This article was written by Dr O’Mahony to send out to patients prior
to a consultation. It specifically covers the contentious issues over cost and
who can have what on the NHS etc. It also allows the patient to consider some
homework and be involved in the final decisions. It was on the BBC choice
website in 2002 but the site was removed after the Daily Mail complained about
using taxpayers money to peddle soft porn on the BBC (Sat 30th Nov 2002)
Dr Colm O'Mahony, Countess of Chester NHS Trust. CH2 1Ul. 01244-363097
INTRODUCTION
So, what's normal for men
? Most young men have no problem getting an erection. Their sex drive is
usually so high that it overcomes any religious or other shame inducing
conditioning, to let them masturbate successfully as teenagers. There was a
time when this was considered a serious moral issue and, indeed, the medical
profession weighed in with dire warnings of all of the serious illnesses that
would befall men who engaged in this "unhealthy" practice. Of course,
masturbation is a normal part of growing up, but I am still constantly
surprised at how many men I see who have guilt and religious hang-ups about the
practice.
HOW LONG DOES IT TAKE FROM ERECTION TO ORGASM &
EJACULATION, & WHAT'S THE NORMAL?
There is no normal.
Even for the same man, sometimes it can take just a minute or less to reach
orgasm, whether he wants to or not, and on other occasions it can seem to take
forever.
For a normal erection to develop, a man must be thinking
sexual thoughts to start the process. In many young men, this is enough to
produce erection, but as men get older they also need sexual stimulation as
well as erotic thoughts. The blood vessels to the penis dilate up under nerve
stimulation and the penis fills with blood, and it drains away very slowly,
hence an erection. The head of the penis has a slightly different supply and
sometimes men find that the head of the penis may not be as rigid as the rest.
This is a normal occasional feature. With enough sexual stimulation, a point is
reached where orgasm and ejaculation become inevitable. A tiny amount of fluid
moves from the testes into the tubes, most of the fluid is produced by the
prostate gland and the seminal vesicles and other glands along the way.
Muscular contractions of the water passage produce the pleasurable sensations
and the semen is ejaculated out of the end of the penis. If it's been a while
since the previous ejaculation, and the stimulation is exciting enough, there
can be a lot of fluid ejaculated and this can even spurt out on occasions. At
other times, the muscular contractions are not as strong and the semen just
trickles out. Again, these are all completely normal and simply depends on the
intensity of the experience and the time since the previous orgasm. In some
cultures, semen is regarded as a precious fluid and men try to conserve it by
concentrating on the muscular contractions and suppressing them. This
technique, according to some men, allows them to be multi-orgasmic. A recent
book by Mantak Chia and Douglas Abrams Arrava, called Multi-orgasmic man
explains this in great detail. However, I remain unconvinced.
As men
get older, it takes longer to develop an erection and it takes longer to reach
orgasm. Erections are also not usually as rigid as in the late teen years, and
for some men this can begin to cause problems, even at an early age. It is not
unusual for a young man to be even nervous or embarrassed at some time when he
is with a girl and finds he can't get or retain his erection. What happens next
depends on his attitude to this event. If he is embarrassed and humiliated, the
next time he is in a sexual situation he will be worried that the erection
might not work again and, of course, that worry can be enough to make sure it
won't and now panic sets in. This is called a "fear of failure", which can be
very difficult to shake off. Obviously, these men are still able to masturbate
and still wake up with early morning erections, etc., so all of the mechanisms
are intact. It's just that the sexual situation with a partner has now become a
stressful and panic laden event. In the majority of cases, with a regular
partner that they become comfortable with, sexual desire usually wins through,
and after a couple of successful episodes the problem disappears. In some men,
however, it can become very significant and they may need professional help to
get back on track. This help can be as simple as a discussion with a friend,
practice nurse or their GP, or sometimes devices or drugs are needed.
More commonly, erection problems develop in the 40's or later. This is
because the blood vessels supplying various organs in the body get narrower as
men get older. This process is accelerated by lack of exercise, being
overweight, cigarette smoking, excess alcohol, etc. These factors also cause
high blood pressure, angina and heart attacks. At 40, at least one in ten men
have significant erection problems and over the age of 50 it's almost 50%.
There will always be times, even in the healthiest of men, when fatigue,
tiredness or just not being in the mood prevents a proper erection developing
or if one does develop it fades quickly. Men should be able to take the
occasional failure in their stride without letting it get to them. They should,
however, have no embarrassment about going for help if the problem becomes
significant or begins to interfere with their relationship. A visit to the
doctor is important to outrule common but serious conditions such as diabetes.
