How one man sought an impotence cure--and found one

This is a report from Viagra's front lines. It is from a married man in his early 50s--a friend of this writer who has tried out Pfizer's new impotence drug. Call him X; he does not want his name used. And call him grateful; Viagra worked for him. Is it a wonder drug? The 75,000 prescriptions written for Viagra in the first two weeks after it came to market in late March suggest that many hope it could be--and the potential market numbers as many as 30 million American men, a significant share in their 40s or even younger.

Mechanically, an erection must accomplish two goals. Blood must flow vigorously into three parts of the penis stuffed with erectile tissue that absorbs the blood like a sponge. And the muscles in the penis and the valves in the veins leading away must keep the blood from leaking out. When a patient complains about impotence, a physician first looks for a history of diabetes or cardiovascular problems, because the circulation disorders that often accompany these conditions can interfere with an erection.

Candor difficulties. X, who has been married about 30 years, began experiencing erectile dysfunction--now the preferred medical term for impotence--about four years ago. He could achieve an erection but could sustain it less and less often. Seeking medical advice didn't help. During a physical exam, the internist posed his usual inquiry about personal problems. "I said something like, 'Well, I've been having some sexual difficulties,' " says X. "He looked at me and made a note but didn't ask anything else, and I just dropped it. I got the impression that he really didn't want to discuss it, and I was self-conscious enough as it was." This conversation echoed an assertion by the National Institutes of Health, in a 1992 report on impotence, that "embarrassment of patients and the reluctance of both patients and health care providers to discuss sexual matters candidly contribute to underdiagnosis."

The physician and patient had similar nonconversations over the next couple of years. Meanwhile, X's ability to perform slipped from occasional to rare and, then, inexorably, never. X's relationship with his wife slowly chilled. "I felt as if we were work colleagues," says X. "We'd go places, we'd get done what we had to do around the house, but there was this huge, dark subject we wouldn't discuss."

Last February, X mustered the nerve to push his doctor. That won a referral to a urologist. Once the specialist learned of X's history of heart disease, he didn't bother with a physical examination. Nor did he think X needed specialized tests. "I am 99 percent certain that you've got a circulation problem," he informed X.

The doctor said X could try mechanical contrivances like a vacuum cuff or pump. Or he could have bendable rods surgically implanted. Or, using a small, fine needle, he could inject alprostadil, a drug that mimics a natural substance produced during sexual arousal, into the penis, to encourage blood flow. X did not care for any of these options.

Priapism warnings. His reaction was slightly less negative to the urologist's final proposal: a tiny alprostadil suppository placed about an inch into the opening of the penis with the aid of a special insertion device. Made by Vivus and called the MUSE system, it produces an erection 60 to 70 percent of the time, and X thought it seemed somewhat less onerous than the other methods.

Yet many men who try MUSE abandon it because of insertion discomfort; nearly one third did so in one large study. The urologist also warned of a small but real danger of priapism--a painful, ongoing erection that threatens permanent damage and must be treated at an emergency room. Too, the timing discourages spontaneity. The drug works five to 10 minutes after it is administered, during which time sitting, standing, or walking around is recommended to stimulate blood flow. And languid dallying is out; the effect wears off after 30 to 60 minutes.

"There's a pill coming out in six months, maybe less," the urologist told X. "Take the MUSE brochure. Look it over. See what you think. Maybe the thing to do is to wait for the pill. It's called Viagra."

The $209 visit did warm up the atmosphere at home. Armed with the MUSE brochure, X was inspired to reveal to his wife that he had been seeking help. "She was touched," he says. "She thought I had stopped caring at all." While put off by the fussy MUSE procedure, she was willing to go along. But X was due for a follow-up talk with his internist. The couple put off the MUSE decision until then.

The internist, his interest now piqued, disagreed with the urologist. X's circulation was fine, he said. As X lay on the examining table, the internist pressed X's fingers to the femoral arteries in his groin. "A strong pulse, right?" The blood vessels to the penis branch off the femoral arteries, and good femoral circulation argues against poor blood flow to the penis.

