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Alprostadil can be delivered to the erectile tissue either via an intraurethral suppository that is massaged and then absorbed across the corpus spongiosum of the urethra to the corpora cavernosa, or directly injected into the corpora cavernosa. When administered urethrally, doses are substantially higher than when directly injected (typical dosing is 500 mcg to 1 mg intraurethral compared with 2.5 mcg to 20 mcg intracavernosal).

Side effects include lightheadedness, fainting, priapism, urethral bleeding (intraurethral), dyspareunia in the partner (intraurethral), hematoma (intracavernosal) or penile curvature secondary to scar (intracavernosal). Efficacy of intraurethral alprostadil has been demonstrated to be around 50% ("able to have intercourse") in randomized controlled trials.

31,32 For intracorporeal injection, typically

alprostadil

inhibitor

Pinsky et al 33 reported an extensive review of the benefits and drawbacks of the combinations of these drugs. Given the high risk of priapism during escalation of therapy for intracorporeal injection, it is recommended that the drugs be administered in a supervised office visit initially and that the patient be given a well-articulated plan for treatment of priapism if it occurs.

Escalation guidelines for alprostadil alone vary, but a general guideline is to start at 2.5 mcg and increase by 2.5 mcg to a dose of 5 mcg and then in increments of 5 mcg to 10 mcg until an erection sufficient for penetration, not lasting more than 1 hour, is achieved. If there is no response to the initial 2.5-mcg dose, escalation dosing can be slightly more liberal. 34 A European prospective trial of PGE1 alone found 91% of the 54 patients completing the 4 years of the study reported good or better tolerability and satisfaction with therapy.

Other Nonsurgical Treatments for Erectile Dysfunction.

Several treatments were promoted in the pre-PGE1, pre-prostaglandin era, including yohimbine, trazodone, testosterone, and various herbal remedies. None of these is currently recommended under the updated American Urological Association Guidelines for the Treatment of Erectile Dysfunction.

15 Testosterone supplementation is only recommended for men with low testosterone levels.

Implantation of penile prosthesis remains an important option for men with ED if medical treatment fails or is inappropriate. Prostheses are available as a saline-filled silicone device or a malleable device. The benefit of the former is a more natural appearance in the deflated state,

closely

Risks of these devices

include

Mechanical failure rates depend on the specific device being investigated.

Overall, the percentage of devices that are free from mechanical failure at 5 years ranges from 84% to 94%. 19 Infection rates in the era of coated devices and improved techniques are reported to be less than 1%.

All devices that are currently approved by the FDA are considered safe for use in magnetic resonance imaging environments. However, 2 previously approved devices–the OmniPhase and the DuraPhase penile prostheses–are not considered safe in this environment. Other surgical procedures–including venous ligation to limit penile venous outflow and penile revascularization procedures–are rarely successful and are not recommended. 19 These surgeries are only indicated when a patient demonstrates recent-onset ED and an

occlusive

It is a pain free, medicine free, surgery free treatment that gets results! It is available to most, if not all men, regardless of the severity or cause of their erectile dysfunction. Each treatment is pain free and is completed in as short as 20 minutes without any restrictions or downtime following treatment!

There are a variety of methods for treating erectile dysfunction (ED). Your doctor can discuss all of these options with you in more detail.

All decisions regarding your best option for treating ED should be made between you and your physician, with consideration given to your individual needs and

the

The treatment options include: Drug Therapy Non-drug Treatment Options Penile Implants Other.

Drugs for treating erectile dysfunction can be taken orally, injected directly into the penis, or inserted into the

urethra

There are several prescription medications that claim to help patients.

These pills may help achieve erections in response to sexual stimulation: Pills can help you achieve an erection quickly and may have an effect on sexual intimacy. Do not provide automatic erections like injection drugs Not effective in approximately 30% of cases 1 Must take at least ? hour to one hour before anticipated sexual activity 2.

Some patients may experience side effects, including: Headaches Facial blushing Upset stomach Mild and temporary visual effects.

Some men may be able to gain an erection by self-injecting drugs into their penis, causing it to become engorged with blood. Potential side effects of injection therapy include fibrosis (scarring) and long-lasting painful erections. Advantages of injection therapy: It can easily be self-administered On-set of erection within 5-20 minutes 3 Injections are shown to have a long-term dropout rate of 37% – 76%.

