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Men with psychogenic erectile dysfunction may relate the onset of problems to a "stressor," such as failed relationship.

Your doctor may suggest a test to determine if you have erections during sleep, which may suggest that there may be a psychological cause of the erectile dysfunction.

Erectile dysfunction may be a symptom of underlying medical conditions, which if not detected may cause further medical problems. A prior history of cigarette smoking, heart attacks, strokes, and poor circulation in the extremities (for example, intermittent claudication or cramping in your leg[s] when you walk) suggest atherosclerosis as the cause of the erectile dysfunction. Loss of sexual desire and drive, lack of sexual fantasies, gynecomastia (enlargement of breasts), and diminished facial hair suggest low testosterone levels. A prior history of pelvic surgery or radiation and trauma to the penis/pelvis/perineum can cause problems with the nerves and blood vessels.

Symptoms of intermittent claudication of the lower extremities with exercise may suggest a vascular problem as a cause of the erectile dysfunction. Is the patient taking medications that can contribute to erectile dysfunction (see causes above), including prescribed, over-the-counter, or recreational drugs? It is important to discuss your prescribed medications, as well as over-the-counter medications and drugs of abuse such as opiates, alcohol, etc.

The physical examination can reveal clues for physical

causes

The doctor will examine the testes to make sure they are in the proper location in the scrotum and are normal in size. Small testicles, lack of facial hair, and enlarged breasts (gynecomastia) can point to hormonal problems such as hypogonadism with low testosterone levels.

A health care provider may check pulses in your groin and feet to determine if there is a suggestion of hardening of the arteries that could also affect the arteries to the penis. The lab testing obtained for the evaluation of erectile dysfunction may vary with the information obtained on the health history, physical examination, and recent lab testing.

A testosterone level is not necessary in all men; however, a physician will order labs to determine a patient's testosterone level if other signs and symptoms of hypogonadism (low testosterone) such as decreased libido, loss of body hair, muscle loss, breast enlargement, osteoporosis, infertility, and decreased penile/testicular size are present. A doctor may ask for the following laboratory tests in the evaluation of erectile dysfunction: Complete blood counts Urinalysis : A high level of sugar (glucose) in the urine may be a sign of diabetes mellitus, and high protein in the urine may suggest kidney damage, which can cause erectile troubles.

Lipid profile : High levels of LDL cholesterol (bad cholesterol) in the blood can cause atherosclerosis.

Blood glucose levels : Abnormally high blood glucose (sugar) levels may be a sign of diabetes mellitus.

Blood hemoglobin A1C : Abnormally high levels of blood hemoglobin A1C in patients with diabetes mellitus indicate that there is poor control of blood glucose levels.

Serum creatinine : An abnormal serum creatinine, a chemical that reflects kidney function, may be the result of kidney damage. Liver enzymes and liver function tests : Liver disease (cirrhosis) can cause low testosterone. Thus, a physician may need to test some men for liver disease.

Total testosterone levels : Health care professionals should obtain a patient's blood samples for total testosterone levels in the early morning (before 8 a.m.) because the testosterone levels go up and down throughout the day.

If you have a low testosterone level, a health care professional should check it again to confirm that it is truly low. In some men, a specialized test measuring the active form of testosterone (free or bioavailable testosterone) may be recommended. Other hormone levels : Measurement of other hormones beside testosterone (luteinizing hormone [LH], prolactin level, and cortisol level) may provide clues to other underlying causes of testosterone deficiency and erectile problems, such as pituitary disease or adrenal gland abnormalities. Doctors may check thyroid levels in some individuals as both hypothyroidism (low thyroid function) and hyperthyroidism (overactive thyroid function) can contribute to erectile dysfunction. PSA levels : PSA (prostate specific antigen) blood levels and sildenafil overnight prostate examination to exclude prostate cancer is important before starting testosterone treatment since testosterone can aggravate prostate cancer. Other blood tests : Evaluation for hemochromatosis, lupus, scleroderma, zinc deficiency, sickle cell anemia, and cancers (leukemia, colon cancer) are some of the other potential tests that a physician may perform based on each individual's health history and symptoms. Health care professionals do not routinely obtain imaging tests in the evaluation of erectile dysfunction. Ultrasound with Doppler imaging (ultrasound plus evaluation of blood flow in the arteries and veins) can provide additional information about blood flow of the penis and may help in the evaluation of patients prior to surgical intervention.

This study is typically performed after the injection of a chemical that causes the arteries to open up, a vasodilator (prostaglandin E1), into the corpora cavernosa in order to cause dilation of blood vessels and promote blood flow into the penis. The rate of blood flow into the penis can be measured along with an evaluation of problems with compression of the veins.

