Sexual Dysfunction And Viagra

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Sexual Dysfunction

Sexual dysfunction refers to a couple of individual problems that prevent them from experiencing satisfaction when performing sexual activities.
It is reported that some 43% of women and 31% of men report some degree of sexual dysfunction, in connection with personal performances or the performance of their partner.
Sexual dysfunction can refer to a problem occurring during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual performances. The sexual response cycle includes the following four stages:

  • excitement (involving desire and arousal),
  • plateau,
  • orgasm, and
  • resolution.

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Even if sexual dysfunction is common (43% of women and 31% of men report some degree of difficulty), the direct approach through a private, face to face discussion, regarding this topic is not easy. Many people face embarrassment issues or get emotional after an unsuccessful sex attempt.
Because many treatment options are now available, it is very important to share your concerns with your partner and healthcare provider.
It is not the end of the world that this happened. Sexual dysfunction can affect any men or women, at some point in life, at any age, dependent or not on organic causes.
You and your partner must be aware that a sexual dysfunction is not something incurable or permanent.

 

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What are the types of sexual dysfunction?

Sexual dysfunction generally is classified into four categories:

  1. Desire disorders, meaning a lack of sexual desire or interest in sex;
  2. Arousal disorders, the inability to become physically aroused or excited during sexual activity;
  3. Orgasm disorders, the delay or absence of orgasm (climax);
  4. Pain disorders, meaning pain during intercourse.

 

Who is affected by sexual dysfunction?

Sexual dysfunction can affect any age, although it is more common in those over 40 because it is often related to a decline in health associated with ageing.

 

What are the major symptoms of sexual dysfunction?

In men:

  • Inability to achieve or maintain an erection suitable for intercourse (erectile dysfunction)
  • Absence or delayed ejaculation despite adequate sexual stimulation (retarded ejaculation)
  • Inability to control the timing of ejaculation (premature ejaculation)

In women:

  • Inability to achieve orgasm
  • Inadequate vaginal lubrication before and during intercourse
  • Inability to relax the vaginal muscles enough to allow intercourse

 

What is erectile dysfunction?

According to the National Institute of Health, erectile dysfunction, the most common sexual problem in men, is defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. Erectile dysfunction has a significant impact on the physical and psychological health of men worldwide and can also affect the quality of life of both the sufferers and their partners. 2,3 In 1995, a number of 152 million men were affected by erectile dysfunction and the number is anticipated to increase to 322 million in 2024.

 

What is the mechanism of penile erection?

Anatomy of the penis

The penis is composed of the following components:

  • Two chambers called the corpora cavernosa which function as blood-filled capacitors providing structure to the erect organ;
  • Urethra, the channel for urine and sperm;
  • Erectile tissue, which surrounds the urethra, two main arteries and several veins and nerves;
  • Shaft, the longest part of the penis;
  • The head (glans), placed at the end of the shaft,
  • The meatus or opening at the tip of the head where urine and semen are discharged.

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How does erection occur?

Penile erection is a complex physiologic process that occurs through a cascade of neurologic, vascular, and humoral events.
In Antiquity, Galen considered that penile erection is the result of an accumulation of air. The meaningful examples of experimental scientific work on the penis have been shown at the beginning of the Renaissance. Da Vinci concluded that erections were caused by blood. Van Haller from Switzerland explained in the 18th century that the nervous system is involved in penile erection. Later, animal studies clarified that stimulation of the nerve erigentes induced small muscle relaxation in the corpus cavernosum.
The penis physiological states of flaccidity or erection result from the contraction or relaxation, respectively, of smooth muscle cells in the corpus cavernosum.
Penile erection is a spinal reflex that is initiated by autonomic and somatic penile afferents and by supraspinal influences from visual, olfactory, and imaginary inducements. There are several central transmitters involved in the erectile control, some of them with a facilitatory role and others with an inhibitory role.

