Medical Mystery: At 48, he wanted a cure for erectile issues

Editor's note: Albert I. Wertheimer, Ph.D., professor of pharmacy administration at Temple University School of Pharmacy, and Patricia J. Bush, Ph.D. professor emeritus at Georgetown University School of Medicine, are co-authors of "Your Drugs & Sex: How Prescription and Non-Prescription Drugs Can Affect Your Sex Life." In today's Medical Mystery, they share a patient quandary that will sound familiar to many readers in an age of TV advertisements for pharmaceuticals promising to fix all manner of problems.

An old friend pulled us aside at a recent party to see whether he could ask a personal question.

He said he understood that male sexual performance declined over the years, but at just 48, he thought it was soon for him to be having this problem.

After giving him a checkup to be sure his overall health was good, his doctor prescribed Viagra, but it didn't help and he was understandably frustrated.

Erectile dysfunction can be a symptom of underlying health problems including diabetes and depression. When those issues are addressed, sexual problems may resolve without needing medication.

Our friend said his doctor told him he was in reasonable health for his age. He isn't overweight, eats a good diet and exercises regularly.

Nor does he take prescription medicines. Erectile dysfunction also can be a side effect of some medications for hypertension, diabetes, depression, anxiety, high cholesterol or a wide variety of other medical conditions.

In our conversation, our friend told us he had tried some herbal remedies he saw advertised on late-night TV, and he ordered some performance-enhancing capsules advertised in a men's magazine. None of that helped, either. This was no surprise to us, having read numerous articles in respected medical journals confirming our friend's experience.

In one study, clinicians tested 150 different products without successful results. We were very gratified to hear that our friend had not tried buying products from a foreign country, as most countries have more lax drug regulations than the U.S. and there is a real possibility of getting a counterfeit or substandard product with little or no active ingredient, or, worse, an undesirable ingredient.

So, how did we counsel our friend?

Men who do not have underlying health issues associated with erectile dysfunction (ED), but who aren't getting good results from Viagra, should not give up.

Viagra is a drug in the class of PDE5 inhibitors whose use to treat ED was discovered by accident. Sildenafil was being tested by Pfizer in England to treat high blood pressure and angina (a heart disease symptom) and the men reported the sexual side effect.

It was approved by the U.S. Food and Drug Administration as Viagra in 1998 and is estimated to have about half of the ED drug market. However, three other ED drugs have come on the market since then.

The first two followed shortly after Viagra. They are Cialis (tadalafil) and Levitra (vardenafil). Both are also PDE5 inhibitors, but sometimes men react differently to each of the three, so it can be worthwhile to try another medication if the first isn't working.

In 2012, a fourth drug in this same PDE5 category entered the marketplace. Its name is Stendra (avanafil). The medical literature shows that it works more quickly than the others and, for some patients, more effectively. This could be an additional option.

Alprostadil, by injection and suppositories, is a drug option in another category that is not as easy to use as the PDE5 drugs, but is still a good answer for some men.

This drug works by relaxing penis muscles and blood vessels, keeping enough blood in the penis to enable and maintain an erection. Alprostadil is a powder that is mixed with liquid provided in the package. It is then injected into the penis or used as a suppository pellet placed into the urinary opening of the penis. The brand names are Caverject, Edex, and Muse. Your physician must teach you how to use it. It works rapidly and cannot be used more than once daily, three times a week.

Urologists can order injections of other ingredient combinations and strengths from specialty compounding pharmacies. These are not cheap, but are usually effective.

We hope to hear a positive report from our friend next time we see him.

"Your Drugs & Sex: How Prescription and Non-Prescription Drugs Can Affect Your Sex Life" lists the top-selling 400 medicines in the U.S. and describes problems and solutions. It is $14.95 at Amazon.com.