Ask the Pharmacist

Q: I’m a 35-year-old male and for the first time ever, I seem to be dealing with “performance” issues. I thought this stuff only happens to old dudes?

A: Since the 1990s, there’s been a general increase in awareness of what clinicians term erectile dysfunction (ED) but many of the general public are still surprised to find out just how common it is, especially in those who are age 40 and under.

Before we more into its prevalence, perhaps it would be helpful to get a general definition of just what we mean when we use that term. ED is defined as a general inability to develop and/or maintain an erection for satisfactory (clinicians aim their sights low) sexual activity.

There does not seem to be any particular agreement as to how consistent (most guys experience this at least once in a while at any age) the problem needs to be or for what duration the issue has to be present in order to meet the diagnosis but a period of persistence of at least three months seems to be a reasonable guideline. Note, a loss of desire for sex (known as a decline in libido) or ejaculatory issues (such as premature) are not included within this definition but can be significant sexual health-type issues as well.

As far as incidence goes, a number of studies has tried to put a percentage to this question. The figures these studies have generated, although perhaps surprisingly high to some, are probably still much lower than the true incidence due to a general reluctance on the part of males to answer these questions honestly.

The Massachusetts Male Aging Study reported an overall prevalence of 52 per cent. Not surprisingly, the incidence increased with age but what many might find mildly illuminating is how common the problem is with those who are younger.

At age 40, approximately 40 per cent of men are affected, with five per cent reporting complete ED (i.e. an inability to produce an erection at any point in time). The numbers increase fairly steadily throughout the decades to the point that almost 70 per cent of 70-year-olds report having difficulties performing sex.

The incidence of ED increases not only with age but also in the presence of such medical conditions as high blood pressure, diabetes, high stress (some of the chemicals your body produces when you’re stressed cause your blood vessels to constrict, limiting blood supply to the penis), certain drugs (the list is extensive and includes many antidepressants and cardiovascular medicines), a lack of sleep (men with ED are more than twice as likely to also have sleep apnea), alcohol (duh!), obesity, high cholesterol, and perhaps gum disease (80 per cent of men with severe ED also have chronic gum disease although this is probably more of an association rather than one contributing to the cause of the other).

However, when ED occurs in those who are age 40 or less, the number one causative factor, by far, is smoking. We spend so much time harping on the cancer-causing, heart-decaying and lung-destroying effects of cigarettes that something as non-life-threatening as ED gets short shrift. Perhaps the anti-tobacco lobby should refocus its message if it wishes to target the young male demographic.

There are any number of studies around to support the connection between ED and smoking but perhaps the most famous one is a 2011 study involving 65 males who wanted to quit smoking and were subsequently put on nicotine replacement patches. The men’s erections were tested using a penile plethysmograph which is capable of measuring changes in circumference and hardness while men watched dirty movies.

The men were tested before they quit smoking, halfway through the eight-week program, and again one month after it had finished. Thirty-one per cent of the men had successfully quit smoking by the end. Compared with those who had relapsed, the nicotine–free men had wider, firmer erections and reached maximal arousal (but not climax) five times faster.

Interestingly enough, these improvements were not seen until after the men had stopped using the patches and the men, themselves, did not feel they had improved as much as they had (lending credence to the generally-accepted theories regarding males and their self-perception of sexual performance).

It’s not really surprising that this is the case as erections are mainly about the flow of blood into the penis, and smoking is known to damage blood vessels and hinder proper blood flow. In a related note, it is also well-established that men who smoke have more damage to their sperm which could quite possibly negatively influence their fertility.

Another important addendum is that men who made lifestyle changes to improve their cardiovascular health - by lowering cholesterol and blood pressure, losing weight and exercising - also showed improvements when it comes to their ED.

The drugs of choice for this condition remain the three oral phosphodiesterase-five inhibitors (better known as Viagra/sildenafil, Levitra/vardenafil and Cialis/tadalafil) unless they are contraindicated in a particular patient. All work in the same general manner and have roughly the same chances of helping.

If one member of the family proves unsuccessful, it is very possible that either of the other two might work better. They are all roughly the same ridiculous price which is, of course, just a crazy coincidence in our ultra-competitive capitalist society.

Ideally, get a prescription for the highest strength available and start off by cutting them in half or quarters to find the lowest dose that works for you. This is because the various strengths available are all the same price which gives you some idea of how much of your $16 is going toward the ingredients and how much is paying for the ads you're about to see at next weekend’s football game.

The side-effect profiles are more similar than not and include decreased blood pressure (the original purpose the drug companies were hoping these drugs would perform until the researchers noticed some pleasant side effects during their clinical trials), headache, flushing, nasal congestion, upset stomach and the very rare possibility of priapism (an erection lasting longer than four hours which is far less pleasant than it sounds) or visual changes with Viagra.

The main difference between the drugs is duration of action as Cialis stays in your system for up to 36 hours as opposed to four hours for the other two drugs, and time to peak effect which is slower for Cialis (two hours) than it is for Viagra and Levitra ( approximately 1.2-1 hour).

As a reminder, all three drugs require sexual stimulation in order to be effective so they may be taken in advance to provide some degree of spontaneity without fear of having to answer uncomfortable questions at work. For patients who cannot take these pills for safety reasons (such as those who rely on nitroglycerine for angina treatment) or who find all three ineffective, there are a variety of other treatment options which can be safely pursued.

For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/?fref=ts