Conversations about sexual dysfunction between men and their doctors once were strained and difficult, if they took place at all. Now urologists find they can hardly avoid requests from their patients for common erectile dysfunction (ED) drugs such as Cialis and Viagra.

“Men are much more open about talking about erectile dysfunction than they were 15 years ago, 10 years ago,” said Robert W. Wake, MD, professor and chairman of the Department of Urology at the University of Tennessee Health Science Center and residency program director. "It's no longer a taboo subject at all.

“It's very common, even when they bring in their wives. And sometimes if they don't mention it, the wives will say, 'Remember you wanted to talk about that other thing?' . . . Often wives want to take control of the samples.”

Doctors say easy access to information about ED on medical sites such as WebMD, as well as the prevalence of television ads for Cialis and Viagra, make it easier for patients to bring up the subject. (Some of the TV ads are so provocative, critics say, they shouldn't be watched by children. One contributor to Forbes magazine called on Viagra to withdraw one of its ads last year, writing that a message featuring a blonde on a bed had strayed too far from the "initially subtle" TV campaigns that employed spokesmen such as former U.S. Sen. Bob Dole, who had undergone a prostatectomy.)

Wake called the new dialogue a healthy one for men.

“We're happy about that,” he said. “The majority of patients between the ages of 40 and 80 years old are interested in getting information about ED drugs. Their interest allows the physician to have a realistic discussion about which patients would benefit from these medications versus those patients who may just want it as a performance enhancer, which is not the intent for these ED drugs.”

David A. Gubin, MD, of The Urology Group, with offices in Memphis and Southaven, called the request for samples “universal” among his patients.

“It doesn't matter what the reason was they came in the office to see you, the last thing they ask when they leave the office is, ‘Hey, doc, you have any samples of some of those drugs?’” Gubin said. “They can come in for kidney stones, doesn't matter what the issue is, universally I would say, they're always asking. People have heard so much about it now that they're very curious, and they want to experiment or try it.”

The downside is that the drugs cost $20 to $30 a pill, he said.

Insurance companies commonly don't cover the cost of pills for sexual dysfunction issues, Wake said. But the U.S. Food and Drug Administration has approved a low dose of Cialis for daily use to treat prostate enlargement -- or benign prostatic hyperplasia (BPH) – which can cause lower urinary tract symptoms including frequent or urgent urination, weak flow and straining to void. Insurance will pay for that treatment.

“People who have LUTS secondary to BPH often have associated ED,” Wake said. “The exact relationship is not known, but both can be associated with aging due to hypertension, vascular disease, diabetes and other co-morbidities often seen as we age.”

While the on-demand dose for ED drugs is 10 to 20 milligrams with Cialis and Levita and 50 to 100 milligrams for Viagra, when patients used a 2.5- or 5-milligram daily dose of Cialis, Wake said, "They saw that it did have some efficacy in the lower urinary tract symptoms (LUTS) and it also had the benefit of helping their erectile dysfunction."

He emphasized that low-dose Cialis is not the common treatment for LUTS. "It does have some efficacy, but it's certainly not as good as the first line treatment, which is the Alpha blockers that everybody's familiar with -- Flomax, Uroxatral." In his practice, 90 percent of BPH patients are treated with the standard Alpha blocker therapy. "And then they're treating their erectile dysfunction on demand. So they're not using the daily dose."

Men may put up with a headache, facial flushing and nasal congestion when they use ED drugs on demand, Wake said, but it's a different lifestyle choice if they take the daily low dose of Cialis. They might have continuous side effects while not treating their urinary tract symptoms as well as they could with Flomax.

Doctors have to oversee the ED prescription process carefully, Wake said. "If they think they're functioning pretty good, then they see how good they can function on (ED drugs), they think they need it all the time, so you've got to be very careful," he said. “In that 50-to-70 age group, almost any of them will say, ‘Yeah, I'm not like I was – could I be?’ And the medication can do that.”

The Mayo Clinic's website points out, “In most cases, erectile dysfunction is caused by something physical." Among the common causes the clinic lists are heart disease, atherosclerosis, high cholesterol, high blood pressure, diabetes and obesity, as well as treatments for prostate cancer and enlarged prostate. Psychological causes of ED include depression, anxiety and stress.

“Usually erectile dysfunction is a sign of underlying issues,” said Gubin, of The Urology Group. “Penile arteries are smaller than the heart arteries, so where are you going to have issues initially show up? People who are diabetics, or have hypertension, et cetera, will show up with issues of erectile dysfunction, and that may be an underlying sign.

“So patients who come in complaining of that, one thing the doctor should do is see that they have a routine physical and see their primary-care physician and make sure that nothing underlying is being missed. Psychological issues also do play a role, obviously. I don't think we understand everything associated with sexual dysfunction.”

RELATED LINKS:

 The Urology Group, www.memphisurology.com

Mayo Clinic, www.mayoclinic.org

UTHSC Department of Urology, www.uthsc.edu/urology