Monday, March 24, 2003
Copyright © Las Vegas Review-Journal

ERECTILE DYSFUNCTION: The Little Blue Pill

After five years on the market, Viagra proving successful in attracting men to seek medical help, but it also can cause problems in relationships

What prescription drug is an official sponsor of Major League Baseball?

What drug is featured on the priciest part of NASCAR driver Mark Martin's car?

What drug has boasted as its pitchman no less a personage than former U.S. senator and presidential candidate Bob Dole?

It's Viagra, the little blue pill that has not only been a sexual godsend to -- according to manufacturer Pfizer's count -- more than 16 million men, but has become nothing less than a staple of American popular culture.

It was five years ago this month that Viagra received its formal U.S. Food and Drug Administration approval.

And today, according to Pfizer, nine Viagra tablets are dispensed every second around the world.

As Viagra celebrates its fifth birthday, it's as good a time as any to ask: What has the little blue pill wrought?

Erectile dysfunction, the currently preferred name for what used to be called impotence, isn't new. Nor are ways of treating it.

But vacuum pumps don't lend themselves to seamless spontaneity. Urethral suppositories aren't particularly effective in many men. Penile implants require surgery and are fairly costly. And the injectable drug Caverject -- which remains an effective impotence treatment-- requires an unromantic precoital injection in a place no man wants to have an injection.

There's also sex therapy, which was, and remains, an effective means of treating erectile dysfunction in many men, said Gerald Weeks, chairman of the counseling department at the University of Nevada, Las Vegas, who's also a board-certified sex therapist and author of several textbooks, including a groundbreaking work on erectile dysfunction.

But, generally speaking, in the days before Viagra, men often didn't get help for the problem, Weeks said.

"They didn't think any help was available," he noted. "They didn't know about medical treatments and didn't think that sex therapy would be effective. And there were a lot of psychological barriers to overcome."

Then came Viagra, which offered the promise of restored erectile function simply by taking a pill.

"We realized there would be a lot of interest (in Viagra)," recalled Dr. Victor Grigoriev, a urologist and associate professor of surgery at the University of Nevada School of Medicine.

"But, first of all, we didn't know if it would be effective or not. A lot of drugs get approved, and everybody says how effective they're going to be, and they turn out to be not very good."

But in the five years since it went on the market, Grigoriev said, Viagra has "turned out to be as-advertised."

Viagra causes minimal side effects, primarily flushing, headache and indigestion, Weeks said, and the drug works in about 80 percent of the men who take it. The major contraindication is that people who take nitrate drugs, such as the nitroglycerin pills used to treat angina, shouldn't take it.

"The thing most people liked about (Viagra) is that, like most oral medications, it's easy to take and it also works in a fairly natural way," he continued.

"In other words, it's not a pharmacologically induced erection, but a pharmacologically facilitated erection. That has a great impact on how a couple perceives the medication."

"I think a lot of us could see the possibility of it having a huge impact on the culture," Alexa Elkington said of Viagra. She is a Southern Nevada marriage, family and sex therapist.

First, Viagra has helped to bring erectile dysfunction out of the closet.

"I think that people are talking about erectile dysfunction now," said Dr. Thomas Hunt, assistant residency director of the University of Nevada School of Medicine's family practice program. "There weren't really a lot of (treatment) options 10 years ago and, for the most part, men were keeping it to themselves."

Urologists now routinely see patients who come in specifically to talk about erectile dysfunction, said Las Vegas urologist Dr. Mark Leo. "In the pre-Viagra days, it was more a casual mention rather than a primary problem."

The age of men who seek help for erectile dysfunction also has dropped during the past few years, Grigoriev said, from men in their late 50s and 60s to patients in their mid-40s to early 50s.

Hunt suspects doctors today are more apt to routinely screen for erectile dysfunction than they were before the introduction of Viagra.

"It was something we should have screened for before, but I don't think everybody did," he said. "You learn in medical school, `This is what you should be asking for,' but when there isn't a good treatment for it, a lot of physicians don't ask."

It's not just men who are talking about Viagra, either. "Probably about half the time it's the wife who brings up the issue," Grigoriev said.

Because Viagra requires getting a doctor's prescription, doctors also are detecting other medical problems, such as hypertension, earlier than they otherwise might have.

High cholesterol, high blood pressure and coronary artery disease are three conditions that can cause erectile dysfunction, Grigoriev said. "A lot of times, we talk about impotence being the first sign of a vascular disease such as heart disease."

"If I was going to say what the major impact of Viagra was -- other than making a lot of people happy -- it's that we now have access to a much larger patient population for screening," Leo said.

However, for all of the benefits Viagra can offer, marriage and sex therapists say it shouldn't be viewed as a quick fix, but as one part of a broader, more comprehensive, course of therapy.

Viagra can mask whatever sexual problems exist in a relationship, Weeks said.

"If a woman wasn't orgasmic, it doesn't matter because they're not having sex. If a man is a premature ejaculator, it doesn't matter because they're not having sex. If he had trouble reaching ejaculation, it doesn't matter because they're not having sex."

As a result, the use of Viagra can introduce tensions into a relationship. Weeks recalled sending one couple he was counseling to a physician to obtain Viagra.

The next week, he continued, the couple returned for their session and "the wife sits down, and she's just glaring at me, and she said, `I'm just furious with you.'

"She said, `My husband went out and got Viagra and took it,' and she said it turned him into an animal. She said, `Now he wants to have sex two or three times a week.' "

It was interesting, Weeks added, because "she was the one who was bitterly complaining about not being able to have sex. She had, historically, always been the one to initiate sex, and now that he had the Viagra and the confidence, he had started to initiate sex, and she didn't like that."

A prescription for Viagra "should have a prescription for sex therapy or counseling to go along with it," said Amy Ellwood, a marriage, family and sex therapist and associate professor of family medicine at the University of Nevada School of Medicine.

Sexuality is complex and biology is only part of the equation, she said. "There's a lot more to it than saying, `Take a blue pill.' "

Weeks recommended that any couple who introduces Viagra into their relationship first see a sex therapist for counseling in case there are other sexual problems.

"The nice thing about it is, sexual problems can be treated by brief therapy, and success rates are very high."