treatED 12pp A4

A consumer guide to understanding
and treating erectile dysfunction
A consumer guide to understanding
and treating erectile dysfunction
Contents
3 Authors
3 Introduction
4 ED: What is it?
4 Oral medications: Cialis, Levitra, Viagra
6 Injections: Caverject
6 Other options: Rings and vacuums
7 Surgery
7 Counselling and relationships
7 Important things to consider
8 Things to consider if your treatment
isn’t working
8 References
Disclosure
Costs associated with the development of this resource have been funded by Eli Lilly Australia. Eli Lilly Australia did not have
any involvement in the development of the content in this resource, however the company has reviewed the document to ensure
it complies with the guidelines for communicating health information to consumers, outlined in the Medicines Australia Code of
Conduct, and required by law under the Therapeutic Goods Act.
2
Authors
Introduction
The content of this document has been developed
by the following experts using available medical
evidence, and should be used as a guide only.
Treatment advice specific to your situation should
be sought from your doctor. A thorough medical
assessment should be conducted before any
treatment is commenced.
In recent years, erectile dysfunction (ED) has
been increasingly discussed, encouraging men
and their partners to seek advice about the
condition. Because ED can be an indicator of
other health problems, it’s important to seek
treatment as soon as possible. It’s also important
to remember when seeking treatment for ED that
there is a lot of information out there - not all
of it correct - from a variety of sources, and that
your best source of information is a healthcare
professional such as a doctor, pharmacist or
sexual health counsellor.
Professor Doug Lording
Endocrinologist/Andrologist
Cabrini Health, Victoria
Dr Michael Lowy
Sexual Health Physician
Sydney Men’s Health New South Wales
Dr Andrew Pattison
General Practitioner
Victoria
This resource has been developed to provide
up-to-date, factual information on the main,
proven treatments that are approved by the
Australian health regulatory authorities.
All products covered in this guide (except for the
external devices) are available on prescription
from a doctor.
The guide has been developed by a team of
doctors with expertise in treating a range of ED
patients. It has also been reviewed by a number
of men who have ED, to provide important
information in easily understood terms.
IMPORTANT: This resource is intended as a
guide only. Advice on your specific situation
should be sought from a medical doctor.
The content of this resource has been reviewed and
approved by Impotence Australia (IA), an independent
not-for-profit consumer organisation, which provides
counselling and information on ED (impotence) and sexual
health. IA supports the development of this type of resource
to achieve ongoing improvements in treatment and care
for men and their partners.
3
ED: What is it?
Erectile dysfunction (ED) is the inability to achieve
or maintain an erection of sufficient quality for
sexual activity. Several studies have estimated
that about 40% of males aged 40 years have
some degree of ED, increasing to 70% of men
aged 70 years (1).
While ageing is the most common cause, ED can
be associated with a number of health problems
such as high blood pressure, diabetes and
cardiovascular disease. It is believed that around
80 per cent of ED has a physical cause (2). It’s a
good idea to get a medical check up if you are
experiencing problems, as it can be an indicator of
other health conditions. Couples can then choose
whether or not to pursue treatment.
Don’t be embarrassed to talk to a doctor about
ED – they can help you. It is recognised that
having a satisfying sexual experience has positive
health benefits – it’s good for your health and
good for your relationship.
Follow-up appointments with your doctor are very
important to answer your questions and to check
that any treatment is working as intended.
For more information on ED visit:
www.impotenceaustralia.com.au
www.andrologyaustralia.org
4
Tablets for ED: Cialis®,
Levitra®, Viagra®
Doctors will often start your treatment with
tablets (oral medications):
°
There are three tablets approved for use in
Australia: Cialis (see-ah-liss), Levitra (le-veetrah) and Viagra (vy-ag-rah). These treatments
are generally well tolerated, and work in the
majority of men with mild to moderate ED.
Remember that you should always talk to a
doctor before commencing medical treatment
to assess your individual suitability for taking
these tablets or other treatments
°
IMPORTANT: These medicines should not be
used by patients also taking medicines known
as “nitrates”, which are used for the treatment
of angina (“chest pain”) or other heart
conditions. A sudden and serious drop in blood
pressure can occur in this situation
°
You should obtain these tablets on prescription
from your doctor and purchase through your
pharmacist for personal use only
°
The tablets work by enhancing the normal
sexual response, allowing greater blood flow
to the penis
°
A common misconception is that men will have
a permanent erection while the medication is
working – this is not the case. They require
sexual stimulation to work
How do I use the tablets?
