Browsing Posts in Erectile Dysfunction

Intraurethral Therapy

The effectiveness of injectable intracorporal forms of therapy over the last 15 years has encouraged the development of more acceptable and appealing delivery systems for these medications. Some men are opposed to the use of a needle placed in the penis to deliver medication, and this has contributed to the high dropout rate for patients who are prescribed intracorporal injections. Medicated urethral system for erections (MUSE) was introduced in early 1997 as an alternative method of delivering PGE1 to the erectile bodies. After urination, an applicator is placed about 1.5 in. into the urethra. After pushing a button, a pellet of PGE1 approximately the size of a grain of rice is deposited in the urinary tract. Absorption occurs in the corpus spongiosum; through venous communications between the corpus spongiosum and the corpora cavernosa, some of this medication gains entry into the erectile bodies. PGE1 then acts on the adenosine triphosphate system to decrease intracellular calcium and relax the penile smooth-muscle cells. Because of this direct action, intact innervation of the erectile mechanism is not necessary. To enhance delivery of this compound into the erectile body, a constricting band (ACTIS) at the base of the penis should be used. Penile, urethral, testicular, and perineal pain may be seen in up to 50% of the patients. Although hypotension and syncope rarely occur, this medication should be nonetheless applied while sitting to avoid falling. The effectiveness of MUSE at providing an erection that can be used for intercourse is in the range of 30% to 40%.

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A MUSE-induced erection is rarely rigid but may be described as a swollen penis that does not buckle when it is used for vaginal penetration with some assistance. MUSE may be useful in some patients following radical prostatectomy, who have not responded to type V phosphodiesterase inhibitors. This medication has also been used in conjunction with oral medication to provide additional support when adequate rigidity is not provided by one treatment alone. In addition, the use of MUSE with a previously placed penile implant has provided some increase in girth and length as engorgement of the glans penis and corpus spongiosum readily occurs with its use. Such increases in size, however, have only been in the range of 1 cm and each application costs approximately $20.

Vacuum Erection Devices

Vacuum erection therapy as a treatment for impotence had been used sporadically with homemade devices until the pioneering work of Geddings Osbon, who obtained Food and Drug Administration (FDA) approval for such a device in 1982. Over the next decade, primarily through the efforts of the Osbon Corporation, these constriction devices became a definite player in the treatment of erectile failure. Initial reports of Witherington and Nadig et al. have claimed success and satisfaction in over 90% of the patients using these devices. In a series of 45 patients of Gilbert and Gingell, 84% reported adequate rigidity, but only 27% were satisfied with the device. This experience was reinforced by Earle et al., who reported a satisfaction rate as low as 9%. The key to patient satisfaction with this treatment is the careful instruction of patients and adequate practice in removing the ring from the cylinder before the seal at the penoscrotal junction is broken to allow maintenance of penile rigidity. Common reported side effects include pain on ejaculation, inability to ejaculate, petechiae or bruising of the penis, and numbness during erection. Partners will frequently relate that the resulting erection is unpleasantly cold. The recommended maximum time period that the constriction ring may remain in place is 30 minutes. Even if this device is left on for longer periods—i.e., if the patient falls asleep with the ring in place—blood flow will continue at a very slow rate, but this volume is usually adequate to prevent necrosis of the penis.

The major advantage of the vacuum device is its relative margin of safety when compared to pharmacologic or surgical treatments of erectile dysfunction. Serious problems such as skin necrosis have only occurred with misuse. The relative safety of vacuum devices has encouraged the FDA to remove them from the list of prescribed devices, and they are now sold over the counter. Older patients in a stable marital relationship, who have failed in restoring erections with the use of medications, tend to choose the vacuum device when they are not inclined toward the surgical placement of a penile prosthesis.

Penile Prostheses

Effective penile prostheses were first introduced to the impotence marketplace in the early 1970s. Prior to this, there was no effective treatment for the unfortunate patient who had significant erectile dysfunction. Since less aggressive forms of treatment such as vacuum devices and medications were introduced, the market share of penile prostheses has become smaller; however, they do provide a predictable and reliable means of restoring erectile function, and the satisfaction rate among patients and partners who use penile prostheses has been the highest of all treatment modalities for erectile dysfunction, in the level of 85%. The small percentage of patients who report disappointment with this modality typically have unrealistic expectations regarding penile size, sensitivity, and arousal. Malfunctions may occur due to either wearing of parts or breakdown of the coverings of the erectile body or the skin of the scrotum, with the resulting extrusion of prosthetic parts. A recent multicenter study of 372 patients with the AMS-700 CX (American Medical Systems) prosthesis shows a mechanical reliability of:

  • 92% at 3 years,
  • 85% at 5 years,
  • 71% at 10 years.

