Getting treatment
On 1st July 1999, the UK Government introduced restrictions on impotence treatments under the NHS. (It was worried that the NHS in the UK would be bankrupted by demand for these medications, perhaps with some reason – for the year 2000, the Viagra bill topped £19 million and, in total, the NHS spent over £73 million on treating impotence.) Only men with certain conditions (prostate cancer, spinal cord injury, kidney failure, diabetes, multiple sclerosis, spina bifida, polio, Parkinson’s disease, ‘single-gene neurological disease’, severe pelvic injury) can receive any kind of NHS impotence treatment. The restrictions apply to all types of impotence treatments, not just tablets. The only exceptions are men who were already receiving impotence treatment on 14th September 1998, the date Viagra was licensed. If your erectile dysfunction is causing ‘severe mental distress’, you may be able to obtain NHS impotence treatment, but not from your family doctor – it has to be prescribed by a specialist hospital consultant. Doctors have been advised not to prescribe more than one treatment a week.

In the UK, if you are not eligible for impotence treatment under the NHS, your family doctor can give you a ‘private’ prescription. You will not be charged for the actual prescription if it is written by your NHS family doctor, but you will have to pay the pharmacist for the medication.

Many family doctors are very knowledgeable about impotence. Otherwise, your family doctor may decide to refer you to a hospital specialist called a urologist. The urologist can provide the full range of treatments, and will discuss these with you to see which would suit you best.

Avoid the private clinics you see advertised in the press. Health Which? magazine found that some private clinics employed slick salesmen and charged over £1000 for a small supply of anti-impotence drugs.

And do not buy impotence treatments from Internet sites. Some of the ‘treatments’ on offer do not work at all. Medications for impotence (such as Viagra and similar drugs) can be bought from Internet sites that first make you fill in a health questionnaire supposedly to ensure that the medication would not be dangerous for you. Health Which? investigated some of these sites and found that some were dangerous. The US Food and Drug Administration (FDA) is cracking down on these sites and, in the UK, the Medicines Control Agency is also looking into them. There is also a risk that, unknowingly, you may buy fake medication.

Types of treatment
There are many different treatments for impotence. They include tablets that you take by mouth (oral medication) and other treatments, such as injections and vacuum devices. Your doctor will help you to select the treatment that is best for you.

In the UK, there are three main oral medications (tablets) – Cialis, Levitra and Viagra, which are basically similar. They prevent the breakdown of some of the chemicals in the penis that are involved in erections, so they help the normal erectile mechanism. Therefore the man becomes erect only when he is sexually aroused – unlike some other treatments, which produce an erection automatically, whether or not the man feels sexually stimulated. So these medications seem to produce a more natural erection than other methods.

What you need to know about Cialis (tadalafil)

• Cialis is a tablet treatment for impotence that became available in the UK in February 2003. It works in a similar way to Levitra and Viagra.
• If you take Cialis, you will have an erection only if you are sexually aroused.
• Never take more than one Cialis tablet in a day.
• The effect of Cialis lasts about 24 hours, so you can have sex whenever you choose for about 24 hours after taking it (whereas Levitra and Viagra are taken about 1 hour before sex).
• Unlike Viagra, Cialis does not have to be taken on an empty stomach.
• Of the men taking Cialis, 1 in 7 experiences a headache and 1 in 8 experiences dyspepsia (indigestion).
• There have been rare cases of sudden loss of sight in men taking Cialis, caused by disruption of the blood supply to the main nerve of the eye (the optic nerve). It is not known whether this is due to the drug or just a coincidence. It is most likely in men who have had a heart attack in the past.
• Unlike Viagra, Cialis does not cause abnormal colour vision.
• Do not take Cialis if you are taking nitrate medication for angina or alpha-blocking drugs.
• Do not drink grapefruit juice if you take Cialis. It could make side effects (such as headache and dyspepsia) more likely.