The central transmitters with a facilitatory role in the penile erection are:

  • dopamine,
  • acetylcholine,
  • nitric oxide (NO),
  • peptides, such as oxytocin and adrenocorticotropin/α-melanocyte-stimulating hormone.

The central transmitters that inhibit the penile erection are serotonin which may be either facilitatory or inhibitory, and enkephalins which are inhibitory.
The degree of contraction of the smooth muscle cells in the corpus cavernosa is determined by the balance between contracting and relaxant factors. Noradrenaline contracts both smooth muscle of the corpus cavernosum and penile vessels via stimulation of α1-adrenoceptors, while nitric oxide is considered the most important factor for relaxation of penile vessels and corpus cavernosum.
Nitric oxide is released during sexual stimulation. It activates the enzyme called guanylate cyclase, resulting in an increased level of cyclic guanosine monophosphate (cGMP) in the corpus cavernosum. This, in turn, results in smooth muscle relaxation, allowing increased inflow of blood into the penis. The level of cyclic guanosine monophosphate is regulated by the rate of synthesis via guanylate cyclase and by the rate of degradation via cyclic guanosine monophosphate hydrolysing phosphodiesterase (PDEs).

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Which are the risk factors for erectile dysfunction?

The most common physical or organic causes of erectile dysfunction are:Manage Your Risk Words Dice Reduce Costs Liabilities

  • heart disease and narrowing of blood vessels;
  • diabetes;
  • high blood pressure;
  • high cholesterol;
  • obesity and metabolic syndrome;
  • Parkinson’s disease;
  • multiple sclerosis;
  • hormonal disorders including thyroid conditions and testosterone deficiency;
  • structural or anatomical disorder of the penis, such as Peyronie disease;
  • smoking, alcoholism, and substance abuse, including cocaine use;
  • treatments for prostate disease;
  • surgical complications;
  • injuries in the pelvic area or spinal cord;
  • radiation therapy to the pelvic region.

Patients who are taking medications and are suffering from erectile dysfunction should consult their healthcare professional to see if any of the drugs may be a cause of the problem. These drugs include also the illicit and/or recreational drugs. Drugs and medications that cause erectile dysfunction or other sexual problems as side effects are commonly prescribed for men without them knowing the risks.

Drugs that could be involved in the occurrence of erectile dysfunction are:

  • drugs to control high blood pressure;
  • heart medications (digoxin);
  • some diuretics;
  • drugs that act on the central nervous system, including some sleeping pills and amphetamines;
  • anxiety treatments;
  • antidepressants (monoamine oxidase inhibitors, selective serotonin reuptake inhibitors and tricyclic antidepressants);
  • opioid painkillers;
  • some cancer drugs, including chemotherapeutic agents;
  • prostate treatment drugs;
  • anticholinergics;
  • hormone drugs;
  • the peptic ulcer medication (cimetidine);

Pharmacological therapy for erectile dysfunction

Phosphodiesterase-5 inhibitors

Phosphodiesterase-5 inhibitors represent the most commonly used class of drugs in the treatment of erectile dysfunction. These medications are highly efficacious, are well tolerated, and have very favourable safety profiles. Four phosphodiesterase type 5 inhibitors are available on market: sildenafil (Viagra®, Pfizer), vardenafil (Levitra®, Bayer), tadalafil (Cialis®, Lilly-ICOS) and avanafil (Spedra®). These agents do not directly cause penile erections but instead affect the response to sexual stimulation. Sildenafil (Viagra) was the first in this series of phosphodiesterase type 5 inhibitors.
Phosphodiesterase type 5 inhibitors are recommended as the first-line therapy for erectile dysfunction. According to the European guidelines the choice between a short-acting phosphodiesterase type 5 inhibitor and a long-acting phosphodiesterase type 5 inhibitor depends on the frequency of intercourse (occasional use or regular therapy, 3-4 times weekly) and the patient’s personal experience.

