDE5) is also released to break down the chemicals that caused the muscles to relax in the first place and causes the muscles to constrict again, which results in blood leaving the penis.

When vasoconstriction starts, blood cannot flow into the penis well and combined with the release of the PDE 5, it eventually causes erectile dysfunction. Sildenafile works by blocking PDE5 and letting the blood to stay in the penis longer, thus allowing the man to maintain an erection.

“The blood vessels in the penis are tiny so once erectile dysfunction starts, the symptoms of vasoconstriction are revealed. If patients don’t control such risk factors as weight, cholesterol and sugar, the chance of constriction in bigger blood vessels is very possible,” says Dr Somboon.

With patients still finding it hard to talk about erectile dysfunction problems with their physicians whether because of embarrassment, lack of knowledge or cultural and religious beliefs, Mullhull says there’s an urgent need for doctors to integrate sexual problems with normal discussions about losing weight, quitting smoking and exercise.

The introduction of the Erection Hardness Scale, a reliable measure of erection hardness and an indicator of other health issues, is making life easier for both patient and physician. This four- scale method uses tofu, a peeled banana, an unpeeled banana and a cucumber to assess the level of erectile dysfunction.

“When the patient see the symbols, they can easily relate them to their erectile dysfunction status,” says Dr Soomboon.

It’s working too, with Thailand beating out all other Asian countries in terms of patient responses to physicians about sexual difficulties.

“We tend to ask patients suffering from diabetes, high cholesterol or hypertension about their erectile dysfunction symptoms. Anyone with all three is certain to have erectile dysfunction problems,” says Dr Somboon.

While sildenafile is usually prescribed to these men, Somboon points to the dangers of Viagra being sold over the counter along with the cheaper erectile dysfunction drug Sidagra, produced by the Government Pharmaceutical Organisation and launched last year.

Patients taking nitrates for coronary artery disease should never take sildenafile, he says, as the combination of these two drugs is likely to cause severe hypotension (low blood pressure) and syncope (fainting.)

“The problem is that more than 100 medicines sold under different names are nitrates. Even the doctors can’t even remember all that names. I check the textbook all the time. Before taking sildenafile, it’s very important to consult a doctor,” Dr Somboon says.

Mullhull adds that taking that little blue pill will not, as many believe, cause an instant erection. A man also needs stimulation and should take the pill on an empty stomach, as fatty foods decrease its effect.