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Taking nitroglycerin and a PDE-5 inhibitor within 24 hours of each other may greatly lower your blood pressure.

This could lead to a heart attack, stroke , or death. Talk with your doctor about whether medicines for erection problems are safe for you if you: Have heart disease. If you are taking a PDE-5 inhibitor and are going to have a test for heart disease, make sure that your doctor knows you are taking it. You should not take sildenafil (for example, Viagra) or vardenafil (for example, Levitra) for 24 hours before the test.

Do not take tadalafil (for example, Cialis) for at least 48 hours before the test. Then if you have a problem during the test, it will be safe to use nitrate-containing medicines such as nitroglycerin. If you are using a combination of drugs for high blood pressure, PDE-5 inhibitors could cause low blood pressure (hypotension).

Also for this reason, you should not take alpha blockers—used to lower blood pressure and to treat an enlarged prostate—with these medicines without talking to your doctor.

The combination could cause a dangerous drop in blood

pressure

. If you have a heart condition and have not been sexually active for a while, talk with your doctor to make sure you can engage in sexual activity safely. In a

few

cases, surgery may be an option to treat erection problems.

Surgery will rarely be recommended before non-surgical treatment and counselling have been tried.

Think carefully about non-surgical options and about the possible risks of surgery.

Doctors who specialize in conditions of the urinary tract (urologists) do most penile implants. Specially trained urologic surgeons usually do blood vessel repair surgery. Vacuum devices are useful for all types of erection problems—physical, psychological, or both. You pump the device to create a vacuum that leads to an erection. Counselling (psychotherapy) is recommended for men whose erection problems are caused, at least in part, by psychological factors.

It focuses on ways to improve attitudes toward sex.

Evidence shows that group therapy helps with erection problems in some men.

Adding group therapy to treatment with sildenafil (for example, Viagra) helped more than sildenafil alone.

Men who were taking part in group therapy also were more likely to keep taking their medicine.

Counselling also may be used with medicine treatment or vacuum devices for erection problems that have psychological and physical causes.

Medicines are usually the main treatment for erection problems. If you don't want to use medicine, or if medicine doesn't work for you, you may want to talk with your doctor about some of the following options. Most of these treatments need more research before doctors can know if they work for sure.

It has been shown to work for some men who have erection problems. But because it is sold as a dietary supplement, it is hard to know if you are getting the right amount. Some men take this dietary supplement to try to treat erection problems. The amino acid increases the amount of nitric oxide in the blood, which relaxes blood vessels.

Some men who have low zinc levels in their body have had success using zinc supplements to treat erection problems. Male Genital Problems and Injuries Reducing Medication Costs Healthy Aging Dealing With Medicine Side Effects and Interactions Premature Ejaculation Tests for Erection Problems Low Testosterone. Psychosocial interventions for erectile dysfunction.

In AJ Wein et al., eds., Campbell-Walsh Urology , 10th ed., vol.

American Urological Association (2005, reviewed and confirmed buy cialis over the counter usa 2011). Also available online: http://www.auanet.org/content/clinical-practice-guidelines/clinical-guidelines.cfm?sub=ed.

Use of sildenafil (Viagra) in patients with cardiovascular disease. Effect of lifestyle changes on erectile dysfunction in obese men. In AJ Wein et al., eds., Campbell-Walsh Urology, 10th ed., vol.

Gregory Thompson, MD - Internal Medicine Brian O'Brien, MD, FRCPC - Internal Medicine Adam Husney, MD - Family Medicine Christopher G. Erectile dysfunction can have organic or psychological causes.

Often, an organic problem can be complicated by psychological factors.

The cause can usually be found by history and examination, but testosterone, luteinising hormone and prolactin should be measured.

Non-drug treatments are suitable for some patients, while prostaglandin E1 is the most appropriate drug for intracavernosal injection.

Introduction Erectile dysfunction (impotence) is the inability to obtain and sustain an erection adequate for sexual intercourse.

This is a common problem and the prevalence increases with age. It is important to distinguish erectile dysfunction from ejaculatory disorders including premature ejaculation and ejaculatory failure. Many men are reluctant to seek help from their doctors as evidenced by the proliferation of franchised, entrepreneurial clinics advertising in the popular press. Basic clinical assessments should be undertaken for all men presenting

with

erectile dysfunction to identify. – men who have significant underlying medical disease.

