Erectile dysfunction (ED) is extremely common, with around 35% of men having at least some degree of difficulty getting or maintaining an erection. About 10% of them have a total inability to obtain and maintain an erection.
ED is a common condition affecting many men worldwide, with significant impacts on mental health and relationships. ED carries an estimated 400,000 outpatient healthcare visits, 30,000 hospitalizations, and 146 million dollars in healthcare costs yearly.
Fortunately, with the Food and Drug Administration (FDA) approval of Viagra (sildenafil) in 1998, multiple medications have been introduced that have changed the lives of millions of men suffering from ED.
This article explores the key features, benefits, differences, and considerations of ED medications to help you make a more informed treatment decision.
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Understanding Erectile Dysfunction and Its Causes
Several different conditions can cause erectile dysfunction and can vary in intensity.
What is Erectile Dysfunction?
Erectile dysfunction was previously called impotence. ED is the inability to get or keep an erection that is strong enough for intercourse. There is no specific length of time required for the symptoms, though it isn't considered chronic until after six months.
Erectile dysfunction begins to become more common around age 40, but the incidence increases with age, with a prevalence of nearly 75% by age 80.
Causes and Risk Factors
ED is usually caused by more than one factor. Some causes of ED are physical, while others are psychological. ED can be related to depression, performance anxiety, or even other sexual disorders. The psychological causes can co-exist with some of the physical causes.
Some of the possible medical causes of ED include:
- Trauma
- Neurological diseases
- High cholesterol
- Strokes
- Sleep apnea
- Chronic lung disease
- Prostate problems
- Diabetes
- Hormonal problems
- Medication
- Previous surgical procedures
- Cardiovascular disease
- Alcohol use
- Obesity
Erections occur through the relaxation of a smooth muscle in the penis called the intracavernosal muscle. This allows blood to flow into the corpora cavernosa in the penis and decompresses the veins that flow out of the penis, which helps the penis to become erect.
This process is generally started by the release of nitric oxide released by nerve cells in the penis.
The Role of Medications in Treating ED
The most common medications for ED work by causing increased release of nitric oxide, boosting blood flow, and improving erections.
Overview of ED Medications
Sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) are all in a class of medications known as phosphodiesterase 5 inhibitors (PDE5 inhibitors).
Initially, these medications were investigated to treat high blood pressure and chest pain when the side effect of increasing erections was noted.
Sildenafil (Viagra)
Sildenafil was the first medication for ED approved in 1998. In addition to treating ED, sildenafil is also a treatment for primary pulmonary hypertension.
Sildenafil also has off-label uses, such as Raynaud phenomenon, altitude-induced hypoxemia, and female sexual arousal disorder.
It works by inhibiting PDE5 and causes relaxation of the smooth muscles in the corpus cavernosum to allow engorgement of the penis leading to erection.
Sildenafil comes in 25, 50, and 100mg tablets for treatment of ED. It is taken around 1 hour before sexual activity. It is often started at 50mg and adjusted up or down depending on side effects or effectiveness.
Sildenafil can be taken as soon as 30 minutes before intercourse or as long as four hours. The medication usually takes effect as soon as 30 minutes and lasts up to 18 hours.
Tadalafil (Cialis)
Tadalafil is another PDE5 inhibitor approved by the FDA in 2003. Tadalafil relaxes the bladder and prostate muscles which increases blood flow to the penis.
Tadalafil is used to treat pulmonary artery hypertension as well as benign prostatic hyperplasia.
Tadalafil comes in 2.5, 5, 10, and 20 mg doses. It is also available as a combination medication with finasteride for benign prostatic hypertrophy. It can be dosed daily or as needed before intercourse.
The daily administrations are generally for benign prostatic hypertrophy or pulmonary artery hypertension. For ED, it is usually started at 10 mg at least 30 minutes before sexual activity.
Vardenafil (Levitra)
Vardenafil is another PDE inhibitor, but it is more specific for PDE 11, which may allow it to be more effective at lower doses.
Vardenafil is dosed in 2.5, 5, 10, and 20 mg tablets and a 10 mg oral disintegrating tablet. For erectile dysfunction, it's generally started at 10 mg around an hour before sex. The dose may be adjusted based on response and side effects.
Key Differences between Sildenafil, Tadalafil, and Vardenafil
While sildenafil, tadalafil, and vardenafil all have a similar mechanism of action, there are differences between them.
Onset and Duration
Of the three medications, sildenafil has the shortest half-life, while tadalafil has the longest. This allows tadalafil to be administered independently of when sexual intercourse is anticipated.
Sildenafil's half-life is 4 hours, vardenafil's is 4-6 hours, and tadalafil's is 17.5 hours. All three medications may take effect as soon as 15-30 minutes after they are taken. Vardenafil may be slightly faster than sildenafil or tadalafil.
Sildenafil generally lasts 4-5 hours, while tadalafil lasts 24-36 hours and vardenafil 4-5 hours.