°
Many men may need to use oral treatments
several times before feeling confident and
gaining maximum benefit from them
°
Some men will stop taking tablets after only
one or two doses, thinking that it just doesn’t
work for them. You may have more success if
you keep trying, and talk through any problems
with your doctor
°
Studies have shown that between 40-55% of
men who have tried tablets unsuccessfully in
the past subsequently found them effective
when taken again at the correct dose and for
the recommended number of attempts (3,4)
°
These days doctors don’t consider these
medications to be ineffective until you have
tried them at least six to eight times at the right
strength of the medication (4), and have also
tried at least one other medication from the
same group
°
There may be slight differences between
tablets – your doctor will discuss these with
you. You may also need to discuss taking these
tablets with food and alcohol
°
Clinical studies show that, typically, Levitra
(5)
and Viagra (6) last between 4 to 6 hours,
while Cialis can work for up to 36 hours (7).
That is, these are the time frames during
which an erection can be achieved with sexual
stimulation. This time frame can vary from
man to man. The tablets usually begin to work
20 to 30 minutes after taking them (8)
°
It is important to follow the manufacturers’
guidelines when using these medicines
How much do they cost?
This can vary slightly between pharmacies.
For a prescription of four tablets, the cost is
generally between $65 and $80. In most cases,
the Government does not reimburse you for
ED medications. Some private health insurance
funds may cover some of the cost of prescription
medications. Holders of Repatriation Health Cards
may also be reimbursed.
Are there any side effects?*
Common side effects you may experience are:
°
Headaches
°
Facial flushing
°
Blocked nose
°
Indigestion
°
Muscular pain
For most men, side effects are rarely troublesome
enough to stop treatment.
There may be a misconception that there is
an increased risk of heart attack with these
medications. There is no evidence to support
this claim, provided your doctor conducts a
thorough medical examination before prescribing
medication to make sure the oral treatments are
appropriate in your specific case.
For further information on other, less common
side effects, you can refer to consumer medical
information provided by the manufacturer of
each medication.
* You may have seen some recent media stories linking
damage to the optic nerve (a condition called NAION) with
oral ED medications. NAION is extremely rare and has
only been seen to occur in men with multiple risk factors
including being over 50 years old, having high blood
pressure or diabetes, or an anatomical variance in the
eye. There is no direct proven link to any of the three ED
medications. Your doctor should assess these risk factors in
you before prescribing a PDE5 inhibitor.
5
Injections: Caverject Impulse®
If you have not found oral medications effective,
don’t give up hope. There are several other
effective treatment options that you can discuss
with your doctor.
°
°
°
6
Men with ED at the more severe end of the
spectrum tend to find injections into the penis
a more effective treatment than the tablets.
Injections have been used in Australia since
the mid-90s. The most widely used injection
is called Caverject (other mixtures are available
and may be recommended by your doctor)
Injections are only available on prescription
and are usually recommended when the
tablets haven’t worked or you aren’t able to
use them for medical reasons
The injections work by directly opening up the
penile blood vessels. It may take between 5
and 10 attempts to master the technique
°
After injecting, the drug will usually work
within 5 to 10 minutes (with or without sexual
stimulation) and ideally will last 30 minutes (9)
°
You should discuss any treatment involving
injections in detail with your doctor. A followup appointment is important to ensure you are
correctly using the injection
°
It is recommended to start injections at
a lower dose, then work your way up to
minimise the chance of a prolonged erection
(called priapism), which can cause permanent
damage. By working with your doctor, this risk
can be minimised
°
Some men will experience pain in the penis
and sometimes scarring may occur
°
A pack of two injections costs between $30
to $40
External devices (rings
and vacuums)
°
There are two external devices your doctor
may suggest – penile rings and vacuum pumps
°
Penile rings are made of rubber and tend to be
used when a man can get an erection initially
but can’t sustain it
°
Rings are placed around the base of the penis
to make it rigid enough for intercourse
°
It is recommended that its use is limited
to 30 minutes. The ring must be removed
when this time has elapsed or there is a risk
of permanent damage to the penis (i.e. it’s
important not to go to sleep with it on)
°
A vacuum device, consisting of a cylinder that
extracts air, is also used when a man can’t
achieve or sustain an erection
°
The vacuum is placed over the penis and, as air
is pumped out of the cylinder, blood is drawn
into the penis making it enlarge. A ring is
then placed around the base of the penis to
maintain the erection
°
Your doctor will recommend where to
purchase these devices
Surgery
°
Surgery requires a referral to a urologist, who
will assess whether your erection problem is
suitable for surgery and discuss details of the
operation
°
Penile implants are suitable for a small
number of men. Some types require pressure
to be applied to a small reservoir at the base
of the scrotum. This pumps fluid into the
implant tubes and makes them go firm to
create an erection
°
A surgical implant would only be likely to be
considered when all other treatments have
failed or are unsatisfactory for you
°
Severe curvature of the penis (called Peyronie’s
Disease) may interfere with intercourse and
this condition can also be surgically corrected
°
Rarely, there may be surgery on the blood
vessels in the penis. This is called vascular
surgery and is not performed very often for ED.
