Viagra appeared on the prescription drug market in 1998. It was met with excitement from all quarters. Viagra jokes were everywhere, television commercials dotted every sporting event, middle-aged and elderly men were ecstatic, and middle-aged and elderly women shuddered. A new conversational phrase was introduced that became an open, unashamed topic of discussion: ERECTILE DYSFUNCTION. The embarrassing, politically-incorrect term, Impotence, had been replaced by this sophisticated, academically professional sounding term.
I was on the practice scene when Viagra was introduced. I can still recall my visit with the Pfizer sales rep and the eagerness with which I wanted to learn all the important information about this revolutionary drug. I learned everything I needed to know in that visit and from the promotional materials he provided. Suddenly, there was an epidemic of ED, Erectile Dysfunction. Out from under rugs and out of the walls appeared man after man who wanted to try this miraculous product. Men, whose wives and grandchildren I had seen regularly, appeared in my office for the first time seeking a prescription. This scenario occurred several times a day for many weeks.
Also appearing at my office were the wives of these men. These women came to my office for two reasons. Some came in to get a prescription for their husband who was too embarrassed to ask himself, and many came in pleading with me not to give her spouse the drug. A lot of time had passed, and she was comfortable in her position of abstinence. She was not ready emotionally or physically to resume sexual intimacy. Men were excited and eager, but women were anxious and reluctant.
Before Viagra came on the market, Physicians and patients had few effective options. “Impotence” was considered a psychological disorder, so none of the available products got to the base of the problem. I remember one particularly insensitive colleague who referred to “importent” patients as “nut cases.” He didn’t win much respect from patients as you might imagine.
BV, before Viagra, treatments for ED were a bit on the barbaric side. Caverject (Alprostadil) is a drug the patient injected into the shaft of the penis to stimulate an erection. It didn’t get a lot of use for obvious reasons. Then there was the suction device the man attached to his penis to pull blood into it to cause an erection. Once an erection was achieved, a loose band was placed around the base of the penis to prevent blood from escaping and losing the erection. That product certainly had its limitations. The same drug in Caverject (Alprostadil) was used in MUSE. This was a suppository the man placed in his urethral to stimulate an erection. The suppository melted inside the penis, was absorbed into the vascular tissue, and sometimes achieved the desired effect. MUSE did not do a “land office business,” either.
So you can see why Viagra was met with enthusiasm when it came on the market. Here was a pill you could take which gave you a 4-6 hour window of opportunity. No painful injection, no awkward suction device, no penile suppository. A pill; a little blue pill. And it worked. I called it “Vitamin V.” So for $7.50 a pill, this drug could renew your sex life.
Twenty years have passed since the introduction of Vitamin V. Time has sorted out a lot of the issues with Viagra and frequency of use has declined while the price per pill has sextupled, pun intended. The luster has worn off this much-anticipated drug. The most important fact about Viagra is that all it does is cause an erection. Now that’s a big deal, but Viagra does nothing to increase a man’s desire for sex, it won’t heal damaged relationships, and if your partner is not a willing participant, it won’t make her be. Side effects have become a concern as well. Flushing, headache, visual disturbances (blue tint to the vision), nasal congestion, and nausea are seen often and discourage use. ED is one of the earlier signs of systemic arteriosclerosis (hardening of the arteries) and may be a harbinger of serious coronary artery disease. So here’s a patient with coronary disease he doesn’t know he has who suddenly resumes strenuous physical (sexual) activity and has a heart attack. Not a rare scenario.
In 2003, both Levitra and Cialis, competing ED drugs, entered the market. They both were as effective as Viagra, but the “window of opportunity” with Cialis lasted a much-longer 36 hours, and it came in a daily dosing form “to be ready when the moment was right.” This was a great marketing ploy, and Eli Lilly & Co. profited handsomely from it.
But all of these drugs (except daily Cialis) require the patient to take them 1-3 hours before they’re needed, and they are not aphrodisiacs. Viagra will not cause male arousal so an erection will occur only if there is some external stimulus. If the couple has significant relationship problems and sex is not fulfilling, taking Viagra to achieve an erection won’t solve the problem. Sometimes men take a pill and the “right moment” never occurs so he’s just spent $40 on a whim.
Drug-makers claim these drugs work in 70% of patients, but in the “Viagra Falls: Older Men….” article they reviewed “14 studies involving 18,337 men show(ed) success rates closer to 50%.” So over time “Vitamin V” has evolved into a drug used by middle-aged men who are losing their edge, don’t want “to let go of intercourse,” and use it for “erection insurance.” Older women, though, develop vaginal dryness, thinning of the vaginal lining, and have pain with intercourse, so, the combination of ED and menopausal changes lead many older couples to “be sexual without intercourse.”
Fifty percent of men over 50 admit to some degree of ED, but of those men, studies have shown that only 24% of American men use ED drugs. And the average of 27 Western countries was a meager 7%. To me that says two things: the sex drive of men over age 50 mellows, and the importance of treating ED lessens with age.
Erectile dysfunction is not just an isolated disorder that happens to older men “out of the blue!” Aging is often accompanied by hypertension, diabetes, high cholesterol, testosterone deficiency, obesity, depression and decreased physical activity which when coupled with smoking and the side effects of multiple prescription drugs inevitably results in erectile dysfunction. Unless you are devoid of any of these risk factors, you’re doomed to have it. For some men it’s the end of “life,” and they grasp for anything they think will keep them young. For them, Viagra fills the bill. But others accept their lot. It appears that more and more men are in the latter category.
Dr. G’s Opinion: It is very true that ED drugs effectively assist in the mechanical needs of the act of intercourse. But that’s just the starting point. The emotional needs, the compatibility of partners, and the enjoyment of intimacy have to be found by other means.
References: https://www.psychologytoday.com/us/blog/all-about-sex/viagra-falls-older-men–aren-t-vert-erection-drugs.
Mehmet Ilker Gokce Erectile Dysfunction in the Elderly Male Turk J Urology 2017;43(3):247-51
Personal knowledge of William Gilkison MD
