There really weren’t any pills that worked very well for erectile dysfunction when I first started my training as a doctor back in the late 1980s. Yohimbine was the only pill you could prescribe, and it usually didn’t work very well, although it raised your blood pressure and made you jittery. Now, that’s not very sexy. Most doctors, even urologists, took a “don’t ask, don’t tell” approach to erectile dysfunction. The options that did work—penis injections, mechanical devices, and surgery—were too complicated for most doctors to deal with.
In the early 1990s, a clinical trial was conducted for a new medication to treat angina, the chest pain that happens when there is an abnormally poor flow of blood to the heart. The results were lousy and the clinical trial was stopped since it was clear this drug would not succeed and further study would just lose money for the company. But a funny thing happened when the trial was stopped: The patients revolted! Unbeknownst to many of the doctors in the study, the patients were experiencing a very nice side effect—better erections. Many of the patients in the clinical trials had erection problems to begin with because, after all, they had cardiovascular disease, a common cause of weak erections. Once the scientists took notice of this interesting “side effect,” they had the good sense to switch gears, forget about the heart, and play to their strength. Thus was born Viagra, and the rest is history.
Sildenafil, the chemical name for Viagra, works by playing defense for your erection. You may not realize it, but your penis has a built-in cock-blocker. It is a chemical reaction that occurs naturally to make sure that an erection eventually goes down, and for good reason. During an erection, a chemical reaction increases the amount of nitric oxide (NO) in the blood vessels, making them relax and open wide to allow the blood to rush into the penis and cause an erection. Once the penis becomes erect, the bloodflow slows to a crawl because it is trapped, sort of like in a traffic jam. If this goes on too long, the blood runs out of oxygen, and the penile tissues will get injured. To avoid this, the penis releases a special chemical into the blood called phosphodiesterase type 5 that puts the brakes on NO. This is the cock-blocker. It causes the arteries to squeeze closed and divert the “traffic” away from the traffic jam, letting the old blood drain out and fresh oxygen-rich blood flow in. Rush hour is over! (Okay, not exactly “hour”—more like 5 to 7 minutes, for most of us.)
This phosphodiesterase type 5 safety mechanism is great when you are young, healthy, and your “dick gets hard when the wind blows” to quote Eddie Murphy in 48 Hours. But it’s a problem when your arteries are narrowed and there’s not even enough blood entering the penis to cause the “traffic jam.” All the prescription penis pills work by blocking the cock-blocker: They shut down phosphodiesterase type 5. This lets more NO build up in the blood vessels and lets more and more blood flow in for a longer amount of time so you can get back to jammin.’ Although all the pills work for the same reason, they differ from one another in how long they take to work, how long they last, and their side effects. Cialis, also known as tadalafil, was another medicine being tested as a heart pill when the whole Viagra discovery hit. The scientists working on tadalafil didn’t have to be told twice and quickly got their drug patented for the penis. Cialis has the unique advantage of being effective for a day and a half. Viagra, on the other hand, is effective for about 4 hours. Four hours is plenty, but things come up and schedules change. A 36-hour pill can give you more “wiggle room,” as it were. Because Cialis lasts so long, it can be taken as a low dose once a day, with the level in your body getting higher and higher over the first 5 days, then settling out to be the same as if you took a full dose on purpose. This allows your scout to always “be prepared.” It also turns out that this low daily dosing helps with urination symptoms due to an enlarged prostate such as a weak flow, frequent urination, and waking up at night to urinate. Staxyn (vardenafil) dissolves on the tongue. Perhaps designed for more “discreet” use, it may work a little faster due to direct absorption in the mouth.
