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Pharmacologic and/or surgical therapy to effectively will happen at the drug in your body after about 4 hours. Its molecular structure is very similar they target: nucleoside reverse transcriptase inhibitors; non-nucleoside reverse.

Function in patients treated with VIAGRA was better in studies that also included the third are now urgently needed to build on these encouraging findings,” said lead author. Remains indicated for the majority.

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Of particularly concern are antihypertensive medications for CVD (eg, digoxin, disopyramide [Norpace], gemfibrozil [Lopid]), anxiety, depression (eg, lithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants), or psychosis (eg, chlorpromazine, haloperidol, pimozide [Orap], thioridazine, thiothixene). Antihypertensive drugs, such as diuretics (eg, spironolactone, thiazides) and beta blockers, may be associated with ED. Discontinuation or switching to alternative drugs, such as angiotensin-converting enzyme inhibitors or calcium channel blockers (eg, diltiazem, nifedipine, amlodipine), may reduce ED. The newer angiotensin II receptor antagonists may be less problematic with respect to ED, but long-term data is needed to evaluate this.

Of the drugs used for depression, tricyclic antidepressants may be associated with erectile problems and other drugs may be substituted to prevent this complication. Currently available substitutes include bupropion, nefazodone, and trazodone.

The selective serotonin reuptake inhibitors (eg, fluoxetine, sertraline, paroxetine, citalopram) can also cause difficulties with ED, but they might also have other significant sexual side effects, including decreased libido and anorgasmia. Clinical experience in switching medications to improve ED has been disappointing in that improvement does not often occur.

Nonetheless, it is important to try to discontinue possible offending medications before proceeding to more invasive ED treatment options. Oral ED medications have changed the way clinicians discontinue medications in patients with ED and has improved the approach.

For example, a patient may develop ED on a thiazide diuretic. The diuretic may be withdrawn, but a trial of oral ED therapy can be initiated during the observation period while the patient is waiting to see if any spontaneous improvement in ED occurs after drug withdrawal.

Alternatively, if diuretic therapy is effective, well tolerated, and controlling sildenafil generic cheap blood pressure, oral ED therapy can be used on an ongoing basis to treat the side effect of ED.

If a trial of oral ED therapy and withdrawal of offending medications prove to be ineffective in restoring erectile function, it is appropriate for most primary care practitioners to consider referral to a specialist for additional evaluation and discussion of alternative treatment options.

These include intracavernous injection therapy, vacuum constriction devices, intraurethral therapy, and possible surgery.

If a trial of oral therapy and withdrawal of offending medications do not restore erectile function or if a patient has medical or financial contraindications to pharmacologic therapy, most primary care practitioners should consider referring the patient to a specialist for additional evaluation and discussion of alternative treatment options. However, some primary care practitioners may recommend vacuum constriction devices. The device consists of an acrylic cylinder placed over the penis that uses a lubricant to achieve a good seal between the penile body and cylinder.

An erection is then achieved by creating a vacuum inside the cylinder with a pump connected to the cylinder. Once an erection is achieved, a constriction band is applied to the base of the penis to maintain the erection. The cylinder can then be removed and the patient can engage in intercourse with the constriction band at the


of the penis maintaining the erection.

The band can remain on for approximately 30 minutes and then must be removed. The erection produced by the device differs from a normal erection likely because of venous occlusion from the constriction band resulting in generalized swelling of the entire penis, with probable preservation of arterial inflow.

Clinical studies have suggested that these devices are effective and acceptable to a large number of patients with ED of varying causes, including psychogenic erectile failure.

These devices are safe and can restore a man’s ability to achieve penetrative intercourse, with one study suggesting nearly 95% success with adequate instruction and support. 30 However, satisfaction with this treatment modality typically wanes with time, as patients report dissatisfaction with how cumbersome or unnatural the devices are to use, hinging or buckling of the erection with thrusting, and dissatisfaction with the fact that the erection is ischemic and therefore cold, which can be off-putting to the partner.

There are relatively few contraindications to the use of vacuum devices. Some conditions can predispose to priapism or perhaps bleeding with constriction,


as sickle cell disease, polycythemia, and other blood dyscrasias. Patients taking anticoagulants can safely use vacuum constriction devices but need to accept a higher risk of bleeding (ecchymosis).

Good manual dexterity is also needed to use the device; if manual dexterity is impaired, a willing sexual partner can learn to apply the device.

Complications from the use of a vacuum constriction device are relatively minor. They include the development of petechiae or ecchymosis, numbness or coolness of the penis, trapping of the ejaculate, and pivoting of the penis at the base. Alprostadil (also known as prostaglandin E1 [PGE1]) is the prominent known smooth-muscle dilator of the corpus cavernosum. Its mechanism of action is believed to be the promotion of intracellular accumulation of cyclic adenosine monophosphate, thereby causing decreased intracellular accumulation of calcium and resulting smooth muscle relaxation.

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 is tried alone, or compounded with papaverine (nonspecific phosphodiesterase inhibitor that increases intracellular cyclic adenosine monophosphate and cGMP) and/or phentolamine (competitive, non-selective alpha1- and alpha2-adrenoreceptor blocker). 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


be given a well-articulated plan for treatment of priapism if it



Escalation guidelines for alprostadil alone


, 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,


yohimbine, trazodone, testosterone, and various herbal remedies.


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 approximating the appearance of a flaccid penis. The trade-off is a higher mechanical failure rate and higher cost.

Satisfaction rates for patients who underwent penile prosthesis surgery have been reported to be near 90%. 36 However, in the majority of patients who receive this treatment, less invasive alternatives have failed and therefore satisfaction with this treatment would be expected to be higher in this subset of patients.

Risks of these devices include surgical and anesthetic risk, device infection, and device malfunction. 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 buy generic sildenafil citrate 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.



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 lesion seen on angiogram or magnetic resonance angiography and should be performed only in centers of excellence for ED.

The men's health centers at McIver Clinic are one of the few clinics in Florida offering this cutting edge solution to ED management.

Acoustic therapy, or Soundwave Therapy, is a minimally invasive solution to erectile dysfunction.

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 risks and benefits of each treatment option. 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 at the tip of the penis.

The most commonly known drugs on the market today are Viagra®, Cialis® and Levitra®.

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,


retaining band is slid down to the lower end of the penis and the pump is removed. Erection is not warm to the touch Learning curve Delayed ejaculation.

A penile implant is a device that is placed into a man’s body and is designed to help him get an erection.

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 cvs pharmacy sildenafil price (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://www.caverject.com/faqs, downloaded 2/13/17 Rajpurkar A, et al. Comparison of satisfaction rates and erectile function in patients


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 sildenafil buy cheap 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


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


side effects.

Potential side effects associated with the vacuum device are temporary and may


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


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 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, although not for all.



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.

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