Reasons for dropping out of drug therapy include: Desire for a permanent treatment alternative Inadequate response Fear of needles Side effects. Penile Pumps (Vacuum Devices) Also called vacuum constriction devices, penile pumps are devices that are placed over the penis to draw blood into the shaft.

Once the vacuum creates an erection,

the

A penile implant is a long-term treatment, that is covered by many insurance plans, which allows an erection as often as you like, for as long as you wish. Easy to use Totally concealed in the body Erections when desired. Surgical Procedure No longer able to get natural erections. Your doctor can provide you with specific details about the pros and cons of each of the following treatments: Lifestyle changes like stopping smoking, losing weight and eating healthier Oral testosterone Intraurethral suppositories (ex. Oral sildenafil in the treatment of erectile dysfunction. 1998 May 14;338(20):1397-404 http://uspl.lilly.com/cialis/cialis.html#ppi downloaded 2/14/17

http

Comparison of satisfaction rates and erectile function in patients treated with sildenafil, intracavernous prostaglandin E1 and penile implant surgery for erectile dysfunction in urology practice.

Cialis®, Levitra®, Viagra®, MUSE® are trademarks of their respective companies.

Contact the McIver Clinic in Jacksonville FL today by calling (904) 355-6583. There are a variety of treatment options available for erectile dysfunction, which will be explained to you by your doctor.

Your therapy will depend on the cause of ED, your age, your health and you and your doctor's preferences.

In most cases, an oral medication, such as Viagra, Levitra or Cialis, will be recommended first.

Depending on its effectiveness and your tolerance to the medication, other approaches may be tried. In patients who have blood vessel blockage or leakage, microvascular surgery may be recommended.

For those who do not respond to non-surgical treatments or are not candidates for surgery, penile prosthesis is an excellent alternative.

It is important to note that it is not necessary to have an erection to have an orgasm. A vibrator or creative and attentive partner can be helpful. Viagra, Levitra and Cialis are oral medications that have been approved by the Food and Drug Administration (FDA) for the treatment of ED. Since its introduction in 1998, Viagra has become the drug of choice for treating ED. When a man is sexually stimulated, chemicals like nitric oxide are released into the nerve terminals, which cause the penile smooth muscles to relax, helping to foster an erection. A compound called cyclic guanine monophosphate (cGMP) is involved in this process. After an erection occurs, an enzyme called phosphodiesterase-5 (PDE-5) breaks down cGMP and returns the penis to a flaccid state.

Viagra works to improve smooth muscle relaxation and erections by blocking the action of PDE-5, which causes an increase in the levels of cGMP in the penis.

Levitra and Cialis have a similar mechanism to Viagra.

It is important to note that all oral medications for ED must be followed by sexual stimulation in order to achieve the desired erection. Urethral Suppository (MUSE) Medicated urethral system for erection (MUSE) is often used when oral medications are not effective.

This approach uses a small suppository of medication that is placed in the penile uretha without needles. The suppository is then absorbed and helps to produce an erection. Large studies conducted in Europe and the United States reported that MUSE was effective in 43 percent of men with impotence of varying causes. The major advantage of the therapy is that is applied locally by patients or their partners, and has few side effects.

However, the therapy has been shown to cause moderate penile pain and can have inconsistent response rates. Sometimes an adjustable rubber tension ring is applied at the base of the penis and improves results. Patients using MUSE should have their first application performed in their doctor's office, to prevent complications such as urethral bleeding, decreased blood pressures, and sustained and prolonged erections. In addition, in rare instances, feelings of lightheadedness or decreased blood pressure may occur. It also is important to note that after inserting the suppository into the penile uretha, sexual stimulation is required to increase blood flow to the penis.

Medication should be refrigerated and maximum use is limited to one suppository per day.

Penile injections are another treatment option for ED when oral medications are ineffective.

Although the idea of inserting something into your penis is probably unappealing, thousands of men will testify to the effectiveness and ease of the injections.

In addition to two FDA approved medications called Caverject and Edex, urologists also use a combination of drugs, including papaverine, phentolamine and alprosdid. In most cases, a combination of two or three medications is used for injection.

This combination, known as Trimix, allows

for

Men must receive appropriate training and education by their doctor before beginning home injection therapy. The goal of the injection medicine is to

achieve

The injections must be given in proper amounts with the appropriate technique to minimize the

risk

For more information sildenafil citrate tablets buy online on how to use penile injections, please see Patient Guide to Penile Injections. In patients who only have partial erections, and do not respond to other treatments or prefer not to use them, a vacuum device may be helpful.