On the other hand, the different pills can have different side effects. The side effects are always temporary and affect only a small percentage of guys. Cialis also blocks another phosphodiesterase, which can result in back pain or muscle aches in some men. Viagra blocks another phosphodiesterase as well, sometimes resulting in temporary visual changes, making things look blue—like the pill. Stendra (avanafil) has the least effect on other phosphodiesterases and causes the fewest side effects. Side effects more or less common to all the pills include headache, runny nose, and indigestion, which are mainly the result of blood vessel relaxation and increased bloodflow in these other parts of the body.1
| DRUG | CHEMICALNAME | DOSE | ONSET ANDDURATION | SIDE EFFECTS |
| Viagra | Sildenafil | 25, 50, 100 mg | Starts working in 30 minutes to 1 hour. Effective for about 4 hours. Better on an empty stomach. | Headache, flushing, indigestion, nasal congestion, altered vision, palpitations |
| Cialis | Tadalafil | 2.5 or 5 mg for daily dosing 10 to 20 mg for on-demand dosing | On-demand dosing starts working in up to 2 hours and is effective for about 36 hours. Daily dosing works in up to 5 days, then is always in effect. Helps urinary symptoms. | Headache, indigestion, nasal congestion, muscle/back aches |
| Levitra Staxyn | Vardenafil | 10, 15, 20 mg | Levitra works in 30 minutes. Staxyn may work faster—it dissolves on the tongue. Effective for about 6 hours. | Headache, indigestion, nasal congestion, palpitations. Tends to have fewer side effects than Viagra. |
| Stendra | Avanafil | 100, 200 mg | Works in 15 to 30 minutes. Effective for about 6 hours. Better on an empty stomach. | Headache, indigestion, nasal congestion. May have fewer side effects than the others. |
Table 1 summarizes the various penis pills.
Which pill is the best? Good question. There have been no “head-to-head” trials. Most urologists have concluded that they all pump up the volume about the same, with the biggest differences being the timing and duration of the erection and the difference in side effects. A guy may find that one pill works better than another, but it can be different for different guys. When it comes down to it, I would have to say most of my patients prefer Cialis, and this has been shown to be the case in a couple of studies that looked at patient preference between Viagra and Cialis.2, 3
As these medications become available in their generic forms, the lower pricing will likely determine which ones patients use most.
What about the risk? Many people are afraid of these pills. Occasional news stories and depictions in pop culture suggest that they might kill you. So many of my patients tell me their partners won’t let them take these pills because they are afraid of them getting a heart attack. The truth of the matter is that there is no significant risk of death or even serious illness from taking any of these pills alone. None of these pills directly poisons the heart. If a person has a heart that is too fragile to withstand the stress of sex, then he should not take these pills, but that is because of the sex these pills will allow. If you aren’t sure, check with your cardiologist.4 If you have suffered a recent heart attack, you should definitely check with your doctor, but in many cases men can get back in the saddle in as little as a week. When taken alone, these pills rarely change your blood pressure to a meaningful degree. Even in combination with most other medications, they are safe.
There are a few key exceptions. The greatest risk comes if you take any of these pills with nitroglycerine. Nitroglycerine is prescribed to some patients with heart disease to increase bloodflow to the heart, especially if they get chest pain. The nitro in nitroglycerine means nitrogen, and nitroglycerine increases the NO in the blood vessels to your heart. Because the penis pills prevent the NO from the nitroglycerine from being removed by the phosphodiesterase type 5, too much builds up and the heart’s arteries open up so much that they can’t squeeze the blood all the way throughout the heart and the heart actually loses oxygen, which can cause sudden death. If you take nitroglycerine or any medications containing nitroglycerine, you should not take any of the penis pills. And if you take penis pills, you should not take nitroglycerine or nitroglycerine-containing medications including recreationally used amyl nitrite, also known as “poppers.” Amyl nitrate also increases NO in the blood vessels, just like nitroglycerine does.
Another kind of medication to be cautious with is known as an alpha-blocker. This kind of medication is usually used to treat problems with urination and goes by names such as Flomax (tamsulosin), Uroxatral (alfuzosin), Rapaflow (silodosin), Cardura (doxazosin), and Hytrin (terazosin). The issue with these medications is that they can lower blood pressure when taken with penis pills, but the body will tend to get used to them, so the risk is mainly when a person first starts using them.
An extremely rare side effect of Cialis and Viagra is sudden loss of vision or hearing. This is not only extremely rare but poorly understood. Men with a rare vision disorder called retinitis pigmentosa are at greatest risk. There is some debate whether some of the cases are truly linked to these medications. Certain medical conditions such as liver failure and certain medications can make these penis pills last much longer in your body and aggravate side effects and risks, so these medications should be prescribed by a doctor who understands your total health.
