Medicine shoppe sildenafil

Patients admin­is­ter the med­ica­tion them­selves as need­ed before intercourse. Penile Self-Injec­tion Therapy Injec­tion ther­a­py was the first FDA-approved med­ica­tion for the treat­ment of ED and uses a tiny nee­dle to inject med­ica­tion direct­ly into the base or side of the penis. The inject­ed med­ica­tion can cre­ate an erec­tion by improv­ing blood to flow into the penis direct­ly. Patients can admin­is­ter the injec­tion them­selves as need­ed before intercourse.

Penile Implant Surgery In use since the 1970 s, a penile implant is a med­ical device that is implant­ed into the penis dur­ing an out­pa­tient or overnight-stay sur­gi­cal pro­ce­dure.

The device is entire­ly con­tained with­in the body, so it is dis­crete. The device allows for an arti­fi­cial

erec­tion

If you are expe­ri­enc­ing erec­tile dys­func­tion, talk to your pri­ma­ry care physi­cian or urol­o­gist to help find the best solu­tion for you.

HEIDELBAUGH, MD, University of Michigan Medical School, Ann Arbor, Michigan.

Patient information : See related handout on erectile dysfunction, written by the authors of this article.

Author disclosure: No relevant financial affiliations. Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References.

Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References. Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.

The five-question International Index of Erectile Function allows rapid clinical assessment of ED. The condition can be caused by vascular, neurologic, psychological, and hormonal factors. Common conditions related to ED include diabetes mellitus, hypertension, hyperlipidemia, obesity, testosterone deficiency, and prostate cancer treatment. Performance anxiety and relationship issues are common psychological causes. Medications and substance use can cause or exacerbate ED; antidepressants and tobacco use are the most common. ED is associated with an increased risk of cardiovascular disease, particularly in men with metabolic syndrome. Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions. Oral phosphodiesterase-5 inhibitors are the first-line treatments for ED.

Second-line treatments include alprostadil and vacuum devices. Surgically implanted penile prostheses are an option when other treatments have been ineffective.

Counseling is recommended for men with psychogenic ED. Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.1 ED becomes more common as men age ( Figure 1 ) .2 At least 12 million U.S.

Current smoking is significantly associated with ED, and smoking cessation has a beneficial effect on the restoration of erectile function. Men with metabolic syndrome should be counseled to make lifestyle modifications to reduce the risk of cardiovascular events and ED.

Phosphodiesterase-5 inhibitors are the first-line treatment for ED.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series.

For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort .

Current smoking is significantly associated with ED, and smoking cessation has a beneficial effect on the restoration of erectile function. Men with metabolic syndrome should be counseled to make lifestyle modifications to reduce the risk of cardiovascular events and ED. Phosphodiesterase-5 inhibitors are the first-line treatment for ED.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort .

BEST PRACTICES IN UROLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN. Do not prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.

Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org.

For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm .

BEST PRACTICES IN UROLOGY: RECOMMENDATIONS FROM THE CHOOSING

WISELY

Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org.

For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm . The prevalence of erectile dysfunction increases with age. The prevalence of erectile dysfunction increases with age. Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References.

The five-question International Index of Erectile Function (IIEF-5) allows rapid clinical assessment of ED and can measure the effectiveness of ED treatments (see https://www.aafp.org/afp/2010/0201/p305.html#afp20100201p305-t3).

Other diagnostic options include a single-question self-assessment (Table 1) 4 and the Brief Male Sexual Function Inventory.5.

Single-Question Assessment of Erectile Dysfunction. Impotence means not being able to get and keep an erection that is rigid enough for satisfactory sexual activity. Not impotent: always able to get and keep an erection good enough for sexual intercourse.

Minimally impotent: usually able to get and keep an erection good enough for sexual intercourse. Moderately impotent: sometimes able to get and keep an erection good enough for sexual intercourse. Completely impotent: never able to get and keep an erection good enough for sexual intercourse.

Single-Question Assessment of Erectile Dysfunction.

Impotence means not being able to get and keep an erection that is rigid enough for satisfactory sexual activity. Not impotent: always able to get and keep an erection good enough for sexual intercourse.

