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How one man sought an impotence cure--and found one

This is a report from Viagra's front lines. It is from a married man in his early 50s--a friend of this writer who has tried out Pfizer's new impotence drug. Call him X; he does not want his name used. And call him grateful; Viagra worked for him. Is it a wonder drug? The 75,000 prescriptions written for Viagra in the first two weeks after it came to market in late March suggest that many hope it could be--and the potential market numbers as many as 30 million American men, a significant share in their 40s or even younger.

Mechanically, an erection must accomplish two goals. Blood must flow vigorously into three parts of the penis stuffed with erectile tissue that absorbs the blood like a sponge. And the muscles in the penis and the valves in the veins leading away must keep the blood from leaking out. When a patient complains about impotence, a physician first looks for a history of diabetes or cardiovascular problems, because the circulation disorders that often accompany these conditions can interfere with an erection.

Candor difficulties. X, who has been married about 30 years, began experiencing erectile dysfunction--now the preferred medical term for impotence--about four years ago. He could achieve an erection but could sustain it less and less often. Seeking medical advice didn't help. During a physical exam, the internist posed his usual inquiry about personal problems. "I said something like, 'Well, I've been having some sexual difficulties,' " says X. "He looked at me and made a note but didn't ask anything else, and I just dropped it. I got the impression that he really didn't want to discuss it, and I was self-conscious enough as it was." This conversation echoed an assertion by the National Institutes of Health, in a 1992 report on impotence, that "embarrassment of patients and the reluctance of both patients and health care providers to discuss sexual matters candidly contribute to underdiagnosis."

The physician and patient had similar nonconversations over the next couple of years. Meanwhile, X's ability to perform slipped from occasional to rare and, then, inexorably, never. X's relationship with his wife slowly chilled. "I felt as if we were work colleagues," says X. "We'd go places, we'd get done what we had to do around the house, but there was this huge, dark subject we wouldn't discuss."

Last February, X mustered the nerve to push his doctor. That won a referral to a urologist. Once the specialist learned of X's history of heart disease, he didn't bother with a physical examination. Nor did he think X needed specialized tests. "I am 99 percent certain that you've got a circulation problem," he informed X.

The doctor said X could try mechanical contrivances like a vacuum cuff or pump. Or he could have bendable rods surgically implanted. Or, using a small, fine needle, he could inject alprostadil, a drug that mimics a natural substance produced during sexual arousal, into the penis, to encourage blood flow. X did not care for any of these options.

Priapism warnings. His reaction was slightly less negative to the urologist's final proposal: a tiny alprostadil suppository placed about an inch into the opening of the penis with the aid of a special insertion device. Made by Vivus and called the MUSE system, it produces an erection 60 to 70 percent of the time, and X thought it seemed somewhat less onerous than the other methods.

Yet many men who try MUSE abandon it because of insertion discomfort; nearly one third did so in one large study. The urologist also warned of a small but real danger of priapism--a painful, ongoing erection that threatens permanent damage and must be treated at an emergency room. Too, the timing discourages spontaneity. The drug works five to 10 minutes after it is administered, during which time sitting, standing, or walking around is recommended to stimulate blood flow. And languid dallying is out; the effect wears off after 30 to 60 minutes.

"There's a pill coming out in six months, maybe less," the urologist told X. "Take the MUSE brochure. Look it over. See what you think. Maybe the thing to do is to wait for the pill. It's called Viagra."

The $209 visit did warm up the atmosphere at home. Armed with the MUSE brochure, X was inspired to reveal to his wife that he had been seeking help. "She was touched," he says. "She thought I had stopped caring at all." While put off by the fussy MUSE procedure, she was willing to go along. But X was due for a follow-up talk with his internist. The couple put off the MUSE decision until then.

The internist, his interest now piqued, disagreed with the urologist. X's circulation was fine, he said. As X lay on the examining table, the internist pressed X's fingers to the femoral arteries in his groin. "A strong pulse, right?" The blood vessels to the penis branch off the femoral arteries, and good femoral circulation argues against poor blood flow to the penis.

The internist ordered up a testosterone blood test, and the results made him smile with satisfaction; the number was extremely low. A depressed level of the male sex hormone, pumped out by the testes under the control of the pituitary gland in the brain, does not automatically produce erectile dysfunction--men with low testosterone can have normal sexual function--but it might explain X's problem.

