Some men should not take PDE5 inhibitors. They can cause hypotension (abnormally low blood pressure that can lead to fainting and even shock) when given to patients who are taking nitrates (medications taken for heart disease). Therefore, patients taking nitrates daily should not take any of the PDE5 inhibitors. Nitrates relieve angina (chest pain due to insufficient blood supply to the heart muscle because of narrowing of the coronary arteries); these include nitroglycerine tablets, patches, ointments, sprays, and pastes, as well as isosorbide dinitrate and isosorbide mononitrate. Other nitrates such as amyl nitrate and butyl nitrate also are in some recreational drugs called "poppers."


Several pre-treatment factors have been described that may indicate success with PDE5i therapy. The presence of an upper motor neuron lesion up to T12 suggests a successful response, as well as requirement for a lower dosage of medication (62,68-71). Additionally, the presence of residual erections after injury or an incomplete SCI (ASI-A vs. ASIB-D) also improve the chance of PDE5i treatment success (59,67,68,71).
Sildenafil (Viagra) was the first oral phosphodiesterase type 5 (PDE5) inhibitor approved by the FDA in the United States for the treatment of erectile dysfunction (it is not approved for women). Sildenafil inhibits PDE5, which is an enzyme that destroys cGMP. By inhibiting the destruction of cGMP by PDE5, sildenafil allows cGMP to accumulate. The cGMP in turn prolongs relaxation of the smooth muscle of the corpora cavernosa. Relaxation of the corpora cavernosa smooth muscle allows blood to flow into the penis resulting in increased engorgement of the penis. In short, sildenafil increases blood flow into the penis and decreases blood flow out of the penis.
In some cases, nocturnal penile tumescence testing is performed to find out whether the man has erections while asleep. Healthy men usually have about four or five erections throughout the night. The man applies a device to the penis called a Rigiscan before going to bed at night, and the device can determine whether he has had erections. (If a man is able to have normal erections at night, this suggests a psychological cause for his impotence.)
You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your healthcare providers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
The most common inflatable prosthesis is the three-piece penile prosthesis. It is composed of paired cylinders, which doctors surgically insert inside the penis. Patients can expand the cylinders using pressurized fluid (see figure 3). Tubes connect the cylinders to a fluid reservoir and pump, which doctors also surgically implant. The reservoir is usually in the pelvis. A doctor places the pump in the scrotum. By pressing on the pump, sterile fluid transfers from the reservoir into the cylinders in the penis. An erection is produced primarily by expansion of the width of the penis, however, one model can increase in length a small amount also. Lock-out valves in the tubing prevent the fluid from leaving the cylinder until a release valve is pressed. By pressing the relief valve and gently squeezing the penis, the fluid within the cylinders transfers back into the reservoir.
A duplex ultrasound is a diagnostic technique that uses painless, high frequency sound waves to visualize structures beneath the skin's surface. The principle is similar to the sonar used on submarines. Sound waves are reflected back when they contact relatively dense structures such as fibrous tissue or blood vessel walls. These reflected sound waves can be converted into pictures of the internal structures being studied.
Hello everyone my name is john Scott,i was heartbroken because i had very small penis, not nice to satisfy a woman, i had so many relationship called off because of my situation, i have used so many product which i found online but none could offer me the help i searched for. i saw some few comments about this specialist called Dr Austin and decided to email him on DRaustinenlargementhome

Oral therapy (pills) is the least effective and the most likely to be associated with liver problems, even though this is a small risk. This is related to the first-pass effect of all medications ingested via the digestive system. Once absorbed from the intesting, all food materials must pass through the hepatic (liver) system and be metabolized. As such, the actual delivery to the systemic blood system is low due to the liver metabolism of the testosterone. For this reason, the oral doses are quite high in order to get serum levels higher.


