BMJ  2004;329:E310-E311 (24 July), doi:10.1136/bmj.329.7459.E310

BMJ USA: Editorial

Editorial

Pharmacologic treatment of erectile dysfunction

Not always a simple matter

The phosphodiesterase-5 (PDE-5) inhibitors are remarkable designer drugs. Not only have they benefited countless men and couples all over the world—they have created optimism that other male and female sexual dysfunctions may someday be treatable pharmacologically. Optimism about prosexual drugs needs to be tempered by the awareness that all sexual behavior is the sum of psychological, interpersonal, cultural, and biological elements. Sex can seem like a simple matter, but it is not. As Tomlinson and Wright's study in this issue of BMJ USA (p 339) demonstrates, physicians and patients should not expect a panacea.

Stripped to its psychological essence, potency requires a man to be willing to make love to his partner and to be able to experience arousal during sexual behavior. If he can feel this emotion and his neural, vascular, and endocrine systems are relatively intact, nitric oxide will be secreted in his corporal endothelial cells. This gas binds to an enzyme that generates cyclic guanosine monophosphate (cGMP), which in turn induces vasodilatation in overlaying smooth muscle cells. All PDE-5 inhibitors slow the degradation of cGMP by competitively binding to the enzyme that hydrolyzes it.

Sildenafil was the first PDE-5 inhibitor, but now there are also vardenafil, which has an earlier onset of action, and tadalafil, which has a much longer duration of action. The science behind the PDE-5 inhibitors is very good. The drugs are safe (although they cannot be used along with organic nitrates), effective in approximately 75% of men (although not nearly at the same rate in men with diabetes and those who have been treated for prostate cancer), and often helpful.

Erectile dysfunction is generated by a wide variety of biogenic and psychological causes.¹ Those affected may be young, middle-aged, or older men. They may be single, married, divorced, faithful, unfaithful, heterosexual, homosexual, or paraphilic. These factors make a difference. Clinicians should be wary of glib generalizations about emotional reactions to treatment. Emotions arrive in a series, not singly. Each one has a time course. New feelings appear when patients perceive additional limitations of treatment success. Other events commonly occur that change the original meanings of treatment.

Our group gave Viagra to 54 consecutive men with erectile dysfunction in a private mental health group practice in 1998.² We found differing degrees of success and four recurring responses during the first month of successful treatment. Most men were grateful to be the beneficiaries of modern medical technology. Some felt initial shame for requiring assistance with what should be a normal capacity. They transiently saw Viagra as a badge of their inferiority. Some had a pervasive excitement about their new sexual confidence and were again preoccupied with their earlier ambitions to be with multiple partners. A few placed great hope in their improved erections as a solution to longstanding interpersonal problems with a particular partner. Most of the men had all of these reactions, to some extent.

Improved erections induce a range of behavioral responses. Rejuvenation of the primary sexual relationship is often seen, but it is far from guaranteed. Disappointment with the spouse as a sexual partner is sometimes seen after a few initial sexual acts. Longstanding resentment of the partner leads some men to use the drug with another partner—woman or man—to enjoy masturbation more, or to abandon the use of the drug. Others increase the number of their partners, typically with duplicity.

Spousal concerns are highly relevant to the long-term outcome when a PDE-5 inhibitor is prescribed. Partners are not necessarily psychologically ready to resume a regular sexual life when their husbands are. Post-menopausal intercourse cessation may have predisposed them to dyspareunia. Many partners correctly predict that their partners' improved erections will not benefit their sexual arousal capacities and sex will be one-sided. And most wonder whether their partners will use the medication only with them, which triggers transient fears of abandonment. How a man and how a couple cope with this new opportunity depends very much on their unique mental and relationship states.

This diversity of responses is not what physicians and the public are being told. Marketers rely on appealing, simplistic images of men and implicitly promise an improvement in their psychology, interpersonal relationships, and well being. The marketing departments of the companies that make these products are actively making the case to patients and physicians that their product is best in some way. The specific PDE-5 inhibitor does not matter. Clinicians quickly learn that just because a man's erections are improved does not mean that his sexual life at home will be.³

Because of their long-term relationships with men and their spouses, primary care physicians have several advantages in taking care of men with this problem. Not all men with erectile dysfunction want a prescription. The cost of the drugs, youth, and anti-medication philosophy enable the doctor to look beyond the PDE-5 inhibitors for some men. When they receive a prescription, patients often expect a follow-up visit. These ensuing visits can rescue some men from failure by correcting their misunderstandings of how to use the drugs and helping to process their initial emotional reactions. They also educate the physician. Subsequent patients benefit from the doctor's growing skill in managing the forces that prevent the drugs from rejuvenating sexual life. Eventually some patients for whom the drug is not enough will accept a referral to a mental health professional, who can help the patient realize that no sexual act is without biological, psychological, interpersonal, and cultural contributions.

Case Western Reserve School of Medicine Cleveland, OH, Center for Marital and Sexual Health Beachwood, OH sbl2{at}case.edu

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Paper p 339

Competing interests: SBL has received an independent research grant from Pfizer and is a principal investigator for a Pfizer study. He is a member of a Mental Health Advisory Board for Lilly-Icos and was a principal investigator for a Lilly-Icos study.

References

1. Leung AC, Christ GJ, et al. Physiology of penile erection and pathophysiology of erectile dysfunction. In: Lue TF, ed. Atlas of male sexual dysfunction. Philadelphia: Current Medicine, 2004.
2. Pallas J, Levine SB, Althof SE, Risen CB. A study using Viagra in a mental health practice. J Sex Marital Ther 2000;26: 41-50.[Medline]
3. Althof SE. Therapeutic weaving: the integration of therapy techniques. In: Levine SB, Risen CB, Althof SE, eds. The handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge, 2003.

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AK Al-Sheikhli
bmj.com, 23 Jul 2004 [Full text]