Minimally impotent: usually able to get and keep an erection good enough for sexual intercourse.

Moderately impotent: sometimes able to get and keep an erection good enough for sexual intercourse.

Completely impotent: never able to get and keep an erection good enough for sexual intercourse.

Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References. ED has vascular, neurologic, psychological, and hormonal causes. Conditions commonly associated with ED include diabetes mellitus, hypertension, hyperlipidemia, obesity, testosterone deficiency, and prostate cancer treatment (Table 2) .6 – 8 Performance anxiety and relationship issues are common psychological causes. Erectile Dysfunction: Related Conditions and Approaches to Evaluation.

Endocrine disorders (e.g., hypogonadism, hyperprolactinemia, thyroid disorders) History and physical examination; if an endocrine disorder is suspected, consider laboratory testing.

Blood pressure; fasting glucose, high-density lipoprotein, and triglyceride levels; waist circumference.

Neurologic conditions (e.g., multiple sclerosis, Parkinson disease, spinal cord injury, stroke) History and physical examination.

Prostate cancer treatment (e.g., surgery, radiation, hormone therapy) Psychological conditions (e.g., anxiety, depression, guilt, history of sexual abuse, marital or relationship problems, stress) History and physical examination; if venous leakage is suspected, consider urology consultation for venous flow testing.

Erectile Dysfunction: Related Conditions and Approaches to Evaluation.

Endocrine disorders (e.g., hypogonadism, hyperprolactinemia, thyroid disorders) History and physical examination; if an endocrine disorder is suspected, consider laboratory testing.

Blood pressure; fasting glucose, high-density lipoprotein, and triglyceride levels; waist circumference.

Neurologic conditions (e.g., multiple sclerosis, Parkinson disease, spinal cord injury, stroke) History and physical examination. Prostate cancer treatment (e.g., surgery, radiation, hormone therapy) Psychological conditions (e.g., anxiety, depression, guilt, history of sexual abuse, marital or relationship problems, stress) History and physical examination; if venous leakage is suspected, consider urology consultation for venous flow testing. Many medications cause or exacerbate ED (Table 3) .9 – 12 Antidepressants are a common cause, especially the selective serotonin reuptake inhibitors citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), and the

serotonin-norepinephrine

Bupropion (Wellbutrin), mirtazapine (Remeron), and fluvoxamine are less likely to cause ED.11 Tobacco, alcohol, and illicit drugs can cause ED.13 , 14 Marijuana use may cause ED, although further study is needed.15.

Medications and Substances That May Cause or Contribute to Erectile Dysfunction.

Alcohol, nicotine, and illicit drugs (e.g., amphetamines, barbiturates, cocaine, marijuana, opiates) Analgesics (e.g., opiates) Anticonvulsants (e.g., phenobarbital, phenytoin [Dilantin]) Antidepressants (e.g., lithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants) Antihistamines (e.g., dimenhydrinate, diphenhydramine [Benadryl], hydroxyzine, meclizine [Antivert], promethazine) Antihypertensives (e.g., alpha blockers, beta blockers, calcium channel blockers, clonidine, methyldopa, reserpine) Antiparkinson agents (e.g., bromocriptine [Parlodel], levodopa, trihexyphenidyl) Antipsychotics (e.g., chlorpromazine, haloperidol, pimozide [Orap], thioridazine, thiothixene) Cardiovascular agents (e.g., digoxin, disopyramide [Norpace], gemfibrozil [Lopid]) Cytotoxic agents (e.g., methotrexate) Diuretics (e.g., spironolactone, thiazides) Hormones and hormone-active agents (e.g., 5-alpha-reductase inhibitors, androgen receptor blockers, androgen synthesis inhibitors, corticosteroids, estrogens, gonadotropin-releasing hormone analogs, progesterones) Immunomodulators (e.g., interferon alfa) Tranquilizers (e.g., benzodiazepines) Information from references 9 through 12 .