Rarely, a doctor may perform an angiogram (injecting a dye into the arteries that supply the penis and taking X-rays to look for areas of narrowing of the arteries) in cases in which possible vascular surgery could be beneficial. Monitoring erections that occur during sleep (nocturnal penile tumescence) can help you and your doctor to understand if the erectile dysfunction is due to psychological or physical causes. The nocturnal penile tumescence test is a study to evaluate erections at night. Normally men have three to five erections per eight hours of sleep.

The test can be performed at home or in a sleep lab.

The most accurate way to perform the test involves a special device that is connected to two rings.

The rings are placed around the penis, one at the tip of the penis and the other at the bottom (base) of the penis.

The device records how many erections occur, how long they last, and how rigid they are. The test is limited in that it does not assess the ability to penetrate.

If there seems to be a psychological cause contributing to your erectile dysfunction, the doctor may ask the patient questions to help determine stressor, events, and relationship issues that may be causing your erectile

troubles

Erectile dysfunction is a common concern among aging males.

Not only does ED affect quality of life, but it is also linked to cardiovascular disease, hypertension, diabetes, and overall health. Currently, there are three categories of ED treatments. Oral medications such as phosphodiesterase type-5 (PDE-5) inhibitors (sildenafil, vardenafil, tadalafil, and avanafil) have comparable efficacy. Intracavernosal injections (alprostadil, phentolamine, papaverine, and/or atropine) or intraurethral suppositories (alprostadil) are alternatives in patients who are non-responders to oral medications or have side effects.

Penile implants are the most invasive treatment but provide durable results and the highest satisfaction rates of all of treatments.

Given the prevalence of ED, there is significant incentive to find more effective and less invasive treatment options.

Here we review new

and

We also review the use of nutraceuticals, which are not new but have seen explosive growth in recent years (see, “Nutraceuticals for ED at a glance.") New oral agents and pathways. PDE-5 inhibitors remain the cornerstone of oral therapies. Researchers have explored alternative pathways for novel therapeutics (table), although success has been limited. Currently, no novel oral medications are in clinical development.

Prior targets have focused on central pathways (dopaminergic and melanocortin) and peripheral pathways (guanylyl cyclase and Rho-A/Rho kinase), but novel oral therapies directed at these pathways have shown limited efficacy and tolerability.

An overview of the cellular pathways is shown in the figure.

Initially, the use of dopamine agonists for Parkinson’s disease was associated with increased libido. Apomorphine is a dopamine D1 and D2 receptor agonist that was approved for ED in Europe in 2001.

In a phase III double-blind, parallel-arm, crossover study of nearly 900 men with ED, more than 50% of those using apomorphine were able to obtain an erection sufficient for intercourse compared to 33% of men using placebo (BJU Int 2002; 89:409-15). However, the FDA did not approve the drug in the United States because of concerns about hypotension.

Similar medications (ABT-724 and ABT-670) targeted to the D4 receptor have also been studied, but development was stopped after phase II studies. Melanocortin receptor agonists including melanotan II (subcutaneous administration) and bremelanotide (intranasal administration) have been studied for ED. Both formulations improved erectile function in studied men, although they were poorly tolerated in clinical studies. Patients given melanotan II experienced severe emesis, and bremelanotide caused severe hypertension. Further clinical development has been discontinued.

Recently, a landmark study identified a single locus near the SIM1 gene that was associated with viagra buy over the counter risk of ED independent of known risk factors in a large cohort (Proc Natl Acad Sci USA 2018; 115:11018-23). SIM1 encodes transcription factors involved in the leptin-melanocortin pathway and may represent an exciting target for future novel therapies. Soluble guanylyl cyclase is a key component of the nitric oxide (NO) pathway (figure).

In post-prostatectomy patients or diabetics who have severe endothelial dysfunction and cavernous nerve injury, PDE-5 inhibition does not increase endogenous NO levels sufficiently.

In these patients, direct activation of soluble guanylyl cyclase may enhance erections.

In a study of human cavernosal tissue obtained from patients during penile prosthesis implantation, compared to patients undergoing transurethral surgery, a combination of vardenafil and guanylyl cyclase activator enhanced cavernosal smooth muscle relaxation (J Sex Med 2013; 10:1268-77).

Unfortunately, this medication has not progressed past phase II studies.

The RhoA/Rho

kinase

When activated, the smooth muscle myosin light chain (MLC) is flibanserin online buy phosphorylated by inhibiting MLC phosphatase, leading to calcium sensitization and smooth muscle contraction.

Studies of hypertensive and diabetic rats have suggested upregulation of this pathway and a resultant worsening of erectile function.

SAR407899 is a specific RhoA/Rho kinase inhibitor that induces penile erection with greater potency and longer duration than sildenafil in a diabetic rabbit model, as well as in human cavernosal tissue strips (J Transl Med 2012; 10:59). However, development of this drug ceased after completion of phase II clinical trials, without reporting of results.

