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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 penis (eg, hypospadias, Peyronie plaques) There is a strong correlation between hypertension and ED.

There is also a correlation between benign prostatic hyperplasia and ED, though the causality is unclear.

Laboratory testing for ED depends on information gathered during the interview; it is necessary for most patients, although not for all. 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 and epididymides; rarely indicated) Transrectal ultrasonography (to disclose abnormalities in the prostate and pelvis that may interfere with erectile function) Angiography (in patients who are potential candidates for vascular surgery) See Workup for more detail. Treatment options for ED include the following: Sexual counseling, if no organic causes can be found for the dysfunction.

Injected, implanted, or topically applied medications. 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 of zotarolimus-eluting stents in focal atherosclerotic lesions was both safe and feasible and was associated with clinically meaningful improvement on subjective and objective measures of erectile function. [3] Hormone replacement may benefit men with severe hypogonadism and may possibly be useful as adjunctive therapy when other treatments are unsuccessful. Replacement androgens are available in oral (rarely used), injectable, gel, and transdermal preparations.

Intracavernosal injection therapy may be considered and is almost always effective if the vasculature within the corpora cavernosa is healthy.

Agents used include the following: Alprostadil (most common) The Medicated Urethral System for Erections (MUSE) involves the formulation of alprostadil (PGE1) into a small intraurethral suppository that can be inserted into the urethra. This may be useful for men who do not want to use self-injections or those in whom oral medications have failed. 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 elimination of venous outflow (rarely indicated) Placement of penile implant (semirigid or malleable rod implant, fully inflatable implant, or self-contained inflatable unitary implant) – Once the only effective therapy for men with organic ED, this is the last option considered in current practice.

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, 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 sildenafil store 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 prevent the misuse or overuse of these remarkable medications. Although this article focuses primarily on the male with ED, it is essential to remember that the sexual partner plays an integral role in treatment. If successful and effective management is to be achieved, evaluation and discussion of any intervention must include both partners. The 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 experience of at least one of the following three3 symptoms: (1) marked difficulty in obtaining an erection during sexual activity, (2) marked difficulty in maintaining an erection until the completion of sexual activity, or (3) marked decrease in erectile rigidity. The symptoms above have persisted for approximately 6 months. The symptoms above cause significant distress to the individual. The dysfunction cannot be better explained by nonsexual mental disorder, a medical condition, the effects of a drug or medication, or severe relationship distress or other significant stressors.

The severity of delayed ejaculation is classified as mild,

moderate

The duration of the dysfunction is specified as follows: Lifelong (present since first sexual experience) Acquired (developing after a period of relative normal sexual functioning) In addition, the context in which the dysfunction occurs is specified as follows: Generalized (not limited to certain types of stimulation, situations, or partners) Situational (limited to specific types of stimulation, situations, or partners) Lifelong erectile disorder is associated with psychological factors, whereas acquired erectile disorder is more often related to biologic factors. Distress associated with erectile disorder is lower among older men than among younger men.

An understanding of penile anatomy is fundamental to management of ED. [2] The common penile artery, which derives from the internal pudendal artery, branches into the dorsal, bulbourethral, and cavernous arteries (see the image below).

The dorsal artery provides for engorgement of the glans during erection, whereas the bulbourethral artery supplies the bulb and the corpus spongiosum.

The cavernous artery effects tumescence of the corpus cavernosum and thus is principally responsible for erection. The cavernous teva pharmaceuticals sildenafil artery gives off many helicine arteries, which supply the trabecular erectile tissue and the sinusoids. These helicine arteries are contracted and tortuous in the flaccid state and become dilated and straight during erection. [9] Venous drainage of the corpora originates in tiny venules that lead from the peripheral sinusoids immediately beneath the tunica albuginea. These venules travel in the trabeculae between the tunica and the peripheral sinusoids to form the subtunical venous plexus before exiting as the emissary veins (see the image below). [9] Sexual behavior involves the participation of autonomic and somatic nerves and the integration of numerous spinal and supraspinal sites in the central nervous system (CNS). The penile portion of the process that leads to erections represents only a single component.

The hypothalamic and limbic pathways play an important role in the integration and control of reproductive and sexual functions.

The medial preoptic center, paraventricular nucleus, and anterior hypothalamic regions modulate erections and coordinate autonomic events associated with sexual responses. Afferent information is assessed in the forebrain and relayed to the hypothalamus.

The efferent pathways from the hypothalamus enter the medial forebrain bundle and project caudally near the lateral part of the substantia nigra into the midbrain tegmental region. Several pathways have been described to explain how information travels from the hypothalamus to the sacral autonomic centers.

