Jul 26, 2019
It’s 21 years since Viagra was first approved to treat erectile dysfunction, now some new treatments are being added to the options.
Since Viagra rocked the world of adult relations 21 years ago, there have been no new blockbuster drugs for the bedroom but there have been notable changes in the way erectile dysfunction (ED) is perceived and managed.
Today, there is more to it than just restoring blood flow, and doctors are having to take a raft of social trends into account.
On the medical side, a new drug recently became available in Australia and clinics around the country have begun offering a handful of new therapies, some supported by evidence and, worryingly, some not.
Online and out of view, men continue to buy dubious pills, sprays and lotions. They try herbal remedies and hide medication, purchased abroad, in their luggage.
The history of medicine is littered with hopeful treatments for ED. Complicated potions exist in Chinese texts dating to 2600BC, and balms made from baby crocodile hearts mixed with wood oil appear in Egyptian medical texts from 1600BC.Dr Eric Chung, the co-author of new Australian guidelines on the management of erectile dysfunction.
Through millennia, innumerable animals’ testes, horns and hearts have been ground up in the quest for male potency.
Finally, last century, effective penile implants followed by penile injections came along, only to be topped by the most outstanding development so far, the Viagra family of drugs, which then only included Cialis and Levitra.
As ED is a natural part of ageing, it is one of the most common conditions affecting middle-aged and older men. But today, caught in new social trends, more younger men are showing up with it, too.
So that GPs can help men deal with ED, new Australian guidelines for its management are being drawn up. These will deal with complexity of sexuality, not just its mechanics.
“There was a time that, when a man presented with ED, the doctor looked only at his penis,” says one of the guideline authors, Associate Professor Eric Chung.
“Now we are looking at the man’s whole body in its social context: from his cardiovascular function to lower urinary tract symptoms to blood-sugar, his medication, lifestyle, weight, mental health, sexual preferences and relationships.”
Chung, chair of the Andrology Group for the Urological Society of Australia and NZ, is compiling the guidelines with Dr Michael Lowy, a sexual health physician commissioned by the Australasian Chapter of Sexual Health Medicine of the Royal Australian College of Physicians.
They say prominent sociological factors such as pornography on the phone, dating apps, easy access to sex, gender fluidity and the #MeToo movement, are affecting ED.
Viagra triggered a new openness, shifting ED from a taboo to a mainstream subject of discussion, but Chung says social trends have widened the discussion.
“As physicians, we have had to become more open minded. Many of us were brought up with a strictly heterosexual definition of erectile dysfunction.”
The gay community was the first to challenge this and doctors had to educate themselves about the subtle differences in perception of what is desirable and effective function.
“Among gay men, there is often a greater emphasis on aesthetics, on the perfect shape of the penis, on the ability to perform on demand, and on the ability to last.”
Chung, an associate professor at the University of Queensland, Macquarie University Hospital and a visiting professor at Hong Kong University, says the easy accessibility of pornography has posed challenges too.
“In adult relationships there is a lot of controversial data about its effects. There are basically two camps. One says watching online pornography reduces engagement with a partner. The other says it encourages more.
“We are also now seeing a lot of younger men struggling with what they perceive as normal, based on pornography. They have unrealistic expectations and are anxious.
“Some can’t perform because they live in a bubble world of pornography. They seek advice on the internet, where the messaging is often mixed and compounds their problems.”
A new treatment delivers sound waves to the shaft of the penis hopefully to create new blood vessels.
Lowy, who has been working in the field for 27 years, says the impact of pornography is marked, particularly in young men who have developed a dependency on it.
“They may watch it daily, for hours, often edging [forcibly stopping themselves from ejaculating]. Eventually they become so conditioned that when they are with a partner, they can’t ejaculate. We try to decondition them, suggesting cold turkey, or that they limit themselves to five minutes of viewing.”
For older men, he says although the Viagra family changed the landscape, many who start these drugs don’t continue even if they are effective.
