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If you are a man and you have never faced an erection problem, then you might be not human at all. Practically at any stage of their lives males have to admit they are not 18 anymore and just live with this fact. The times when we could be easily aroused by small details of woman’s accessories, behavior or lingerie are long gone and perfect sexual performance became the thing that visits us in our dreams only.

Doesn’t it sound to despairing? Well, it surely does, as impotence is a kind of hot question men are not willing to discuss. However, as the practice has shown, this is not the reason to bury your sexual drive and fantasies, buy a rocking chair and get prepared to grow old.

ED? There Surely Is a Way out

When I felt there was something with my erection, I didn’t pay too much attention to it. Everyday stress and other business and family matters might have made me weaker, I thought then. It took me several times to try to finally understand there was something wrong and that I needed to do something urgently. Seeing beautiful women and thinking about hot stuff hardly made me a sexual beast in terms of erection and that’s where I resorted to seeking for the best way to fight and eliminate the condition.

Surely, being a grown-up man I’m quite shy and even embarrassed of discussing my sexual life and problems with someone, and health care provider as well. Browsing the Internet just gave me a quick glimpse on the problem of erectile dysfunction but the solutions offered at various websites were just numerous. Online pharmacies offer brand and generic drugs promising to treat impotence and give me my stamina back. Volume pills, ED medications – sounds too good to be true, I thought. But that is really true, and I can prove it.

Once surfing the Internet I stumbled upon Canadian pharmacy Viagra offering generic medications that are sure to help men experiencing erectile dysfunction. Upon contacting the support service I figured out the recommendations were given by a medical advisor, not some sort of website manager. And it was absolutely perfect for me and my inner world. No one has seen my face. Looked me in the eye and thought something like “Wow, so young and has already faced impotence”. My privacy was my shield in buying Viagra from this online pharmacy www.canadianhealthcaremalll.com (Canadian health&care mall website).

Viagra Effect: How It All Turned from a Problem into Success

Certainly, you might know the difference between brand and generic drugs. They are identical and I really mean it: the components, dosage, even color of the pills. So why pay more if the effect is the same? Generic Canadian Viagra became my real life saver – it was delivered overnight and on the following day I tried it out and saw its action. To tell the truth, I was quite surprised to get an erection so fast and my wife was pleased as well. However, there are certain restrictions for Viagra usage which you are informed of prior to purchasing this ED medication.

General principles

The purpose of clinical assessment is to identify and agree the nature of the individual’s/couple’s problem(s), why i t has occurred, their aims for treatment outcome, and whether this may realistically be achieved with biomedical or pysychotherapeutic interventions. These are summarized in Figure 12. The ‘diagnosis’ of the causes of a complex, multifactorial problem requires a holistic approach, considering biomedical, psychological, behavioral , partner , and relationship issues.

Working with individuals and with couples

When assessing a sexual problem, it is almost always desirable to see both partners in a sexual relationship, even if there only seems to be one person affected. The partner can provide important additional information and may also need help with their own sexual problems. Co-existing problems in both partners are common, and may be an obstacle to successful treatment. Sexual dysfunctions in women are a common problem, affecting perhaps 40% of women, although only around 20% have sought help. Problems with desire, genital and subjective arousal, orgasm, and sexual pain have been described. Their assessment and management is beyond the scope of this book. However, these problems are important: they can cause significant distress, may have a negative impact upon ED treatment outcome, and, importantly, are amenable to treatment.

Women with concerns over sexual function may benefit from a holistic biomedical and psychosexual evaluation, and should be strongly encouraged to seek professional help. Postmenopausal women who are partners of men with ED and who have not had intercourse for some time may notice impaired vaginal lubrication and elasticity. This is often due to estrogen deficiency-related atrophic vaginitis. They should be warned that this might occur and be made aware that they should seek treatment if necessary. This advice should be given concurrently with any ED treatment , rather than waiting for the problem to emerge. In practice, many men are reluctant to involve their partners and, not infrequently, the partner does not wish to attend. There are frequently perfectly valid reasons for this but, occasionally, the absence of a partner may indicate that they are unwilling to allow resumptions of sexual intercourse. It is very important to ask men attending alone about their general relationship satisfaction and to solicit information about their view of their partner’s perception of their problem. Sometimes, men with ED will admit that they have not told their partner that they are seeking treatment and suggest that they ‘want it to be a surprise’ for them. This may Mell be the case for a partner who has not had intercourse for several years and is suddenly confronted with an unwelcome erect penis. While i t might not be appropriate to insist that a man tells his partner that he is seeking ED treatment , he should be strongly encouraged to do so. Taking a sexual history presents different challenges to the physician, not least because most physicians have had little or no training or experience in doing so.

Medications are available that can substantially delay ejaculation. The familiar 5-PDE inhibitors (Viagra, Levitra and Cialis) that are commonly used for erectile dysfunction, may have a role in the treatment of P.E. in men with acquired P.E. secondary to erectile dysfunction.

