By Dr. Cynthia Paulis

Erectile dysfunction or impotence occurs when a man can no longer get or keep an erection firm enough for sexual intercourse. If this is an ongoing problem, it can be a sign of a serious health condition that needs evaluation, such as heart disease or poorly controlled diabetes. Oftentimes treating the underlying problem can reverse erectile dysfunction, but if it still occurs there are alternative treatments.

Dr. Aaron Katz, chairman of the department of urology at Winthrop University Medical Center, said, “The goal of oral medications is to restore or enhance blood flow to the penis.”

He said Viagra, which comes in three dose levels, works for about four hours.

“It can be very helpful for men recovering from prostate cancer surgery, where the nerves and the blood supply to the penis may have been damaged during the surgical removal of the prostate,” he said. “We typically would use this medication much earlier after the surgery than we had in the past.

“In the past, we had the philosophy of just watch and wait and maybe the blood flow and the nerves will be restored. But some of the more recent studies have shown that if you use these drugs early on…the long-lasting effects can be much greater,” he said.

“Viagra can be used as a bridge and hopefully it will restart, almost like a battery, and then maybe—hopefully—Viagra will not be used for long-term use.”

One of the other well-known drugs on the market is Cialis (tadalafil), which has a much longer-acting component but works in a similar way to Viagra.

What makes this drug unique is that it can work for 36 hours. “It does give you much more spontaneity than Viagra does,” Katz said. “Cialis is known in Europe as the ‘weekender.’ You can take it on a Friday and have sex for the entire weekend.”

Cialis comes in a 20-mg dose, but the company has now come out with 2.5-, 5- and 10-mg doses that can be taken daily.
Both Viagra and Cialis take effect within an hour of taking them. Side effects of both drugs are minimal; some men can develop back pain after taking Cialis, and both medications can cause flushing and headaches. However, they are fairly safe drugs as long as you are not taking them with nitrates, drugs commonly prescribed for chest pain such as nitroglycerin, Nitro-Bid, Nitrostat, Imdur, Monoket, Dilatrate and Isordil.

Other medications that can cause problems with erectile dysfunction meds are blood thinners, alpha blockers for benign prostatic hyperplasia and high blood pressure medication.

A third oral medication is Levitra, which works similarly to Viagra and has a four-hour window.

A recent call to a pharmacist broke down the prices as following. Their best-seller was Viagra, with a six-pill pack costing roughly $135; Levitra was the least expensive, at $10 a pill; and Cialis ranged in price from $134 for the 20-mg pill to $147 for the lower dose of 5 mg, which is taken daily.

Most of these are covered by insurance but according to the pharmacist, Viagra seems to be the one favored by insurance companies.

There are two other, non-oral medications used to treat erectile dysfunction. The alprostadil penis suppository is a small suppository that goes into the opening of the penis and delivers blood flow there. Erections usually begin within 10 minutes and last 30 to 60 minutes. It is not used often because it can cause pain and bleeding in the urethra, along with the formation of fibrous tissue.

Another method is alprostadil self-injection (brand names Caverject, Edex), wherein a fine needle is used to inject alprostadil into the base or side of the penis. The injection will produce an erection that occurs within a few minutes and lasts an hour. Side effects from this method include bleeding, prolonged erection and formation of fibrous tissue at the injection site.

Katz said, “More than 50 percent of [male] diabetics have erectile dysfunction, so this may be very helpful for those patients.”

Testosterone replacement for men with low levels of testosterone have helped some men who are menopausal and experiencing erectile dysfunction.

If medications fail, the patient may have to seek alternative treatments such as a penis pump, a penile implant or blood vessel surgery.

Katz said he has patients in their eighties with very active sex lives. One thing he emphasizes is that “you need to take care of your body. It’s all about flow and cholesterol and preventing arterial plaque that builds up in the heart and the small arteries to the penis. Men who are overweight and want to have sex, they want to take the quick fix, they want to take the Viagra—well, that’s not the answer.

“The answer is to get in shape, work out, do yoga, meditate, be mindful of what we take into our bodies,” he explained. “Eat less fat, less red meat, eat more vegetables and practice more healthy living, do more aerobic exercise—running, jogging, swimming, biking—then you will have a better sex life and you won’t need the Viagra.”

Dr. Aaron Katz

If you ask my cousin Sonny, the only reason he is alive today is because of free bagels and a PSA test.

“Our local hospital was offering a free men’s prostate screening test, and afterward they served free coffee, bagels and donuts,” he said. “My friends and I would hang around, compare our numbers and socialize, so a group of us made this a yearly thing.”

Sonny’s numbers were always low, until one year when they weren’t. He followed up with his urologist for a biopsy and found that he had prostate cancer. He made the decision to have his prostate removed after discussing the options with his doctor and others, and has now been 13 years cancer-free.

One in six men in this country will be diagnosed with prostate cancer in his lifetime; it is one of the most common causes of cancer in men. Prostate cancer is usually slow growing and initially remains confined to the prostate gland.

When I was in medical training, I knew a family practice doctor who was in great shape, was healthy, exercised regularly and died at the age of 45 of prostate cancer, leaving behind a young family. He had not had a screening test and his cancer advanced quickly, and he was dead within a few months.

Prostate cancer may not have signs or symptoms in the early stages. Cancer that is advanced may cause problems urinating, decreased force in the stream of urine, blood in the urine, blood in the semen, swelling in the legs, discomfort in the pelvic area and bone pain.

One of the ways to detect prostate cancer is through the combination of a rectal exam and a PSA test. PSAs, or prostate-specific antigens, appear in the blood in elevated amounts in the presence of cancer, so the blood test is used as a screening tool. However, the test has come under fire in the press and by certain organizations who feel that it is unnecessary because it produces some false positive results. These are common—only about one in four men who have a positive PSA test turns out to have prostate cancer. Things that can increase PSA levels are benign prostate enlargement, benign prostatic hyperplasia or prostate infection.

Dr. Aaron Katz, author of The Definitive Guide to Prostate Cancer, a board certified urologist and chairman of the department of urology at Winthrop University Medical Center, said, “We are detecting a lot more prostate cancer because of the PSA screening. The issue is that we are detecting a lot of cancers that probably don’t need to be treated, and men are still undergoing surgery and radiation; unfortunately, some of the men do wind up with side effects like erectile dysfunction and urinary incontinence.”

The U.S. Preventative Services Task Force now recommends against PSA screening, because “they felt that PSA screening tests did not save enough lives to make it worthwhile and the cost to society was high,” Katz said.

He disagrees with the findings and feels that without the test, we are missing an opportunity to find cancer early on.
“The doctors who sit on that task force—none of them are urologists, none of them are even cancer specialists,” Katz said. “They are looking at a couple of flawed studies and making recommendations. The head of the task force is a pediatrician from Texas.”

The Mayo Clinic recommends offering PSA screening and rectal exams to men age 50-75 years and to men 45-75 years with a positive family history of prostate cancer.

Katz recommends “diet, exercise and supplements to try to prevent men who have early stage prostate cancer from going on to treatment. We recommend men eliminate red meat and fried food, get on pomegranate extract pills, anti-inflammatory herbals, fish oils and lycopene pills and do aerobic exercise. This is a very successful program.

“Men need to get screened for prostate cancer by the age of 50,” he continued. “I think men need to be informed about the result and what it means. Men need to take on a more active holistic life style to prevent prostate cancer. You need to take care of your body.”