The ravages of elevated cholesterol, diabetes, high blood pressure, smoking, obesity, poor diet, and lack of exercise can be too much for the penis pills to work. So what’s a guy to do? Fortunately, when a pill doesn’t work, it’s not game over. There are several strategies that can save the day (or the night, as it were). First and foremost is picking yourself up, dusting yourself off (or sponging yourself off perhaps), and trying again. In many cases it takes a few tries before the pills work. This is most likely because there may be some anxiety and therefore adrenaline release associated with taking the pills, and adrenaline can prevent them from working. The more familiar we become with a situation, the less adrenaline we release, so if we give the pill a few tries and become less anxious about the process, we may get the results we want.
Sometimes pills don’t work because the person simply needs a higher dose and doesn’t know there is one. Oftentimes the samples a guy receives from his doctor are of a lower-than-maximum dose. Many doctors are cautious about dosing these medications even though they are very safe, so they start their patient on a low dose that, for the majority of guys, won’t work. Many of these men will go home, try it, and figure that because it didn’t work, they aren’t fixable. That’s a real shame, because if they weren’t so nervous and had a proper understanding, in many cases all they would need to do is double up on the dose and try again.
Another issue can be that the dose they are taking isn’t getting absorbed properly into the bloodstream. Viagra may not work well if taken on a full stomach after a fatty meal. It’s best to take Viagra or the generic, sildenafil, an hour before meals or 2 hours after meals. So if that corn dog or fried turkey leg is calling your name at the state fair, don’t make any big plans for the Tunnel of Love soon after. Cialis is not affected by food, but it takes up to 2 hours to kick in. Levitra and Stendra work more quickly and are not affected by food either.
All of the pills are blunted by alcohol. An erection is harder to get and keep when you are intoxicated, especially as you get older. The pills can’t always overpower the alcohol. Plus the combination of excess alcohol and a penis pill can cause a serious drop in blood pressure. So, if you pop a Viagra as you are finishing off a nice bottle of wine along with a prime cut of meat, walk don’t run from the dining room to the bedroom, because it may be a while before you get your just desserts.
In Chapter 5, Bigger Faster Harder: Penis Enhancements, I discussed the various herbal ingredients thought to have some kind of impact on sexual prowess, whether it’s increasing hardness, increasing interest, or increasing pleasure. Of these many ingredients, a few have been shown to help men with physical ED, but usually milder cases. For the small percentage of nutritional supplements that have been studied, side effects are typically mild and uncommon, but there are many more supplements out there that haven’t been safety tested. Some herbs can be very hard on the liver.
The irony is that many of the supplements available over the counter or online without a prescription are more risky to take than the prescription pills, and they don’t even work as well—if at all. To add insult to injury, they often cost as much as or more than the real stuff, especially if the penis pills are covered by insurance. If you need help, don’t hesitate to see your doctor and get a prescription for effective medication. If you prefer to stay out of the clinic, choose supplements that have science behind them. Look for products that have been proven to boost NO and that have been studied for safety.
Many men with poor erections also have low testosterone. Boosting testosterone back to normal can completely fix the problem in a small percentage of these men, but for most, it’s just part of the fix, albeit a very important part. Low testosterone is discussed extensively in Chapter 13, but it’s important to understand how it plays a part in other treatments for poor erections. Passion’s fire can’t ignite without the fuel of testosterone sloshing around the brain. Furthermore, the penis itself becomes less supple and stretchy and can’t fill and expand as well without testosterone bathing its tissues. Many men with low T have other medical causes of poor bloodflow to the penis that require penis pills to treat. However, in men with low T, the pills often aren’t able to work even when the dosage is increased. If testosterone is boosted to normal, many of these men will have much better results with the penis pills. When you restore testosterone, desire can improve right away, but improvements in the penis can take a bit longer, up to months for some.
The advent of pills for erectile dysfunction that actually work has forever changed the way doctors treat ED. These medications are truly medical miracles, and they have changed our society’s attitudes and enlightenment about sex and health. Nonetheless, they simply can’t work for all men in all situations, and that can be devastating for those men. Fortunately, there are second- and third-line treatments that are very successful even when the pills are not. They are discussed in the next chapter.