Twenty years after it first got regulatory approval in the US, Viagra has cemented its position in popular consciousness as a “go-to” drug to help men with sexual performance problems - including in Singapore, where doctors have been prescribing more and more of it every year.

SINGAPORE: Seven years ago Desmond (not his real name) popped a little blue pill in a bid to rescue his marriage. And the Singaporean businessman still remembers being blown away by his virgin Viagra experience.

“It worked very well,” said the 57-year-old, who had been struggling to keep an erection. “I was shocked by the result initially, and then the lasting strength of it.



“It helped me maintain a sexual relationship with my wife. It took away the stress I felt from being unable to perform ... It might have helped my marriage in one way or another,” he reflected. “And I haven’t stopped taking it since.”

Twenty years ago in March 1998, the drug got regulatory clearance by health authorities in the US, a significant first step into the global mainstream. Since then, Viagra has firmly cemented its identity as the signature, "iconic" treatment for erectile dysfunction (ED), at least according to the pharmaceutical firm responsible for its birth and subsequent entrenchment into popular culture.

A local spokesperson for the US corporation Pfizer, whose name is branded on each diamond-shaped tablet, said approximately 66 million men worldwide have taken Viagra since 1998. It was first approved for use in Singapore in 1999, as a prescription-only drug which cannot be bought over the counter in pharmacies.

Viagra pills displayed at a press conference in Singapore in 1999. Local hospitals and clinics had begun receiving the drug as manufacturer Pfizer assured supplies were sufficient to meet "encouraging" demand. (Photo: AFP/Roslan Rahman)



There are no specific local statistics available, though doctors Channel NewsAsia spoke to indicated a year-on-year growth in usage.

“Currently, I expect to see at least one or two new patients a day for ED,” said Dr Justin Sim of Atlas Pacific Medical, a clinic specialising in sexual health. “Most often, new patients will try one box of the medication first to make sure it works for them and that they tolerate it well.”

“For returning patients, I expect to see three to five per week. Usually they buy several boxes at once - as long as I’ve performed the physical examinations to make sure it is safe for them to continue.”

Said Dr Tan Kok Kuan of the Dr Tan & Partners group of sexual health clinics: “For the past two years, our group prescribed about 4,000 tablets of Viagra per year. There are many other factors like natural business growth … but I can definitely say we’ve been prescribing more Viagra and other medications for ED.”

“I expect the upward trend to continue as more men look towards Viagra and its like for help with ED,” Dr Sim affirmed.

“IT ALWAYS WORKED”

After having “intimacy issues” with his wife for “a while”, Darren (not his real name), a Singaporean in his late 40s, sought help with Dr Tan and was prescribed Viagra in October last year.

Describing his first time using the drug, he said: “I felt warm. It wasn’t spontaneous, but it helped. And after that, it always worked.

“It’s just the headaches I need to deal with … but if you need to do something, you need to do something.”

Patients are usually warned they could experience headaches, blurred vision, blocked nose, nausea and other side effects. But for many, these issues are outweighed by the results. According to Dr Tan’s website, the pill works for about 70 per cent of men with ED, and it is clear also that he and his peers hold Viagra in some regard.

“It was the first oral medication with proven efficacy for ED,” said Dr Ng Chee Kwan, director of the CK Ng Urology and Minimally Invasive Surgery clinic.

“Viagra has had an immense impact on sexual health for men in Singapore, and the rest of the world for that matter,” Dr Sim asserted. “If ED is an issue, you can be sure Viagra has played a big part in relieving that issue for many men. When we consider sexual function and ED, it would be a challenge to identify many other options that have had such an impact.”

“Viagra revolutionised the treatment of ED not only in Singapore but the world,” said Dr Tan. “It was the first effective, painless and convenient treatment for ED.”

He could not emphasise the latter two aspects enough, in contrast to the pre-Viagra days when penile pumps, injections, surgical implants, shockwave therapy and pellets thrust into the urethra were the only “painful, cumbersome” options on the table.

A shockwave therapy device for erectile dysfunction displayed during a conference of sexology in France in 2016 (Photo: AFP/Francois Nascimbeni)

The doctors noted that these methods either failed to work for everybody or caused considerable discomfort and inconvenience - in some cases even leading to emergencies such as priapism, a prolonged and painful erection.

“The situation today is certainly much more favourable,” Dr Sim commented. “Viagra is safe, readily available and easy to manage.”

As Dr Ng put it plainly: “Much easier to swallow a pill.”

