Viagra was an accident.

Sildenafil was a drug being investigated by Pfizer for treating blood pressure. It flunked the stringent FDA criteria to make the grade, but as the story goes, the men participating in the study began snickering about all the erections they were having. And the rest, as they say, is history.

 

What is Erectile Dysfunction (ED)?

Erectile dysfunction (ED)—formally called impotence—is a failure to have or maintain an erection, which is sexually crippling. Along with premature and other ejaculatory abnormalities, it is one of the categories of sexual dysfunction in men.

The penis normally has a mechanism by which engorgement with blood expands the flaccid, erectile tissues such that penetration in intercourse is possible. Erectile dysfunction—or, ED—affects up to 40% of men over 40 and 70% over 70.

What’s going on? Is it a mutation? A new type of zombie apocalypse?

 

Why is ED getting to be so common?

We were never meant to last as long as we do. As our technology evolved faster than our physical bodies, advances that resulted in increased life expectancy brought with them age-related diseases never seen when we were all expected to be dead before age 40. Heart disease is new for us. Cataracts, Type II diabetes, atherosclerosis, prostate enlargement and cancer, and even menopause—all new. This baggage also includes erectile dysfunction, since age is a prominent risk factor.

 

Everyone began throwing their hats in the ED ring

When Pfizer made billions from their Viagra and with reports of 80% or greater rates of successful penetration, it wasn’t long before other ED drugs hit the market to cash in on this lucrative niche, filling the vacuum created and maintained by the sometimes perceived embarrassment and humiliation of ED.

Enter vardenafil (Levitra) and tadalafil (Cialis), which soon joined the ranks of options, fine-tuning the properties and earning patents—and patients—in their own right. After adequate assessment for causes of ED—circulatory, low testosterone, anatomical, psychological—if all that was needed were something to open the erectile tissues to increased blood flow, relief from this sexual dysfunction was just a prescription away...or not… but buying Viagra without a prescription is not such a good idea. Read why in the article OTC Viagra-A Bad Idea.

 

Which to choose? Viagra? Cialis? Others?

Once Viagra proved its mettle, the race was on to compete. Not only content to just offer another Viagra knock-off, drug companies searched for properties they could tweak to give their own contenders a competitive edge. This is the arena where the pros and cons of the different drugs could guide one’s choice:

Chemical structure. Viagra and Levitra both have a similar chemical structure. Cialis is a different chemical structure altogether. Mainly of academic interest. They all work the same, inhibiting the enzymes that degrade nitric oxide, the chemical needed to open blood vessels for increased circulation.

 

The timing of taking it

  • Viagra requires an empty stomach to be its most effective.
  • Levitra and Cialis do not.
  • Viagra, Levitra, and Cialis all create some loss of romantic spontaneity, since they should be taken before a planned intercourse.
  • Cialis, however, offers a daily scheduling option, making intercourse something that can just happen, anytime, anywhere (careful!). This benefit has been used to great advantage in its television advertising.
  • A newer FDA-approved drug, avanafil (Stendra), boasts a 15-minute onset of action, as opposed to about an hour for the others.

 

Side effects and contraindications

Because they all have a similar mechanism of action, they all have the same side effects and contraindications:

 

  • Headaches
  • Dyspepsia (stomach complaints)
  • Vasodilation and hypotension
  • Diarrhea
  • Runny nose
  • Nosebleed
  • Priapism (prolonged, painful erection)
  • Blue vision and other visual disturbances (primarily with Viagra)
  • Contraindicated with nitrates, certain antibiotics, and antifungals, in liver and kidney impairments, and in men not heart-healthy enough for sex.

 

Duration of action

Viagra and Levitra both last for about four hours. Cialis can last over a day.

While this may seem to tip the decision toward Cialis, one must keep in mind that if it lasts longer, one is stuck with it longer, which can be sobering when encountering some emergency requiring medications that might mix badly with it.

 

Which one is best?

There are multiple options for those who seek relief from ED. A Clinical Practice Guideline from the American College of Physicians (ACP) recommends that the choice be based upon on the patient's preferences, including cost, ease of use, desired duration of action, and adverse effects.3

 

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Resources:

  • https://www.uptodate.com/contents/treatment-of-male-sexual-dysfunction?source=search_result&search=vardenafil&selectedTitle=4~73#H430294557
  • Montague DK, Jarow JP, Broderick GA, et al. Chapter 1: The management of erectile dysfunction: an AUA update. J Urol 2005; 174:230.
  • Qaseem A, Snow V, Denberg TD, et al. Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2009; 151:639.
  • The Medical Letter; 56 (1442):34 May, 2014 and United States approved prescribing information available at National Library of Medicine.
  • Rampin O, Giuliano F. Central control of the cardiovascular and erection systems: possible mechanisms and interactions. Am J Cardiol 2000; 86:19F.
  • DeBusk RF. Evaluating the cardiovascular tolerance for sex. Am J Cardiol 2000; 86:51F.
  • Möller J, Ahlbom A, Hulting J, et al. Sexual activity as a trigger of myocardial infarction. A case-crossover analysis in the Stockholm Heart Epidemiology Programme (SHEEP). Heart 2001; 86:387.
  • Ishikura F, Beppu S, Hamada T, et al. Effects of sildenafil citrate (Viagra) combined with nitrate on the heart. Circulation 2000; 102:2516.
  • https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm465024.htm.


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