Topical agents for the treatment of ED are an appealing alternative for patients who experience adverse effects with the use of oral PDE-5 inhibitors and who do not desire more invasive treatments. Topical alprostadil has been studied in several double-blind, placebo-controlled trials with notable improvements in International Index of Erectile Function (IIEF) scores and few minor side effects such as erythema at the administration site. Topical sildenafil is currently being studied for the treatment of ED.

A phase I pharmacokinetic and safety trial has shown good penetration of topical sildenafil without significant side effects (bit.ly/topical-sildenafil). A phase II proof-of-concept study has been completed, although results have not yet been reported.

Various formulations of both topical alprostadil and sildenafil are available through online outlets and compounding pharmacies, although tissue penetration and efficacy are likely variable.

While promising, considerable investigation of topical agents is still needed. Stem cells have become an attractive

therapy

Additionally, combination treatment with brain-derived neurotrophic factor (BDNF), PDE-5 inhibitors, and adipose-derived stem cells have suggested a synergistic effect in improving erectile function in the rat model (Tissue Eng Part A 2014; 20:2446-54).

However, data examining the therapeutic efficacy and safety of stem cells for treatment of ED in humans are limited, and this therapy remains experimental.

Platelets play an important role in inflammation, tissue remodeling, and angiogenesis.

The use of autologous platelet-rich plasma (PRP) has been explored in the treatment of a number of conditions, including cheapest place to buy sildenafil ED.

Whole blood is obtained from the patient through venipuncture and the sample is then centrifuged to remove white and red blood cells.

The supernatant contains platelets and plasma proteins, including growth factors and other components that can aid healing, which are then directly injected into the corpus cavernosum.

Wu et al performed intracavernosal injection of PRP in an animal model of ED after cavernous nerve crush injury, observing an improvement in erectile function after PRP (J Sex Med 2012; 9:2838-48).

However, no studies evaluating the efficacy of PRP for ED in humans are currently available.

The safety of PRP has been suggested in a study by Matz et al in which PRP fibrin matrix was used in 16 patients for ED and/or Peyronie’s disease. There were no major complications, and minor complications included mild pain or bruising at the injection site in approximately 20% of patients (Investig Clin Urol 2018; 59:61-65).

Although PRP is an interesting potential therapy for ED, further studies are warranted to evaluate its safety and efficacy. Next: Extracorporeal low-intensity shock wave therapy Extracorporeal low-intensity shock wave therapy.

Extracorporeal low-intensity shock wave therapy (LISWT) is an emerging treatment for ED.

It has been studied previously for a number of other conditions, including tissue ischemia, wound healing, and musculoskeletal disorders. LISWT utilizes direct mechanical forces from a pulse energy source and indirect force through cavitation that is directed at the treatment target. For ED, LISWT is thought to induce microtrauma to the cavernosal tissue that upregulates angiogenic factors, resulting in new blood vessel growth. Vardi et al were

the

Several ongoing randomized clinical trials will help our understanding of the role of LISWT in the treatment of ED. Over the last decade, we have developed a better understanding of the pathophysiology of ED. However, novel therapies-especially oral agents-with demonstrable efficacy and favorable side effect profiles are lacking. Other innovative therapies in early clinical stages show promise, but there remain unanswered questions about patient selection and efficacy. Continued technological advances and a detailed understanding of the spectrum of pathophysiologic mechanisms of ED will translate to novel therapies in the future.

Nutraceuticals are therapies that use alternative, natural, or herbal additives with claims of health benefits. Consumption of these therapies has exploded over the last decade.

As a result of the Dietary Supplement Health Act of 1994, supplements are regulated as foods rather than medications.

The aversion that men with ED often have to seeking medical care, in part from the negative stigma associated with the condition, has likely fueled this growing market.

Many nutraceuticals are commercially available without prescription and include up to a dozen different ingredients, including yohimbine, L-arginine, red ginseng, and Epimedium spp (or horny goat weed).

However

An early meta-analysis suggested yohimbine had therapeutic efficacy with few adverse effects.

More recently, a study explored on-demand L-arginine glutamate and yohimbine in 45 patients with mild to moderate ED in a double-blind, placebo-controlled study (Eur Urol 2002; 41:608-13; discussion 13). Those who received the combination had improved erectile function domain responses on the International Index of Erectile Function (IIEF) compared to placebo.

Yohimbine is the most promising nutraceutical, although it is uncertain how it compares to current oral ED medications.