Patient selection, proper sizing, placement by an experienced surgeon, and prompt attention to problems that may develop are of paramount importance in assuring success and satisfaction. Silicone and polyurethane used in the construction of these devices have not had detrimental effects on the body as shown in studies of patients with breast implants. Despite this, the FDA mandated that AMS and the Mentor Corporation conduct prospective clinical trials to document the safety, efficacy, and patient satisfaction of these devices. These studies have provided no evidence related to the presence of these foreign bodies, which would be considered detrimental to the patient’s health. In the past, while infection of a penile prosthesis has been uncommon—in the range of 1% to 3%—when it occurs, however, it is a catastrophic occurrence that necessitates immediate removal of the device. Recent experience with salvage procedures in which the infected prosthesis is removed completely, the wound thoroughly cleansed, and a new device placed at the same procedure, has shown successful outcomes in about 82% of the patients with up to eight years of followup.

An additional advantage of these devices is that they can be satisfactorily placed in patients following external beam therapy or brachytherapy for prostate cancer. They are also sometimes placed in patients following radical prostatectomy in conjunction with an artificial urinary sphincter, which is used to control incontinence if it develops following this procedure.

Note that I said “we” because the basis of this Step by Step Therapy is to empower you to treat your ED condition with my guided help. Available treatments are:

1. My Step by Step Therapy including Lifestyle & Nutrition.
2. Visiting a Doctor or sex therapist.
3. Specialist medical help for” plumbing issues”.
4. Pharmaceutical interventions like Viagra, Cialis, Levitra et al.
5. Other Props:
a. Invasive Devices and Mechanical Interventions
b. Alternative Treatments: Viagra Australia Pharmacy

The treatment will depend on the source(s) of ED you will identify in Step 3. You will see that some of the Sources of ED come from medical conditions (what I like to call plumbing issues) that need an invasive procedure or specialist help. They have to be fixed separately and I will summarise what specialist help to seek in Step 4.

Assuming there are no plumbing issues that need fixing, there is no substitute to My Step by Step Therapy (i.e. Behavioural Therapy and Psychotherapy) and my advice on Lifestyle & Nutrition. This is the basis of my Steps 5-11 that follow. For some of the sources, Pharmaceuticals may also be relevant and at the end of this Step I provide all the information you need on Approved Pharmaceuticals so that you can make an informed decision should you require to access them.

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I strongly believe that through guided self help you will achieve your goal quicker than visiting a Doctor or good sex therapist which involves substantial cost and time to achieve the same result. Finally, absorbing my Therapy will give you the powerful knowledge for lifelong management of your ED condition. Not to mention the development of your sexual persona or prowess. Let’s repeat how my Step by Step Therapy works in a bit more detail:

– In the next Step 3, you will identify the Source(s) of your ED condition. You will also identify what I call any plumbing issues that need to be fixed and they have to be addressed with the relevant specialist first.

– Step 4 includes my algorithm to advise the primary and secondary targeted Therapy Steps. The primary Therapy is based on the identified source(s) of your ED condition from Step 3. The secondary recommended Steps will get you to absorb the remaining Steps because completing all the Steps will empower you for lifelong management of your ED condition and develop your sexual prowess. And, as you probably guessed, knowledge is power.

– As knowledge is power, you will find out all about erections and how they happen in Step 5.

– Steps 6-11 will provide all the Therapy you need and will develop your sexual persona and prowess whilst you are having fun treating your ED condition. What I mean by sexual persona and prowess is that there is a lot more to sex than just the Therapy resources that help to get your Dick erect. The Therapy treatment set out in Steps 6-11 is as follows:

Step 6: Lifestyle & Nutrition. This is relevant for everyone.
Step 7 will prepare you for the following exercises/workouts.
Step 8 will get you to bring The Correct Mindset to sex encounters.
Step 9 will get you Get to Know your Body.
Step 10 will get you to discover the Situation Condition Factors that uniquely work for you and express your sexual needs.

And if and when you have a Partner, Step 11 will get you together.

Sounds daunting? Well, we are talking about regaining control over one of life’s most beautiful experiences here and there is absolutely no reason why with a bit of application you shouldn’t continue to enjoy sex.