Androgens

Studies have shown that hormone replacement may have beneficial effects for men with severe hypogonadism, which is associated with diminished libido and erectile dysfunction.
Replacement androgens are available in several forms:

  • Oral: oral therapy is rarely used, and it is often associated with hepatotoxicity.
  • Injectable: injectable therapy is the most common approach to restore androgen levels to the reference range, but it requires periodic injections to sustain an effective level.
  • Gel: testosterone gels have the advantage to be non-invasive, but they require daily application and are expensive.
  • Transdermal (skin patches): deliver a sustained dose and are highly tolerated by patients.
  • Longer-acting testosterone pellets

The use of exogenous androgens suppresses natural androgen production. Elevation of serum androgen levels has the potential to stimulate prostate growth and may increase the risk of activating latent cancer. Periodic prostate examinations, including digital rectal examinations, prostate-specific antigen (PSA) determinations, and blood counts are recommended in all patients receiving supplemental androgens. Obtaining a testosterone level during therapy is necessary for optimizing the dosage.
Intracavernosal injection of vasodilators
In 1993, Papaverine, an alpha-receptor blocker that produces vasodilatation, was shown to produce erections when injected directly into the corpora cavernosa. Later, other vasodilators such as alprostadil and phentolamine were demonstrated to be effective as single agents and in combination.
The main adverse events that may occur after intracavernosal injection of vasodilators are:

  • Painful erection;
  • Priapism;
  • Development of scarring at the injection site.
  • Intraurethral prostaglandin E1 pellets
  • Medicated Urethral System for Erections (MUSE) represents another option for erectile dysfunction treatment. Medicated Urethral System for Erections involves the formulation of alprostadil into a small intraurethral suppository that is inserted into the urethra. This formulation is useful for men who do not want to use self-injections or for men in whom oral medications have failed.

Other oral agents

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Before the development of phosphodiesterase type 5 inhibitors, various other oral medications were investigated for the treatment of erectile dysfunction, including the following:

  • Adrenergic receptor antagonists: phentolamine, yohimbine and delequamine;
  • Dopamine receptor antagonists: apomorphine and bromocriptine;
  • Serotoninergic receptor activators: trazodone;
  • Xanthine derivatives: pentoxifylline;
  • Oxytocinergic receptor stimulators: oxytocin.

 

What is Viagra?

Viagra is the brand name of sildenafil, a phosphodiesterase type 5 inhibitor used for the treatment of erectile dysfunction.
Viagra is formulated as 25mg, 50mg or 100mg blue film-coated tables. They are marked ‘Pfizer’ on one side and VGR 25”, “VGR 50” or “VGR 100 on the other side. The tablets are provided in blister packs containing 2, 4 or 8 tablets within a carton. In addition to the active ingredient, sildenafil citrate, each tablet contains the following inactive ingredients:

Tablet core:

  • microcrystalline cellulose,
  • calcium hydrogen phosphate (anhydrous),
  • croscarmellose sodium,
  • magnesium stearate.

Film coat:

  • Hypromellose,
  • titanium dioxide (E171),
  • lactose monohydrate,
  • triacetin,
  • indigo carmine aluminium lake (E132).

 

Do I need to see my GP when taking Viagra? Why?

Yes, it is very important to consult your GP or other doctors before taking Viagra. First, Viagra is a prescription-only medication and must be taken only under doctor’s care. Only a doctor can assess your health and decide whether you have any medical problem. The doctor is the only one who can perform any diagnostic tests that may be necessary.
Your doctor will decide if you are a good candidate for Viagra or not. Viagra is not recommended for patients who have certain medical conditions or take other medications. Erectile dysfunction can be indicative of an underlying health condition that should be treated before taking Viagra. Erectile dysfunction could interfere with any illness that affects blood circulation or the nervous system. Also, it is caused by low libido resulting from a psychological condition. Discussing with your doctor, the root cause of erectile dysfunction will be determined. It can be one of the first warning signs that the patient has atherosclerosis, high blood pressure, or diabetes. If you are suffering from heart diseases or diabetes, it is very important to treat this condition first, before taking Viagra.
Erectile dysfunction can also be related to lifestyle. People who are obese, smokers or physically inactive have a high risk of erectile dysfunction. In this case, your doctor will recommend changing your lifestyle to resolve your condition.