What you need to know about Levitra (vardenafil)

• Levitra is a tablet treatment for impotence that became available in the UK in 2003. It works in a similar way to Cialis and Viagra.
• If you take Levitra, you will have an erection only if you are sexually aroused.
• Levitra does not have to be taken on an empty stomach, but its effect may be delayed after a high fat meal. It is not affected by alcohol.
• Its effect wears off after 5–12 hours, which is sooner than Cialis.
• Like Cialis and Viagra, you should not take Levitra if you take nitrate medication (an anti-angina medication) or alpha-blocking drugs.
• Do not drink grapefruit juice if you take Levitra. It could make side effects more likely.
• The most common side effects with Levitra are flushing and headache.
• There has been one case of loss of vision in a man taking Levitra, as a result of damage to the blood supply to the main nerve of the eye (the optic nerve). It is not known if this was caused by the drug.
• Levitra can sometimes work for people who do not respond to Viagra.

What you need to know about Viagra (sildenafil)

• Studies originally showed that 88% of men taking it had improved erections, but doctors now think the true success rate may be lower (perhaps about 50%). On average, with Viagra the quality, rigidity and frequency of erections will be about 30% above what you could achieve previously. (This is true only if you previously had erection problems – you will not get a 30% improvement if your erections were previously normal.)
• It is slightly less effective in men whose impotence is caused by diabetes, and may not work if impotence followed a prostate operation (depending on the type of operation).
• Side effects can include headache, flushing, diarrhoea, stuffy nose, nosebleeds and abnormal vision (temporary changes in blue/green colours, increased sensitivity to light).
• There have been rare cases of sudden loss of sight in men taking Viagra, caused by disruption of the blood supply to the main nerve of the eye (the optic nerve). It is not known whether this is due to the drug or just a coincidence. It is most likely in men who have had a heart attack in the past.
• There have been reports of strokes and of deaths from heart attacks in men using the drug. It is unclear whether this was because of an interaction between heart medication and Viagra, or if the Viagra caused clumping of the blood, leading to blockage of a blood vessel, or if unaccustomed sexual exertion was the reason. Viagra is inappropriate if you have had a recent stroke or heart attack.
• Viagra should not be used if you have taken nitrates (for angina) or amyl nitrite (poppers) within the previous 24 hours, under-the-tongue nitrate tablets within the previous 5 days or alpha-blocking drugs. (Viagra with poppers is a potentially lethal combination that has caused a number of deaths.)
• Viagra should not be taken more than once a day.
• If you are taking certain other drugs (such as cimetidine for stomach problems, or erythromycin antibiotic), you will need a lower dose of Viagra.
• A study reported in the Journal of Urology in 2001 suggests that after using Viagra for 1 or 2 years, you may find that it becomes less effective.

What if Viagra, Cialis or Levitra do not work?
There are several reasons why Viagra, Cialis or Levitra might not be effective.

• Like all medications, they are not effective for everyone; they do not work in about 1 in 5 people.
• You need sexual stimulation to have an erection with these medications – you will not get an erection automatically.
• Maybe you are not using the medication correctly, or are expecting it to work too quickly. Re-read the information leaflet that is in the pack.
• Maybe you have not tried it for long enough. Most men have a response the first or second time they use the medication, but in some men the response improves after they have used it six or eight times.
• Maybe the dose is too low – this is something to discuss with your doctor.
• Maybe you are a smoker, drink too much alcohol, have poorly controlled diabetes or have a sedentary lifestyle. Research shows that if you deal with these problems, medications for impotence will have a better effect (Urology 2002;60:28–38).

Viagra, Cialis and Levitra seem to have approximately the same effectiveness, but if one does not work for you it might be worth trying another. Your doctor might also suggest taking a low dose of Cialis (which is long-acting) every day; this can improve the effect significantly (British Medical Journal 2006;332:589–92). If your testosterone level is low, testosterone gel may help the medications to work. Recent preliminary research suggests that a statin medication (which is normally given to people with high blood lipids such as cholesterol) may improve the response to impotence drugs, but more research is needed.

Other types of treatment
Penile rings (for example, Rapport RLS) are helpful for people who can get an erection but find that it does not last.

