In her Saturday feature on the 10th anniversary of Viagra, Globe writer Erin Anderssen interviewed Hamilton urologist Dr. Michael Greenspan, who writes about 400 prescriptions for the little blue pill a year and sits on an advisory board for Pfizer, which holds the patent for the drug.
Dr. Greenspan says the pill revolutionized help for his patients, who previously had to choose between penile injections or implants to solve their problems.
Since Viagra, he says, "I have never had my hand shaken or my back patted as much as I do when people leave my sexual dysfunction clinic."
Do you have questions about Viagra? Erectile dysfunction? Impotence? Would you like to know more about other treatments and medications?
Dr. Greenspan joined us online Monday to answer your questions.
Questions and answers appear at the bottom of this page.
Dr. Greenspan is head of service - urology - at Hamilton Health Sciences in Ontario and director of the hospital's sexual medicine clinic. He has served as a consultant/advisor for Pfizer Canada, Eli Lilly Canada, Bayer Inc., Solvay Pharmaceuticals. Dr. Greenspan is also a member of the Ontario Doctor's Hockey Hall of Fame.
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Brodie Fenlon, globeandmail.com: I'd like to start with a sincere thank you to Dr. Greenspan who took time away from his busy practice today to answer questions. We had a large number of questions, which suggests there are many men seeking answers on this important subject. We'll try to get to as many of them as we can. (I apologize for the brief delay - we had some technical problems).
Sridhar Nadamuni from Toronto writes: Hello Doc. Can you give us 10 solid reasons why you should not take Viagra? By the way, I am a medical writer who writes for the pharmaceutical industry, but I'm curious why certain people have more than a passing interest in pills like Viagra.
Dr. Michael Greenspan: The only reason not to take Viagra is if you are on nitrates for heart problems or if you are physically unfit to have intercourse. If you are looking for reasons NOT to take Viagra, you won't get them from me!
Peter from Canada writes: What are the optimal conditions for maximum effect (i.e. empty stomach, after exercise, morning, evening etc.)? I have had the habit of extremely hot baths for many decades -- could that be partly responsible for my need for stimulants? Viagra seems to be less and less effective with each use. Any comment?
Dr. Michael Greenspan: Hot baths should not be responsible for sexual problems. For some people Viagra does work better on an empty stomach. Try taking it about half an hour before your evening meal. Decrease in effectiveness might mean you should try one of the other pills. Have your testosterone level checked.
Tony from Campbell River writes: Dr. Greenspan, about 15 months ago I had an LRP procedure on my prostate. At the time they told me that my sexual function would eventually come back to a semi-normal state. I realize that the procedure interrupted the main blood vessel that sends blood to the penis. My question is how long will it take for an erection to come. I have all the feelings (nerve sparing procedure seemed to work), and at times I have a full erection but only for about 30 seconds or so. I have tried Cialis and Viagra as well as the pump but they do not seem to produce any satisfactory results. The only thing I have not tried is the needle. Any suggestions would be dearly appreciated. Thank you
Dr. Michael Greenspan: It can take up to three or four years to achieve return of erections or response to pills after this type of surgery. Some patients never achieve the expected response. The problem is not blood supply, but disturbance of nerve function. You should really consider injections at this point in time.
Emery from Toronto writes: I have tried a doctor's sample pill with no complete result...should I have used a stronger dosage?
Dr. Michael Greenspan: Can't answer the question without knowing what pill and the dose you were given.
T J from Canada writes: Reluctantly, reactions to Viagra and more recently, Levitra -- even low doses -- have resulted in my urologist recommending Trimix injections. I'm scheduled for a demo clinic in April. I am nervous. My wife chuckles, knowing how squeamish I am even watching someone getting a flu jab on television. Dr. Greenspan, what can I look forward to? What am I getting myself into here? Should I cancel the clinic appointment and just go back to enduring the nasty side effects of the Levitra samples he gave me?
Dr. Michael Greenspan: I tell my patients that they have done themselves a "disservice" if they don't try injections. Injections are quite tolerable and don't hurt more than a blood test for most patients Would your wife consider giving you the needles?