In men who are diabetic, the blood vessels can get narrower at an earlier age
and sometimes nerves can be damaged, so that they can experience erection
problems much earlier than men who don't have diabetes. Many men have heard
about the myth of the male menopause and most of us in the business believe
that that's just what it is – a myth ! Testosterone levels do get lower as
men get older, but generally speaking, if there's enough testosterone on board
to produce a stubble on a daily basis, and if sexual desire is present, there
is little point in measuring testosterone levels. If you are having a blood
test at the GP's surgery for testosterone, it is best to have it done in the
morning, when the levels are at their highest. It's incredibly uncommon for
erection problems to be attributed to a low testosterone level. In the UK
testosterone is rarely used as a treatment for erection difficulties in most
reputable clinics.
TREATMENTS FOR ERECTILE
DYSFUNCTION
Counselling - All men who get significant
erectile dysfunction do develop psychological disturbance as a result. Not
being able to develop a satisfactory erection really knocks a man's confidence.
They find it difficult to still consider themselves a proper man. They are
reminded on an hourly basis of their inadequacy. Every newspaper or television
programme or conversation with colleagues throws up some reminder of their
inability. Each attempt at intercourse just results in embarrassment and
humiliation, and the psychological baggage builds up. It obviously reaches a
stage where they stop trying as the pain is too much, and of course, they also
stop doing the affectionate bits, and the partner doesn't know what on earth is
going on. These men lose out from the comfort of a close relationship and it
can affect them in every aspect of their life, ie. They can become depressed,
they can lose confidence in business, and their whole attitude to life can
change. The unfortunate partner can do nothing to help and constant reassurance
that it is not all that important only increases his frustration and
desperation. It IS all that important to him! In fact, his annoyance with her
efforts to help eventually lessen her sympathy and the relationship becomes
cold. I find most men are greatly relieved to hear me describe all of these
symptoms that they are undergoing. It's a completely normal male reaction to
erectile dysfunction. Sometimes these men haven't realised the depths to which
they have sunk until the problem is actually cured and then they get all their
confidence back, and in the space of a few weeks, when the problem is resolved,
they only then realise how much it had impacted on them.
PARTNER
ISSUES
When erection problems develop, a man's partner is
often at a loss. She doesn't know how to help and if she does try she can be
met with annoyance or even hostility. She, of course, thinks he doesn't find
her as attractive, or that there is something else going on. No matter how much
she reassures him that she still loves him and enjoys their sexual episodes
together, he is unconvinced and for some men not being able to get an erection
means – no sex and that's it. What many men can't understand is that women
can have a perfectly good orgasm even when there's not an erect penis for miles
around. It's relatively easy for a man to have a sexual experience with his
partner and bring her to orgasm whether it's by manual touching, oral sex,
vibrator, or whatever, so that although the erection is not satisfactory there
can still be a good experience. Many men are still able to have an orgasm and
ejaculate even though the penis is not fully erect or even semierect. It is
important to continue the intimacy and the sexual touching, even during the
difficult times, so that both people in relationships still feel the love and
affection of each other. It greatly compounds the problem if the man withdraws
from any affectionate touching or holding, as this creates a passionless
relationship, and couples can live on in quiet desperation for many years if
not indefinitely. Sadly, this was how the majority of couples used to handle
erectile dysfunction.
BOOK LIST
I always
recommend a book list. I usually tailor the recommended books to the individual
patient but, in general, the books are aimed at improving communication with
their partner, understanding themselves, and understanding the part sex plays
in their relationship. Typical books would be:- Two books written by John Gray
– one is called Men are from Mars, Women are from Venus; the other book is
- Mars & Venus in the Bedroom. There is a very good self-psychology book
written by Robin Skynner & John Cleese – called Families and How to
Survive them. A lovely book on improving self-esteem by Tony Humphreys –
called Self Esteem: A guide to your child's education. There are also books
that explain the causes and treatments, by Kell & Dinsmore – Impotence
– A guide for men of all ages or Kell & Griffiths – Sexual Health
for Men. A book published in 2004 by Michael Metz and Barry McCarthy called
“How to Regain Confidence & Enjoy Great Sex (Coping with Erectile
Dysfunction)” is superb.
