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Viagra, For Me?

Viagra, for me? Yes Virginia, there is a drug for erectile dysfunction (ED) and it may be for you.

As we all were inundated by the face of our former Presidential candidate, Bob Dole, acting as a spokesman for ED and his sponsor, Pfizer Drugs, we could not help but wonder if this miraculous advancement of science would be of benefit to the TG Community. Well it appears that without supporting studies, my best judgment is that we have all the right anatomy to benefit from Viagra during HRT and after SRS. Let me explain.

ED is defined as the inability to achieve and maintain a full penile or clitoral erection resulting in successful intercourse and orgasm. In a variety of medical conditions, this has become a problem for men and women of all ages. In our younger years, we know that stress, fatigue and overwork can produce this condition known as temporary impotence. As we age, high blood pressure, diabetes and peripheral vascular disease take their toll on the peripheral blood vessels of the penis. Drugs for depression, such as Prozac and Zoloft, most anti-hypertensives, alcohol and some diuretics produce impotency. Surgery for prostate cancer, colon cancer and in rare cases for benign prostatic hypertrophy can produce impotency also. And a small number of people have accidental trauma to the pelvis producing permanent impotency.

In our community the introduction of estrogens in HRT reduces testosterone and produces ED and the reduction of a penis to a clitoris in SRS can seriously impact our sexual activity. But a further understanding of the mechanisms of erection shows us that Viagra can certainly improve our sex lives. Human erection is a complex physiologic response that is dependent upon the integration of vascular, hormonal and neurologic mechanisms. Many aspects of the neurohormonal control of erections are still unknown, but it is nevertheless clear that erectile responses can be triggered by a variety of psychogenic and sensory stimuli. These in turn lead to a vasodilation of the penile blood vessels causing increased blood flow and distension of the cavernous penile tissue. In the flaccid state 95% of the erectile tissue is composed of contracted vessels surrounded by a fibrous sheath and skin. During erection the smooth muscles of the arterial walls relax and a large influx of arterial blood enters these vessels. As the erectile tissue expands the outflow veins are compressed at the periphery against the fibrous sheath below the skin. After orgasm the vessels start to contract and venous outflow improves. Anatomically the penis and clitoris are composed of three cavernous tubes, a parallel pair called the corpora cavernosa and a glanular-urethral tube called the corpora spongiosum each supplied by separate arteries and veins originating from a common vessel, the internal pudendal artery and vein. The head of the clitoris and glans penis are served by separate arteries that engorge with increased stimulation but do not become erect like the clitoral or penile shaft. Nevertheless the microscopic anatomy of these tubes which fill with blood are similar, just finer and more delicate in the head with increased sensation due to the thin layer of skin and lack of dense fibrous tissue covering them.

Initial medical treatment of impotency was directed toward vasodilators given by injection into the penile shaft or intraurethrally in the form of a suppository (MUSE) or mechanical penile prostheses. These therapies had their own set of problems but provided excellent erections. In 1977 Ferid Murad discovered that oral nitroglycerin causes the release of nitric oxide, NO, which in turn relaxes the smooth muscles of arteries and allows them to dilate. In 1980 Robert Furchgott discovered that this factor was produced by the internal lining of the arterial wall and causes this relaxation. And finally in 1986 Louis Ignarro showed that this unstable gas NO was the signal molecule that could be propagated from cell to cell. A new neurotransmitter was thus confirmed. As a result of their scientific contributions these three pharmacologists were jointly awarded the 1998 Nobel Prize in Medicine.

These discoveries prompted Pfizer’s research team to look for a way to enhance the effects of the body’s natural nitric oxide. Since this is produced throughout the body, most significantly in the heart, they needed to understand the chemistry of nitric oxide. Nitric oxide (NO) is derived from the amino acid L-Arginine, but simply ingesting L-Arginine does not increase NO locally in the penis as demonstrated by two studies in Germany and Israel. What they found was that NO activates the enzyme guanylate cyclase which results in increased levels of cyclic guanosine monophosphate (cGMP) producing smooth muscle relaxation. They then found the enzyme phosphodiesterase type 5 (PDE 5) which is responsible for degrading cGMP in the penis. So they produced Sildenafil Citrate, Viagra, which enhances NO by inhibiting PDE 5, causing continued arterial smooth muscle relaxation. Now that deserves a Nobel Prize. Since there are other PDEs in the heart and eye, it is easy to see how some cardiac patients taking nitrate vasodilators for their angina had a precipitous fall in blood pressure and died. The good news for most is that a full erection can be achieved in twenty to sixty minutes and will last up to four hours or until orgasm and ejaculation is achieved. After four to six hours of erection, the problem of priapism, a rigid penis, is occasionally encountered which will require an emergency room injection to achieve detumescence.

For those of us without cardiac conditions, I will now tell you why this should work for you. For those of us on HRT, the libido may be suppressed but the nerves and arteries are still intact. Since Viagra is not a direct vasodilator per se, you will still need mental and local stimulation to produce an erection. With a willing partner in a more youthful setting this seems easy enough. But it has been shown to be effective in older men with complete Testosterone suppression being treated for Prostate Cancer. The best results have been achieved with people with psychogenic impotence being treated for depression. In women and men on Prozac, a small study with Viagra and a Placebo arm showed penile erection or clitoral engorgement and increased sensation leading to orgasm in over 80% of patients on Viagra. The most common side effects are headache, flushing, stomach acid reflux, nasal congestion and blue tinted vision. All are the result of vasodilation and are temporary. Pregnancy also could be an adverse event for some. A small study on post menopausal women showed that only 18% had serious improvement in their sex lives, but 20% left the study because of clitoral engorgement and hypersensitivity. That is exactly what we are trying to achieve. The definitive study on Viagra in women has not been published yet. But you must remember from where we started.

In SRS in the last ten years, the clitoris has been formed from the glans penis leaving the complete neurovascular bundle intact and placed in the normal position. Studies on these patients have shown normal sensation, clitoral engorgement and orgasm to be present in the vast majority of patients having this technique. The vagina is lined with inverted penile skin, but does not retain the degree of sensation previously noted since the paired corpora cavernosa are removed. So please discuss this with your surgeon before undergoing SRS.

Wishing you the Best in your New Future.

Cerise Richards, MD

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