The internist ordered up a testosterone blood test, and the results made him smile with satisfaction; the number was extremely low. A depressed level of the male sex hormone, pumped out by the testes under the control of the pituitary gland in the brain, does not automatically produce erectile dysfunction--men with low testosterone can have normal sexual function--but it might explain X's problem.

X met with an endocrinologist in early April, and left, for the first time, with hope. The hormone specialist took a detailed history, including a list of all of the medications X was taking. He examined X thoroughly, including a rectal check of the prostate gland. He was nonjudgmental, empathetic, and eager to answer X's questions.

Moreover, he was flexible. X's testosterone, he said, could be boosted either by injecting the hormone once every week or two or with a testosterone skin patch. But the shots would require frequent visits, or X or his wife would have to learn to give them.

X was aware that Viagra had come on the market the week before. Would it make sense to try the new drug before turning to supplementary testosterone? Sure, replied the endocrinologist, writing a prescription for 10 pills and asking X to report back. The most excruciating moment of his four-year ordeal, says X, was when he approached the pharmacy counter to pick up his prescription. The clerks at the pharmacy have a habit of repeating the name of the medication aloud to prevent mistakes. This time it didn't happen. X was grateful.

The night X and his wife put Viagra to the test taught them that the drug is not an aphrodisiac. It aids an erection but does not cause one. As is true in the absence of Viagra, stress or nerves play havoc with sexual response, the couple found. A more relaxed attitude allowed Viagra to do its work. The phone call to the endocrinologist would be effusive.

Viagra facts. U.S. News health writer Mary Brophy Marcus looked into these common questions about Viagra:

How does Viagra work?

It enhances the effect of nitric oxide. This chemical is released into the penis during sexual arousal and relaxes the organ's smooth muscle tissue so that blood flows in, producing an erection.

Will Viagra help me?

The success rate is about 70 percent. Problem candidates usually have conditions like poorly managed diabetes, blocked arteries, or long-standing high blood pressure.

Do I have to see a doctor?

Don't trust any doctor willing to prescribe Viagra by phone who isn't very familiar with your health and sexual history, and don't get a prescription off the Internet. Erectile dysfunction can signal illnesses such as diabetes, heart disease, and certain prostate conditions. Your regular physician or a urologist will get a full medical and sexual history, do a physical exam, and test your blood and urine.

How quickly does Viagra take effect?

It can take as long as an hour, but some men see results in 20 minutes. Most doctors start their patients on 50 milligrams of Viagra but may later alter the dose up to 100 milligrams or down to 25 milligrams. It may take four or five experiences using Viagra before you learn the dosage and timing that are best.

How long does the effect last?

Four to six hours, or until orgasm.

How often can I take it?

The approved dosage is no more than one pill a day. "I know some of my patients, couples who are high-powered Washington types, who when they finally get away for a weekend together and want to have some fun are probably going to take one in the morning and one at night. That most likely will not cause a problem," says a Washington urologist. It might increase the possibility of side effects, which occur in up to 10 percent of men.

What kinds of side effects?

Mild, temporary reactions such as flushed skin, headaches, upset stomach, and blue-tinted vision. (Or a pregnancy.

Viagra shouldn't be taken along with nitroglycerin because of blood pressure concerns.

Is Viagra good for women, too?

Jennifer Berman, a urologist at the University of Maryland Medical Center in Baltimore, believes there may be as many "impotent women" as men--women who do not enjoy sex because of poor lubrication and other physiological factors--and thinks Viagra could help. This summer Berman will help conduct a study in Boston. Preliminary results should be out within a year. Currently, Viagra is not recommended for women.

Can Viagra improve sex for men who aren't impotent?

No. As Andrew McCollough, a urologist at New York University Medical School, says, "If your tank is full, your tank is full."