It is a highly specialised procedure and is often
not successful
Counselling and relationships
There is, of course, more to a sexual relationship
than the ability to get and maintain an erection.
ED does not always require treatment, and some
men choose not to be treated. However, as ED
may be a sign of an underlying health condition,
it’s important to see your doctor for a thorough
check up.
Important things to consider
You may have heard of other products for
treating ED, but these may not have been
approved by the Commonwealth Department
of Health’s medicines agency, the Therapeutic
Goods Administration (TGA). If you are in
doubt about a treatment, discuss it with your
healthcare professional or phone Impotence
Australia on 1800 800 614.
It is very important that a qualified doctor is
involved with your diagnosis and treatment,
because they will be able to undertake a full
medical assessment and explore health factors
that may contribute to ED.
They will also carefully prescribe appropriate and
safe medications that will not interact or impact
on other medication or treatments being used.
While ED usually has a physical cause, it often has
emotional impacts. Talk to your doctor and your
partner if you need support and advice.
Sometimes ED is the direct result of an emotional
situation without a physical cause. You might find
it useful to talk to a sexual health or relationship
counsellor, or contact Impotence Australia on
1800 800 614.
Useful websites
www.impotenceaustralia.com.au
www.relationships.com.au
www.relationshiphelponline.com.au
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Additional things to consider
if your treatment isn’t working
°
1
Have you had a follow-up appointment?
°
Do you have the correct information about
your treatment?
°
Is your partner involved in the discussions?
°
Is there some stress issue you need
to address?
°
Do you feel you need counselling?
°
You may need to have your testosterone
level checked particularly if your interest
in sex is low – ask your doctor
Have you taken the correct dose of your
medication an adequate number of times?
°
Did you wait long enough after taking the
tablet before attempting sex?
°
Did you obtain your treatment with a
prescription from a legitimate source that
provided adequate medical supervision?
Feldman HA, et al. ‘Impotence and its medical and
psychosocial correlates: Results of the Massachusetts
Have you had a full medical assessment
by your doctor?
°
°
References
male aging study’, Journal of Urology 1994,
vol 151; pp. 54-61
2
Lue TF. ‘Erectile dysfunction’, N Engl J Med 2000,
vol 342; pp. 1802-13
3
Sklar GN et al. ‘Salvage of sildenafil failures referred
from primary care physicians’, Journal of Urology
2003, vol 170; pp. 2356-2358
4
McCullough A., Barada J. et al. ‘Achieving treatment
optimization with sildenafil citrate (Viagra) in patients
with erectile dysfunction’, Urology Aug 2002, vol. 60;
Supplement 2B, pp. 28-38
5
Levitra Product Information
6
Viagra Product Information
7
Cialis Product Information
8
Levitra, Viagra Product Information; Brock, GB et al.
‘Efficacy and safety of tadalafil for the treatment of
erectile dysfunction: Results of integrated analyses’,
Journal of Urology 2002, vol 168; no. 4; pp. 1332-1336
9
Heaton JPW et al. ‘Intracavernosal alprostadil is
effective for the treatment of erectile dysfunction
in diabetic men’, International Journal of Impotence
Research 2002, vol 13; pp. 317-321
8
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