The role of the endothelium in erectile function became clearer with the observation that the phosphodiesterase type 5 (PDE5) inhibitor, sildenafil, enhanced erectile function. Erection occurs with the release of nitric oxide (NO) from the vascular endothelial cells.17 The reduction in endothelial cell production of NO results in the negative impact on the smooth muscles in the corporal bodies and results in less relaxation of the smooth muscle cells with decrease in blood supply and resulting ED. A similar phenomenon is well known to impact the coronary arterial system resulting in CVD.
If you have symptoms of ED, it’s important to check with your doctor before trying any treatments on your own. This is because ED can be a sign of other health problems. For instance, heart disease or high cholesterol could cause ED symptoms. With a diagnosis, your doctor could recommend a number of steps that would likely improve both your heart health and your ED. These steps include lowering your cholesterol, reducing your weight, or taking medications to unclog your blood vessels.
There have been some studies to suggest that a placebo effect that improves ED may work for some men. One study found that men taking an oral placebo pill showed as much improvement in ED symptoms as men who took actual medication to improve ED. Conversely, men who were given therapeutic suggestions to improve ED did not see signs of symptom improvement.
Patient can inject medications directly into the corpora cavernosa to help attain and maintain erections. Medications such as papaverine hydrochloride, phentolamine, and prostaglandin E1 (alprostadil) can be used alone or in combinations to attain erections. All of these medications are vasodilators and work by increasing blood flow into the penis. Prostaglandin E1 (Caverject, Edex) is easier to obtain; however, it is associated with penile pain in some individuals. The use of combinations of two or three of these medications can decrease the risk of having penile pain.
SD in MS can be classified into three categories. Primary SD is due directly due to MS-related neurological deficits, secondary SD is related to physical impairments and symptoms or drugs used for MS treatment, and tertiary SD is due to the psychological, social and cultural problems attributed to MS (38). These classifications are important, and underscore the importance of addressing all the issues leading to SD not just the neurologic impairment.
The inflatable type of device consists of cylinders that are implanted in the corpora cavernosa, a fluid reservoir implanted in the abdomen, and a pump placed in the scrotum. The man squeezes the pump to move fluid into the cylinders and cause them to become rigid. (He reverses the process by squeezing the pump again.) While these devices allow for intermittent erections, they have a slightly higher malfunction rate than the silicon rods.
Erectile problems can happen to men of any age.  There are many factors that contribute to ED including poor health, untreated medical problems, medications and pornography use.  Many men struggle with understanding when they are experiencing situational sexual dysfunction verses when is your erectile issue an ongoing problem that requires medical help.
ED may occur with or without other sexual dysfunction, including decreased libido (decreased interest in sexual activity), orgasmic dysfunction (troubles achieving an orgasm/climax), and ejaculatory dysfunction (problems with the fluid released during sex, including lack of ejaculation [anejaculation], small volume ejaculate, ejaculation that occurs too quickly [premature ejaculation], ejaculate that goes backward into the bladder [retrograde ejaculation] and pain with ejaculation).
Erections are more complicated than you think. Your brain, nerves, heart, blood vessels, and a whole lot of hormones have to work together perfectly or nothing happens. It’s a lot to ask, and sometimes things break down. And while ED happens to most guys at some point in their lives, erectile dysfunction isn’t something you can just ignore and hope it goes away.
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Several medications can interfere with the chemical processing of PDE5i medications by the liver. These can include ketoconazole (an antifungal medication known by the brand name Nizoral), erythromycin (an antibiotic), and cimetidine (also known as Tagamet, for reducing stomach acid). A lower dose of PDE5i medications should be used if one is taking any of these medications.
Suppositories “were developed so men wouldn’t have to use needles,” Bivalacqua says. They contain the drug alprostadil (also known as prostaglandin E1) and are sold under the brand name Muse. If they are going to work, it takes about five to 10 minutes. However, Muse produces erections in only 30 to 40 percent of patients, usually those with mild ED, because some of the drug is absorbed systemically and diverted from its function of opening penile arteries to allow more blood to flow in. The out-of-pocket cost is around $20 to $30 per suppository.
Since sexual arousal is a complex process involving hormones, emotions, nerves, muscles, blood vessels and the brain, a malfunction in any of these can lead to ED. Stress, exhaustion and psychological issues can also contribute, and anxiety over maintaining an erection can actually make it harder to attain. In short, any condition that inhibits blood flow to the penis can lead to ED.
For many men, stopping smoking is an erectile dysfunction remedy, particularly when ED is the result of vascular disease, which occurs when blood supply to the penis becomes restricted because of blockage or narrowing of the arteries. Smoking and even smokeless tobacco can also cause the narrowing of important blood vessels and have the same negative impact. 