Getting back to what else is available, there have been great strides in the development of pharmaceuticals and, if they are right for you, I will provide you with all the information you need to make an informed choice. One recent development showing some promise but needing a lot more research is low-intensity shock wave therapy (LI-ESWT). This therapy uses sound waves normally used for breaking up kidney stones. These low intensity sound waves have been shown to improve blood flow to the heart and increase blood vessel growth. Because of this, researchers believed that the waves may help to increase the blood flow to the penis in patients with ED. It is early days and more work is needed to show how it improves blood flow and in what types of ED it might work for.

Finally, Other Props such as Invasive Devices and Mechanical Interventions are props best relegated to extreme situations and Alternative Treatments do not stand the test of proof that they work. As we have to cover all the bases let’s now review them. I am confident they will confirm my therapy as invaluable. If you want to Fast Track you can skip to the Map Fix: Other Props Conclusion later on in this Step.

Erectile dysfunction is a word that defines the inability of the males at the time of sexual association when they find themselves difficult to hold erection after having sexual stimulation. It is the situation which is different from other sexual incapability which also influences adversely the sexual relationship. Sometimes erectile dysfunction trouble leads to the broken relationship of the couples. It occurs due to many reasons that have made it most common ailment ever in the world but with the medication of kamagra Australia, a generic form of Viagra it is now possible to experience pleasurable and satisfying sexual life.

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Vasoactive Medications

The penis is composed of two twin erectile chambers, the corpora cavernosa, which are surrounded by an elastic membrane called the tunica albuginea that stretches with an erection until the cavities become three times larger in size as this covering reaches its limit of stretch. The components of these two cavities are numerous cul-de-sacs, or endothelial-lined spaces surrounded by smooth muscle. For further information on the anatomy and physiology of the penis, see the chapters in Part I of this volume.

Agents that cause relaxation of this smooth muscle are very effective in allowing blood to flow into the penis, expanding the sinusoids and compressing subtunical venules to hold blood in the penis and to generate an erection. Conversely, agents that cause contraction of the smooth muscle are effective in reducing a prolonged erection (priapism). In recent years, a number of agents have emerged in various forms that affect the smooth muscle surrounding the sinusoids. As with many muscle cells elsewhere in the body, when the calcium content of the cell is lowered, the penile smooth muscle will relax. There are various transmitter substances, which, when released from nerve endings, will diffuse across the intercellular space to stimulate the enzyme systems within these smooth-muscle cells, eventually resulting in the loss of calcium from the cell and producing muscle relaxation. Nitric oxide has recently been discovered as one of the major transmitters that affects this action in penile smooth-muscle cells.

Oral Medications

The recent introduction of sildenafil citrate new zealand (Viagra) and subsequently vardenafil (Levitra) and tadalafil (Cialis) has revolutionized the treatment of erectile dysfunction. These compounds are type V phosphodiesterase inhibitors, and under the influence of sexual stimulation, have been found to be beneficial in enhancing and prolonging erections. When nitric oxide is released from nerve terminals, it diffuses across the interspace to the penile smooth-muscle cell, where it influences the guanyl cyclase enzyme system. This converts GTP to cyclic GMP, which results in decreased intracellular calcium concentration and smooth-muscle relaxation. Type V phosphodiesterase is the enzyme that degrades cyclic GMP to its metabolite. When this enzyme is inhibited by these compounds, cyclic GMP levels stay high, calcium stays out of the cell, and the smooth muscle stays relaxed.

For the three available type V phosphodiesterase inhibitors to work effectively, sexual stimulation is necessary and the penile nerves need to be intact in order to release nitric oxide. Absorption of these agents in the gastrointestinal tract is relatively rapid, and effects are sometimes seen in as short a time as 20 minutes after ingestion. Peak absorption occurs at 0.8 hours, and the drug’s half-life is between four and five hours for sildenafil and vardenafil. The window of opportunity for sexual activity with both of these agents is usually even beyond the five-hour half-life noted. By 24 hours, they are completely gone from the body. Tadalafil has a longer half-life of 17 hours and may be effective for up to 36 hours after ingestion. Overall, the success rate with the type V phosphodiesterase inhibitors has been 80% in psychogenic impotence and about 60% in organic erectile dysfunction.

Generally, the two groups of patients who do not respond as well to phosphodiesterase inhibitors are those with diabetes mellitus and those who have had radical prostatectomy. In clinical trials, the response in the latter group was 43%.

– If bilateral nerve-sparing prostatectomy has been performed, the response rate with sildenafil in patients who were previously potent is 72%.

– If only one nerve was spared during the prostate ablative procedure, the response rate with sildenafil falls to the range of 50%.