L-arginine is a naturally occurring amino acid that is also a component of many nutraceuticals claiming to boost erectile function. It is a precursor to nitric oxide and supplementation with L-arginine can boost nitric oxide levels, leading to smooth muscle relaxation and increased blood flow. However, demonstrable efficacy of L-arginine supplementation is limited. Similar to L-arginine, ginseng affects the NO pathway, stimulating nitric oxide synthase (NOS). Nearly a dozen randomized studies have evaluated the use of ginseng for ED. Most have reported a positive effect, although each of these studies has methodologic flaws including selection bias, dosing, and follow-up. Adverse

effects

Small animal studies have demonstrated an improvement in erectile function after administration of icariin.

Cheng is an andrology and reconstructive urology fellow, University of Utah Health in Salt Lake City.

Pastuszak are assistant professors of surgery (urology) at the Center for Reconstructive Urology and Men’s Health, University of Utah Health. Kaplan, MD, is professor of urology at the Icahn School of Medicine at Mount Sinai and director benign urologic diseases, Mount Sinai Health System, New York.

Erectile dysfunction , commonly known as ‘impotence’, is the ongoing inability to obtain or sustain an erection that is sufficient for sexual intercourse.

It is thought to affect at least one in ten men in the UK and more than 50% of men over 40 will experience some form of ED, from the total inability to obtain an erection, to an inconsistent ability to do so, or a tendency to sustain only brief erections.

Commonly known as ‘impotence’, erectile dysfunction is the ongoing inability to obtain or sustain an erection that is sufficient for sexual intercourse.

It is thought to affect at least one in ten men in the UK and more than 50% of men over 40 will experience some form of ED, from the total inability to obtain an erection, to an inconsistent ability to do so, or a tendency to sustain only brief erections. There can be a range of causes that are both physical and psychological.

Physical causes include: hormonal problems narrowing of the blood vessels to the penis – this is commonly associated with high blood pressure, high cholesterol or diabetes.

Your Consultant will carry out a thorough examination to determine the cause of the problem. ED can be an embarrassing condition for many men with a significant impact on both your quality of life and your partner’s.

It is important that a diagnosis is made, not least because ED is often an early sign that your blood vessels are narrowing and are clogged with fatty substances, such as cholesterol.

As blood vessels in the penis are a lot smaller than the blood vessels elsewhere in the body, they are often affected first, which is risk factor for cardiovascular disease, including coronary heart disease, stroke or heart attack. If you have ED, your consultant will assess your risk of cardiovascular disease and suggest options to reduce this risk.

To determine the nature of ED your consultant will carry out a range of tests and examinations including: A full medical and sexual history examination Physical examination – this can help rule out other problems such as circulatory system problems and unusual characteristics of the penis. Psychological examination – consultants may question patients using a questionnaire relating to the man’s sexual partner to reveal or rule out any psychological explanations. Lab tests – these can help diagnose ED to test for systemic and endocrine problems.

If you have ED, there are various forms of treatment that prove successful. Linear shockwave therapy is a modern non-invasive therapy that is used by one of our specialist erectile dysfunction consultant Mr David Ralph.

It uses shock waves of a low intensity to induce controlled angiogenesis, and significantly improves the function of the male sexual organ.

Linear shockwave therapy has been in the press a lot recently and is known for producing impressive results.

For more information and to book a consultation please contact us. Other Methods For Erectile Dysfunction Can Be Seen Below.

PDE5 inhibitors – these tablets are the most common and effective form of treatment, which work by temporarily increasing blood flow to the penis, causing an erection to occur naturally from sexual stimulation.

Whilst suitable for most ED sufferers, patients who take nitrate-based drugs for heart problems cannot use these drugs. Injection into the penis – this is called intracavernosal injection therapy – medications self-injected into the erectile tissue of the penis causing the blood vessels feeding blood into the penis to relax, allowing the blood flow to increase.

Pellets into the urethra (urethral pellets or Transurethral therapy) – a pellet is inserted into the urethra (the tube that carries urine from the bladder to the tip of your penis) through the tip of the penis to cause the relaxation of the blood vessels, resulting in an increase in blood flow.

Vacuum devices – the penis is inserted into a cylinder and a vacuum is created by a hand or battery pump, causing the penis to fill with blood and harden to produce an erection.

A band is then placed around the end of the penis to keep the erection and the pump removed. It may take several attempts to learn how to use the pump correctly, but they are usually very successful.

After using a vacuum pump, 9 out of 10 men are able to have sex, regardless of what causes their ED.

Penile implants – inflatable implants inserted surgically under general anaesthetic. Psychosexual counselling – this form of therapy may be used for men whose ED is thought to be caused by psychological issues or when medical treatments do not bring about improvement. If you prefer to listen to this article, click on the SoundCloud player below.

Few men want to talk about their inability to get or maintain an erection, however, erectile dysfunction can have a profound impact on relationships and self-esteem. Fortunately, trouble in the bedroom doesn't necessarily mean you're dealing with erectile dysfunction. Most men will have problems with an erection at some point in their sexual history. But one bad day in the bedroom doesn't mean major sexual health problems.