– those for whom specific medical therapy may be beneficial.

– those with a psychogenic cause where psychotherapy as part of the medical management may be important. Extensive investigations are not usually justified.

History A careful history, including a drug history, will usually differentiate organic from psychogenic impotence. Drugs that are commonly associated with sexual dysfunction include antihypertensives (including diuretics), cimetidine, major tranquillisers and most antidepressants. Organic impotence generally has a gradual, insidious onset with progressive worsening until no erection is obtained. At first, there may be loss of rigidity and/or difficulty sustaining an erection.

Organic impotence is evident consistently in all situations, whether during attempted intercourse with his regular or another partner, masturbation or in response to erotic stimuli. Nocturnal erections are markedly diminished and this manifests as a loss of erections on waking. Psychogenic impotence is more likely to have an abrupt onset. This is often related to a distinct precipitating event (e.g. a psychologically traumatic episode of sexual

failure

). The impotence is often inconsistent, occurring only in certain situations.

Nevertheless, organic impotence usually invokes a secondary psychological overlay which may complicate evaluation of the aetiology. This underlines the need for a careful, unhurried approach and empathy during history taking. Androgen deficiency causes more loss of libido than erectile dysfunction. It is unusual for men complaining of impotence to have androgen deficiency as a cause of their sexual dysfunction. This is in contrast to the low sexual activity of androgen-deficient men which often causes them little concern.

Physical examination Evidence of possible causative factors (e.g.

diabetes, pituitary disease, lipid disorders, vascular or neuropathic disease, androgen deficiency) should be sought systematically. Gonadal status (secondary sexual characteristics, testis size) and visual field defects suggesting pituitary tumour should be assessed. Altered peripheral pulses and neurological reflexes in the legs can be evidence of vascular or neurological disorders. Investigation Few investigations of erectile dysfunction lead to specific interventions, so extensive testing cannot be justified in routine practice.

Specific correctable underlying causes such as androgen deficiency or pituitary tumour should be sought, buy cialis over the counter usa even though they are rare. Their treatment may be gratifying and has implications for general health (e.g. general energy and well-being, risk of osteoporosis). Serum prolactin, testosterone and luteinising buy cialis over the counter usa hormone (LH) should be measured and repeated if any is abnormal.

If consistently abnormal, further investigations are required.

Although treatment of diabetes or hyperlipidaemia may not improve erectile function, they should not be overlooked.

Apart from measurement of penile blood pressure which may exclude or confirm a vasculogenic basis, other complex investigations are not usually justified.

Surgically correctable vascular lesions are rarely found and, even then, surgical outcomes are functionally very disappointing. Sleep studies with or without determination of nocturnal penile tumescence are not usually justified clinically. They add information which usually does not influence management. Management The success of most commonly-used therapies will depend on co-operation of the partner.

It is important to

determine

the partner's attitudes to the problem and involve them in discussions of treatment options.

Men who do not have a regular or supportive partner rarely do well with therapies which necessitate treatment at the time of intended intercourse.

Psychotherapy A psychological reaction to persistent erectile failure is almost inevitable and universal. This complicates the identification of primarily psychogenic impotence so it is essential to have an insightful and empathetic manner to manage erectile dysfunction effectively. Even when erectile dysfunction is primarily organic, appropriate counselling provided by the patient's doctor can be reassuring if adequate time is made available. Psychogenic impotence can be improved with the help of an experienced psychiatrist or psychologist.

This psychotherapy requires a supportive and understanding partner willing to participate in couple-oriented behavioural sessions.

In some men with psychogenic impotence, a limited trial of empirical intracavernosal therapy may break the self-reinforcing cycle of performance anxiety and failure.

This may restore their confidence in the ability to obtain an adequate erection.

Mechanical devices Vacuum erection devices These external devices create a vacuum to induce an erection.

This is then maintained by a thick rubber band placed tightly at the root of the penis. They have a modest role in the treatment of men in whom intracavernosal injection therapy is contraindicated (e.g. These devices have modest efficacy and are suitable mainly for men with psychogenic or partial organic impotence.