Injecting alprostadil into the penis is probably the most effective method of obtaining an erection. Alprostadil (as in, for example, Caverject and Viridal Duo) is a synthetic version of prostaglandin E1. This chemical relaxes the tiny muscles of the erectile tissue while increasing the blood supply. It is injected 10–30 minutes before intercourse. The doctor will inject the first dose and assess your erection to find the correct dose for you, and will show you how to inject yourself. You will probably be surprised how easy it is to do the injection. It should produce an erection lasting about half an hour. Occasionally a prolonged response develops (priapism). If you have a needle phobia or cannot easily see the penis, an automatic system is available (Autoject 2.25). Some pain in the penis (usually mild) is experienced by 1 in 6 men following the injection, and there might also be some bruising.

MUSE (alprostadil) stands for ‘medicated urethral system for erection’. A small pellet of alprostadil, no bigger than a grain of rice, is inserted about 3 cm up the urethra, using a tiny plastic plunger. Although it is not an injection, some men find it painful, but this discomfort can be minimized by urinating beforehand. Another disadvantage is that it makes some men feel slightly dizzy. MUSE takes 5–10 minutes to work, and the erection lasts 30–60 minutes. It does not cause abnormally prolonged erections (priapism). It is not a suitable method to use if your partner is trying to become pregnant and, if she is already pregnant, you should use a condom.

Vacuum devices consist of a plastic cylinder with a pump, which may be hand- or battery-operated. A special ring is placed around the cylinder, and the cylinder is then placed over the penis. The pump is activated to produce a vacuum inside the cylinder, sucking blood into the penis, which becomes erect. When the erection is sufficient, the ring is slipped off the cylinder on to the base of the penis, to maintain the erection. The erection lasts until the ring is removed; you must remove it within 30 minutes. Vacuum devices produce a useful erection in about 75% of men, but they are cumbersome and some people find them off-putting because the penis, while erect, is often blue or mottled, and cold. They are supplied with an instruction video. In the UK, vacuum devices are now available on NHS prescription. Side effects such as bruising are uncommon.

Yohimbine tablets. Yohimbine comes from the bark of the Pausinystalin yohimbe tree, which for over a century has been thought to possess aphrodisiac qualities. Various trials have shown success rates somewhat better than the success rates from placebo (dummy) tablets, but mainly in men whose erection problems were not severe. Side effects are usually mild, but may include agitation, anxiety, headache, a slight increase in blood pressure, increased urination and stomach upsets. Also, it is not government regulated, so you cannot be certain of quality.

Surgery to improve blood supply to the penis or to stop blood leaking from it back into the body is possible in certain cases. The results are often disappointing.

Surgical implants to stiffen the penis can be inserted if all else fails, and are helpful if you have Peyronie’s disease. There are several new types, which are much superior to those used just a few years ago. Some are inflatable, and these are much more natural when inflated, and more easily concealed when deflated, than in the past.

• These inflatables use a reservoir that is inserted beneath the abdominal muscle during a small operation. The reservoir is filled with salty water (saline). When you want an erection, you trigger a pump placed in the scrotum next to the testicle. This signal shifts fluid from the reservoir into the cylinders that have been inserted into the penis.
• An alternative to the inflatables is the ‘malleable’ (bendy) type, which maintains a constant erection using flexible rods that can be manipulated into a concealed position afterwards.

Both inflatable and bendy implants are expensive and require surgery, but are effective, and most men who have implants are usually pleased with them (especially because the erection is immediately available). The penis is usually shorter after an implant has been inserted, because of scar tissue, and there may be some change in sensation. Implants do not affect ejaculation. The inflatables and the malleable types seem to be equally successful, though one survey showed that female partners tend to prefer the inflatable type. The main problem with the inflatable type is fluid leakage (which occurs in about 3% of men over 3 years, and will need a further operation to correct the problem) and infection (which occurs in about 3–5% of cases and usually means that the implant has to be removed).

• What is impotence
• How the system works and what causes it to fail
• Questions to ask yourself
• How to approach your doctor and what your doctor can do
• Useful contacts

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