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Erectile Dysfunction: When Viagra Doesn't Work

Experts discuss alternative treatments for erectile dysfuntion.

WebMD Feature

April 10, 2000 (Mill Valley, Calif.) -- In his early 40s, Ron Hanson was too young to be having trouble getting and sustaining erections. But like many men, he was too embarrassed at first to talk about the problem. Hanson (not his real name) waited seven years to see a urologist. By the time he spoke up, erectile dysfunction had become a household word, thanks to the popularity of the drug Viagra. But the widely touted drug, Hanson soon learned, doesn't work for everyone.

When Viagra (sildenafil) hit the market in 1998, some men thought it was the long-awaited answer to their problems. Many rushed to doctor's offices to give it a try. According to the Grey Clinic in Indianapolis, which specializes in erectile dysfunction, 17% of men between 18 and 55 experience occasional impotence, while 6% have regular erectile difficulties. For men over 55, that number jumps to about one in three. Some common causes of impotence are diabetes, heart disease, and psychological problems. It also frequently occurs after prostate cancer surgery.

Because Viagra works in a way that's similar to drugs that contain nitrates, however, it isn't recommended for men who take nitrates for heart disease or those with certain other heart conditions. In some men, it causes bad headaches. In others, it just plain doesn't work. In some instances, men may notice they have trouble telling blue and green colors apart when they start taking the drug.

During an erection, blood flows quickly into the penis, which increases its length, width, and firmness. If the "in" vessels (arteries) are too narrow or if blood drains too quickly through the "out" vessels (veins), men may have trouble achieving or maintaining an erection, says Arnold Aigen, MD, a urologist with Camino Medical Group in Sunnyvale, Calif. Viagra, which increases inflow, may not be strong enough to work its magic if the arteries are too narrow.

Hanson tried Viagra, but he couldn't tolerate the headaches it caused. Luckily, when Viagra fails, he discovered, there are several alternatives.

Alprostadil to the Rescue

A drug called Alprostadil, either alone or sometimes in conjunction with others such as papaverine and/or phentolamine, can be injected directly into the penis to dilate the arteries, experts say. The drug produces an erection in about 10 minutes that can last up to an hour. But there are several disadvantages, says Teresa Beam, MD, a urologist with the Grey Clinic. Some patients are averse to using a needle, which is why many men abandon the therapy. Those who give it a try may experience pain at the injection site or priapism (a painful erection lasting too long).

As an alternative, Alprostadil is available as a pellet-like suppository that is inserted into the tip of the penis and absorbed through the lining of the urethra. This can help produce erections lasting for 30 to 60 minutes, according to the Impotence World Association (IWA). Unfortunately, the suppositories are less effective than injections and may cause pain and irritation, according to both Aigen and Beam.

Last November, a topical gel formulation of alprostadil was approved by the U.S. Food and Drug Administration. It is too soon to know if this form of alprostadil therapy will become widely used.

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