Ask An Urologist: Q&A about Viagra and Cialis

A short interview with Dr. Larry Skellchock from Skellchock Urology Center

Today we’re going to be talking with Dr. Skellchok about the group of ED medications, how they work, how to take them, and what the difference is between them.

We heard that Viagra was the number one most sold drug. Is this actually accurate?

I don’t think it’s a number one sold drug. I believe some cholesterol and blood pressure medications are higher than that. But I think it’s definitely one of the top-selling medicines because erectile dysfunction is so common. About 50% of 50-year-old men have some, and I have seen about 15 men in their early 20s with erectile dysfunction in the past week.

What do you think about the cause of it at such a young age?

Well, if you are young, healthy men, a lot of it is psychological. It doesn’t mean medications like Cialis or Viagra can’t help because it does help with the natural mechanism.

So, why don’t we talk about how these medications work?

Ok, first of all, you have to understand the input comes from the brain. You get sexually excited, and that sends messages down the nervous system. There’s a release of these transmitters, and it causes the sponge-like tissues in the penis to expand, which allows more blood flow.

ED medications

It doesn’t create excitement, right?

It doesn’t. Viagra and Cialis belong to a group of medicines called phosphodiesterase inhibitors, so they do not increase your libido or sex drive. That’s mostly mediated by testosterone. But they really help you get and maintain an erection, and it’s quite simple. When this transmitter comes from the nerves into your penis, it gets broken down by another mechanism, and it’s these medications that actually block that mechanism, that decreases an erection. So, therefore, it helps to maintain an erection.

You need to have that excitement from above in order to make these medications effective. They work 100% with your natural excitement system, and they do not boost desire, libido, or anything like that. There are three medications that I prescribe in my clinical practice: Cialis, Viagra, and Levitra. We won’t talk so much about Levitra because it hasn’t been pushed so hard by the company, and not that many people use it anymore.

Thus, the two main ones are Sildenafil and Tadalafil or Viagra and Cialis. What I usually offer patients is one of three things: you have Viagra, which works within about a half an hour to an hour of you taking it, and it’s good for about six to eight hours. No, that does not mean that you’re going to have an erection for 6-8 hours (it’s the question I get all the time), and it doesn’t mean that when you take it and like you’re walking down the street and all of a sudden erection occur.

So, 30 to 60 minutes in advance for a period of six to eight hours, meaning that if you take it now and your partner is out at work and comes on four hours later, we still have the effectiveness of a medication. It’s not one-time use. Actually, if you take it and use it now and then you have sex six hours from now – you’re still going to have that medication in your body, so you still have a chance of having a second erection.

Also, Viagra can reduce what we call the refractory period between erections. When you’re 18, you can probably have sex four times in a row, when you’re 50 – probably, not, but this can help you get a second direction much quicker.

Tadalafil or Cialis is actually good for 36 hours. People call it “the weekend pill.” It takes a little bit longer to get to that peak, so you could take it half an hour in advance, but some people say better taking an hour to two hours in advance at least. But if you take it Friday night and your wife has a headache – you didn’t just waste $15 on the pill because on Saturday night, you’re going to be ok. That’s why people nicknamed it “the weekend pill.”

So, which one’s better?

People ask me all the time. Well, none of them are better. I often say like well, maybe I’ll give a sample of each one or prescription for each one, so you’ll try it yourself. Because some people say, Viagra doesn’t work so much for me, and Cialis works better or otherwise. So it’s really a patient’s choice.

There is another way to take Cialis, and that’s a regular intake. It’s a third option that we give. The daily dose of this 36-hour pill is 20 milligrams, but there is a 5-milligram pill that exists. It’s a quarter the dose, but you take it every day regularly. Like people take a cholesterol medication every day. What this does is it slowly reaches up a level, so within a week or so, you’re at that level, and because you’re taking it lower dose slowly, some people have fewer side effects. The other thing is it’s just you don’t have to think about it.

The medication is there, and you’re already ready to go because not every one to say: “Ok, I’m going on a date tonight, and I’m gonna take it now cuz it’s two hours in advance or an hour in advance,” and then your date doesn’t show up – “Damn, I just wasted a pill.” You just take it every day, and it actually takes some of the pressure off.

And the worst thing we want to do is to give you more pressure to perform. So sometimes, just taking a daily pill and forget about it is the better decision. That’s what I tell the patients. Then within a week or two, it actually improves erectile function. It’s effective as a full dose of Cialis or a pill of Viagra and but just you take off that planning aspect, which is sometimes helpful in certain relationships.

I try to see what’s best. For a young guy who has sex several times a week, and you can’t always plan does know what’s going to happen – take a daily dose. If you are sixty-five-year-old, who knows that sex will happen every first Tuesday of the month and you can plan it in advance – then Viagra’s a great option. Again, not one of them is more effective. It just goes to what you want, what your lifestyle is, and how you’re able to plan and everything like that.

What about the side effects?

They all have the same side effects, and the side effects are usually not dangerous. They’re sore muscles, sore back, a feeling of flushing in the face, headaches, a little upset stomach, sometimes little visual disturbances like a little blue tinge division. Those are the commonest side effects. Patients can often experience them once and after trying the pill a couple more times, which may decrease with time.