The device consists of a plastic cylinder connected to a pump and a constriction ring. A vacuum pump uses either manual or battery power to create suction around the penis and bring blood into it. A constriction device is then released around the base of the penis to keep blood in the penis and maintain the erection. A vacuum device can be used safely for up to 30 minutes, which is when the constriction device should be removed. The advantage of a vacuum device is it is relatively inexpensive, easy to use and avoids drug interactions and serious side effects.

Potential side effects associated with the vacuum device are temporary and may include penile numbness, trapping the ejaculate and some bruising.

For men with erectile dysfunction who do not tolerate or respond to other treatments, a penile prosthesis offers an effective, yet more invasive alternative because it requires surgery. Prostheses come in either a semi-rigid form or as an inflatable device. Most men prefer the placement of the inflatable penile prosthesis, which consists of a pump that contains the inflation and deflation mechanism. Although the placement of the penile prosthesis requires surgery, patient and partner satisfaction rates are as high as 85 percent. However, it is important to note that full penile length might not be restored to the patient's natural erect status.

Placing the prosthesis within the penis requires the use of an anesthetic. A skin incision is made either at the junction of the penis and scrotum, or just above the penis, depending on which prosthesis and technique is used. The spongy tissue of the penis is exposed and dilated; the prosthesis is then sized and the proper device is placed. The patient can control his erection at will by pushing a button under the skin.

Side effects associated with penile prosthesis include infection, pain and device malfunction or failure. As sildenafil citrate tablets buy online the nerves that control sensation are not injured, the penile sensation and the ability have an

orgasm

Penile arterial surgery generally involves bypassing blocked arteries by transferring an artery from behind the

abdominal

This creates a path to the penis that bypasses the area of blockage, which is inhibiting blood flow to the penis. UCSF Health medical specialists have reviewed this information. It is for educational purposes only and is not intended to replace the advice of your doctor or other health care provider. We encourage you to discuss any questions or concerns you may have with your provider. The National Institutes of Health (NIH) Consensus Development Conference on Impotence (December 7-9, 1992) defined impotence as "male erectile dysfunction, that is, the inability to achieve or maintain an erection sufficient for satisfactory sexual performance." Signs and symptoms. The first step in the management of ED is a thorough history that includes the following: A physical examination is necessary for every patient, emphasizing the genitourinary, vascular, and neurologic systems.

A focused examination entails evaluation of the following: Status of the genitalia and prostate.

Abnormalities of

the

Laboratory testing for ED depends on information

gathered

not

Such testing may include the following: Evaluation of hormonal status (testosterone, serum hormone–binding globulin, luteinizing hormone [LH], prolactin, thyroid-stimulating hormone [TSH]) – Note that the American College of Physicians (ACP) does not recommend for or against routine use of hormonal blood tests or hormonal treatment in ED patients.

Screening blood studies (hemoglobin A 1c , serum chemistry panel, lipid profile) Prostate-specific antigen levels, if the patient is a candidate for prostate cancer screening (controversial) Functional tests that may be helpful include the following: Direct injection of prostaglandin E1 (PGE1; alprostadil) into the corpora cavernosa (see the image below) Biothesiometry – Infrequently indicated. Nocturnal penile tumescence testing – Once frequently performed, this is rarely used in current practice, though it can be helpful when the diagnosis is in doubt.

Formal neurologic testing – Not needed in the vast majority of ED patients, though it may offer some benefit to patients with a history of central nervous system problems, peripheral neuropathy, diabetes, or penile sensory deficit.

Imaging studies are not commonly warranted, except in situations where pelvic trauma has been sustained or surgery performed. Modalities that may be considered include the following: Ultrasonography of the penis (to assess vascular function within the penis) Ultrasonography of the testes (to help disclose abnormalities in the

testes

Many patients with ED also have cardiovascular disease; thus, treatment of ED in these patients must take cardiovascular risks into account. According to American Urological Association (AUA) guidelines, oral phosphodiesterase type 5 (PDE5) inhibitors are first-line therapy unless contraindicated.

[1] Agents include the following: In patients with ED refractory to oral PDE5 inhibitors, one of these agents can be combined with an injection of PGE1. [2] In a prospective, multicenter, single-armed study of ED patients who exhibited a suboptimal response to PDE5 inhibitors, the investigators found that percutaneous

implantation

[3] Hormone replacement may benefit men with severe hypogonadism and may possibly be useful as

adjunctive

Replacement androgens are available in oral (

rarely

External devices that may be used include the following: Vacuum devices to draw blood into the penis.

