Throughout this process, communication is key. The man and his partner need to talk about the pros and cons of each option to find a mutually satisfying solution. Health-care providers can give information, advice, and options, but ultimately it is the couple who must use and be satisfied with the treatment they choose.
Although they are taken differently, the drugs described here are all basically vasodilators that increase the amount of blood that can enter the penis. They mainly differ in side effects, time to onset of action, and convenience.
Pills. Sildenafil (Viagra) took the market by storm several years ago, bringing sexual dysfunction out of the closet and getting men into doctors’ offices to deal with it. The overwhelming response to sildenafil and the increased awareness of erectile dysfunction as a real problem for millions of men enticed two new contenders into the market: vardenafil (Levitra) and tadalafil (Cialis). The introduction of these new drugs increases the choices for treating this problem.
The main difference between the three drugs is that tadalafil can last up to 36 hours compared with 4 hours for sildenafil and vardenafil. However, it has not been studied whether a man can achieve multiple erections per dose of tadalafil, and tadalafil may have a greater potential for drug interactions because of its longer period of effectiveness.
The actions of all three drugs are similar in that they increase blood flow to the penis. They work by stopping the degradation of the vessel-widening chemicals that are produced in response to sexual stimulation; with their degradation stopped, the chemicals are free to continue allowing more blood into the penis. Because these drugs don’t produce vessel-widening chemicals themselves, the user must have some sexual stimulation to start the release of such chemicals and achieve an erection. The three drugs all start to work in as little as 30 minutes. (See this table.)
Each medicine can be taken daily and each has the following possible side effects: headaches, flushing, upset stomach, visual disturbances, and prolonged erections. (Prolonged erections lasting more than four hours require immediate medical attention to prevent permanent damage to the penis.) Tadalafil may also cause muscle aches or back pain while its competitors don’t, but it is also less likely than its competitors to cause so-called “blue vision,” a condition in which users temporarily experience a blue tinge to their vision while using the drug. Sildenafil has been around longer than its competitors and therefore has a more proven safety profile. Sildenafil should be taken on an empty stomach or with a light (low-fat) meal; the others can be taken with food or on an empty stomach. Alcohol may be used in moderation with any of these medicines.
All three drugs have similar precautions. You should not use these drugs if you are taking a drug that contains nitrate or an alpha-blocker (with one exception for tadalafil), which is used to treat high blood pressure or an enlarged prostate gland. Tadalafil may be taken with 0.4 milligrams of once-daily tamsulosin (Flomax).
Again, it’s important to note that erections won’t happen automatically with these drugs. Sexual stimulation is a must for these medicines to be effective, so if the mood isn’t right, a man may not get an erection, even if he has successfully used the pill before.
Urethral suppository. A urethral suppository containing the drug alprostadil (MUSE) hit the market a year before sildenafil. Like the oral medicines, the alprostadil suppository is a vasodilator that allows blood to enter the penis. About the size of a grain of rice, the suppository is placed into the urethral opening at the tip of the penis. (The urethra is the tube in the penis that allows urine to flow out of the body.) It dissolves inside the urethra where it is then absorbed into the blood. Proper insertion of the suppository is important; education and practice are critical to obtain the desired results. An erection that lasts for about one hour will usually occur in about 5–15 minutes. A man first takes the drug in his doctor’s office for instruction, safety, and determining the proper dose for him.