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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 a synergistic effect of the three medications, while keeping the dose of each drug low enough to prevent side effects.

In addition, the response rate of the Trimix solution is as high as 90 percent. Men must receive appropriate training and education by their doctor before beginning home injection therapy.

The goal of the injection medicine is to achieve an erection that is sustained for sexual intercourse, but not prolonged or painful. The injections must be given in proper amounts with the appropriate technique to minimize the risk of scarring the penis or developing priapism.

For more information 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 sildenafil teva online 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 the nerves that control sensation are not injured, the penile sensation and the ability have an orgasm should be maintained.

Penile venous surgery is recommended only for young men who have ED as result of congenital or traumatic venous leakage of the penis. The procedure is performed to improve the trapping of blood in the penis, improving a man's ability to get and maintain an erection.

Penile arterial surgery generally involves bypassing blocked arteries by transferring an artery from behind the abdominal muscle to a penile artery. This creates a path to the suhagra online shopping 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 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, best online sildenafil 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 best online sildenafil be helpful include the following: Direct injection of prostaglandin E1 (PGE1; alprostadil) into the corpora cavernosa (see the image below) Biothesiometry best online sildenafil – 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 best online sildenafil 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 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 best online sildenafil 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).



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