Little Blue Miracle

What's an erection worth? Ask the man who doesn't have one anymore, and you'll understand why Viagra may become the hottest pill since the Pill.

As the first oral drug for impotence approved by the Food and Drug Administration, Viagra stands to transform the treatment of a condition that blights the bedrooms of millions of Americans. It could have the most impact on our national sex life of any pill since the birth control pill. Urologists envision a virtual stampede of new patients. And The Wall Street Journal reports that Pfizer Inc., Viagra's manufacturer, believes its brainchild could make it the biggest drug company in the world.

Pfizer and the doctors who tested Viagra have kept discussion on the high-minded level of medication for a medical condition, perhaps to ensure FDA approval. But some enthusiastic users are calling the little blue pill a wonder drug that can mean bigger, harder erections for the average man. "I was 22 years old again," says one seasoned swinger, who spent a night on Viagra sharing the pleasures of progress with four women. "Viagra has a desensitizing effect," he reports. "I had a two-hour erection. A guy can play hard for hours at a time."

If such testimonials are any indication, Viagra is going to be one great drug, a power pack that can transform Joe Dokes into the Energizer Bunny. Premature ejaculation, a barrier to pleasure for millions, could become an unpleasant memory.

What's more, the pill may prove an equal opportunity eros-enhancer, and not just because women have a lot more fun when their partners use it. Sexual problems are at least as common in women as in men, and some researchers think that what many call lack of desire can mask a failure of arousal. And like the penis, the clitoris and vagina must swell with blood to be aroused.

Erections happen when spongy tissue in the penis fills with blood and stays that way long enough for intercourse. But plenty of things can go wrong. High blood pressure or atherosclerosis may disrupt circulation to the critical region. Diabetes, prostate surgery or spinal injury may damage nerves. Anxiety, depression or just plain stress can screw up the mechanism. But whatever the cause, only five to ten percent of impotent men seek medical (concluded on page 178)Little Blue Miracle(continued from page 125) help. One explanation for their reticence is embarrassment, but a more telling reason is that available treatments were, before Viagra, notably short on charm. These include a vacuum device that draws blood into the penis to make it hard, and surgical implants that stiffen it artificially. Until recently, state-of-the-art therapy meant self-injections--directly into the penis--of one or more chemicals to relax arteries and open the floodgates of blood. Injections work about 75 percent of the time, but they're not fun.

"What men really wanted for impotence was a pill," says Dr. Drogo Montague, who is director of the Cleveland Clinic Foundation's Center for Sexual Function.

Enter Viagra. Just four years ago, it was an experimental heart drug that failed to do much for heart disease. "But researchers in England reported improved erections in men who were taking it," recalls Dr. William Steers, chairman of urology at the University of Virginia. After consulting with Dr. Steers and other impotence researchers, Pfizer shifted gears and began clinical trials. The company enrolled more than 4500 men who hadn't had an erection in years.

The results were exciting. Erections returned for 81 to 89 percent of men whose impotence was psychological and for 60 to 70 percent of those with physical problems.

Equally important, the drug seems safe. "There have been no serious drug-related adverse events," says Dr. Harin Padma-Nathan, director of the Male Clinic in Santa Monica. Five to 15 percent of men who take the pill suffer headaches, stomach upset or muscle aches, but for almost all, the pleasures outweigh the pains. While only two percent of study participants stopped using Viagra because of side effects, many others petitioned Pfizer for "compassionate extensions" of their clinical trials to keep their resurrected sex lives going.

Viagra users and their partners appreciate the ease of the treatment. Instead of interrupting sex with a device or an injection, the men take a pill 30 minutes to an hour beforehand. "They get a natural erection, not an artificially hard one like the kind produced by an implant," Dr. Padma-Nathan says.

Viagra works at a critical point in the complex erection process, when the sexually turned-on brain sends a nerve signal to the genitals. This signal causes the release of a cascade of chemicals, first nitric oxide, then a messenger molecule, cyclic GMP, that opens the arteries that serve the penis. As cyclic GMP is broken down by an enzyme, type V phosphodiesterase, the arteries close, the blood withdraws and the erection wilts.