Anti-depressants of the S.S.R.I. class (selective serotonin reuptake inhibitors) have been clearly demonstrated to delay ejaculation. These medications can have undesirable side effects such as decreased libido, sleepiness, insomnia, headache, nausea and dry mouth. You are generally started on a low dose for two weeks with an increase in dose if necessary for the next two weeks. Once an effective dosage is achieved, you can use the medication on a situational basis, 3-4 hours prior to sexual intercourse.

The most commonly used medications are:

  • Anafranil (Clomipramine): 25-50mg
  • Paxil (Paroxetine): 20-40mg
  • Zoloft (Sertraline): 25-100mg
  • Prozac (Fluoxetine): 5-60mg

A new medication, Dapoxetine (30/60mg), is currently in investigational trials.

Insofar as most cases of P.E. have an underlying psychological basis, it may be beneficial to seek the aid of a sexual therapist who can help manage the problem with counseling sessions. This can be done in conjunction with some of the aforementioned techniques in order to bring about a quicker resolution.

One method of attempting to prolong the time prior to ejaculation is to  employ mental diversionary tactics—that is, filling your mind with thoughts  other than ejaculating in order to prevent doing so. Baseball, work, counting  backwards, etc., are examples of such thoughts. Unfortunately, these “deerotization”  techniques are rarely effective and diminish the pleasure of  sexual activity and intimacy.

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A more successful means of preventing P.E. is the stop-start method  originated by Dr. Semans. This technique requires you to develop an  enhanced awareness of the feelings and sensations surrounding the time  leading up to ejaculation; by achieving such familiarity, you can learn to  accurately predict when ejaculation will occur and how to gain control before  the “point of no return.” Recognizing imminent ejaculation and responding  by slowing the pace of pelvic thrusting as well as varying the angle and  depth of vaginal penetration may allow time for the feeling to dissipate. If  slowing the tempo is not sufficient to prevent the occurrence of premature  ejaculation, you may need to stop thrusting completely while maintaining  penetration in order for the urgency to go away. Once the sensation to  ejaculate subsides, pelvic thrusting may be resumed.

Another option is the squeeze technique originated by Masters and Johnson.  As ejaculation approaches, the penis is withdrawn from the vagina and  the head of the penis is squeezed until the feeling of ejaculation passes,  after which intercourse is resumed. The male or his partner may apply the  squeeze.

Decreasing penile sensitivity can be helpful in the management of P.E. There are various means of accomplishing this, including the use of extra  thick condoms, topical creams that desensitize the penis, and increasing  the frequency of ejaculation, since P.E. tends to be more pronounced after  prolonged periods of sexual abstinence. By masturbating prior to engaging  in sexual intercourse, the ejaculatory latency period can be increased.

Local anesthetics including
Lidocaine (2.5%) or Lidocaine and Prilocaine (EMLA  cream) applied 20-30 minutes prior to intercourse will diminish the sensitivity of  the penis.

Premature ejaculation (P.E.) is defined as ejaculation with minimal sexual stimulation and climax occurring before, upon, or shortly after vaginal penetration, prior to a person’s desire to do so, over which the sufferer has little voluntary control. P.E. typically causes the sufferer and partner extreme bother and distress.

This is a very common male sexual dysfunction, occurring in up to 30% of the male population, and affecting men of all ages, ethnicities, and socio-economic groups. P.E. can be devastating, causing embarrassment, frustration and loss of self-confidence for males, and negatively affecting their relationships with their partners. The basis of P.E. can be psychological and/or biological – with guilt, fear, and performance anxiety, but also genetics and certain medical disorders playing possible roles in its occurrence.

P.E. may be classified as either primary (lifelong) or secondary (acquired). Primary P.E. applies to men who have had the problem since becoming sexually active and is thought to have a strong biological component. Psychological or situational stressors may contribute to secondary P.E., but it is also associated with erectile dysfunction, prostatitis and urethritis.

Our society’s cultural emphasis on ejaculation as the focal point of sexual intercourse tends to exacerbate the performance anxiety that can initiate the problem. The occurrence of P.E. has social and psychological consequences that tend to perpetuate the problem as fear of and mental preoccupation with P.E. can actually induce the unwanted ejaculation, creating an unfortunate vicious cycle. But males experiencing P.E. need to know that various types of help are available and that there is no need to suffer in silence. Treatments are varied, consisting of behavior modification techniques, physical and pharmacological interventions, and sexual counseling.

Peripheral Nerve Injury Peripheral nerve injury is another important cause of ED, especially in patients undergoing prostatectomy. Other causes of peripheral nerve injury include bicycle riding and acute pelvic trauma. Several authors have reported genital numbness and increased the incidence of ED among cyclists. The pathophysiological basis for ED in cyclists is thought to be neurogenic as well as vasculogenic.

A recent systematic review of the literature found that the reported incidence of ED after radical prostatectomy with nerve sparing technique varies widely due to methodology. 50% and 34% for bilateral and unilateral nervesparing surgery, respectively.

