It's been difficult to miss the Viagra revolution, what with a high-profile marketing campaign that makes it the third-most advertised prescription drug in America. Since the drug became available four years ago, impotence is something men are more willing to discuss with their doctor.

"Unquestionably, Viagra is an amazing drug," says Dr. Hossein Sadeghi-Nejad, assistant professor of surgery-division of urology at New Jersey Medical School and a urologist at University Hospital. "Erectile dysfunction (ED) is no longer a taboo subject, and with the assistance of Viagra, millions of people have regained intimacy. It's also a very well studied medication. In a relatively short time frame, more than 300 peer-reviewed articles have been written about Viagra."

Viagra chemically intervenes in the process it takes for a man to achieve an erection. Once he is aroused, nerves send messages to the vascular system to increase the blood flow to the penis. Specifically, a vasodilator molecule, cyclic guanosine monophosphate (cGMP), helps smooth muscle in the penis to relax, enabling more blood to flow. However, phosphodiesterase type 5 (PDE5), a naturally occurring enzyme, breaks down cGMP(sometimes too quickly. Viagra inhibits PDE5, bolstering levels of cGMP. In simple terms, Viagra increases blood flow to the penis, which is necessary for erection. The drug is taken approximately an hour before intercourse but may remain active up to four hours. Some men experience headache, flushing, or a temporary bluish tint to their vision after taking Viagra. There are two new ED oral medications, tadalafil and vardenafil, that are expected to be available next year. They both work in a way similar to Viagra, but may have a different side effect profile.

Not Always the Answer

Dr. Hossein Sadeghi-Nejad

Still, Viagra, or sildenafil citrate, is not for everyone. It should never be used by men who take any type of nitrates(drugs, such as nitroglycerin, that are typically used to treat ischemic heart disease. A Viagra/nitrate combination could cause blood pressure to fall to dangerously low levels, warns Dr. Sadeghi-Nejad, who is fellowship-trained in male erectile dysfunction and male infertility. Men with retinitis pigmentosa, a rare eye disease, should not take Viagra either, as doing so can make their vision worse.

For other men, Viagra isn't the best approach. Viagra often works well for a man who has mild to moderate ED, provided he has no contributing vascular or nerve damage. That's an important distinction to make, says the urologist. "If you have a flat tire because there's not enough air, then a good pump can be very helpful. But if there's a big hole in the tire, then you can pump in all the air you want, but it won't do any good," he says. "The same is true with impotence. If blood flow is the problem, than Viagra can be helpful. If the man has a venous leak, where the veins can't keep the extra blood within the penis to maintain an erection, then, depending upon the severity of the problem, Viagra is less likely to be the solution."

While Viagra has an overall 82 percent effectiveness rate, it might not be as helpful for men with certain medical conditions. Only about 50 percent of impotent men with Type II diabetes, which can damage blood vessels and nerves, and approximately 65 percent of impotent men who've had a radical prostatectomy are helped by Viagra.

Beyond the Little Blue Pill

"Paul," a 49-year-old patient of Dr. Sadeghi-Nejad's, is one of those men for whom Viagra wasn't working. He began to experience ED about four years ago; the first urologist he went to prescribed Viagra. "Viagra helped a little bit, but not as much as I had thought it would," he says. "I was disappointed, but I wasn't ready to give up that part of my life."

Fortunately for men like Paul, who have moderate to severe ED, there's a wide range of treatment options other than Viagra. Dr. Sadeghi-Nejad's approach starts with finding the underlying cause of ED (see "ED: The 'Invisible' Male Health Concern"). Sex therapy can be an appropriate route when the cause is of a psychogenic(emotional or psychological(nature or as a complement to any of the medical or surgical therapies for ED. He has his patients try the least invasive option first(which often, but not always, is Viagra(and go on from there if necessary.

For men who have low levels of testosterone that causes erectile dysfunction or decreased desire, hormonal therapy can be beneficial. A man should have a thorough prostate screening, says the urologist, because prostate cancer is a contraindication to testosterone therapy. The artificial testosterone can be delivered by injection or via a skin patch. When a man's testosterone is restored to a normal level, his potency is often regained.

Would You Like to Know More About Erectile Dysfunction? Click here to read: ED: The "Invisible" Male Health Concern

Other treatments revolve around prostaglandins, which dilate blood vessels in the penis and may be highly effective therapies. Prostaglandins can be delivered through a suppository, such as Medicated Urethral System for Erections, or MUSE.( Using a special hand-held device, the man inserts the suppository into the penis opening and through the urethra, where it is absorbed near erectile tissue. While MUSE can be useful, some men complain of burning or discomfort, says the urologist.

A second way to administer prostaglandins is by injection at the side of the penis. "This can be a highly effective treatment, and when the patient is taught how to correctly give himself an injection, is not very painful," says Dr. Sadeghi-Nejad. One uncommon, but possible, drawback is that the injection could work too well, causing priapism, an erection that lasts several hours and requires medical relief.

A new treatment, a topical prostaglandin gel that can be applied directly to the penis, is under development. However, some men who tried the gel in clinical studies experienced skin irritation as a side effect.

While prostaglandins can benefit blood flow-related ED, vacuum devices are used to treat a wider range of problems. There are three parts of a vacuum device: the pump, a plastic cylinder, and an elastic band. The penis is placed within the cylinder as the air is pumped out, creating a vacuum around the organ and drawing blood into it. Then, the band is placed around the base of the engorged penis to prevent the blood from escaping once the cylinder is removed. Some men and their partners find the device cumbersome, but for patients with venous leak dysfunction, says the urologist, it may be the ideal treatment.

When other treatments are unsatisfactory to the patient, surgery is the remaining option. "Penile implants can be the answer when everything else has failed," says Dr. Sadeghi-Nejad. "There are two types of implants(semi-rigid or inflatable(that can be placed through the scrotum with no cuts on the penis. It's an outpatient procedure that has a 93 percent satisfaction rate, and the implant doesn't interfere with ejaculation or fertility." The semi-rigid prosthesis consists of two rods that are inserted into the penis's corpora cavernosa, chambers that run the length of the organ. The inflatable prosthesis involves two tubes that can be filled with sterile liquid via a pump that is placed in the scrotum. Very rarely, surgery to bypass or reconstruct blocked arteries is attempted in younger men.

Sometimes the patient has to try different treatments before finding the one that best helps him. Paul, who initially tried Viagra, next used the injectable prostaglandin. He experienced some improvement over what he had with Viagra, but because of other existing physical factors, he had penile implants placed in January. Paul, it was found, has Peyronie's disease(an inflammatory condition that causes scarring of erectile tissue, which leads to a curvature of the penis, painful erections, and sometimes ED. In one-third of the cases, this curvature corrects on its own with time. But for Paul, the answer was implants to solve both the curvature and the ED problems.

Paul took what for many men are some courageous steps. Along the way, he says, he found in Dr. Sadeghi-Nejad a trusted and skilled practitioner. "I'm a pharmacist, so I've dealt with many doctors," he says. " Dr. Sadeghi-Nejad knows his subject very well and explains it clearly and with empathy for his patients. He clearly wants to help men overcome this problem in their lives."

For a consultation with Dr. Sadeghi-Nejad, call (973) 972-2888.