Side Effects and Precautions
PDE inhibitors are effective for ED but also come with potential side effects. Some of the common side effects include:
- Headache
- Flushing (more common with sildenafil)
- Heartburn
- Changes in color vision
- Back pain or muscle pain (more common with tadalafil)
- Low blood pressure or dizziness
- Runny nose
The common side effects of PDE inhibitors are rarely severe enough for people to stop taking them. The more serious potential side effects are rare.
Some of the conditions with which PDE inhibitors have been associated include:
- Priapism (prolonged erection)
- Melanoma
- Hearing loss
- Non-arteritic anterior ischemic optic neuropathy (NAION) is a type of painless, irreversible vision loss in one eye
- Prostate cancer
The side effects are infrequent, so they do not require the medications to be removed from the market.
Cost and Accessibility
Medications for ED are not universally covered by insurance. Some insurances may cover these medications, particularly generic forms, while others exclude them from their policies.
Out-of-pocket costs for sildenafil may vary from $0.56-$16.06 per pill depending on strength, while tadalafil costs may vary from $0.72-$21.74 per pill. Vardenafil costs range from $9.46-$50.23 per pill, depending on strength.
These costs are estimates, and specific costs may vary by pharmacy, location, and availability. Some of the medications can be obtained from online mail-order programs.
Who Should and Shouldn't Take ED Medications
While ED medications are very effective for many people with ED, they are not the best option for everyone.
Ideal Candidates for ED Medications
The ideal candidates for ED medications are relatively healthy men who don't have a history of low blood pressure, heart disease, stroke, or uncontrolled diabetes.
The ideal candidate should also not be on any medications, which would make it more dangerous to take the medications as there are several medications with which PDE inhibitors can interact.
Contraindications
There are several contraindications to the use of PDE inhibitors.
People who are taking nitrates such as nitroglycerine, isosorbide mononitrate, or isosorbide dinitrate or those who are on certain types of heart medications that can affect their QT length should not take PDE inhibitors as they are absolute contraindications to these medications.
There are also relative contraindications to the use of PDE inhibitors. Some of these include:
- Recent history of heart attack, stroke, or arrhythmia
- Low or high blood pressure at rest
- History of heart failure
- History of unstable angina (chest pain)
- Use of alpha-blocker medications
Before taking PDE inhibitors, it is essential to consult a healthcare provider and tell them about any medical conditions you have or medications that you may be taking.
Tips for Using ED Medications Effectively
PDE inhibitors can be very effective for treating ED, but there are some things you can do to ensure optimal results.
Timing and Dosage
PDE inhibitors should generally be taken at least 30 minutes before intercourse.
Sildenafil should be taken on an empty stomach 30 to 60 minutes before intercourse, while on-demand use of tadalafil should be 1 to 2 hours before intercourse for best effects.
Tadalafil use is not changed by food intake, so it doesn't require an empty stomach. Vardenafil can also be taken with or without food and is optimally taken about 1 hour before sexual activity.
Your healthcare provider may adjust the dose depending on side effects and efficacy.
Enhancing Results with Lifestyle Changes
Lifestyle changes may help treat ED with or without medications. Some of the lifestyle modifications that may be effective include:
- Weight loss for individuals with overweight or obesity
- Managing stress
- Getting adequate sleep
- Regular exercise
- Healthy diet
- Intercourse
A regular exercise routine, such as walking 30 minutes daily, may decrease your risk of ED by 41%.
Dietary changes, including minimizing the amount of red meat or processed foods and replacing them with vegetables, whole grains, and fruits, may decrease one's risk of ED.
Controlling your chronic health conditions such as high cholesterol, diabetes, or high blood pressure can also help your symptoms.
Consult your doctor before making significant lifestyle changes.
Managing Side Effects
Most of the common side effects of PDE inhibitors do not prevent people from taking them; most of these side effects can be managed.
Fluids and rest can manage headaches. Avoiding alcohol is also important. Your healthcare provider or pharmacist can recommend medications if the pain is severe enough.
Avoiding spicy and rich foods can manage nausea. Taking the medication with food, unless directed otherwise, can help manage these symptoms as well. Antacids can manage heartburn.
Flushing can be treated by decreasing the use of caffeine and alcohol.
If you continue to have symptoms, or if simple remedies don't help, talk to your pharmacist or healthcare provider to determine whether you need to change medications or use another treatment to control side effects.
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Key Takeaways
- ED is a common medical condition that is associated with significant physical and psychological impacts on people with the condition.
- ED is associated with substantial economic costs.
- PDE inhibitors are effective medications for treating ED.
- PDE inhibitors should not be used in people on nitrates or with certain medical conditions.
- Sildenafil should be taken on an empty stomach, while tadalafil and vardenafil can be taken with or without food.
- Tadalafil can be taken independently of the timing of sexual intercourse.
- ED can cause significant distress and decrease quality of life, but fortunately, it is very treatable. If you or someone you love is suffering from ED, talk with your healthcare provider about treatment options that may be right for you.
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