One pathway travels from the dorsomedial hypothalamus through the dorsal and central gray matter, descends to the locus ceruleus, and projects ventrally in the mesencephalic reticular formation. Input from the brain is conveyed through the dorsal spinal columns to the thoracolumbar and sacral autonomic nuclei. The primary nerve fibers to the penis are from the dorsal nerve of the penis, a branch of the pudendal nerve. The cavernosal nerves are a part of the autonomic nervous system and incorporate both sympathetic and parasympathetic fibers.

They travel posterolaterally along the prostate and enter the corpora cavernosa and corpus spongiosum to regulate blood flow during erection and detumescence. The dorsal somatic nerves are also branches of the pudendal nerves. They are primarily responsible for penile sensation. Erectile Dysfunction (ED) Injections: Trimix Penile Implant Vacuum Erection Device (VED) Erectile dysfunction or ED (also known as impotence) is when a man cannot achieve or sustain an erection for sexual intercourse. This can be: a total inability, inconsistent ability, or a tendency to sustain only brief erections. Over 18 million adult men * in the United States have erectile dysfunction.

In fact, at least 50 percent of men over the age of 50 experience some loss of function.

Despite being a common male condition, it is not normal, no matter how old you are. Only 10 percent of men seek treatment and many (50 percent) discontinue treatment once they start it because they are too embarrassed to discuss their sexual health issues with a doctor.

Our urological specialists at University of Utah Health understand your sensitivities related to ED.

We develop treatment plans customized for your needs to help you get your sexual function back. An erection occurs when blood flows into the corpora cavernosa (erection bodies) and gets trapped there.

If the blood has problems getting to or staying in those erection bodies, you may have erectile dysfunction. There are many potential causes for erectile dysfunction, such as these conditions/circumstances: Vascular conditions: High blood pressure Elevated cholesterol Cardiovascular disease Diabetes Trauma: Spinal cord injury Pelvis injury Neurologic disease: Stroke Parkinson’s disease Alzheimer’s disease Radiation to the pelvis for cancer Endocrine: Hypogonadism (teva pharmaceuticals sildenafil low testosterone) Hyperprolactinemia (high prolactin levels) Pelvis surgery: Radical prostatectomy (a surgical procedure for the partial or complete removal of the prostate) Surgeries for rectal cancer or bladder cancer Medication side effects: Antidepressants Antihypertensives (high blood pressure medicine) Antiandrogens (testosterone blockers) Antiarrhythmics (heart rhythm medicine) Alcohol Cigarette smoking Cocaine and marijuana. Half of men with diabetes will experience ED within 10 years of their diagnosis.

High blood sugar levels can damage the nerves that control sexual stimulation.

They can also damage the blood vessels needed to provide adequate blood flow to the penis in order to have and maintain an erection.

While oral medications are a common first step for therapy, they only tend to work in about 50 percent of men with diabetes. Diabetic men are more likely to move on to other treatment options, such as the pump, penile injection therapy, and penile implants.

However, the penile implant has the highest satisfaction rate of all treatment options. Erectile dysfunction can be a warning sign of current or future heart disease sometimes. In fact, ED can precede coronary artery disease in almost 70 percent of cases.

When you have heart disease, or coronary artery disease (blocked blood vessels), it will affect the tiny arteries in your penis sooner. Many times, we will refer you to a cardiologist to determine if you have cardiovascular disease that is causing your ED.

Improving your heart health can help lower your risk for ED.

You can start by: increasing physical activity, quitting tobacco products, losing weight, and consuming a healthy, well-balanced diet.

Erectile dysfunction is a potential complication following prostate cancer treatments.

The nerves that control an erection lie very close to the prostate and may be injured during sildenafil citrate 25 mg price treatment. However, some men may regain their previous level of erectile function with nerve-sparing procedures. But it may take up to a year while some men may never recover their ability to have a natural erection. Radiation for prostate cancer can cause ED symptoms to appear gradually, usually within two to three years after treatment.

If you are experiencing ED after undergoing prostate cancer treatment, you can get a healthy sex life back. We can help you choose the best treatment options for you. If medication doesn’t successfully treat erectile dysfunction, your doctor may recommend surgery or the use of a penile device. Surgery may also be the only treatment option for men with severe erectile dysfunction due to a physical trauma, prior surgery in the pelvis, or a medical condition, such as cancer. Our doctors work with you to determine which device or procedure best suits your needs and lifestyle. One of the first and most effective treatments for erectile dysfunction, a vacuum erection device is a cylinder that is placed around the penis to help pump blood until an erection is created.

