- Patients can be offered Viagra but far better medications have been developed
- One treatment, tadalafil, can be taken in low daily dose rather than when needed
- Daily medication may even bring about long-lasting physical improvementsMen who suffer problems between the sheets are seeing their sex lives left 'in tatters' because NHS doctors are barred from prescribing the latest drugs that target erectile dysfunction, experts warn.
Patients can be offered Viagra, but in the three decades since the famous blue pill was first trialled, medications that are far more effective have been developed.
One such treatment, a tablet called tadalafil, can be taken in a low daily dose. This dispenses with the need, as when using Viagra, to take a pill 30 minutes to an hour before intercourse, making things much more spontaneous.Daily tadalafil – brand name Cialis – may even bring about long-lasting physical improvements, helping to address the nerve and blood circulation problems that cause erectile dysfunction in some cases.
When the drug was first launched in 2003 it was prohibitively expensive, compared with Viagra, leading the NHS spending watchdog, the National Institute for Health and Care Excellence (NICE), to instruct doctors not to offer it.
New medicines, under patent, usually have a higher price. After the patent expires – usually 20 years after it is first granted – other manufacturers can make so-called generic versions, driving down this cost.
US pharma giant Eli Lilly's patent on Cialis ended in 2017, and today the NHS pays as little as 20p a day per patient for generic tadalafil. So why is it still so difficult for men to get it?
Part of the problem lies in the current NICE guidance, say experts. It instructs doctors that generic Viagra can be prescribed 'without restriction'. And it does permit use of tadalafil in certain doses, for men with specific health problems.SHARE THIS ARTICLEShare
Alongside the low-dose daily version, tadalafil is also available in a higher dose that can be taken 30 minutes before sex, much like Viagra.
NICE state that this high dose version is recommended for 'most men' who are eligible. The lower, daily dose should only be offered to 'men who prefer spontaneous (rather than planned) sexual activities'.
And, regardless, daily tadalafil remains prohibited by local prescribing groups in charge of GP spending – a situation described by one expert as nonsensical.
Now urologists are calling for a dramatic rethink of the treatment for erectile dysfunction, which affects one in five men.
Common causes of the condition include diabetes, neurological illnesses and mental health problems such as anxiety and depression, while men with prostate cancer who have surgery to remove the gland are often left with some degree of erectile dysfunction.
These groups are eligible for NHS help – but in the vast majority of cases, Viagra is the only option given.
All erectile dysfunction drugs work by improving the blood flow to the penis.
'The problem is that the effect of Viagra isn't long-lasting, which means you have to get your timing right,' says Marc Lucky, consultant urologist and surgeon at Aintree University Hospital NHS Foundation Trust.
'You need to take it between 30 minutes to an hour before you have sex. If you wait too long after having the dose, the effect can be weaker or it might not work at all. Similarly, if you take it and don't wait long enough before having sex, it won't work and you'll have to stop and wait.
'It's a very unnatural way to approach intimacy, and basically requires men to disclose to their partners that they need an erectile dysfunction drug.
'This might be fine for some men in long-term relationships, but particularly for younger men it can be hugely embarrassing. Many try to keep it a secret – and this fuels myths and misunderstandings about the causes of erectile dysfunction, and the role drugs play in treatment.
'Women often mistakenly believe that their partner takes Viagra because they're not attracted to them – which isn't the case.
'Erectile dysfunction medication allows men to have erections, but they won't happen if a man isn't sexually aroused.'
Dr Geoff Hackett, a men's health specialist at Good Hope Hospital, Birmingham, says Viagra often leads to 'dysfunctional sex'.
He adds: 'Many men feel like once they've taken the tablet, they have to make use of it. But what if their wife then has a headache and doesn't want to?
'Patients have also told me their doctor would only write them a prescription for one tablet a week, which both ups the pressure, and isn't very encouraging.'
Unlike Viagra, tadalafil can be taken in a low-dose daily tablet and stays in the system for up to 36 hours. There are few to no side effects and this regime allows men to have sex without worrying about timescales.
Mr Lucky adds: 'I've had patients whose sex lives have been left in tatters, and some who were even suicidal after a relationship broke down due to problems with Viagra. Don't get me wrong – it still has its place. We'll offer it to patients, but the problem is, if it doesn't suit them, we've got no other options.
'It's frustrating to know there's a drug available that could help solve these problems but we are not allowed to prescribe it.'
One patient to have been affected is James, a teacher from Liverpool who didn't want his full identity revealed.
The 35-year-old, who has type 1 diabetes, suffered erectile dysfunction as a complication of his condition and was prescribed Viagra in 2019.
But using the pills, he says, zapped his relationship with his fiancee of 'all spontaneity', resulting in the end of their two-year engagement.
'It turned sex into a scheduled task, putting me under even more pressure to get it right,' he says. 'And most of the time it didn't even work, which made me feel like I'd failed.' After a year of trying different doses, the couple stopped even attempting sex.
James says his mood was 'bleak, most of the time' as he struggled to feel confident in every area of his life. He returned to his GP to ask for an alternative to Viagra and was referred to a private doctor, who was able to offer a prescription for daily tadalafil, costing about £100 a packet.
