Please note that Dr Stuttaford isn't familiar with all the circumstances in individual cases and can only deal with the points raised in general terms. Patients should always discuss any specific problems they have with their own doctors.

Readers' questions are answered as examples of general problems commonly met in practice. It is a good rule in medicine that only their own doctors know the patient well enough to pontificate on the case as there are often other factors unknown to strangers.

Does viagra have a 100 per cent success rate - what are the alternatives? Mark L, London

No. Viagra is not always 100 per cent effective There are three drugs of the Viagra group, Viagra, Cialis and Levitra. Each has its own merits. The time taken for each to be effective, the persistence of the effect (it is not always, but is sometimes, an advantage to have a long action) and the side effect profile varies. Not all these three drugs mix equally well with food or alcohol. If one of the three is not successful it is worth trying others. Viagra was the first on the market and is therefore perhaps is best known. Viagra, Cialis and Levitra are indicated for the treatment of men who have poor quality, inadequate erections for a physical reason, a poor blood supply to the penis, rather than any psychological cause. However they are always worth a trial even in those men who are unable to have any form of serviceable erection.

The three drugs are least likely to be effective in patients with diabetes, or after radical prostatectomy. Complications of diabetes may affect both the nerve and blood supply to the pelvis. Radical prostatectomy inevitably damages the nerve supply to the penis that controls erections. Nerve sparing procedures are carried out on many men when having a radical prostatectomy, but even so after surgery the nerve supply to the penis is not what it was. Before the nerve sparing operation was introduced only about forty, to fifty per cent of men managed some form of erection, after its introduction this figure went up by ten per cent. In all post prostatectomy cases it is worth trying these three drugs, sometimes they can tip the balance and produce an effective erection. However if the nerves to the penis have been cut that is that, a penis without its nerve supply is as useful, so far as erections are concerned, as a telephone without the telephone wire. If the nerves have only been damaged recovery may take place over 18 months. 56 per cent of men with diabetes report improved erections with Viagra.

Other groups of men who have trouble that doesn't always respond are those with spinal cord injuries, multiple sclerosis, or some forms of neurological complaint.

Often erectile dysfunction although primarily the result of physical problems (this applies to well over 80 per cent of men with this trouble) there is often a psychological overlay. Although there is no good scientific reason why these drugs should help those in whom the causes of the impotence are entirely psychological sometimes they so boost the physical response that they give such confidence that the circle of tension and anxiety, followed by poor erections circumstances that then creates even greater tension and even feebler erections, is broken.

What are the alternatives to Viagra, Cialis and Levitra? Self injections into the penis work in many cases, in others the erection is not hard enough to penetrate. Giving the injection is a bit of a performance and 80 per cent of those in whom it has been successful give up the treatment within a year. An easier remedy is intra urethral pellets injected down the penis. Although less tiresome to administer it is less effective than the jab. There is talk of a gel with the Viagra mechanism that can be rubbed into the skin being launched, but there are obvious problems that will have to be overcome. Mechanical devices - pumps, rings etc. - will improve a poor erection, but like the injection their use includes a ritual that is difficult to fit into standard lovemaking.

I am a 57 year old healthy man. I always had a no hassle sex life until about a year ago when I started noticing a slow down of my spontaneous erections. Now I have a fear of not being able to maintain a erection during sex. It happened a few times. I am very much surprised by the strong psychological effect that this fear induces. With this comes a decreasing interest in sex all together. Should I ask for medication or just accept that such is life? RD, Vancouver, Canada

You should consult your doctor. It would be necessary to decide the extent to which your general loss of sexual enthusiasm is responsible, and how much can be attributed to some physical cause. It is always imperative to exclude cardiovascular disease, often increasing impotence is the first evidence of this but just as the arteries to the penis may be furred up so may those around the heart or in the neck. Any middle aged man who has increasing erectile dysfunction must be tested for diabetes, both with blood tests and urine testing. Other physical neurological causes must also be excluded.

If the impotence has a psychological cause it is necessary to exclude depression. Many of the newer anti depressants have an adverse effect on sexual ability although even when they improve their desire. Molipaxin trazodone is an anti depressant anti anxiety agent that may have the opposite effect and may even give the occasional patient too prolonged an erection that requires intervention. Don't put up with erectile dysfunction, the overwhelming majority of men suffering from it can be helped. It is always an important symptom that needs an explanation.