Medications and Substances That May Cause or Contribute to Erectile Dysfunction. Alcohol, nicotine, and illicit drugs (e.g., amphetamines, barbiturates, cocaine, marijuana, opiates) Analgesics (e.g.,

opiates

International

At least three criteria must be present to diagnose metabolic syndrome . †— Patients currently receiving drugs to manage lipid disorders or high blood pressure are considered positive for these criteria . ‡— Thresholds according to International Diabetes Federation recommendations .

§— Thresholds for white patients differ significantly according to the recommending organization. Thresholds listed are from the International Diabetes Federation.

However, the American Heart Association and National Heart, Lung, and Blood Institute set thresholds of 40 inches (102 cm) for U.S. women, noting that there is increased risk at the lower International Diabetes Federation values . Metabolic syndrome: insulin resistance and prediabetes .

? 100 mg per dL (5.6 mmol per L) High-density lipoprotein level† *— Criteria listed are the harmonized criteria proposed by the joint statement from the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity.

At least three criteria must be present to diagnose metabolic syndrome . †— Patients currently receiving

drugs

incidence

ED is associated with an increased risk of CVD, coronary artery disease (CAD), stroke, and all-cause mortality, and it is probably an independent risk factor for CVD.35.

ED typically occurs two to five years before CAD, providing a potential window during which men diagnosed with ED can make lifestyle changes to prevent CAD.36 Men with ED are at higher risk of angina, myocardial infarction, stroke, transient ischemic attack, congestive heart failure, and cardiac arrhythmias compared with men who do not have ED.37 Men with ED have a 75% increased risk of developing peripheral vascular disease.38.

ED has a positive predictive value for the development of CVD that is equal to or greater than that for smoking, hyperlipidemia, or a family history of myocardial infarction.37 , 39 ED can accurately predict silent CAD.40 – 45 ED in men 40 to 49 years of age is more predictive of

CAD

Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References. The A1C or fasting glucose level can be used to assess for diabetes.

A thyroid-stimulating hormone level is recommended for men with signs or symptoms of hypothyroidism. Routine measurement of testosterone levels is controversial.

As part of the Choosing Wisely campaign, the American Urological Association recommends that physicians not prescribe testosterone to men with ED who have normal testosterone levels. A diagnosis of hypogonadism must be based on more than just an abnormal laboratory test result.51 Measurement of morning total testosterone may be considered for men with small testes, lack of male secondary sex characteristics, significantly low libido, or a history of inadequate response to phosphodiesterase-5 (PDE-5) inhibitors; if the initial result is

abnormal

Free testosterone levels vary widely across laboratories and are not uniformly recommended for screening.

However, when hypogonadism is clinically suspected but the morning total testosterone level is repeatedly normal, bioavailable testosterone or free testosterone may account for the effects of sex hormone–binding globulin levels on testosterone activity.

Levels of follicle-stimulating hormone, luteinizing hormone, sex hormone–binding globulin, estradiol, and prolactin can help differentiate between

primary

Abstract Diagnosis Causes and Related Conditions History and Physical Examination Laboratory Evaluation Treatment Managing Psychogenic ED References.

An algorithm for the diagnosis and

management

Algorithm for the diagnosis and management of erectile dysfunction. Information from references 6 through 17 , 33, and 49 through 68 .

Lifestyle modifications can

improve

Weight loss can modestly improve low testosterone levels, although the extent of the benefit on ED is unclear.54 Statin use seems to improve ED, as measured by IIEF-5 scores.55 Tobacco cessation is highly recommended. Compared with men who have never smoked, the risk of ED is increased by 51% in current smokers and 20% for ex-smokers.14.

Oral PDE-5 inhibitors are first-line treatments for ED.57 Sexual stimulation is needed to produce an erection; the PDE-5 inhibitor helps to maintain the erection by enhancing

the

Food and Drug Administration (FDA) for treatment of ED: avanafil (Stendra), sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra).

Table 4 summarizes these medications.56 – 58 All are effective within about one hour of dosing and are typically used on an as-needed basis.

The effects may be delayed or decreased if the patient has recently eaten a fatty meal, particularly for sildenafil and vardenafil.69 PDE-5 inhibitors are ineffective in some men, particularly those with severe ED.