While the NHS can buy drugs in bulk for a lower cost, the so-called 'list price' charged to private patients for a single packet of tablets is far higher.
'Within a few weeks our sex life completely went back to normal,' says James. 'We felt closer again and I just stopped thinking about my sex problems all the time, which made it happen naturally, like it should do.
'But I just couldn't afford to keep getting it – spending more than £1,200 a year on pills just so I could have sex.'
A year later, the couple split up. 'Maybe if I had stayed on the pills, and just kept paying, I'd still be getting married,' he says, sadly.
According to official guidance set by NICE, GPs can offer the generic form of Viagra, called sildenafil, and also tadalafil, to men with erectile dysfunction.
In its guidance, it suggests tadalafil daily tablets may be considered for men who 'prefer spontaneous rather than planned sexual activity'.
When health chiefs first evaluated tadalafil, under the brand name Cialis, it cost more than £50 per patient for a month's supply.
Now, in its generic form, it is roughly ten times cheaper. But critically, in NICE's guidance it suggests generic sildenafil 'has the lowest acquisition cost'.
This alone, says Mr Lucky, deters GPs from offering tadalafil. 'In many doctors' minds, tadalafil is an expensive drug so they won't offer it,' he says. 'In fact, both sildenafil and tadalafil cost the NHS the same, about 20p per dose.
'As men don't necessarily take sildenafil every day, just as and when they need it, there is a cost difference, but it's fairly marginal.'
Local health authorities also make their own rules about which pills can be routinely prescribed, and many prohibit tadalafil due to cost and as it has not been proven to be more effective than Viagra. Experts say this is in urgent need of updating.
'The current NHS rules on tadalafil are nonsensical,' says Professor Roger Kirby, president of The Royal Society of Medicine and a retired urologist who was involved in the original UK research and approval of Viagra in the 1990s.
Prof Kirby, who is in his early 70s, had his prostate removed in 2013 after being diagnosed with prostate cancer and now takes daily tadalafil.
'We know it's a better drug,' he says. 'Most middle-aged men will take a few tablets a day, maybe a statin or something for blood pressure.
'Tadalafil can be added to that, and it becomes a normal part of life. You don't have to think about it.
'When I first started taking it, I also took a dose of Viagra as and when I needed it. But now I don't need this.
'We're not sure why, as the studies haven't been done, but we think, at least in the case of men who've got erectile dysfunction after prostate surgery, that the daily dose regime might help recovery of the blood supply and nerves, leading to a long-term physiological improvement.'
Urologists have written several letters to NICE, urging it to reconsider the restrictions and encourage local heath chiefs to promote the use of tadalafil, but so far it has failed to act.
There was a similar reluctance to offer Viagra widely: the drug was licensed in the UK in the late 1990s but was only available privately until 2014 when it was approved for prescribing by the NHS.
Dr Hackett says that despite its prevalence, there is still a stigma around taking Viagra, particularly in younger men: 'Many of my patients tell me that women are instantly put off when they say they are taking Viagra. Some say they are even laughed at.
'For men who already struggle with confidence issues, this can be really traumatising.'
All the experts agree that taking tadalafil offers men a feeling of normality.
Mr Lucky adds: 'Considering so much of erectile dysfunction is psychological, this alone can help them rebuild their confidence and get past the issue.'
While erectile dysfunction drugs increase blood flow to the penis, there is also evidence that tadalafil helps increase it in the limbs of people with severe type 2 diabetes, who can be at risk of losing their legs or feet due to dangerously low blood flow.
Tadalafil is also available on the NHS to treat other conditions, including pulmonary hypertension – high blood pressure in the part of the heart that supplies the lungs. 'It really is an incredibly powerful drug,' said Dr Hackett.
'There are just so many benefits to taking it.'
Another man with erectile dysfunction to have benefited is 54-year-old Daryl Tompkins, from Birmingham, who describes the treatment, which he pays for privately, as life-changing.
Daryl, who has type 2 diabetes, was convinced his 25-year marriage would end after spending three years on ever-increasing doses of Viagra.
'Even the highest dose didn't work,' says Daryl, a research assistant who has struggled with erectile dysfunction since 2011. Before then, Daryl and his wife Sunita had an active sex life, enjoying intimate moments at least twice a week.
Gradually, following his diabetes diagnosis, this dwindled to roughly once every two weeks – and usually, he says, these were only 'attempts'.
'I was given only four Viagra pills to last me a week, so if I took them and we didn't have sex, we both felt like failures and like we'd wasted a chance, which piled on the pressure for both of us,' he says.
'And because it wasn't working, Sunita became convinced the real problem was that I'd lost interest in her. She became self-conscious when it came to intimacy, which wasn't like her.'
Daryl went to see Dr Hackett privately, who prescribed a daily dose of tadalafil. After three months, Daryl says he felt like a completely different person.
'It was almost like we'd just got married again,' he adds. 'I've noticed other benefits too – my blood pressure is lower and I have bags more energy to go out and exercise, which I wasn't interested in before.
'In fact, I didn't have much interest in anything. But these drugs changed that. They've changed everything.'