X met with an endocrinologist in early April, and left, for the first time, with hope. The hormone specialist took a detailed history, including a list of all of the medications X was taking. He examined X thoroughly, including a rectal check of the prostate gland. He was nonjudgmental, empathetic, and eager to answer X's questions.

Moreover, he was flexible. X's testosterone, he said, could be boosted either by injecting the hormone once every week or two or with a testosterone skin patch. But the shots would require frequent visits, or X or his wife would have to learn to give them.

X was aware that Viagra had come on the market the week before. Would it make sense to try the new drug before turning to supplementary testosterone? Sure, replied the endocrinologist, writing a prescription for 10 pills and asking X to report back. The most excruciating moment of his four-year ordeal, says X, was when he approached the pharmacy counter to pick up his prescription. The clerks at the pharmacy have a habit of repeating the name of the medication aloud to prevent mistakes. This time it didn't happen. X was grateful.

The night X and his wife put Viagra to the test taught them that the drug is not an aphrodisiac. It aids an erection but does not cause one. As is true in the absence of Viagra, stress or nerves play havoc with sexual response, the couple found. A more relaxed attitude allowed Viagra to do its work. The phone call to the endocrinologist would be effusive.

Viagra facts. U.S. News health writer Mary Brophy Marcus looked into these common questions about Viagra:

How does Viagra work?

It enhances the effect of nitric oxide. This chemical is released into the penis during sexual arousal and relaxes the organ's smooth muscle tissue so that blood flows in, producing an erection.

Will Viagra help me?

The success rate is about 70 percent. Problem candidates usually have conditions like poorly managed diabetes, blocked arteries, or long-standing high blood pressure.

Do I have to see a doctor?

Don't trust any doctor willing to prescribe Viagra by phone who isn't very familiar with your health and sexual history, and don't get a prescription off the Internet. Erectile dysfunction can signal illnesses such as diabetes, heart disease, and certain prostate conditions. Your regular physician or a urologist will get a full medical and sexual history, do a physical exam, and test your blood and urine.

How quickly does Viagra take effect?

It can take as long as an hour, but some men see results in 20 minutes. Most doctors start their patients on 50 milligrams of Viagra but may later alter the dose up to 100 milligrams or down to 25 milligrams. It may take four or five experiences using Viagra before you learn the dosage and timing that are best.

How long does the effect last?

Four to six hours, or until orgasm.

How often can I take it?

The approved dosage is no more than one pill a day. "I know some of my patients, couples who are high-powered Washington types, who when they finally get away for a weekend together and want to have some fun are probably going to take one in the morning and one at night. That most likely will not cause a problem," says a Washington urologist. It might increase the possibility of side effects, which occur in up to 10 percent of men.

What kinds of side effects?

Mild, temporary reactions such as flushed skin, headaches, upset stomach, and blue-tinted vision. (Or a pregnancy.

Viagra shouldn't be taken along with nitroglycerin because of blood pressure concerns.

Is Viagra good for women, too?

Jennifer Berman, a urologist at the University of Maryland Medical Center in Baltimore, believes there may be as many "impotent women" as men--women who do not enjoy sex because of poor lubrication and other physiological factors--and thinks Viagra could help. This summer Berman will help conduct a study in Boston. Preliminary results should be out within a year. Currently, Viagra is not recommended for women.

Can Viagra improve sex for men who aren't impotent?

No. As Andrew McCollough, a urologist at New York University Medical School, says, "If your tank is full, your tank is full."

In December, 1994, Lorne had just turned 40 and life was good. Married, he had two young children, a house near Vancouver and a job he enjoyed. Then disaster struck: as he changed a tire on his car beside a roadway, another automobile hit him. Though Lorne can walk and is about to go back to work, the accident damaged spinal nerves and left him with enduring problems, including numbness in some parts of his body and distressing limits on his sex life due to difficulties having and maintaining erections. "It was depressing," he recalls, "when my wife was in the mood for sex and I just wasn't interested." Doctors suggested remedies involving pumps and injections, but Lorne was not interested in them. Then, he had the opportunity to take part in clinical trials for a new drug called Viagra that is designed to deal with problems like his. In December, 1996, Lorne began popping a sky-blue tablet whenever sex was in the offing. Once again, his life was transformed. "Sex is as good as it used to be-maybe even a little better," he says. "This medication is just fantastic."