I am 79 and my wife is 69. Very happily married for 49 years. Heart attack in 2003 treated by angioplasty with 4 stents. 6 months before the MI I had noticed a slight erectile disfunction (ed) and since then libido good but ed has worsened - penetrative sex is now almost impossible. I am very fit and maintain my share of a 3acre garden and 11 acres of woodland I play golf once a week (without a buggy)and also attend a low impact aerobics class weekly. We have a good low fat, whole food, fruit @ veg. rich demi veggie diet and take a comprehensive vitamin/mineral supplement. My medication includes aspirin 75mg, Lipitor 10mg, Amlodipine 5mg and Candesartan 4mg. I have also been prescribed a GTN spray but have never had to use it. My doctor has given me some Viagra but as it precludes the use of GTN I am very wary of taking it. We would be really grateful if you could suggest a solution to the ed problem. Name and address withheld

Unfortunately but inevitably your cardiovascular system won't be quite what it was even though you must be delighted that in other ways you have done so well after your angioplasty. Istin amlodipine is a calcium antagonist and may occasionally give rise to impotence and mood changes. Amias candesartan is an angiotensin II antagonist, it is not recorded as causing impotence or mood changes. Lipitor is a statin. Statins have been implicated as a factor in impotence but it is hard to accept the alleged evidence as quite correctly statins are widely taken, and most of the people who take them are likely by definition to have arterial problems. You certainly shouldn't use your GTN spray after taking Viagra. Viagra would mix with all your regular drugs. You only need your spray if you have angina and if sex causes angina it is doubtful if you should be having it. Viagra shouldn't be taken soon after a stroke, or heart attack but yours was now three years ago. If Viagra is taken in a small dose first and work it up.

Can prolonged use of viagra have any side effects? I have heard that it can be bad for your heart. Is this true? J. T. Derby

Yes. Viagra, like every other drug that works has some side effects. The one that matters most is eye damage but this is so rare that it shouldn't be a reason for not taking Viagra unless it is known that you have retinal damage optic nerve disease or other degenerative diseases of the eye - your local optician or ophthalmologist will tell you about the state of your retina and optic nerve.

Immediately after a coronary or stroke the drugs of the Viagra, Cialis, Levitra group should be avoided, the patient's doctor will tell them when and if it is safe to resume sexual intercourse. Some men have heart problems that makes the excitement and physical exertion of sex risky. This is rare. Sex is most dangerous with girlfriends, rather than wives or after a heavy meal. These drugs should never be taken with nitrates. Patients who have severe kidney or liver disease, some bone marrow diseases and anaemia active stomach or duodenal ulcers should not take drugs of this group.

Many men, in fact research has shown most men, stop having spontaneous erections - those in which their partner has not provided some manual stimulation - sometime between the ages of 45 and 60. This encouragement needs to be given willingly and with at least the pretence of interest and pleasure if it is to be effective. Men tend to preserve the power of spontaneous erections to a greater extent if there is strong psychogenic stimulation such as a period of absence from each other or even with a new partner. To suffer from impotence at 49 or 50 is not uncommon but it does need investigation to exclude cardiovascular, diabetic or neurological problems. If the cause is cardiovascular it should improve with Viagra, Cialis or Levitra, discuss the drug that will suit you best with your doctor. These drugs improve erections when there is a vascular problem but not if the erectile dysfunction is related to ejaculation, orgasm or the penile nerve supply. Don't give up.

Having been impotent for several years now (basically suffering in silence), I did initially seek my GP's advice being worried that at the then age of 49 (now 56) my GP offered no examination at all and sent me away with Viagra 50m, which quite frankly didn't work. My wife is very understanding though and we just get on with life (married now for 36 years). I have visited my GP on at least another three occasions but on each visit have only been offered Viagra. Am I right to give up? Medication on at present: coversyl 2mg Citalopram 10mg. Name and address withheld

Citalopram is an anti depressant anti anxiety agent. It is one of the 5 HD reuptake inhibitors. This group of drugs may occasionally cause changes in sexual desire but Citalopram is certainly not one of them that is known for this. Coversyl is an ace inhibitor. Occasionally mood changes may occur with them but there is no evidence in the standard data that is likely to be responsible for other causes of impotence. Hypertension (high blood pressure), for which Coversyl may be prescribed, may however be associated with impotence of other forms of erectile dysfunction.