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Men's Sexual Health > Impotence

The Viagra era was launched on March 27, 1998. More than six million Americans are using the drug with an approximate overall success rate of about 75 percent. What can be done for those patients who have suboptimal results or no effect on their erectile dysfunction?

I generally suggest using the 100 mg dosages since the side effect profile is the same with the 25, 50, or 100 mg dosage, and the effectiveness rate of the 100 mg dose overall is approximately 20% greater than the 50 mg dosage.

The drug works best with an empty stomach so no food should be eaten at least two hours before taking the Viagra pill. The neurological system must be intact between the brain and the penis, and sexual stimulation is necessary for the Viagra to be effective.

Patients often ask what they can do if the drug is still not effective, suboptimal, or needs additional improvement? A simple non-pharmacologic way of handling this problem is to use a vacuum compression device without a constriction band.

Even in those cases in which the Viagra poorly improves erectile dysfunction the addition of a vacuum compression device brings enough blood into the penis that the veno-occlusive aspects of Viagra are working well enough to maintain sufficient erection for sexual activity and not necessitating the use of a constriction band.

Men can also use an intraurethral pellet of Muse usually in the 500 to 1000 mcg range. After Viagra and sexual stimulation the pellet is inserted into the urethra usually after voiding, moistening the plastic applicator, and massaging the urethra for approximately two to three minutes. The combined effects of the Viagra on the cyclic GMP system appear to be synergistic with the prostaglandin on the cyclic AMP system.

In some cases a constriction band is more effective, especially in those in which the Viagra gives a very sufficient erection, but the erection is of short duration or lost in the reclining position. Viagra followed by sexual stimulation would cause a full erection, and prior to penovaginal intercourse a constriction band could be placed around the base of the penis to allow for veno-occlusion. In rare circumstances the combination of Viagra and an injectable drug such as Prostaglandin E-1 (Caverject) is an effective way of resolving a suboptimal result from Viagra.

More commonly the Viagra is given as a supplement to injectable Prostaglandin which in these cases is not effective to establish a good enough erection for penovaginal intercourse. The Viagra sensitizes the penis to allow a more effective result when the injection is administered after the usual one to four hours of delayed stimulation.

For those patients who have penile implants and desire increased engorgement of the shaft of the penis or rigidity of the glans penis, supplemental Viagra one to four hours prior to utilizing their implants may be done. In addition, in the same group of patients, intraurethral Muse or a vacuum device alone may be all that is necessary.

A large number of patients utilizing Viagra for erectile dysfunction are quite happy with the results. For those in which there is no effect or suboptimal results alternatives as described above can be utilized. These alternatives can provoke and enhance the erectile functions of Viagra alone. Being aware of the peculiarities of Viagra including an absorption no faster than thirty minutes, sexual stimulation at least one hour after oral intake, better absorption with an empty stomach (two hours), and need for sexual stimulation best between one and four hours after oral intake must be confirmed in order to maximize the effects. Patient education and discussion on follow-up with the patients is an absolute. If the patient is indeed utilizing the drug appropriately, especially at the 100 mg dosage, the addition of Muse, vacuum, compression rings, and/or injection therapy may be all that is necessary to maximize the effects of ED therapy using Viagra and making for a happy patient and partner.

(Note: Dr.Murdock, a board certified urologist, conducts research field tests on drugs, including Viagra.)
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