– If both nerves were removed during the prostatectomy, only a 15% positive response is seen.

These drugs have also been effective to some degree in patients whose erections have been diminished following brachytherapy or external beam radiation.

Side effects of these medications include headache, flushing, and dyspepsia. These side effects are uncommon and usually very well tolerated. They also tend to diminish with time as patients continue to take the medication. There have been a number of deaths reported in conjunction with the use of these drugs, but more recent studies have shown that they have no significant effect on the heart. A study of patients with cardiac disease measured cardiac dynamics before and after ingestion of sildenafil and found no difference— i.e., no effect of this medication on the heart muscle and function.

It should be noted, however, that there has been some synergy of type V phosphodiesterase inhibitors with nitrates in lowering the blood pressure, and for this reason, the American College of Cardiology has recommended that nitrates and these medications not be used simultaneously. In addition, phosphodiesterase inhibitors should be used with extreme caution in patients with congestive heart failure, myocardial disease, or in those on a complex antihypertensive regimen. In one set of clinical trials, no priapism was seen in patients using sildenafil; this was, however, a controlled group, and the medications that patients were taking in addition to the trial drug were limited. Now that these compounds are readily available, patients are using cocktails or mixtures with other treatments that enhance erections. In addition, they may be using these medications combined with other medicines that predispose to priapism, such as thioridazine (Mellaril), trazodone, or the phenothiazine compounds. Under these circumstances, prolonged, painful, and unwanted erections have been seen. The advent of sildenafil in 1998 has broadened the awareness of erectile dysfunction as a problem related to various disease processes. This awareness has brought many new patients into the clinic for treatment. Before the introduction of sildenafil, yohimbine (Yocon) was the most commonly prescribed treatment for erectile dysfunction. Most studies, however, have failed to demonstrate any significant benefit of yohimbine over placebo in the treatment of poor erections. A number of other oral preparations are now under study and in clinical trials for the treatment of erectile dysfunction. Intracorporal Injections – viagra sydney australia.

At the American Urological Association meeting in Las Vegas in 1983, Dr. Giles Brindley, a British pharmacologist, dramatically and memorably illustrated the effectiveness of intracorporal injections of papaverine by demonstrating to the audience his own erection induced by this medication. Following this graphic display, the use of this agent and other intracorporal injections rapidly gained popularity. Now, papaverine, phentolamine, and prostaglandin E1 (PGE1) (Caverject) (EDEX) alone or in combination are used effectively in generating an erection with up to 80% success. Both papaverine and PGE1 act directly on penile smooth-muscle cells via the cyclic AMP pathway to cause smooth-muscle relaxation by decreasing intracellular calcium. When injected into one portion of the penis, this effect is rapidly spread throughout the entire length of both corporal bodies by gap junction or cell-to-cell transmission. Phentolamine is a selective α-adrenergic adrenoceptor blocker that inhibits sympathomimetic amines such as norepinephrine and blocks contraction of penile smooth-muscle cells. It acts synergistically with papaverine and PGE1, but has not been practically effective by itself in generating an erection by intracorporal injection.

Almost 90% of patients following nerve-sparing radical prostatectomy will respond to intracavernosal PGE1, in contrast to only 66% of patients who have had non–nerve-sparing procedures. In addition, nearly 25% of the nervesparing prostatectomy patients who have responded did so at a low dose of PGE1, in contrast to those with non–nerve-sparing procedures, who required high doses of the same medication.

PGE1 may result in pain in some patients, and this is particularly distressing in cases of neurapraxia, which may be seen following prostatectomy. Montorsi et al. have shown that instituting intracavernous injections of PGE1 very shortly (two months) after performing radical prostatectomy will result in a return of spontaneous erections without medication at one year in 67% of patients. In a controlled group that was not treated with intracavernous injections of PGE1, only 20% of patients noted the spontaneous return of erections by that time interval. The exact mechanism for this is unknown, but it may be related to the prevention of a buildup of transforming growth factor in the low oxygen states associated with reduced penile blood flow. This leads to the occurrence of fibrosis in penile muscles. In the aging patient, it is well known that the more erections are used, the better they tend to work. Abstinence from sexual activity for a period of time as is necessitated by a surgical procedure and the subsequent recovery period is certainly contributory to sexual dysfunction in this regard. When approaching patients who are impotent before nerve-sparing prostatectomy, the surgeon should be aware that pharmacotherapy afterward will be more effective if the nerves have been spared. Priapism or prolonged painful erection has been seen about 7% of the time with papaverine and phentolamine and about 1% of the time using PGE1. Such erections are usually easily reversed using dilute sympathomimetic amine solutions such as epinephrine or phenylephrine injected intracorporally. The incidence of development of corporal fibrosis (i.e., penile plaques) varies from 1.9% to 16% in patients using a pharmacologic erection program. This can be minimized by less frequent use (less than twice a week), varying the site of injection, and compressing the site of injection for a period of about 30 seconds to prevent internal bleeding. Long-term follow-up studies with patients on intracorporal injections show a relatively high dropout rate in the range of 70% over three years. Reasons for discontinuation of therapy include a desire for a permanent treatment alternative, fear of injections with needles, poor response, lack of a suitable partner, comorbid health conditions precluding comfortable positions for intercourse, and loss of sexual spontaneity.