“VIAGRA THE STRONGEST"

Viagra’s invention, however, was pure accident. In the early 1990s, Pfizer scientists were synthesising an ingredient - first labelled UK 92-480, later named sildenafil citrate - to treat high blood pressure and chest pain.

But in the first round of trials, patients reported an unexpected side effect: Spontaneous erections. The sildenafil was relaxing certain penile muscles, allowing blood to flow into the soft tissues and producing the requisite rigidity.

Viagra was discovered in unforeseen circumstances during trials at a Welsh hospital (Illustration: Kenneth Choy)

Pfizer promptly dipped into its name bank of words certified by linguists as meaningless, came up with “Viagra”, and went on to make a mind-boggling US$1 billion in its first year on sale.

Despite the emergence of direct competitors Cialis and Levitra in 2003, revenue peaked at more than US$2 billion in 2012, and in 2016, Viagra continued to hold market share of about 45 per cent.

While the Pfizer treatment remains the best-known of the trio, local doctors called the medications fairly similar, with prescriptions based on patients’ background, needs, expectations and preferences.

“Viagra and Levitra are effective for up to 4 hours post-dose. Cialis is effective for up to 36 hours post-dose,” Dr Ng explained.

Said Dr Sim: “Broadly speaking, I would consider Viagra the strongest followed by Levitra then Cialis.”

Viagra has also become Pfizer’s - if not the world’s - most counterfeited drug, with potentially harmful bootlegs easily purchasable online and on the streets.

Last year, Channel NewsAsia reported on peddlers in Singapore’s Geylang area selling 10 fake "Viagra” pills for S$25. According to Dr Tan’s website, a box of four Viagra pills costs at least S$53.50.

Some of the purported Viagra pills for sale in Geylang show a dosage of 1000mg, when legitimate ones usually come in dosages of 25mg to 200mg. (Photo: Aqil Haziq Mahmud)

Although he started out with a legitimate doctor’s prescription of Viagra, Desmond admitted he later “got it from other sources across our checkpoints”, but did not reveal more. Viagra is also prescription-only in Malaysia.

“I’ve gotten used to the effects … I don’t feel any different,” he claimed.

Desmond may also have gotten lucky. In October 2017, Singapore’s Health Sciences Authority (HSA) said there were 17 cases over the past five years of people suffering “adverse effects” from illegal sex drugs. Back in 2014, HSA also revealed that since 2008, these illicit substances had left at least 11 men dead and caused over 300 to experience “nasty reactions”.



Pfizer is now exploring the option of making Viagra a non-prescription drug - and late last year announced it would start with Britain in 2018 (Photo: AFP)

“THERE IS LESS SHAME”

With the expiry of its patents, Pfizer’s Viagra sales have declined in recent times, dropping to US$1.2 billion in 2017. But go to its official Viagra.com website and the tagline below the instantly-recognisable blue silhouette reads: “Original brand, still the one to talk about”.

On this, the doctors agree that if Viagra has done anything right over the last 20 years, it is to make men more open to talking about their sexual issues.

“Viagra certainly has helped by being a conversation starter,” Dr Tan observed.

Viagra is credited with turning a bedroom frustration for many men into an openly-talked about medical issue (Illustration: Kenneth Choy)

In an email, the Pfizer Singapore spokesperson said: “Through Pfizer’s investment in research and education, and partnerships with academia, Pfizer has helped transform ED from being a topic of private shame to a publicly discussed and accepted medical condition.”

Desmond concurred. “I feel that there is less shame to it now. ED is a common and widely accepted illness that many men have suffered from or will suffer from in the future.

“It used to be associated with a lack of masculinity, but now that we are more educated we understand that like cancer it can happen to anyone, anytime.”

Dr Ng said Viagra’s introduction has led to more men seeking medical treatment for their sexual problems. “Its availability was a strong factor in bringing men's sexual health issues into the mainstream,” he added.

Said Dr Sim: “I would also say that public awareness topics such as World Aids Day have also helped bring the other aspects of sexual health to the forefront … But we are still only scratching the surface.

“Most men will experience erectile dysfunction for many months to years before they seek help, even though they know about options such as Viagra.

“Most often the taboo and perceived emasculation is enough to stop them,” he stated. “Most have taken big steps just to see me.”

Darren has no regrets taking that leap of faith to go to a doctor. “I’m definitely more confident now. I’ve stopped giving excuses,” he declared.

“In just these few months I can say yes, in terms of my marriage, Viagra has changed my life.”