Their efficacy and acceptability are limited in men with severe neurovascular impotence.

Apart from occasional penile bruising, they are generally safe if the duration of each use is limited. Compared with penile implants or long-term intracavernosal injections, their cost is low. Implants Surgical penile implants are an expensive last resort when simpler measures (such as psychotherapy, vacuum devices or intracavernosal injections) are ineffective or inappropriate. As flibanserin buy online most cavernosal tissue is excised, the procedure is functionally irreversible.

It is justified only for men with complete organic impotence.

Devices vary in complexity from simple semi-rigid rods to fully inflatable with an implanted reservoir.

Satisfaction with the implants is variable, but depends on thorough pre-surgical counselling and close involvement of the partner. Complications include infection, mechanical failure and erosion.

Hormonal treatment Treatment with testosterone should never be given without clear evidence of androgen deficiency. 1 Once testosterone starts, the endocrine investigations become confusing and it can

take

many months to clarify the patient's requirement for ongoing therapy.

Furthermore, testosterone therapy has a significant placebo effect in eugonadal men with psychogenic impotence. Unlike genuine androgen deficiency, such men generally have an inconsistent and poorly maintained response to testosterone treatment.

This further confuses the diagnosis and leads to frustration and disappointment for the patient. A borderline low plasma testosterone is rarely significant in otherwise healthy men presenting

with

erectile difficulty, particularly if the plasma LH is normal.

Patients with hyperprolactinaemia require evaluation for a prolactinoma and their management is dictated by the pituitary tumour. For microprolactinomas, bromocriptine treatment alone can be effective. The more common macroprolactinomas usually require surgery, sometimes with adjuvant radiotherapy.

Intracavernosal therapy Due to the lack of specific treatments for most causes of erectile dysfunction, intracavernosal injections are in wide use.

They represent buy cialis over the counter usa a major advance in the empirical treatment of erectile dysfunction. The original drug used for intracavernosal therapy was papaverine, a smooth muscle relaxant, often supplemented with phentolamine, an alpha adrenergic blocker.

Neither is registered for treatment of erectile dysfunction in any country. Despite the wide ad hoc usage of these two drugs and their combination, there is little reliable information on their efficacy or safety. Indeed, there is doubt that these combinations are chemically compatible, stable or sterile under the usual circumstances of use. The main reason for the preference for prostaglandin E 1 over the papaverine or papaverine/phentolamine combination is that these older drugs are believed to have a higher incidence of priapism and long-term penile fibrosis.

The use of 3 or 4 drug cocktails represents shotgun therapy which is contrary to sound pharmacological principles.

Prostaglandin E 1 Prostaglandin E 1 has the most extensive efficacy and safety record, making it the current drug of choice.

It relaxes the smooth muscle of the corpora cavernosa, resulting in a dose-dependent increase in penile blood inflow and tumescence.

The magnitude of the blood flow and erectile response varies between individuals and according to the pathology.

The usual starting dose of prostaglandin E 1 is 2.5-5 micrograms.

Generally, men with vasculogenic impotence require higher doses than those with neurogenic or psychogenic impotence.

The optimal dose for each patient varies considerably and must be individually titrated by progressively increasing the dose (up to a maximum of 30 micrograms) with successive test injections until an adequate response is achieved.

In practical terms, this is defined as an erection firm enough for penetration and lasting from 20-60 minutes. The first injection (at least) should be given under the direct supervision of a doctor and the patient subsequently taught how to self-inject. It is not sufficient just to send the patient home with a prescription and diagram on how to self-inject any more than it is appropriate to ask a diabetic to start insulin self-injection without careful instruction and supervision. Intracavernosal therapy should generally be supervised by a doctor with appropriate experience. If an inadequate response is achieved with maximal prostaglandin E 1 dosage, combination therapy with papaverine alone or with buy cialis over the counter usa phentolamine has been reported to improve the response.

Reliable clinical trials of such add-on therapy are lacking.

The risk of adverse effects (priapism, fibrosis, hepatotoxicity, hypotension) is higher with such multi-drug regimens. In addition, the chemical compatibility, stability and sterility of these ad hoc mixtures is not assured.

The

most frequent adverse effect of prostaglandin E 1 intracavernosal

therapy

is penile or perineal pain.