Ejaculation

As men age or undergo surgical procedures that result in the loss of erection, ejaculation is usually preserved. This function consists of two components: “emission,” or the placement of semen in the prostatic urethra, and “ejaculation,” or the forceful expulsion of semen to the urethra and out the urethral meatus in a rhythmic fashion. During emission, the bladder neck or internal sphincter closes, and the prostatic muscles contract with the resultant expressing of semen or prostatic fluid into the prostatic urethra. During the ejaculatory phase, the rhythmic contraction of the vas deferens propels sperm to the prostatic urethra to mix with the seminal fluid and the rhythmic contraction of the bulbocavernosus and ischiocavernosus muscles propels the semen in spurts along the urethra and out the meatus.

With radical prostatectomy, the emission phase is lost, since there is no prostate to expel semen into the urethra and the vas deferens has been ligated. The ejaculatory phase, however, may be preserved and patients following radical prostatectomy will frequently reach climax – female viagra canada with adequate sexual stimulation. There is a feeling of pleasure and relief with the rhythmic contractions of the bulbous muscles but no elimination of fluid.

Other forms of treatment for prostate cancer, such as external beam therapy and brachytherapy do not significantly affect ejaculation per se. Premature ejaculation does not seem to be age dependent because it appears to be equally prevalent in younger and older men. Less direct, tactile stimulation prior to penetration, the use of distracting maneuvers such as the squeeze technique , and biofeedback exercises have all been used in the past with modest success. Recently, it has been found that the selective serotonin reuptake inhibitors (SSRIs) such as Paxil (paroxetine) 20 mg, given two to four hours prior to ejaculation, have been effective in 80% of the cases in prolonging ejaculatory latency.

Counseling

As mentioned previously, prostate cancer is a disease of aging and is almost unheard of before the age of 40. As men reach this milestone, erections become less reliable. It should be noted, however, that each man’s particular environmental circumstance plays a major role in whether erection can be satisfactorily achieved. For example, if the patient is rested, erections will be easier to produce than when he is tired. Similarly, if the patient is distracted by pain, career or financial worries, or other such concerns, he will be unable to focus on sexual activity. This is in contrast to a man’s younger years—i.e., the teens and twenties—during which concentration is not very necessary to achieve an erection. In young men, only slight stimulation is necessary to achieve a complete erection rapidly. Also, as one ages, the importance of a partner’s participation becomes greater, and with the partner’s help, an erection will be more readily achieved. In addition to these environmental influences, comorbid features such as smoking, obesity, diabetes mellitus, hypertension, and hyper lipidemia that may further contribute to erectile dysfunction should be discussed and appropriate treatment and a change in lifestyle advised. Even though the treatments of prostate cancer may have a detrimental effect on erections, such counseling may be very beneficial in improving marginal erectile function. To fight erectile dysfunction buy Kamagra Australia.

Male Hormone Replacement

Male hormone, testosterone, is below the normal level in 7% of men below age 60 and 20% of men above age 60. The gradual decline of testosterone levels with age, termed “andropause,” occurs at about 1% per year. If this circumstance occurs, sex drive may be low, erections may be problematic, and energy level or enthusiasm for the activities of life may be reduced. Replacement of the male hormone may improve each of these three problems. As previously discussed, one treatment of advanced prostate cancer is the reduction/removal of testosterone. To date, such a study has never been done, but by inference, testosterone in the normal range—or even in the supraphysiologic range, which may occur with intramuscular replacement—may stimulate the growth of prostate cancer. Hence, it is recommended that patients with known prostate cancer not be given testosterone replacement as a treatment for sexual dysfunction unless the cancer is considered cured and it is believed that the individual patients in question would comply completely with follow-up evaluations.