Headache, flushing, and dyspepsia are common adverse effects.58 PDE-5 inhibitors are contraindicated in men using nitroglycerin or other nitrates because of the risk of catastrophic low blood pressure. Tadalafil has a longer half-life, which gives men the option of taking it up to 12 hours before sex or as a lower-dose, once-daily medication; however,

adverse

Insurance coverage for these medications is limited, and prescriptions may require prior authorization. PDE-5 Inhibitors for Treatment of Erectile Dysfunction.

NA ($280 for 30 tablets) 10 or 20 mg once daily as needed. note : Contraindications include concomitant use of nitrates, stroke or myocardial infarction in the past six to eight weeks, significantly low blood pressure, uncontrolled high blood pressure, unstable angina, severe cardiac failure, severe liver impairment, and end-stage kidney disease requiring dialysis. Lower doses should be used in patients with chronic kidney disease or moderate liver impairment . NA = not available or not applicable; PDE-5 = phosphodiesterase-5 .

*— Other PDE-5 inhibitors not currently approved by the U.S.

Food and Drug Administration include lodenafil, mirodenafil, and udenafil .

†— Estimated retail cost based on information from http://www.goodrx.com (accessed July 27, 2016).

Generic price listed first; brand price in parentheses .

PDE-5 Inhibitors for Treatment of Erectile Dysfunction. NA ($280 for 30 tablets) 10 or 20 mg once daily as needed. note : Contraindications include concomitant use of nitrates, stroke or myocardial infarction in the past six to eight weeks, significantly low blood pressure, uncontrolled high blood pressure, unstable angina, severe cardiac failure, severe liver impairment, and end-stage kidney disease requiring dialysis. Lower doses should be used in patients with chronic kidney disease or moderate liver impairment . NA = not available or not applicable; PDE-5 = phosphodiesterase-5 . *— Other PDE-5 inhibitors not currently approved by the U.S.

Food and Drug Administration include lodenafil, mirodenafil, and udenafil .

†— Estimated retail cost based on information from http://www.goodrx.com (accessed July 27, 2016). Generic price listed first; brand price in parentheses .

Second-line treatments for ED include alprostadil (Caverject) and vacuum devices. These treatments can be used to establish an erection before sexual stimulation.

They should be avoided in men who are receiving anticoagulants or who have sickle cell disease or other bleeding or clotting disorders.

Alprostadil causes penile vasodilation by relaxing arterial smooth muscle; it is available in injectable and intraurethral forms and can be used in combination with PDE-5 inhibitors. Injectable alprostadil is administered intracavernosally into one side of the penis. Intra-urethral alprostadil is a dissolvable pellet that is placed into the urethra with an applicator.59 The injectable form is more effective.60 The lowest effective dose should be used, and the patient should be instructed on proper technique by administering a test dose in the physician's office. Fear of needles or pain can limit patient acceptance of alprostadil.

Patients should be warned to seek emergency urologic treatment if an erection lasts four hours or longer.

Penile fibrosis is another possible adverse effect; in one study, persistent fibrotic changes occurred in 4.9% of patients using intracavernosal alprostadil for four years.61 A similar ED treatment that has not been approved by the FDA is intracavernosal injection of compounded mixtures of alprostadil, papaverine, and phentolamine.60.

Vacuum devices consist of a tube that is placed over the penis and sealed at the base with lubricant ( Figure 3 ) .62 A vacuum pump removes air from the tube, pulling blood into the penis and creating an erection.

A constricting ring is then slid off the base of the tube onto the penis to maintain the erection.

To prevent ischemic damage, the constricting ring should generally not be left in place for more than 30 minutes. Vacuum devices can be cumbersome, require several minutes to produce an erection, may lead to bending at the base of the penis where the ring is in place, and will cause the erect penis to seem cool or cold because of restricted blood flow. However, success and satisfaction rates are fairly high.63 Vacuum devices can be used in combination with an oral PDE-5 inhibitor or with alprostadil for men who have not had success with single-component treatment. These devices are also useful in men receiving daily nitroglycerin or other long-term nitrate therapy, in whom PDE-5 inhibitors are contraindicated.

Patients can obtain vacuum

devices

Surgically implanted penile prostheses are a

third-line