Constriction devices placed at the base of the penis to maintain erection.

Selected patients with ED are candidates for surgical treatment. Procedures to be considered include the following: Revascularization (rarely indicated)

Surgical

Suggested measures for preventing ED include the following: Optimal management of diabetes, heart disease, and hypertension. Lifestyle modifications to improve vascular function (eg, not smoking, maintaining ideal body weight, and engaging in regular exercise) See Treatment and Medication for more detail. Erectile dysfunction (ED) affects 50% of men older than 40 years, [4] exerting substantial effects on quality of life.

[5] This common problem is complex and involves multiple pathways.

Penile erections are produced by an integration of physiologic processes involving the central nervous, peripheral nervous, hormonal, and vascular systems. Any abnormality in these systems, whether from medication or disease, sildenafil citrate tablets buy online has a significant impact on the ability to develop and sustain an erection, ejaculate, and experience orgasm. A common and important cause of ED is vasculogenic.

Many men with ED have comorbid conditions such as hyperlipidemia, hypercholesterolemia, tobacco abuse, diabetes mellitus, or coronary artery disease (CAD).

[6] The Princeton III Consensus recommends screening men who present with ED for cardiovascular risk factors; ED may be the earliest presentation of atherosclerosis and vascular disease.

[7] Additionally, the physiologic processes involving erections begin at the genetic level. Certain genes become activated at critical times to produce proteins vital to sustaining this pathway. Some researchers have focused on identifying particular genes that place men at risk for ED.

At present, these studies are limited to animal models, and little success has been reported to date.

[4] Nevertheless, this research has given rise to many new treatment targets and a better understanding of the entire process. The first step in treating the patient with ED is to take a thorough sexual, medical, and psychosocial history. Questionnaires are available to assist clinicians in obtaining important patient data. (See Presentation.) Successful treatment of sexual dysfunction has been demonstrated to improve sexual intimacy and satisfaction, improve sexual aspects of quality of life, improve overall quality of life, and relieve symptoms of depression.

(See Treatment.) The availability of phosphodiesterase-5 (PDE5) inhibitors—sildenafil, vardenafil, tadalafil, and avanafil—has fundamentally altered the medical management of ED. In addition, direct-to-consumer marketing of these agents over the last 15 years has increased the general public’s awareness of ED as a medical condition with underlying causes and effective treatments.

Unfortunately, some patients may have an overly simplified understanding of the role of PDE5 inhibitors in ED management. Such patients may not expect or be willing to undergo a long evaluation and testing process to obtain a better understanding of their sexual problem, and they may be less likely to involve their partner in discussing their sexual relationship with the physician. They may expect to obtain medications through a phone call to their doctor or even over the Internet, with minimal or no physician contact at all. In such cases, the physician’s role may have to include efforts to educate patients about realistic sexual expectations (see Patient Education). These efforts can

help

If successful and effective management is to be achieved, evaluation and discussion of any intervention must include both partners. The sildenafil citrate tablets buy online Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-5 ), classifies erectile disorder as belonging to a group of sexual dysfunction disorders typically characterized by a clinically significant inability to respond sexually or to experience sexual pleasure. [8] Sexual functioning involves a complex interaction among biologic, sociocultural, and psychological factors, and the complexity of this interaction makes it difficult to ascertain the clinical etiology of sexual dysfunction.

Before any diagnosis of sexual dysfunction is made, problems that are explained by a nonsexual mental disorder or other stressors must first be addressed. Thus, in addition to the criteria for erectile disorder, the following must be considered: Partner factors (eg, partner sexual problems or health issues) Relationship factors (eg, communication problems, differing levels of desire for sexual activity, or partner violence) Individual vulnerability factors (eg, history of sexual or emotional abuse, existing psychiatric conditions such as depression, or stressors such as job loss) Cultural or religious factors (eg, inhibitions or conflicted attitudes regarding sexuality) Medical factors (eg, an existing medical condition or the effects of drugs or medications) The specific DSM-5 criteria for erectile disorder are as follows [8] : In almost all or all (75-100%) sexual activity, the sildenafil citrate tablets buy online experience of at least one of the following three3 symptoms: (1) marked

difficulty