Sildenafil has been previously suggested as a treatment option for ED in men with epilepsy (77,78). However, Matos et al. warned that PDE5i are potentially pro-convulsant and should be used with great caution in men with epilepsy (79). Animal studies in rat and mice overwhelmingly suggest PDE5i can reduce seizure threshold. In human trials, seizures were rare but reported. PDE5i exerted their proconvulsive effect by lower seizure threshold possibly by worsening sleep or obstructive sleep apnea, causing cardiovascular changes, or leading to EEG changes specifically with tadalafil use.
Some injectable formulations need to be refrigerated — yet another reason many men steer away from the needle option. Among ED treatments, injections are also the most common cause of extended erections — rigidity lasting more than four hours, also called priapism — which afflict about 3 to 7 percent of users, Kohler says. That condition, while easily treated with an adrenaline shot, requires urgent attention at a clinic or hospital. The cost of this ED treatment is $2 to $5 per injection.
Men with a rare heart condition known as long QT syndrome should not take vardenafil since this may lead to abnormal heart rhythms. The QT interval is the time it takes for the heart's muscle to recover after it has contracted and is measured on an electrocardiogram (EKG). In addition, vardenafil is not recommended for men taking medications that can affect the QT interval such as quinidine, procainamide, amiodarone, and sotalol.
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The most common inflatable prosthesis is the three-piece penile prosthesis. It is composed of paired cylinders, which doctors surgically insert inside the penis. Patients can expand the cylinders using pressurized fluid (see figure 3). Tubes connect the cylinders to a fluid reservoir and pump, which doctors also surgically implant. The reservoir is usually in the pelvis. A doctor places the pump in the scrotum. By pressing on the pump, sterile fluid transfers from the reservoir into the cylinders in the penis. An erection is produced primarily by expansion of the width of the penis, however, one model can increase in length a small amount also. Lock-out valves in the tubing prevent the fluid from leaving the cylinder until a release valve is pressed. By pressing the relief valve and gently squeezing the penis, the fluid within the cylinders transfers back into the reservoir.

Injection therapy: The modern age of such drug therapies began in 1993 when the injection of papaverine (Pavabid), an alpha-blocker that produces vasodilatation (widening of the blood vessels), was shown to produce erections when injected directly into the penis. Soon afterward, other vasodilators, such as prostaglandin E1 (PGE 1) monotherapy (Caverject, Edex), PGE1 and phentolamine (Regitine), and Trimix (papaverine, phentolamine and prostaglandin E1), were demonstrated to be effective. The benefit of combination therapy is the decreased dosing of each with less side effects. Most important is the reduction of the prostaglandin PGE1 dosing, which is associated to the localized pain.
You can also consider using a cock ring or penis ring if you are able to get an erection but have trouble maintaining it.  Cock rings work by trapping the blood inside your penis so it remains harder for longer.  You can purchase one in a sex store or online for about $5 and you put in on over your penis and testicles when you are half hard and keep it on until you are finished with sex.  It’s a great cheap fix for erectile issues.
Commercials for drugs to improve “low T,” or testosterone, the male hormone, are now vying for airtime, but they address desire, not performance. "Male hormone is not an approved treatment for erectile dysfunction," notes Bennett. "It may be used to increase desire in men who have low testosterone, but it doesn’t improve blood flow to an erection." A doctor can do a blood test to check you for low testosterone, but it is a rare cause of ED. Hormone therapy with injections, patches, or gels applied to the skin may improve mood and sex drive, but it likely won’t fix any mechanical issues. Also, testosterone drugs should not be used by men with prostate cancer. Side effects include acne, breast enlargement, prostate enlargement, and fluid retention.
Intraurethral therapy (Medicated Urethral System for Erections, or MUSE): Alprostadil (PGE1) has been formulated into a small suppository that can be inserted into the urethra (the canal through which urine and semen are excreted). The suppository is preloaded into a small applicator and by placing the applicator into the tip of the penis and compressing the button at the other end of the applicator and wiggling the applicator, the suppository is released into the urethra. Gentle rubbing/massaging of the penis will cause the suppository to dissolve and the medication is absorbed through the urethra and passes into the penis where it stimulates the relaxation of the muscle in the arteries and increases blood flow to the penis. It takes 15 to 30 minutes for this to occur. Success rates in the clinical studies were noted to be about 65%, however lower rates were noted when it started being used in the real world setting. This drug may be effective in men with vascular disease, diabetes, and following prostate surgery. This is a useful alternative for men who do not want to use self-injections or for men in whom oral medications have failed. Few side effects occur. The most common side effect is penile pain, which can vary from minor to uncomfortable. MUSE use has been associated with lowering of the blood pressure and thus it is recommended that the first time using the MUSE be in the physician's office so that you can be monitored. One cannot use lubricants of any type to help with the insertion of the applicator thus to make it easier to insert you should urinate immediately before using the MUSE system as this will lubricate the urethra. A temporary tourniquet is often helpful in allowing the medication to stay in the erectile tissue a little longer and seems to give a somewhat better response.