Before taking Viagra, you should inform your GP if you have any of the following medical conditions:

  • Anaemia (abnormality of red blood cells);
  • Leukaemia (cancer of blood cells);
  • Multiple myelomas;
  • Deformity of your penis;
  • Heart problems;
  • Stomach ulcer;
  • Bleeding problems.

Tell your GP about any other drugs or food supplements that you are taking because some of them are contraindicated to be co-administered with Viagra. These drugs include:

  • Organic nitrates (nitro-glycerine, isosorbide dinitrate, isosorbide mononitrate, nitroprusside, amyl nitrite,): these drugs are used to treat angina pectoris. Using Viagra with this type of drugs may cause an excessive decrease in blood pressure and finally, cardiovascular collapse because both drugs are vasodilators with blood pressure lowering effects.
  • Alpha androgenic blocking agents (doxazosin, tamsulosin, alfuzosin) are contraindicated to be co-administered with Viagra due to their vasodilator effect.
  • Guanylate cyclase stimulators (riociguat): the co-administration may potentially lead to symptomatic hypotension.
  • Ritonavir, a drug used in the treatment of HIV infection: it is contraindicated to take Viagra when you are taking ritonavir because ritonavir has inhibitory effects in the enzyme CYP3A4 which is responsible for Viagra metabolism. Pharmacokinetic analysis of clinical trial data indicated a reduction in Viagra clearance when co-administered with CYP3A4 inhibitors.
  • Medicines for fungal infections (ketoconazole, itraconazole).

Consulting a doctor before taking Viagra is necessary for the following reasons:

  • The doctor will determinate the cause of your erectile dysfunction.
  • The doctor will inform you about other treatments available.
  • The doctor will decide if you need pills or lifestyle changes are enough to resolve your problem.
  • The doctor will assess the risks and benefits and will decide of Viagra is suitable for you or not.

 

How should I use Viagra?

Viagra is administered orally, once a day as needed.
The recommended dose in adults is 50 mg taken as needed approximately one hour before sexual activity. To be effective, sexual stimulation is required.
Please read carefully the patient information leaflet before jumping into action and please consider your degree of cardiac risks associated with the sexual activity.
If you are in the case of co-administering substances known to lead to symptomatic hypotension (blood pressure < 90/50 mmHg), do not take Viagra.

 

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References:

  1. https://my.clevelandclinic.org/health/diseases/9121-sexual-dysfunction
  2. K. Hatzimouratidis (Chair), F. Giuliano, I. Moncada, A. Muneer, A. Salonia (Vice-chair), P. Verze EAU Guidelines on Erectile Dysfunction, Premature Ejaculation, Penile Curvature and Priapism
  3. Bella A, Lee J, Carrier S, Bénard F, Brock G. 2015 CUA Practice guidelines for erectile dysfunction. Canadian Urological Association Journal. 2015;9(1-2):23
  4. Ismail E, El-Sakka A. Innovative trends and perspectives for erectile dysfunction treatment: A systematic review. 2018.
  5. https://my.clevelandclinic.org/health/articles/10036-erection-ejaculation-how-it-occurs
  6. van Driel MF. Physiology of Penile Erection-A Brief History of the Scientific Understanding up till the Eighties of the 20th Century. Sex Med. 2015 Oct 22;3(4):349-57. doi: 10.1002/sm2.89. eCollection 2015 Dec. Review. PubMed PMID: 26797073; PubMed Central PMCID: PMC4721040.
  7. http://pharmrev.aspetjournals.org/content/63/4/811
  8. https://www.medicalnewstoday.com/articles/5702.php
  9. https://emedicine.medscape.com/article/444220-clinical?src=refgatesrc1#showall
  10. https://emedicine.medscape.com/article/444220-treatment#d9
  11. https://www.medicines.org.uk/emc/files/pil.1072.pdf

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