Some people can’t tolerate it, and when they try Viagra, they felt horrible, but after Cialis, they don’t feel any side effects, so they’ll stick with that one. There are some people that can’t tolerate it. They just get uncomfortable side effects, so we have to explore other options.

But the common one which people think is can it hurt my heart. It’s not bad for your heart. Some people believe that a daily dose or a frequent dose may actually be good for your heart. I know a cardiologist who’s taking it.

But Viagra was initially made for something like that, isn’t it?

Yes, they were testing it for heart disease. But this issue comes with men when they get angina or chest pain from heart disease, so they pop a little pill under their tongue called Nitro. Nitro relaxes the blood vessels (that’s how it works for the heart), and that allows the blood to flow through.

So if you take these medications at the same time, it relaxes the blood vessel in your body too much, and your blood pressure shoots down, and that’s the danger. Thus, it’s not causing heart disease, but it’s for men with heart disease who take Nitro. It’s a dangerous mix.

What about alcohol? Can you drink some wine?

Alcohol can affect erections, but there’s no problem with that. I mean, it may decrease the effectiveness of the drug a little bit, but certainly not dangerous.

Some people a little bit disinhibited when they take alcohol, and it’s actually a good thing a little bit, but the more you take and the more it impairs your senses. Then it actually is bad for erections in general but no danger and taking it with Viagra or Cialis.

Should you take it on an empty stomach, so it’s more effective? Or can it be affected by food absorption?

Yes, if you’re going on a date and you plan on having sex, unless you take it a couple of hours before dinner, it can affect the absorption to some point.

But I’d like I don’t like people to think too much about it because the more you think about the act of having sex, the more the psychological demons come in and worsens any performance anxiety and stuff.

At what point you decide to give it? Like if somebody walks into your office and says: “I want Viagra,” do you just give it to them, or is there a series of questions?

I go over first because some people come in thinking they have erectile dysfunction, and they don’t have it – they actually have premature ejaculation or painful orgasm. I got to really make sure that when they say they have erectile dysfunction, weaker erections, or losing erections, they actually have erectile dysfunction and not have another sexual dysfunction.

I want to make sure that we go through all the basic health issues. I will prescribe it if they need it, but I want to make sure that we are treating ED. Also, you should treat the whole body like losing weight, exercise, and stop smoking. Because if you have biological erectile dysfunction, not just a 20-year-old with psychogenic ED, you’re at risk for heart disease. If your blood vessels to your penis are not great, there is a good chance you have heart disease.

So if I see a 40-year-old guy and we have documented vascular genic erectile dysfunction, I will send them to a cardiologist for an evaluation. Again, we want to treat the whole patient and because Viagra will help them today, but in the long term, if they want to maintain and get better erections, they should lose weight, control diabetes, heart, etc. So, I’m not just going to say: “Here, have a Viagra and go have a good time.”

Could we get an addiction to these meds, like mentally?

You do not become addicted. I mean, you don’t become dependent on it, and it doesn’t lose effectiveness because you’ve been taking it. But with a lot of young men, even if they have psychological erectile dysfunction, I say: “Take it, get yourself some good erections, have some good experiences, and the pressure will be off, and you will need it less because you’ll be thinking about it less. You will have more confidence again.”

It’s not as if you take Cialis or Viagra and not going to have to be able to have an erection without it in the future. You do not become dependent or addicted to it, and it can only help. It’s like a muscle – the more you exercise it, the better. So the more erections you have, it’s going to be better.

What’s good for the heart is good for the penis. Healthy diets, cardio exercises, stopping smoking. It’s not the only therapy that was studied for the heart, that was found out to be good for erections. We do a treatment called shockwave therapy. It’s a series of 12 times sessions for 20-minute.

Is it painful?

No, it doesn’t hurt. It was initially studied for heart treatment, and they were looking at trying to improve blood flow. It’s also used in other places of the body to stimulate blood flow.

So, you take the penis, and you shock it with something?

Yes, there’s a probe like a flashlight, you come in, and you put it on the base of the penis, and it works. There have been studies that show a success rate of about 70%. It’s meant for people that have vascular disease in the penis to increase blood flow.

You were talking about this machine that checks if the blood flow is good, what is that?

We called it a penile Doppler, and it’s an ultrasound machine that can measure blood flow. Lots of patients come in saying: “I know something wrong. It’s not psychological. I need to know.” The uncomfortable part is we have to make an injection into the penis to give you an artificial erection, and then we measure the blood flow in, and the blood flow out.

It can tell us different things about how good the blood flow is, which means if there’s an arterial disease or the blood flow out. Because some people have good blood flow in, but they have a venous leak. The blood flow comes in, but it leaks out better. It leaks out too quickly. So there are several things we can do with the penile Doppler.

All in all, Viagra and Cialis, this whole class of drugs, are are safe when used properly. Patients come to me and say: “I’m thinking to take two pills of Cialis per day because one wasn’t enough,” and that’s a higher risk of side effects. I’m not prescribing that, and you have to understand that that’s against my advice.

So, use safe, use appropriately, and in conjunction with other things like weight loss, exercises to improve your health, you can use those good erections for longer.

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