ORAL
TREATMENTS
There are three popular drugs currently available
for erection problems. They are Viagra, Cialis and Levitra. These drugs have
revolutionised the management of ED and the vast majority of men will have
success with one or other of these. One point has to be emphasised over and
over again, however, and that is, that patients shouldn’t just try one or
two of these and then give up. There needs to be a proper trial of therapy of
these drugs before deciding whether they are suitable or work for that
individual. In my practice I always prescribe at least 12 initially and then
tell the patient to select a suitable 3 week period when there is no hassle at
home or in-laws or children staying, etc. Then they take 3 a week for three
weeks, and let them notice the changes in ability to have erections. They often
notice the return of early morning erections and more spontaneous erection
activity, and the confidence comes back. Many patients who have been referred
to me as oral treatment failures have simply not had this trial of therapy to
properly assess the drug’s ability to work for them.
Some doctors
worry about giving Viagra, Cialis or Levitra to patients who have a
cardiovascular history. In my opinion, the boost in confidence, the enhancement
of the quality of life, the results from restoring erections easily outweigh
the tiny increased risk that there may be from the mild physical activity
associated with intercourse with a regular partner. As one such patient said to
me ; - Dr O'Mahony – I know there's a bit of stress involved in having
sex, but have you ever tried having sex without an erection ? You are there
whacking away for ages doing your best, she's doing her best, you nearly get it
in, it comes out, it starts to fade – the whole thing turns into an
emotionally charged humiliating event – Now Doc, that's what I call stress
! With the Viagra, I just take the tablet, we have sex, we have a lovely time,
it's all over in 5-10 minutes and everybody is happy ! Where's the danger ? The
main contra-indication with Viagra is that it cannot be taken in patients who
are treating angina with drugs containing nitrates, ie. GTN spray.
VIAGRA
This drug has been a
massive success story. It was developed by Pfizer Laboratories and initially
was being tried as an anti-anginal drug, where men were taking this tablet on a
daily basis. The effects on erectile dysfunction were a surprise bonus. Further
sophisticated scientific analysis discovered that this drug was blocking an
enzyme that is found predominantly in the arteries of the penis, to allow
erections to develop and stay erect. The drug is extremely successful in men
with all types of erectile dysfunction. The usual dosage is 50 mg and the
medication has to be taken at least an hour before sexual activity, and it's
best taken on an empty tummy. If it's taken shortly after a heavy meal, it
takes the drug longer to be absorbed. There is a saying that “a curry
kills it”! Many men, however, describe its effects kicking in within half
an hour. The drug will only work if it's coupled with sexual thoughts and
sexual stimulation. Men who have very poor blood supply or nerve damage to the
penis, ie. men who don't get early morning erections or any spontaneous
erections may not be successful with Viagra. Some ability to produce some
erection is usually needed for the drug to be able to work. Like all of these
oral treatments, several goes of the drug are needed before deciding whether
it's the ideal treatment for any individual patient. It's unfortunate that some
patients will just try these once or twice. The embarrassment of the whole
thing can cause so much anxiety that the drug may not work, and they then lose
heart, and stop. It's important to try Viagra and other drugs for at least
eight doses over a relatively short period, say 3 weeks, to fully assess its
effects. The drug is absolutely safe, even in patients who have had
cardiovascular problems. Obviously, the man needs to be reasonably fit enough
to have intercourse, but the physical activity involved in sexual intercourse
has been calculated as the same as walking for one mile on the flat in twenty
minutes.
CIALIS
This drug has
a similar method of action to Viagra, so most of the above information applies
to Cialis. However, it stays in the system for much longer. This may help take
some of the planning out of the situation. Some men find it embarrassing that
they have to organise when they are going to have sex, and this drug may
restore the spontaneity. It can be taken with or without food. It comes in 2
strengths – 20mg and 10mg – both the same price. It becomes effective
in about 50% of men within half an hour. The drug stays in the system at
effective levels for about 2 days (officially it's 36 hours !). Again it is
important that at a few doses are tried i.e. eight doses over a 3 week period
is a good idea. Trials suggest it is as successful as Viagra and the side
effects are similar. Commonest is headache and facial flushing but these
decrease with further doses. Again, No nitrates allowed.
LEVITRA
Another Viagra type drug. Duration
of action is similar to Viagra. Can be taken with or without food but activity
may be delayed if taken with a high fat meal. Scientifically it is very
selective for the target enzyme and has been marketed as possibly having
superior efficacy in difficult to treat patient groups.