In prescribing sildenafil, a doctor considers the age, general health status, and other medication(s) the patient is taking. The usual starting dose for most men is 50 mg, however, the doctor may increase or decrease the dose depending on side effects and effectiveness. The maximum recommended dose is 100 mg every 24 hours. However, many men will need 100 mg of sildenafil for optimal effectiveness, and some doctors are recommending 100 mg as the starting dose.

ED can also occur as a side effect of some medications, for example some high blood pressure medications such as certain diuretics and beta blockers. If you think that a medication you are taking has a negative effect on your sex life, you should discuss this with your prescribing doctor. Your doctor may be able to recommend an alternative treatment.


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early 15c., "physical weakness," also "poverty," from Middle French impotence "weakness," from Latin impotentia "lack of control or power," from impotentem (nominative impotens); see impotent. In reference to a want of (male) sexual potency, from c.1500. The figurative senses of the word in Latin were "violence, fury, unbridled passion." Related: Impotency.
Something else to consider is your porn use.  If you are masturbating to very stimulating porn on a regular basis then it might be difficult to get as aroused in the bedroom with your partner.  Watching video pornography is very stimulating and often men have difficulty creating that same level of arousal or stimulation with their partners.  Consider masturbating without technology as visual images in your head are less stimulating then watching something live. Try this for two weeks and see if your erection quality improves.
Alprostadil is an FDA-approved erectile dysfunction drug that can be injected directly into the penis to trigger an automatic erection. "Penile injection is the most effective type of ED treatment for men who can't take oral treatment," says Nelson Bennett, MD, a urologist at the Lahey Clinic in Burlington, Mass. In fact, it has an 85 percent success rate. Possible side effects include a burning sensation and priapism, an erection that lasts more than four hours and requires medical treatment.
Cosgrove et al reported a higher rate of sexual dysfunction in veterans with posttraumatic stress disorder (PTSD) than in veterans who did not develop this problem. [42] The domains on the International Index of Erectile Function (IIEF) questionnaire that demonstrated the most change included overall sexual satisfaction and erectile function. [43, 44] Men with PTSD should be evaluated and treated if they have sexual dysfunction.
All NOS subtypes produce NO, but each may play a different biologic role in various tissues. nNOS and eNOS are considered constitutive forms because they share biochemical features: They are calcium-dependent, they require calmodulin and reduced nicotinamide adenine dinucleotide phosphate for catalytic activity, and they are competitively inhibited by arginine derivatives. nNOS is involved in the regulation of neurotransmission, and eNOS is involved in the regulation of blood flow.
For best results, men with ED take these pills about an hour or two before having sex. The drugs require normal nerve function to the penis. PDE5 inhibitors improve on normal erectile responses helping blood flow into the penis. Use these drugs as directed. About 7 out of 10 men do well and have better erections. Response rates are lower for Diabetics and cancer patients.
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