DR. GOLDSTEIN: Those are, those are wonderful thoughts that we commonly hear about. People think that erection and ejaculation and orgasm are sort of all the same, and in fact, physiologically they're extremely different. Impotence is the inability to get an erection. Orgasm is a sensory phenomenon that occurs with stimulation to the skin of the penis, which passes to a portion of the brain. And ejaculation is the reflex from that sensory activity, which then results in fluid release from the end of the penis. In many reasons that you don't have orgasm, it can be from drugs. It can be from aging, sensation changes in the penis. You need to see a doctor for that one to find out which is the reason. In many cases, use of a vibrator will add so much increased sensation to the brain that it will result in ejaculation and orgasm. Sometimes the vagina simply doesn't provide the standard sensation for orgasm.

KEN BADER: So Viagra has no effect on --

DR. GOLDSTEIN: Well, you know, that's an interesting question. You know, Viagra, statistically, in the New England Journal paper, when it's released will show that orgasm was enhanced by Viagra as well as intercourse satisfaction, and overall satisfaction, independent of erection. The only thing Viagra didn't work on was libido, successfully. Which is good, because you don't want things to increase your desire. You should intrinsically have your own desire. So Viagra may yet be another therapy for a sexual disorder in the male.

KEN BADER: A 70 year old gentleman from New Jersey asks, "What about drug interactions with Viagra. For instance, is it compatible with Prozac?"

DR. GOLDSTEIN: There are very few reasons to not take Viagra that we presently know of. There's an eye problem called retinitis pigmentosa that means you should not be on Viagra. And it's a rare vision issue. And there's a pill that is called nitro-glycerin, or versions like nitro-glycerin. Nitro-glycerin would be a fast acting nitrate. There are medium acting and long acting nitrates. Short of those two conditions, it's reasonable to use Viagra. Now, should you use Viagra to overcome medication problems, Prozac being one of them, but actually the most common medication problem is cardiac medication or hypertension medication. But let's just say Prozac is the issue. Absolutely, use Viagra to overcome the adverse effects of other pills. If you have to be on any medication stay on that medication. If it has the side-effect of diminished erectile function use the Viagra or other therapies to restore that erectile function.

KEN BADER: Dr. Goldstein, here's a question from a gentleman, 64 years old from New York. He says, "For all my adult life my erection has curved downward rather than upward to my embarrassment." He says, "I once told a urologist about this, but he simply said I didn't have a full erection. Since it was firm, I didn't believe him, but couldn't convince him he was wrong. Is this a common condition. Have you ever heard of it?"

DR. GOLDSTEIN: Yes, it's a fairly common condition. It's actually called congenital penile curvature. There are two ways to have penile curvature. One where you acquire it, and that's usually from an intercourse injury. And most commonly you get that with a partner in the superior position. You can also be born with curvature and that is essentially what this gentleman has. It makes intercourse difficult in certain positions, especially if it's significantly bending downward, and we've seen patients where the degree of bending is more than 90 degrees. And it's a congenital problem where the urinary system, the urethra, which is a part of the penis, is shorter than the erection chamber. So as the whole penis erects, of course you don't see that in the flaccid state, only when it erects, but it's like a tethering, as the erection generates, the urethra doesn't stretch like the erection chambers and the system is bent down. Surgical correction is actually not complicated , usually as an outpatient, and that would be the solution for many men.

KEN BADER: We have another question here, "Dr. Goldstein, I have heard of a topical cream being introduced. What do you know of this product?"

DR. GOLDSTEIN: Actually, Viagra being the example of a first line therapy for erections, which is a little more user friendly than say, pellets, or vacuum devices or injections or implants, there are a host of other things being developed. There are other pills being developed, and now we're in the era of topical creams. There are a series of companies generating topical cream data. Here at Boston University we're working on one. We actually have a little more than 100 people on the topical cream. And it looks like a very exciting alternative to oral pills. Not everybody is happy with an oral pill, and topical creams will fill their needs. Just a little caveat, topical creams will be widely used for treatment of the very first question we had, which was on female sexual dysfunction. I think women are a little more at ease using a topical substance to enhance blood flow delivery to the vagina and/or clitoris than perhaps an oral pill. So it's for the future. It will b e, I don't know, the early 2000's when it's released, and it will be very widely effective.

KEN BADER: I think I read in the "Wall Street Journal" that they're looking into making Viagra into a wafer form. Is that true?

DR. GOLDSTEIN: Anything to enhance this sort of one hour to one and a half hour delay that you get with this drug at the present time. When we look back, many years from today, let's say the year 2005, there will be probably three or four, maybe five or six drug companies with similar drugs like Sildenafil, which is a phosphodiesterase type 5 inhibitor, that have probably better onset of action, better deliveries than Viagra. But we will always remember Viagra for its ability to stimulate the entire country. You opened your talk by saying this is the most talked about subject in America, impotence. And I have to share with you, having been in this field for almost 20 years, it was the least talked about subject in America until this drug. So we will remember Viagra for allowing us to discuss this and as time goes on we will have just better ways to manage it.