UPRIMA
This interesting drug has a
completely different method of action to Viagra. It works on the areas in the
brain that initiate the sexual response. The quoted success rates for Uprima
are not as high as Viagra, but it does have an interesting advantage in that
it's absorbed very quickly. The tablet is put under the tongue and it’s
absorbed in that fashion, it reaches peak levels in about 15 minutes. It's not
interfered with by food and, again – like Viagra, at least eight goes of
the drug over a three week period should be tried before deciding whether it's
suitable for that individual or not. This drug is not interfered with by
nitrates, so patients with angina on nitrates can take this drug.
L-ARGININE, YOHIMBINE & OTHER
SUPPLEMENTS
Many drugs and compounds have been claimed to be
effective in erectile dysfunction. However, controlled trials, using dummy
drugs (placebo) have been conducted and don't appear to show any significant
benefit. Having said that, if a patient tells me these drugs work for him, I
say – Well you just carry right on using them – good for you !
TESTOSTERONE
IIt's rare for low
testosterone to be a contributing factor to erectile dysfunction. The medical
attitudes to testosterone vary. In the United States it is considered a useful
treatment, but in the United Kingdom, by and large it's not. There is a
significant danger of enhancing the growth of prostatic cancer. In the age
group our patients tend to be in, I feel this is a real danger and I virtually
never use it.
PENILE INJECTIONS
This may sound
outrageous and unbelievable, but I have shown over 500 men how to inject their
penises without any difficulty. The needle is tiny – they just have to put
the needle in at either side of the penis and inject a small amount of a
compound called prostaglandin. This dilates up the blood vessels and depending
on how much they inject, an erection develops. This is an excellent way of
producing erection, even in men who have had failures or problems with all the
other treatments. The right dose for each man must be worked out slowly,
because if too much is injected the patient can end up with a very hard penis
for several hours. This might sound like a good idea, but believe me, it isn't.
If the penis is erect and doesn't go down at any stage over a 4-hour period, it
is a medical emergency and the patients will need to come into Casualty and
have blood removed from the penis by another needle. This is an extremely
uncommon occurrence and to my mind this has never happened to a single patient
of mine. I emphasise to all the patients that they should work out a sensible
dose that gives them an erection for at least half an hour, but not longer than
an hour or more, and they should never exceed this dose.
MUSE
(Medicated urethral system for
erection) - This is a small plastic device that allows a little pellet of
the drug prostaglandin to be placed into the urethra (water passage). This
pellet dissolves and the chemical gets into the penis producing an erection.
It's a bit like the injection system, except there's no needle. The success
rates are not as high as with the injection process or with the oral tablets,
but some patients find it ideal for them.
VACUUM
DEVICES
There's a whole range of vacuum devices available and
the price varies from around £100 to £250 for these. Since July
2002, some of these have become available on an NHS prescription, from general
practice but NOT hospital, provided the man falls into one of the categories
that allows them free treatment for erectile dysfunction (more of that later).
One system called Genesis have a website
www.genmedhealth.com.
Another one is Osbon Medical UK ltd, Freepost London N8 9BR, phone 0845 658
8877, They have a unique erection maintenance ring that a lot of patients like.
Owen Mumford also do devices. They work by creating a vacuum that draws blood
into the penis and then an elastic ring is slipped off over the base of the
penis, as tightly near the body as possible. This keeps the blood in the penis
and allows a reasonable erection for as long as the elastic is left on.
Obviously, the advantage of these is that they are completely safe and once you
have paid the price for the initial device there's no more cost involved.
LUBRICANTS
IIt is important to use a good
lubricant when there is questionable rigidity. Some men find that they get a
reasonable erection, but when they go on and try to put it into their partner
it just buckles up, causing dismay and disappearance. If a really good
lubricant is used then even a soft penis can slide into the vagina – no
problem. The one we issue here in this clinic is called Sensilube, but there
are lots of other silky types of water based lubricants that are ideal.
COSTS OF TREATMENT & WHAT'S AVAILABLE ON THE
NHS
The Department of Health have decided that only certain
groups of men can have treatment for erectile dysfunction on the NHS. These are
patients who were receiving erectile dysfunction treatment prior to 14th
September 1998; they will continue to be eligible. The following medical
conditions are also entitled to free prescriptions – these are :-
Diabetes / Multiple Sclerosis / Parkinson's Disease / Poliomyelitis /
Prostate Cancer / Prostatectomy / Radical Pelvic Surgery / Renal Failure –
treated by dialysis or implant / Severe Pelvic Injury / Single Gene
Neurological Disease / Spinal Cord Injury / Spina Bifida.