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Nerve-sparing techniques are based on the seminal study by Walsh and Donkers in which they identified the path of the nerves to the corpus cavernosa.
They identified the branches of the pelvic plexus traveling through the urogenital diaphragm adjacent to the prostatic capsule and then adjacent to and through the wall of the membranous urethra. Not surprisingly, they found that men with tumors that did not invade the prostatic capsule and were amenable to salvage of this structure had reduced rates of ED.

Recovery and improvement in erectile function after radical prostatectomy has been reported to continue up to and beyond 2 years postoperation, perhaps indicating healing of injured nerves.
Loss of erectile function is also related to anatomical changes in the penis, specifically fibrosis of the penis due to prolonged lack of tumescence. In animal models, histological changes occurring after nerve injury are prevented by regular pharmacologically induced erections.

Psychogenic Risk The number of cases of ED attributed purely to psychogenic etiology have greatly declined in the past several decades. Younger men who complain of ED are more likely to have a psychogenic component than older men. Psychogenic ED is generally classified into generalized and situational pathologies and further subclassified.

This classification scheme has been criticized as it fails to account for advances in neurobiology that have linked certain psychiatric illnesses with neurochemical and neurohormonal derangement. Depression Depression and ED are often comorbid conditions. Several epidemiologic studies report men with ED are more likely to report depression, and that this association is independent of associated comorbidities, demographic factors and medications. In a study of men diagnosed with Major Depressive Disorder but not yet treated, almost half had trouble sustaining an erection and reported decreased sexual desire

Respiratory Disease and Erectile Dysfunction: Spinal Cord Injury, Cerebrovascular Accidents

Posted by Ed medications in Erectile Dysfunction - (Comments Off on Respiratory Disease and Erectile Dysfunction: Spinal Cord Injury, Cerebrovascular Accidents)

Spinal Cord Injury The nature of ED caused by spinal cord injury (SCI) is dependent on the acuity and location of the injury. Estimates of the preservation of erectile function vary widely, and are as high as 95% for reflexogenic erection.

Erections in men with SCI are characterized as reflexogenic when the stimulus is tactile or psychogenic when visual, auditory, or memory serve as the stimulus. Since erections are the result of parasympathetic output to the penis arising from S2 to S4, reflexogenic erection is maintained in suprasacral injuries or those not involving the lower motor neurons (LMN).

Cerebrovascular Accidents Cerebrovascular accidents (CVA) are another important cause of sexual dysfunction and, specifically, ED. As with other neurological diseases, the pathophysiology of ED in these patients is multifactorial and related to the physical, psychological, and social consequences of stroke. Sexual complaints in stroke patients include the loss of libido, frequency of sexual intercourse, ED, and sexual satisfaction.

These complaints are most attributable to interpersonal variables, such as the inability to discuss sexuality with a spouse or changed attitude toward sex, but the fear of impotence is a significant variable. Erectile dysfunction increases from 36% prestroke to 76% poststroke, and is associated with the degree of depression poststroke.

In a study that specifically assessed ED in stroke patients, approximately half of stroke patients reported ED.

A more important finding in this study was that preexisting diabetes, hypercholesterolemia, obesity, and smoking increased the prevalence of ED after stroke. The neurogenic component of ED in stroke patients is complex due to the various central structures involved in erectile physiology and the complexity of stroke distributions. Only one study to date has attempted to associate lesions on MRI with sexual dysfunction. Erectile dysfunction was only weakly associated with lesions involving the right pons.

While the specific nature of neurological insults that determine ED in stroke patients is yet to be determined, it is evident that psychosocial factors are an important determinant of sexual dysfunction after stroke.

Chronic Obstructive Pulmonary Disease There is a clear association between respiratory diseases and ED independent of comorbid conditions, such as peripheral vascular disease or coronary artery disease. Chronic obstructive pulmonary disease (COPD) is a common chronic disease in men. Dyspnea and hypoxemia diminish a patient’s functional capacity and can lead to ED. The prevalence of ED in patients with respiratory disease has been reported as high as 75%.

Several investigators have demonstrated that as pulmonary function tests (i.e., FEV1, FRC, PaO2) worsen, so does a man’s erectile function. Pathophysiology of ED in patients with COPD is multifactorial. Disruption of the hypothalamic– pituitary–gonadal axis has been reported in patients with COPD.

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Reversal of hypoxemia with long-term oxygen has been shown to be effective in improving impotence. Obstructive Sleep Apnea Obstructive sleep apnea (OSA) is also a common chronic disease. It has been reported in as many as 10% of men over 40 years old. Recurrent intermittent hypoxemia and transient increases in sympathetic tone during apneic episodes result in an increased risk of daytime somnolence, hypertension, and ischemic cardiovascular events. Erectile dysfunction has also been found to be associated with OSA.

This association appears to be strongest in the most severe cases of OSA. Causes for ED in these patients include hypoxemiadriven neural damage, microvascular endothelial damage from increased sympathetic tone and hypertension, low gonadotropin secretion, and psychosocial abnormalities, including daytime somnolence and depressed mood