VIAGRA:
EVERYTHING YOU NEED TO KNOW

[Note: There is a great deal more to erection maintenance and restoration than Viagra. The material here represents only about 10 percent of the Great Sex chapter on erection problems. However, many people have questions about erection medication. This should answer them.]

Sexual arousal stimulates release of nitric oxide in the penis, which triggers synthesis of compounds that relaxe the organ’s smooth muscle tissue. The result is increased blood flow into the penis’ spongy erectile tissues, which produces erection. Viagra (sildenafil) increases the relaxation of the penis’ smooth muscle tissue, spurring greater blood flow into the penis.

Viagra has many advantages: It’s is a pill, and Americans love pills because they are familiar and convenient. It works best when taken two to four hour before lovemaking, so the woman need not know you’re using it. It helps men with erection dysfunction (ED) caused by both physical illness and stress/anxiety problems. Most studies show that it produces erections in 75 percent of cases, with even greater effectiveness among men with only mild or occasional problems. It raises erection only with normal sexual stimulation. No walking around with an embarrassing bulge in your pants that signals you’ve taken a drug. For most--but not all--men, it’s also quite safe. Its only significant side effects are headache (16 percent of users), flushing (10 percent), upset stomach (7 percent), nasal congestion (4 percent), and rarely, visual disturbances, mostly in men with chronic eye conditions such as macular degeneration. Few health insurers cover it, but it’s quite affordable. The dose most men take, 50 mg, costs about $10, a small price to pay for an amorous evening free from erection worries.

However, Viagra has limitations: It doesn’t work in about 25 percent of cases. As severity of ED increases, Viagra’s effectiveness decreases. For example, it works well in most men with diabetic ED, but less well in diabetics with considerable cardiovascular and neurological damage. Even in men with mild erection balkiness, Viagra may not work in some situations--if you feel particularly stressed, distracted, or alienated from the sexual experience.

Finally, some men should absolutely never use Viagra--those taking nitrate medication for heart disease, notably nitroglycerine for angina, or the party drug, amyl nitrate (“poppers”). The combination of Viagra and nitrate drugs can cause a precipitous drop in blood pressure--and possibly death. Before this problem was identified, the combination of Viagra and nitrate medication killed more than 500 men. If you take any nitrate drug, don’t use Viagra.

In addition, Viagra is associated with a small increased risk of heart attack and stroke. It slightly increases the tendency for blood to clot. Internal blood clots trigger heart attack and most strokes. Men with histories of heart attack and stroke should consult their doctors before using Viagra, and consider taking an anticoagulant, for example, aspirin, to reduce risk of internal clots.

Viagra comes in 50 mg pills. The typical dose is 50 to 100 mg--one or two pills. Side effects are more likely with the higher dose.

The latest studies suggest that some men need to increase their dose over time. University of Alabama researchers tracked 150 men who took Viagra regularly for two years or more. During that period one-third of them had to increase their dose from 50 to 100 mg.

Viagra was approved for persistent ED, but once a drug is approved for any reason, doctors are free to prescribe it for other, so-called “off label” uses. Viagra’s main off-label use is as “erection insurance” for men with occasionally balky erections who don’t want to worry about them. If you use Viagra for erection insurance, you might not need 50 mg. Try cutting the pills in half. Twenty-five mg is often sufficient.

If you have balky erections or feel anxious about getting it up, should you use Viagra for erection insurance? That’s up to you. If you’re over 40 and you ask for a prescription, most physicians are willing to oblige. Many are happy to prescribe it for younger men. The real issue is what you do with your more reliable erections once you have them. If you use Viagra to imitate pornography--mechanical, all-genital sex with a headlong rush into intercourse--the drug may not work because porn-style sex is often stressful enough to overwhelm Viagra’s benefits. In addition, your lover may experience “Viagra-vation” (see below). But if Viagra allows you to relax about your erections and focus on whole-body sensuality, then it can enhance lovemaking.

At this writing (Sept. 2003), the Food and Drug Administration has just approved another erection medication, Levitra (vardenafil), and appears poised to approve Cialis (tadalafil), which is already available in Europe. Both work that same way as Viagra, but they last longer. Instead of producing erection for 3-4 hours, these drugs are good for about 24 hours, and in some men up to 36.