Ryan from Toronto writes: Dear Dr. Greenspan, I'm 50 years old and have been using intermittently Viagra for the last year, and on some occasions I had difficulty to ejaculate; then I reduced the dosage from 100 mg to 50 mg, believing that the higher dosage was the reason for this problem. However, on my last 2 dates I experienced the same lack of ejaculation, which is pretty worrisome, to say the least. So, do I have to stop using Viagra and change medication altogether ? What is your advice? Thanks in advance.
Dr. Michael Greenspan: Are you on any other medications? Are you having orgasm without ejaculation or no orgasm at all? This is not a side effect of Viagra. You and your partner may need to go to see a sex counsellor to resolve this issue.
Ron from Kelowna writes: I have been taking Viagra for over 5 years with varying degrees of success. My dosage has been increased from 50 mg thru 75 mg to 100 mg. It has continued to decline in potency. I have now tried the two remaining options, Cialis and Levitra, also subject to varying degrees of success. Has a maximum mg dosage of each drug been determined? Increased dosages of Viagra seemed to work for a while, but the side effects (stuffed up, runny nose, lasting several hours) also has become very bothersome. My family doctor has resorted to pep talks, and my urologist was less than helpful. I am generally in good health.
Dr. Michael Greenspan: Going beyond the recommended max dose for the pills generally gives side effects and little increased success. You need your testosterone checked. Many patients who fail oral therapy can be salvaged with testosterone
Al from Victoria writes: I am a senior, and at one point I had surgery to enlarge the passage around the urethra, removing the pressure on my bladder. It was very successful, so much so that I was asked to join a survey on Viagra. I was accepted, even though I was single. I told the young lady in charge that finding a girlfriend who enjoys an evening of fun has never been a problem. Being French and still attractive, I joined the survey and enjoy the free samples of Viagra or placebo given to me. Even though I didn't think I needed help from this little blue pill, I sensed I was on the real thing. So much the better. This is my question: I have mild hypertension which is under control. Even so, is it dangerous to take Viagra even though I limit myself to one?
Dr. Michael Greenspan: It is totally safe for you to take Viagra. There are no dangers in taking any of the ED drugs even for patients on multiple blood pressure medications.
Steverino writes: I am 66 years old and had my prostrate removed 2 1/2 years ago due to prostrate cancer. It was at the lowest stage for this type of cancer. The procedure was supposed to be nerve sparing but it appears that this was not successful. Additionally I am on Effexor on a daily basis. I have tried Viagra without any success and now use Cialis and only have the occasional success without the erection. Most often this just leads to a higher feeling of frustration for me. I have tried injections with long lasting painful results and stopped trying this method as we could not find the proper dosage. My wife and I would like to continue to have some romantic relationship although we recognize that this will not be anywhere near the same as when we were younger. Can you suggest any help for us?
Dr. Michael Greenspan: It sounds as if you need to see a urologist who does penile implants. Patient and partner satisfaction after implants is greater than 80% in motivated couples.
Mike from Canada writes: When a prostate biopsy turns up P I N, what is it and how much of a concern should it be?
Dr. Michael Greenspan: PIN means "prostatic intraepithelial neoplasia. " It used to be thought a warning sign for cancer, but not so much any more. Much more important would be such things as the absolute PSA number, any change of PSA over time, your age, a positive family history of prostate cancer
John from Victoria writes: I have Peyronie's disease. About 13 years ago I was operated on to remove the plaque. It was only partly successful: The plaque could not be removed because it was too dense, but the urologist sliced into it to make it more flexible. I still have a slight bend. Unfortunately, the process (which also included circumcision) caused me to loose some sensation in my penis. Consequently, I tried different ED solutions, including penis injections. Most worked but had some negative impact. Viagra works (in as much as it creates an erect penis) but it causes my heart to beat much faster and harder. This lasts all night and keeps me awake. Two questions: Has any progress been made towards finding a cure for Peyronie's? My surgery was in 1994. My wife and I are separating now, mainly due to loss of intimacy (we haven't been intimate in over 13 years). I want to find a new mate but am nervous about the bend and pure performance. 2) Is there a better solution for me than Viagra? Is there another pill that doesn't have the same active ingredient? Sorry this was a bit long. Thank you in anticipation.
Dr. Michael Greenspan: Not much progress in treatment for Peyronie's. Early on in the disease, we are now injecting the scar with Verapramil. If the curvature is not the rate limiting factor for you but erectile rigidity is, you should try Cialis or Levitra. Many patients have side effects on one pill and not from the others.