Some pain occurs after approximately 20% of injections, but is rarely ( Erectile dysfunction treatment.

When Roman started, 80% of Viagra sold online was counterfeit. It became our mission to make it safe and simple for people to get medication they can trust from a licensed pharmacy, prescribed by a real, US-licensed healthcare professional.

Erectile dysfunction is the inability to get or maintain an erection adequate for sex.

There are many different causes, but ED ultimately occurs when there is too little blood flow into the penis and too much blood flow out, partially due to an enzyme called PDE5. Oral ED medications block PDE5 to increase blood flow into the penis and decrease blood flow out. ED medication interferes with the breakdown of chemicals required to obtain and maintain an erection.

This interference keeps more of those chemicals in action longer, improving the ability to get and maintain an erection. A physician in our network will evaluate whether ED treatment is appropriate for you.

If prescribed, we’ll ship it to you in discreet, unmarked packaging.

Do not use Viagra/sildenafil if you aren’t healthy enough for sex or if you take nitrates for chest pain. Side effects may include headache,

flushing

, upset stomach, nasal congestion and abnormal vision.

To avoid injury, seek immediate attention if you have an erection lasting longer than 4 hours. Stop taking Viagra/sildenafil and seek care if you experience a sudden loss or decrease in vision or hearing. Do not use Viagra if you aren’t healthy enough for sex or if you take nitrates for chest pain.

Side effects may include headache, flushing, upset stomach, nasal congestion and abnormal vision. To avoid injury, seek immediate attention if you have an erection lasting longer than 4 hours. Stop taking Viagra and seek care if you experience a sudden loss or decrease in vision or hearing. Do not take Cialis if you aren’t healthy enough for sex or if you take nitrates for chest pain. Side effects may include headache, upset stomach, delayed backache, or muscle ache.

To avoid injury, seek immediate attention if you have an erection lasting longer than 4 hours.

Stop taking Cialis and seek care if you experience a sudden loss or decrease in vision or hearing or if you experience an allergic reaction like rash, hives, swelling of the lips, tongue or throat, or difficulty breathing or swallowing.

To learn more about Cialis, please see the Important Safety Information. Sildenafil & Viagra manufactured by Pfizer in France.

A physician in our network will evaluate which (if any) ED treatment is appropriate for you.

Then we’ll ship it to you in discreet, unmarked packaging. Many people get great results the first time they use the medication.

For some, it can take 2-3 uses to see results, and research shows that best results occur after 8 uses . If you still don’t see results, your doctor or nurse practitioner may be able to increase your dose or switch you to a different medication.

If you experience side effects, message your doctor or nurse practitioner and they’ll help determine if a different medication or dose is better for you.

Sexual health and overall health are inherently related.

If erectile dysfunction is interrupting your sex life, your general wellbeing (and that of your partner) is impacted greatly. Report your symptoms and medical history to a U.S.-licensed physician or nurse practitioner for evaluation.

Your treatment will be sent in discreet packaging, always with free 2-day shipping. Send your doctor or nurse practitioner a message any time to discuss updating your treatment, solving for side effects, or any other questions or concerns.

For more information about erectile dysfunction, Roman, Ro and more, visit our FAQ page. To speak to a care representative, give us a call at (888) 798-8686 or email us at [email protected] . Roman uses telemedicine technology to provide a discreet, convenient, and affordable way for you to receive erectile dysfunction treatment from a U.S. Complete the dynamic onboarding, submit your photo, ID, and recent blood pressure reading, and our physicians will determine if you’re a candidate for telemedicine. Erectile dysfunction is often a symptom of a more serious underlying condition—like heart disease, diabetes, high blood pressure, or even depression.

That’s why we strongly recommend optional laboratory tests. These tests aren’t required to receive treatment on the Roman platform. But they help identify the underlying cause of your ED.

We want you to get the most comprehensive treatment possible.

Just send us your most recent blood test and we’ll add it to your account information to help our physicians give you the most comprehensive care from the convenience of your phone.It might sound funny but regular erections are a great barometer of your overall health.

Learn why paying attention to the strength and frequency of your erection might actually save your life. Which medications do doctors and nurse practitioners on the Roman platform prescribed for ED?



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