I saw a patient a few weeks ago who came to see me for prostate surgery. He did not have a particularly big prostate and found that if he took the alpha-blocking drugs he had been prescribed in primary care, his symptoms were quite manageable. Unfortunately, he haddeveloped side effects linked to both postural hypotension (when a man falls over on getting up from a chair or out of bed) and also a dry orgasm.
There was no absolute indication for surgery here, and his prostate was not big enough to benefit from a prostate-shrinking medication. What I did offer him, however, was the drug Tadalafil. After a month of taking this, he called me to say that his symptoms were very much better, that his erections had improved, although he had not noticed a massive difference there to begin with, and that he was very happy to stay on the Tadalafil. This meant one operation saved, and a very happy patient.
Tadalafil (CialisTM) is not a drug which is usually available on the NHS, and it is often on a banned list in primary care formularies. The drug became available in 2003, being launched as a competitor for Viagra, which appeared on the market in 1998.
In its first incarnation, the drug was available as a single-use pill on demand before sex and had the advantage, possibly over Viagra, in lasting for 36 hours, giving a longer window of opportunity.
When Viagra was launched, the then health secretary, Mr Frank Dobson, restricted its prescription on the NHS limited to a few disease types and allowed the pill to be given once a week at most. Most experts in the area did not really understand the rationale behind the limitations on Viagra. With Tadalafil, the development of clinical trials was interesting in that we had a number of patients coming back very happy with the medication, but telling us that they were finding they passed urine much more freely when on the medicine. We initially thought this was probably because they were generally happier, but indeed, there is a measurable benefit of Tadalafil, taking a low dose of 5 mg once daily, on passing urine.
Restrictions on prescribing were put in place, however, and perhaps when the drug was only available as a branded drug and costing close to £90 a month, this was reasonable. Now, however, Tadalafil 5 mg daily is available for £2.45 a month to NHS practices and is licensed both for use in erectile dysfunction and male lower urinary tract symptoms. It is a little hard to understand why it is so difficult to get hold of, but the rules are the rules.
Interestingly, recently, we have seen that Tadalafil (and to a lesser effect sildenafil) has benefits in stroke prevention, overall mortality, cardiovascular disease, and dementia. It is hard to think of a pill that has so many benefits, and major side effects are very unusual, although some men do get muscle cramps and others do get gastric reflux disease. It can very rarely cause muscle cramp.
There is a bit of a health inequality here since men who have access to private specialists will be able to get prescriptions for the drug, which rarely costs more than £6 or £7 a month in a high street chemist. But those who do not are either banned on the NHS or end up paying much higher rates through online pharmacies, some of which charge over £50 for a one month supply. It is unusual to find patients who want to keep taking medicines after they have had prostate surgery, but that is the case for the majority of my patients who take tadalafil!
For men who are being treated for their prostate blockage by pills, it is always worth a discussion.