“They don’t because there is so much more to treatment of ED than improving blood flow and creating an erection. This condition needs an unrushed, broad investigation which often involves bringing in the partner too.”
So, what is new since the Viagra family arrived?
A second generation of it recently arrived in Australia. Called Spedra, it can be taken 30 minutes before sex and can last up to six hours.
Also new is a Viagra-like wafer to place under the tongue for faster absorption. Wafesil Wafers are available in the US and Europe but not, officially, in Australia.
Lowy says a form of Viagra-like gel, Kamagra, is not registered in Australia but is frequently brought back from Thailand. It’s quick-acting and is being used by young people, even if they don’t need it.
He says Viagra helped initiate a new understanding of ED. It demonstrated that ED is often related to the health of the thin layer of cells that line blood vessels.
If these endothelial cells are not intact, the penile vessels can’t release nitric oxide which is as essential part of the erectile mechanism.
These cells can be damaged by oxidative stress from lifestyle factors such as smoking, drinking, over-eating and being sedentary. It’s now established that taking up regular exercise assists potency.
Also new is interest in low-intensity shock wave therapy. It delivers sound waves to the shaft of the penis, hopefully to create new blood vessels.
While regarded as experimental in the US, this therapy has been endorsed by the European Association of Urology and the European Society for Sexual Medicine.
Although not a standard treatment, it is offered here. The Asia Pacific Society for Sexual Medicine (which includes Australia) is preparing a consensus statement for its use.
A narrative review in the Medical Journal of Australia emphasised that ED is often a flashing red light for other disorders.
There is also high interest in stem cell therapy, which has been effective in animals. Its success has not been replicated in humans.
But with technology to produce stem cells being cheap and easy to use, clinics are offering it. Chung says men are naively lining up to have stem cells harvested from their fat or muscle tissue and reinjected into their penis – with no evidence it works.
The same naivety can be seen at clinics advertising the P-Shot, also known as the Priapus Shot or the Vampire Shot. At these clinics, platelet-rich plasma is extracted from men’s own blood.
This contains many growth factors and is reinjected into the penis – again with no evidence it works and with potential harm, he says.
On a more sophisticated level, there is gene therapy that aims to deliver genes that produce products that may not be functioning properly in the penile tissue of men with ED.
Success in animals has been limited and it is likely that it will take a long time to determine if this works in men.
Meanwhile, researchers are racing for the next breakthrough. Work is under way on a tablet that dissolves under the tongue, on a cream that can be applied to the penis and on a drug delivered through the nose.
This year, a narrative review of the management of ED in the Medical Journal of Australia emphasised that ED was often a flashing red light for other disorders, such as cardiovascular disease and diabetes.
The author, Dr Chris McMahon, a pioneer of male sexual health in Australia, says ED is an opportunity to assess a man’s overall health and detect unrecognised disease.
Viagra helped initiate a new understanding of erectile dysfunction.
“It’s well recognised the majority of men who’ve got ED will have underlying penile vascular disease,” he said in an MJA podcast with the review.
“Most of these men will have risk factors which include diabetes, high cholesterol, high blood pressure and smoking.”
McMahon, director of the Australian Centre for Sexual Health in Sydney, says if a man presents with ED he should probably be tested for cardiovascular disease, particularly if he has significant risk factors.
Despite all this activity for men, little is happening for women. Some say it is hard to find effective therapies because female sexuality is more complex, with many more neurological factors at work.
The first drug to treat low libido in women, Addyi, was approved in the US in 2015. It received a lukewarm reception.
Last month, a second female drug, Vyleesi, delivered via an injector pen into the abdomen or thigh, received US approval and is yet to hit the shelves.
Neither are available here. But just this week, Australian researchers suggested a special form of testosterone should be formulated to boost sexual wellness in post-menopausal women.
Professor Susan Davis: “Increasing their frequency of a positive sexual experience from never, or occasionally, to once or twice a month can improve self-image.”
Via Jill Margo for AFR.