Thousands of American men appear to agree. Since Viagra was approved for sale in the United States early in April, demand has soared to the point that physicians are scribbling an estimated 40,000 prescriptions a day. Manufactured by New York City-based Pfizer Inc., Viagra-which has yet to be cleared for general use in Canada-can apparently restore virility in about 80 per cent of men who have problems, with only minor side-effects including headaches and indigestion. "This isn't just another drug, it's the drug-the magic bullet we've been waiting for," says Dr. Sidney Radomski, a urologist at The Toronto Hospital, one of 27 Canadian centres that took part in the clinical testing of Viagra. "It's going to revolutionize the treatment of impotence."

Pfizer developed Viagra after researchers testing a drug for angina found that it triggered erections in men. Now, it seems destined to largely replace existing treatments which-though effective-cause many men to recoil in horror. The most popular method requires a man who expects to have sex to use a needle to inject an erection-causing drug into the side of his penis. Another involves using a vacuum pump to draw blood into the penis to create an erection, then placing rubber bands around the base of the organ to keep it erect. "It was such a performance," says one middle-aged Viagra user, who lives near Washington. Those methods, he adds, "undermined erotic moments by taking the spontaneity out of sex."

Unlike older treatments, which can leave men with erections that last for hours if sex does not occur, Viagra only becomes effective when a man is sexually aroused. The drug works by blocking the operation of an enzyme that normally breaks down a chemical-cyclic GMP-that plays a key role in maintaining erections. Even though Viagra-assisted erections subside after intercourse, some men report that the drug can remain effective for up to 24 hours. "It means that when they have a sexual thought during the day, they feel a physical response," says Dr. Rosemary Basson, a sexual medicine specialist at The Vancouver Hospital, who has prescribed the drug to 20 men as part of a long-term study. "That says, OK, you're a man again. It's tremendously important to them."

At the same time, U.S. doctors say some men who do not have potency problems are using the drug to enhance their sexual performance. There is no evidence that Viagra increases sex drive or staying power, and at $14.50 per tablet, cost is a factor. Still, Dr. Arthur Barnett, a urologist at Johns Hopkins Medical Center in Baltimore, expects men will experiment with the drug "to see if it will give them super erections or an increased number of erections over a limited period."

While experts estimate that about three million Canadians, including perhaps half of all men over 65, have potency problems, many doctors say the real number is unknown because so many males are unwilling to discuss the issue, even with their doctors. That may be changing. "Some patients who never told me they had a problem are asking about Viagra," says Toronto physician James Brooks. "Now that they think they won't have to mess around with pumps or needles, they're coming out of the closet."

For all its early promise, experts caution that Viagra's long-term effects are not yet known. Moreover, the drug will not be a panacea for every man who suffers from penile dysfunction-the medical term that covers a wide range of potency problems. Some men, including diabetics and those with diseases that cause serious neurological or tissue damage, will remain difficult to treat, says Kingston, Ont., urologist Jeremy Heaton. But for those who experience physical arousal but still have performance problems, says Heaton, "Viagra is going to be just great"-a judgment that Lorne and other early users of the drug wholeheartedly endorse.

Japanese tourists head overseas to get Viagra. Male Health Weekly Plus (June 22, 1998):10 (1 page).

A Japanese travel agency is putting together tours to Hawaii for men who want to buy the drug Viagra, which has gotten huge publicity here but has yet to be approved by health officials.

The Flight More travel agency organized its first Viagra tour in April, and has flown 25 men to Hawaii for the drug, company president Mineichi Sudo said today.

Sudo said the agency gets about 10 queries a day and is planning more tours. Sudo said most of the participants are in their 50s, with the youngest so far 45 and the oldest 64. Most of the participants go on the tour alone and are met by a guide in Honolulu.

Sudo said participants need to get blood tests from a Japanese doctor before leaving. The results are faxed to a doctor in Hawaii who then prescribes the drug, which can help men overcome some forms of impotency.

Flight More's cheapest tour - which lasts four days - costs the equivalent of $710 for accommodations and flight. An additional $600 is needed for the consultation, prescription and first bottle of 30 Viagra tablets.

The second bottle is available for $300.

Two bottles are the maximum a participant can bring through Japanese customs, according to Flight More. Any more than that requires a doctor's letter explaining why it is needed.

Sudo said that so far, "none of the participants have complained."