MANILA, Philippines—Last week, I sat beside a friendly German gentleman, who must be in his late 60s, while on a train trip from Cologne to Stuttgart. Seeing that I was reading a journal article on erectile dysfunction or ED, he started relating his case to me. He was diagnosed to have diabetes and high blood pressure more than 10 years ago and his virility started to wane soon thereafter. Since five years ago, “getting it up”—as he expressed it—was history.

He’s now enrolled in a clinical trial in one of the university hospitals in Cologne. Although it was explained to him as a double-blind trial such that neither he nor his doctor knew whether he was taking an active drug or just a dummy pill, he thinks he’s taking the active drug because he has noted considerable improvement in his erectile function. He’s worried though that he might have some side-effects since he was also diagnosed to already have heart disease.

Lengthy explanation

With another two hours of train travel, I accommodated him with a lengthy explanation on the risk factors that cause ED, and the safety and efficacy of current drugs for ED belonging to the phosphodiesterase enzyme 5 (PDE5) inhibitor class.

As a male reaches his fifth decade of life, ED may start to be a problem. The presence of risk factors which affect the blood vessels such as diabetes, high blood pressure, elevated cholesterol levels, and smoking increases the risk of developing ED. A diminishing level of the male hormone or androgen has also been implicated.

Males with prostate problems may also complain of ED. Surgical removal of the prostate does not improve sexual function and may even worsen it. Some classes of drugs for hypertension, excessive alcohol intake and psychological problems can also cause ED.

Many have the misconception that ED is a muscle problem. It’s actually a blood vessel problem caused by another ED which is endothelial dysfunction. The endothelium is the innermost lining of the blood vessel.

Penile erection involves interaction between the nervous system and the blood vessels. The end result is dilation of the blood vessels in the corpus cavernosum of the penis.

In most instances, ED is mild and affected individuals are still able to carry out the sexual act although the satisfaction level is not as good as in previous years. In an unfortunate 25-30 percent however, ED is severe enough as in my newly acquainted German friend, such that the male organ no longer stands up to the occasion no matter how strong the desire might be.

Treatment mainstay

The mainstay of treatment still consists of lifestyle modification, stress or anxiety reduction and psychosocial counseling. When properly established, androgen replacement therapy can also help the problem.

However this has to be administered and closely supervised by a physician because serious side effects such as damage to the liver may also occur occasionally. What is currently being popularly used are the PDE5 inhibitors which offer what one may call as symptomatic relief. It does not cure the problem but it helps what matters most, i.e., standing up to the occasion when needed.

Three types of this class of drugs are available in Europe, the United States and even in the Philippines. These are vardenafil, sildenafil and tadalafil. They all enhance blood vessel dilation and relaxation of penile vascular smooth muscles to promote penile erection. But none of these drugs can be effective without appropriate sexual stimulation.

Effectiveness of these drugs vary from one person to another but the majority report benefit or some improvement. Various clinical trials have shown that they can enhance erectile function and sexual performance and the quality of life has been improved for millions of men worldwide because of these drugs.

“It may be good for my ED but is it safe for people with heart disease like me?” the German gentleman asked.

The truth is, the first PDE5 inhibitor was initially tested for patients with constricted heart arteries since it is a vasodilator. But when performing the clinical trials, the doctors noted that many of the patients enrolled in the trials requested that they keep the leftover active drug pills.

Unusual side effect

They reported an unusual side-effect; but unlike most side-effects which are undesirable, the side-effect they experienced made them feel good. It improved their sexual life. The use of PDE5 inhibitors was then repositioned for ED. This is known to be one of the serendipitous discoveries of modern medicine.

So experts on ED recommend that even patients with stable, repeat that, stable heart disease can take PDE5 inhibitors safely. Clearance from one’s doctor is necessary. The clearance is actually not concerning the safety of the drug but more for the degree of the heart function of the individual whether or not he’s physically capable of carrying out the sexual act. Even patients who already experienced a heart attack in the past can still take it. Again the key factor there is stability of the heart condition.

One important precaution though is that nitrates, alpha blockers or any drug which also causes blood vessel dilation should be avoided within 24 hours of intake of a PDE5 inhibitor because undue lowering of the blood pressure may occur if these drugs are taken together.

After my explanation, the German jokingly asked me: “Are you also taking any of these drugs?” I looked at him seriously for a second and asked: “Do I look like I need it already?”