Obviously,
the biggest group of these are patients with diabetes. The Department of Health
recommends that they are allowed one treatment a week on the NHS initially, but
information specifically states that if more than one treatment a week is
needed that should also be prescribed on the NHS.(Health service circular
number 1999/148 dated 30th June 1999)
Most patients, however, will see
a doctor on the NHS, but be given a prescription and they will have to pay for
the cost of the drugs at the Chemist. This definitely varies depending on which
Chemist you go to, so it's important to phone the Chemist beforehand and find
out the price. You don't want to be having that sort of discussion over the
counter in a packed shop. As a guide, four tablets of 100 mg Viagra costs
between £31 and £41. Four tablets of 50 mg Viagra costs around
£24
Viagra, Cialis and Levitra, and other ED treatments can be
purchased from Pharmacy2U or Boots. Their prices are very cheap and it's an NHS
service. The first prescription has to be posted, but then they keep a record
and further prescriptions can then be ordered on line. You simply post them
your prescription, with payment, and they post the drugs next day. If you GP or
Specialist writes "Repeat x 10" on the prescription, then each time you need
more, you just phone and pay, -- no need for another prescription or visit to
the doctor!
Pharmacy2U Ltd, Deacon House, 1 Seacroft Avenue, Seacroft,
Leeds LS14 6JD. Website address:
www.pharmacy2u.co.uk
Tel: 0870 787 6210
Boots the Chemist Ltd, 1 Town End Square,
Walsall, West Midlands WS1 1NP. Tel: 0845 121 9040 Website
www.boots.com/pharmacy - go on to the prescription section
and “order my prescription” medicine section and fill in the details.
The first prescription has to be posted, but then they keep a record
and further prescriptions can then be ordered on line.
| Drug Name: |
Quantity: |
Pharmacy2U
Price: |
Boots Pharmacy
Price: |
| Cialis 20mg |
4 |
£25.59 |
£24.46 |
| Levitra 20mg |
4 |
£23.50 |
£23.50 |
| Viagra 100mg |
4 |
£23.50 |
£23.50 |
Other erectile dysfunction treatments can be purchased by mail
or internet from Pharmacy2U or Boots. Injection treatments cost around
£10 each. Many men find that they get a lot of their confidence back
after a couple of weeks or months of therapy and find they don't need as much
of the treatments as they thought they would, ie. some men even start cutting
up the tablets or using less of the injections, and find that they don't mind
the odd failure as much, now that they know that there's help at hand in the
drawer, whether they decide to use it or not.
There tends to be long
NHS waiting lists for erectile dysfunction and many patients opt to see someone
privately. The cost for this various throughout the United Kingdom, but in
general, the initial consultation privately would be £80 - £150
(depending on length of consultation and investigations) with a follow-up of
about £50 - £80. In my practice at the Countess of Chester, I
rarely need to see patients more than twice, whether I'm seeing them privately
or on the NHS. Most private practitioners will see patients without a referral
letter from their GP, but if a medication is prescribed, patients are strongly
encouraged to allow their GP to be informed of this.
USEFUL
WEBSITES
The
Sexual Dysfunction Association (formerly the Impotence Association) have an
excellent website with lots of information, usually accessible on
www.sda.uk.net or
www.40over40.com or
www.lovelifematters.co.uk – Sexual Dysfunction
association helpline 0870 7743571. They also have a list of doctors who treat
problems in your area.
The FP Sales which is a branch of the Family
Planning Association have a good Sex Aids catalogue called Sex Ware –
Website www.fpsales.co.uk E-mail:
sales@fpsales.co.uk – telephone
0870 444 5116. They have some good videos with various sex toys, and also have
the Owen Mumford vacuum pump. The penile rings can be bought separately if
that's all that's needed.
There is also the Osbon Erecaid vacuum
therapy system – accessible on
www.osbonerecaid.co.uk – telephone 01494 551200.
Another excellent UK website is Blissbox -
www.blissbox.com where
there are excellent books, videos and sex toys.
DR COLM O'MAHONY,
Consultant in Sexual Health, Department of Sexual Health, Countess of Chester
Hospital NHS Trust, Liverpool Road, Chester CH2 1UL. Telephone: (01244) 363097.
Fax: (01244) 363095. |