Today it is most often used when medications for erectile dysfunction do not work.

To use this device, lubricant is applied to the penis, which is inserted into a tube attached to the vacuum device.

Then you manually pump the vacuum device until air is pumped out of the tube and an erection is achieved. The erection is then held in place during intercourse by a constrictive band around the base of the penis for up to 30 minutes. After intercourse, the band is removed, and the erection goes away. Side effects may include light bruising on the penis, which is usually not associated with pain and generally goes away within days. Some men dislike the lack of spontaneity associated with using medication or a vacuum device. In this case, our specialists may recommend a mechanical device called a penile prosthesis, which is implanted in the penis to create an erection-like state.

A penile prosthesis can be implanted in men with erectile dysfunction related to the symptoms of diabetes, vascular disease, and spinal cord injuries. There are two types of implants, neither of which change sensation in the skin of the penis or negatively affect a man’s ability to orgasm or ejaculate.

Malleable penile implants are mechanical devices that are surgically implanted in the penis to provide permanent firmness.

A surgeon makes an incision near the base of the penis and creates an opening in the two long tubes of spongy tissue of the shaft. The procedure, performed with anesthesia in the hospital, takes 30 to 60 minutes. Often, you can leave the hospital the day of surgery.

Following surgery, your doctor may advise you to avoid sexual activity for at least six weeks and may also prescribe pain medication as needed. These implants are always firm, making them more detectable in clothing than inflatable implants.

This can be concealed by manually bending the implanted rods downward.

Inflatable penile implants can be inflated to create an erection-like state and then deflated after sexual intercourse, allowing for reliable, rigid, and spontaneous erections. In a one- to two-hour procedure, a surgeon installs the implant—which includes two inflatable cylinders, a reservoir, and a pump unit—into the penis and scrotum.

Pressing on the area of the scrotum where the pump portion of the device is embedded allows fluid to flow from the reservoir implanted near the bladder, inflating the prosthesis and creating an erection-like state. The surgical procedure to install the penile prosthesis requires anesthesia and four to six weeks of recuperation, during which your doctor may advise you to avoid sexual activity. Some men go home the day of surgery, although some may require extra monitoring and return home the next day.

Pain medicine is prescribed as needed after the surgery.

Inflatable implants are mechanical devices and, as such, can break down eventually.

If this occurs, surgery may be required to remove, repair, or replace them. This surgical procedure is used mostly in men younger than age 40 who have had a traumatic injury to the pelvis that affects penile blood vessels.

In these men, microsurgical revascularization can improve erections by restoring blood flow to the penis. Performed with anesthesia in the hospital, this procedure allows the doctor to surgically bypass blocked penile arteries by connecting an artery in the lower abdomen to one at the top of the penis.

This ensures adequate blood flow, which is needed to sustain an erection.

This procedure is not recommended for men with atherosclerosis, a condition that causes hardening of the arteries, which can lead to permanent damage to the lining of the blood vessels of the penis.

Treatment for Erectile Dysfunction (ED) in Alexandria & Woodbridge.

Erectile dysfunction, or impotence, is the inability to maintain an erection firm enough to perform sexual intercourse.

While erectile dysfunction can be experienced by men occasionally with no cause for concern, more frequent occurrences can cause problems with self-esteem and could also be a symptom of an underlying condition.

Potomac Urology specializes in diagnosing and treating the underlying causes of erectile dysfunction.

Men’s health experts at our Alexandria and Woodbridge, VA offices have experience treating ED with a variety of treatment options. Learn more about ED and book your appointment today!

Symptoms of erectile dysfunction include decreased libido, or sexual desire, and problems with getting or maintaining an erection.

You should seek out medical attention if you are experiencing erectile dysfunction and have heart disease, diabetes, or other health conditions that could be associated with erectile dysfunction. You should also see a doctor if you experience other problems in conjunction with erectile dysfunction, such as premature ejaculation, or if you begin to notice erectile dysfunction more often or become concerned.

Erectile dysfunction is normally caused by other, underlying conditions, such as heart disease, high blood pressure, obesity, sleep disorders, diabetes or other conditions. However, it can sometimes be caused by stress, anxiety or other mental health disorders. Weakened nerve signals from the brain to the penis may also be to blame. A urologist can check hormone levels, such as testosterone or prolactin, via blood tests. They may also utilize other lab tests to check for abnormalities that could tie in to erectile dysfunction.