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Back pain and myalgia can occur with tadalafil, but are unusual with sildenafil or vardenafil.

Patients at high cardiovascular risk should not be treated for ED until their cardiac condition is stabilize.

These conditions include unstable or refractory angina, myocardial infarction or cerebrovascular accident within the past 2 weeks, uncontrolled hypertension, New York Heart Association (NYHA) flibanserin online order Functional Classification III-IV congestive heart failure, high-risk arrhythmias, hypertrophic obstructive cardiomyopathies, and moderate-to-severe valvular disease. 25 This class of drugs is also contraindicated in patients who use nitroglycerin or nitrate-containing compounds. Although vardenafil does not seem to produce significant clinical QT prolongation, it has been suggested that it be avoided in patients who have congenital QT prolongation abnormalities and in patients using class I antiarrhythmic drugs, such as quinidine and procainamide. It is also best to avoid the use of vardenafil with class III antiarrhythmic drugs, such as amiodarone or sotalol.

Due to the risk of hypotension, caution should be used in patients using alpha blockers for prostate hyperplasia and patients using other antihypertensive medications and alpha blockers, which should not be co-administered with PDE5 inhibitors.

In patients who take 50 mg of sildenafil or more and use alpha blockers, sildenafil dosing should be avoided for at least 4 hours after the dose of the alpha blocker. In patients who take 25 mg of sildenafil, use of any alpha blockers is considered safe. Dose-adjustment is recommended in patients with hepatic failure and with co-administration of drugs also metabolized by the cytochrome p450 enzymes. There is a reported risk for nonarteritic anterior ischemic optic neuropathy (NAION) with the use of PDE5 inhibitors.

Although the association is controversial, it is prudent to consider alternative treatments for ED in patients with NAION or at risk for it. Withdrawal of Medications Causing or Contributing to ED. It is extremely important to take a complete drug history for patients reporting ED.

Medications that may cause or contribute to ED include: Alcohol, nicotine, and illicit drugs Analgesics Anticonvulsants Antidepressants Antihistamines Antihypertensives Antiparkinson Antipsychotics Cardiovascular agents Cytotoxic agents Diuretics Hormones and hormone-active agents Immunomodulators Tranquilizers. Of particularly concern are antihypertensive medications for CVD (eg, digoxin, disopyramide [Norpace], gemfibrozil [Lopid]), anxiety, depression (eg, lithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, flibanserin online order serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants), or psychosis (eg, chlorpromazine, haloperidol, pimozide [Orap], thioridazine, thiothixene). Antihypertensive drugs, such as diuretics (eg, spironolactone, thiazides) and beta blockers, may be associated with ED.

Discontinuation or switching to alternative drugs, such as angiotensin-converting enzyme inhibitors or calcium channel blockers (eg, diltiazem, nifedipine, amlodipine), may reduce ED. The newer angiotensin II receptor antagonists may be less problematic with respect to ED, but long-term data is needed to evaluate this. Of the drugs used for depression, tricyclic antidepressants may be associated with erectile problems and other drugs may be substituted to prevent this complication.

Currently available substitutes include bupropion, nefazodone, and trazodone.

The selective serotonin reuptake inhibitors (eg, fluoxetine, sertraline, paroxetine, citalopram) can also cause difficulties with ED, but they might also have other significant sexual side effects, including decreased libido and anorgasmia.

Clinical experience in switching medications to improve ED has been disappointing in that improvement does not often occur.

Nonetheless, it is important to try to discontinue possible offending medications before proceeding to more invasive ED treatment options.

Oral ED medications have changed the way clinicians discontinue medications in flibanserin online order patients with ED and has improved the approach. For example, a patient may develop ED on a thiazide diuretic.

The diuretic may be withdrawn, but a trial of oral ED therapy can be initiated during the observation period while the patient is waiting to see if any spontaneous improvement in ED occurs after drug withdrawal.

Alternatively, if diuretic therapy is effective, well tolerated, and controlling blood pressure, oral ED therapy can be used on an ongoing basis to treat the side effect of ED.

If a trial of oral ED therapy and withdrawal of offending medications prove to be ineffective in restoring erectile function, it is appropriate for most primary care practitioners to consider referral to a specialist for additional evaluation and discussion of alternative treatment options.

These include intracavernous injection therapy, vacuum constriction devices, intraurethral therapy, and possible surgery.

If a trial of oral therapy and withdrawal of offending medications do not restore erectile function or if a patient has medical or financial contraindications to pharmacologic therapy, most primary care practitioners should consider referring the patient to a specialist for additional evaluation and discussion of alternative treatment options.

However, some primary care practitioners may recommend vacuum constriction devices.

The device consists of an acrylic cylinder placed over the penis that uses a lubricant to achieve a good seal between the penile body and cylinder.

An erection is then achieved by creating a vacuum inside the cylinder with a pump connected to the cylinder. Once an erection is achieved, a constriction band is applied to the base of the penis to maintain the erection.

The cylinder can then be removed and the patient can engage in intercourse with the constriction band at the base of the penis maintaining the erection.

The band can remain on for approximately 30 minutes and then must be removed.

The erection produced by the device differs from a normal erection likely because of venous occlusion from the constriction band resulting in generalized swelling of the entire penis, with probable preservation of arterial inflow. Clinical studies have suggested that these devices are effective and acceptable to a large number of patients with ED of varying causes, including psychogenic erectile failure.

These devices are safe and can restore a man’s ability to achieve penetrative intercourse, with one study suggesting nearly 95% success with adequate instruction and support.

30 However, satisfaction with this treatment modality typically wanes with time, as patients report dissatisfaction with how cumbersome or unnatural the devices are to use, hinging or buckling of the erection with thrusting, and dissatisfaction with the fact that the erection is ischemic and therefore cold, which can be off-putting to the partner.

There are relatively few contraindications to the use of flibanserin online order vacuum devices.

Some conditions can predispose to priapism or perhaps bleeding with constriction, such as sickle cell disease, polycythemia, and other blood dyscrasias. Patients taking anticoagulants can safely use vacuum constriction devices but need to accept a higher risk of bleeding (ecchymosis). Good manual dexterity is also needed to use the device; if manual dexterity is impaired, a willing sexual partner can learn to apply the device.

Complications from the use of a vacuum constriction device are relatively minor.

They include the development of petechiae or ecchymosis, numbness or coolness of the penis, trapping of the ejaculate, and pivoting of the penis at the base.

Alprostadil (also known as prostaglandin E1 [PGE1]) is the prominent known smooth-muscle dilator of the corpus cavernosum.

Its mechanism of action is believed to be the promotion of intracellular accumulation of cyclic adenosine monophosphate, thereby causing decreased intracellular accumulation of calcium and resulting smooth muscle relaxation.