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Date : 13-05-19 06:24     



In April 1998, the FDA approved the use of Viagra (Sildenafil) for the treatment of impotence. Since then over 3 million prescriptions have been written in 3 short months. Viagra is expected to achieve over $1 billion in sales in its first year.  15 years later, there are 3 oral medications for treatment of sexual dysfunction.

Impotence, defined as the inability to achieve and/or maintain an erection adequate for satisfactory sexual performance, is estimated to affect approximately 10 to 18 million men in the U.S. Penile erection is a complex phenomenon involving psychological, neurological and vascular responses. Therefore, impotence often has multiple overlapping etiologies.

Since the introduction of Viagra, and there after introduction of Levitra and Cialis, the first line of treatment for impotence is a trial with oral medications.  The main difference between the medications is how quickly it works and how long it is in the body.  

Viagra takes 1 hour to work and is in the body for 4 hours.  Levitra takes 30 minutes to work and is in the body for 4 hours.  Cialis takes 2 or 3 hours to work but it is in the body for 36 hours.  Which medication is chosen depends on the patient’s goals and plans for sexual activity.  

Viagra is available in 3 doses: 25 mg, 50 mg and 100 mg. Levitra is available as 10mg and 20 mg tablets and as a sublingual form called Staxin.  Cialis is available as 10 and 20 mg doses as well as the new daily 2.5 or 5 mg doses.  There are few side effects with all of these medications (10-20 %) including hot flushes, upset stomach, headaches, and blue vision. The only contraindication to the use of these medications is concomitant use of nitroglycerin products because of profound hypotension. All 3 medications boast a 70 % effectiveness, and although there have been reports of death with Viagra; all the medications seem safe if patients are chosen carefully.

When a patient fails Viagra, the next option includes MUSE, vacuum device or injection therapy. Medicated Urethral Suppository for Erection (MUSE) became available in January 1997. Using Prostaglandin E1, it causes vasodilation. It is quite safe and effective although some have complained of mild urethral burning. It has lost significant market share since the introduction of oral medications, but it is still an excellent choice for some patients who fail oral medications.

The vacuum device is in wide spread use throughout the world for treatment of impotence. It is a simple device to use and user satisfaction is high despite the fact that it can be quite cumbersome. It is particularly useful for patients who have venous leaks.

Penile injections have become widely used since the mid 80’s. There are several medications being used alone or in combination. These medications include Papaverine, Regitine and Alprostadil. Among these, only Alprostadil is FDA approved for penile injection. These medications are quite effective but can cause some scarring and pain with injection. Another significant side effect is Priapism (a prolonged erection).

When the patient fails above method, the next step is the use of penile prosthesis. Penile prosthesis has undergone many evolutionary changes since its introduction in the early 1970’s. Currently there are semi-rigid devices, 2 piece inflatable devices, and 3 piece inflatable devices. The mechanical failure rate is low (less than 2 %) and it provides the best long-term treatment of impotence.

In summary, although there are many ways to treat patients with impotence, each patient should be evaluated and treated individually. In general, oral medications should be tried first. If unsuccessful, MUSE, vacuum device, injection or prosthesis are available. More research of female sexual dysfunction is necessary and is currently in progress.

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