While the pill has already made some men very happy, it won't work for everyone. Viagra amplifies nerve impulses that instruct the penis to rise, but it can't produce an erection when the nerve paths have been destroyed--the case after some spinal injuries, as well as for 25 to 40 percent of men who become impotent after prostate surgery. Nor can it jump-start the process when libido is lacking. "Low desire is a real cause of sexual problems in our society," says Dr. Montague. "Viagra won't create desire." Without sexual stimulation, the drug apparently does nothing.

"Viagra isn't an aphrodisiac," says Padma-Nathan. "It's a revolutionary medical treatment, not a sexual revolution." Although the drug can restore near-normal sexual function to most men who have been impotent, researchers have seen no indication that it enhances a healthy man's sexual prowess. "Viagra will open opportunities for a lot of men who were just managing with partial or occasional erections," says Dr. Arthur Burnett, director of the Male Consultation Clinic at Johns Hopkins University. "It could give them a terrific boost." Padma-Nathan predicts that there will be a large increase, perhaps as much as tenfold, in the number of men who seek therapy.

Yet untapped is the huge potential demand from women. "Viagra doesn't discriminate between the sexes," says Dr. Irwin Goldstein, professor of urology at Boston University School of Medicine. The same bloodflow-boosting biochemical--the ones that are enhanced by the drug--are major players in female genital tissue too, he observes. "I've had a lot of calls, a lot of e-mails from women about Viagra. They're interested and motivated." Studies of the pill in women are just beginning, but in Dr. Goldstein's clinical experience with a small number of patients, it has been extremely effective in restoring vaginal lubrication--a key index of arousal.

With an easy-to-use pill at hand, many men (with or without true impotence) are bound to bypass specialists and seek prescriptions from their internists or family doctors. Nothing wrong with that, says Montague, who chaired the American Urological Association's Treatment Guidelines Panel for Erectile Dysfunction. In fact, the association is planning an educational campaign to inform primary-care doctors about a condition they may not have treated much before.

Others worry, though, that the pill solution could have a dangerous downside. Waning erections are often a warning sign of serious disease, which will be missed if a quick prescription takes the place of a thorough workup. "About five times a year, I diagnose diabetes in a patient who came in for impotence," says Steers. "About twice a year, I find a brain tumor." Impotence could signal low testosterone levels, which can lead to osteoporosis or heart disease.

When impotence has a psychological cause, Viagra could prove to be a mixed blessing: It would relieve the most obvious symptom while underlying problems--anxiety, depression, stress--continue to fester. Leslie Schover, a psychologist at the Cleveland Clinic Foundation's Center for Sexual Function, is concerned that an impotence pill could feed the American male obsession with sex as performance. "A lot of men think they can fix everything in a relationship with better erections--that they are the way you satisfy a woman and make her happy. For most women, they're not that high a priority."

While the Viagra story has so far been positive, researchers caution that experience with the pill is limited and point out that it's not unusual for problems with a new drug to surface only after wide and prolonged use.

"The number of men who have used Viagra, 4500, is a drop in the bucket considering that millions may eventually take the drug," says Steers. "We won't really know the side effects and effectiveness until a lot more men have been treated."

Unique as it is right now, Viagra may soon be joined by other pills for impotence, as the field that some call sexual pharmacology grows. Phentolamine, which opens blood vessels, may be approved by the end of the year. Sublingual apomorphine, which acts on the brain center that initiates erections, has been effective in 70 percent of men with psychogenic impotence and could become available in 1999.

"We may be able to combine drugs, as we do in chemotherapy, for a better result than we'd achieve with any one alone," says Steers. In fact, studies with animals suggest that apomorphine and Viagra can boost each other's therapeutic powers.

By the millennium there may be something better yet--a preventive drug to stop impotence before it starts, says Padma-Nathan. Right now, with its potential impact on women, Viagra itself could well become a revolutionary sex drug.

One doctor predicts a large increase, as much as tenfold, in the number of men who seek therapy.