Bruce from Toronto writes: I use a Nitro patch 0.4%. I have been advised I cannot use Viagra while using the patch. My question is: If I discontinue using the patch could I use Viagra? Thanks.
Dr. Michael Greenspan: You would need to consult with your doctor before discontinuing the nitropatch. You also should not be prescribed Viagra if you are substituted with nitrospray.
PM from Canada writes: My PSA test went from 2.6 to 5.0 in six months, but has since held steady for over a year at 5.0. Given that a biopsy is invasive, and would spread cancer, if there, what would you recommend to a 70-year-old man whose life style is still very active? Biopsy or just monitor the PSA?
Dr. Michael Greenspan: Has your doctor considered placing you on a 2-4 week course of CiproXL before your next PSA to see if there is a drop in the PSA reading? Essentially, in this day and age, you probably should consider a biopsy if your are in good general health
Rich from Canada writes: I have been a Type1 diabetic for 35 years and was diagnosed with CAD 2 years ago. I take the usual heart medicines (i.e. beta blocker, ACE inhibitor, cholesterol lowering drugs, etc). My question: Is Viagra safe for me to take?
Dr. Michael Greenspan: As long as you don't have or use nitroglycerine, it is totally safe for you to use Viagra
Paul from Canada writes: Following my prostate removal (Aug 2005) along with having MS, I am unable to achieve an erection. Is there anything that might prove helpful?
Dr. Michael Greenspan: You should consider trying Viagra, Cialis or Levitra. If they don't work, you would need a referral for a trial on injection therapy. Failing all of these, a penile implant is a very viable third option.
Carlos from Ottawa writes: Is there any help for people suffering from pe? What are the options available? Thank you.
Dr. Michael Greenspan: I assume you mean premature ejaculation. The options are a trial on Paxil 20 mg at bedtime for 6-12 weeks, sexual counselling, or a combination of both.
Brodie Fenlon, globeandmail.com: The following two questions are related, so I grouped them together:
N A from Canada writes: Circumcision: It has been shown that circumcision removes the frenulum and the ridge band which contain highly sensitive and erogenous nerves. Furthermore, a high rate of Viagra use is correlated with circumcision (ex in the States and the Middle east). What is your experience with that? Do intact men suffer less from erectile dysfunction? I was circumcised at birth and I feel as if my body has been violated without my consent. I know plenty of intact men who have no problem handling their foreskin and have never encountered a serious issue. Even phimosis can be treated with creams and stretching. Apparently the main reason for Abrahamic circumcision was to reduce the pleasure for the male and indirectly for the female. Sexual pleasure has always been frowned upon in religion. What is your stance on this? Thank you.
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Rae from Canada writes: Dr. Greenspan, What are the roles of the foreskin in a healthy male? Does it have lots of nerve tissue in it? Is sensation lost when men are circumcised? Do you ever have men see you about having their foreskin re-grown? Thanks.
Dr. Michael Greenspan: There is no established relationship between sexual satisfaction and circumcision. As well, there is no evidence that Viagra usage depends on foreskin status. Ritual circs were done for hygienic reasons. Any sexual dysfunction that results from circumcision is psychological in nature
Brodie Fenlon, globeandmail.com: We are at the end of today's discussion. Dr. Greenspan has kindly offered to answer a few more of your questions that we didn't get to. I will post them later in the day. Thank you again to Dr. Greenspan and to Globe readers for your frank and thoughtful questions.
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Extra Questions
Seymore from Toronto writes: Besides using Viagra for helping with erections for sexual activity isn't it important to have erections for heart health? If you are not having erections on a regular basis without Viagra are you at greater risk of heart or other circulatory diseases particularly if you are over age 50? This has implications for men who do not have a partner. There are a lot of single men out there!
Dr. Michael Greenspan: There are certainly studies that imply generally better physical and mental health in both members of a relationship where there is still sexual activity. Viagra, Cialis and Levitra, as a drug class, have been shown to improve "blood vessel health" when taken on a daily basis, even at a small dose. However, this indication is not, might we say, ready for "prime time" yet.
Steffen from Canada writes: Are there other solutions to erectile dysfunction other than Viagra (e.g. diet and exercise)?
Dr. Michael Greenspan: A healthy lifestyle including regular exercise, weight control, and a healthy diet, has certainly been shown to improve sexual function without having to resort to Viagra.