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Concerning vascular causes, the risk factors for

atherosclerosis

Concerning the arousal response, decreased testosterone blood levels can influence the efficacy of sildenafil (Viagra). If the sildenafil response is not reliably improving erection, the physician should first check if the patient is taking the pill correctly.

The physician should also check the patient’s testosterone level. One investigator in Italy gave testosterone to patients with low testosterone who did not respond to sildenafil (Viagra).

When daily testosterone was given, subsequent sildenafil (Viagra) use resulted in IIEF (the International Index of Erectile Function questionnaire used to determine erectile function) scores improving significantly.

Other risk factors for erectile dysfunction include neurologic problems (multiple sclerosis, stroke), depression and medications for treating diabetes, hypertension, heart disease and depression.

There are many oral therapies for erectile dysfunction, but the only approved medication in the US is the PDE 5 enzyme inhibitor sildenafil (Viagra). Unapproved therapies, some of which are available in the US and some elsewhere, some of which have data to prove efficacy and some not, include tadalafil (Cialis), vardenafil (Levitra), yohimbine, phentolamine, trazodone, apomorphine and neutraceuticals. PDE5 inhibitors act to relax penile erectile tissues with sexual stimulation thus enhancing your ability to get an erection.

Sildenafil (Viagra) is effective for all sorts of erectile dysfunction in 69% of people.

In some cases the erection is not hard enough, sometimes sildenafil (Viagra) just doesn’t work. Structurally vardenafil (Levitra) is similar to sildenafil, while tadalafil (Cialis) is very different. Vardenafil (Levitra) is almost 10 times more biochemically potent than sildenafil, therefore a lower dose is needed to facilitate the penile erection, potentially resulting in less side effects. Selectivity is the ability of the drug to attach to the specific enzyme PDE 5 found in penile tissues.

Vardenafil (Levitra) is more selective than sildenafil and tadalafil (Cialis) to PDE5, which again means a lower dose is needed with potentially less side effects. Tadalafil is very specific for PDE5 and is also very specific for the enzyme PDE11. Unfortunately, we don’t know much about PDE11, which is found in the heart, in the pituitary gland in the brain and in the testicles. Pharmacokinetics, half-life, is how long the medication stay s in the blood.

Sildenafil (Viagra) has a half-life of 4 hours and vardenafil cipla viagra tablets (Levitra) has a half-life of 4-6 hours while tadalafil (Cialis) has a half-life of 17.5 hours.

This means that vardenafil (Levitra) should act longer than sildenafil (Viagra) but the clinical significance is not known. Tadalafil (Cialis) has the longest half-life and allows you to take the medication and not relate the sexual activity to the immediate use of the medication.

The drawback is if you need nitrates after using tadalafil (Cialis), this medication lasts a long time in your blood stream and may place you at a higher risk.

Younger people might do well treated with tadalafil, (Cialis) while older people with other health issues might be better off using sildenafil (Viagra) or vardenafil (Levitra) but more data are needed. The side effects of vardenafil (Levitra) are potentially

less

Many people stop taking drugs because they are experiencing side effects, they no longer have a partner, or they are worried about safety. Sexual activity is not a major contributor to the risk of a heart attack. Sexual activity, with or without sildenafil (Viagra) increases the chance of an MI during sexual activity by only 0.1%.

If pills fail, there are vacuum devices, Muse, injections, bypass surgery and implants.

The patient making a presentation has had penile bypass surgery. In addition he takes testosterone and sildenafil as needed..

This is a classic example of why people with ED need complete care: a psychological exam, history and physical exam, and diagnostic studies with long term follow-up care.

Patients with ED should not just be prescribed sildenafil (Viagra) and then be lost to follow-up. Some men with erectile dysfunction, or ED, find they can return to an active sex life by treating an underlying condition, such as high blood pressure, or with counseling and lifestyle changes.

But others find they may need medication to get and keep an erection.

The FDA has approved several prescription drugs you take orally to treat ED.

All of these work by relaxing your muscles and boosting blood flow to your penis, making erections easier to get and maintain.

They are: Caution: Do not use these ED medications if you take nitrates, such as nitroglycerin or a similar medicine, for chest

pain

These medications all work similarly to each other.

However, there are subtle differences in how long they stay effective and how quickly they begin to work. Levitra takes about 30 minutes to start working and the effects last a little longer than Viagra, about 5 hours. It contains

the

Viagra takes around 30 minutes to become effective and lasts about 4 hours. Cialis lasts much longer -- up to 36 hours in some cases. Stendra can start doing its thing in as little as 15 minutes, and its effects last up to 6 hours.

You may find that one works better for your schedule or that there are differences in the side effects for you.

But these medications work the same basic way, so you’re likely to have similar results. Again, do not use these ED medications if you take nitrates, such as nitroglycerin or a similar medicine, for chest pain. But there are other situations that may make these medications unsafe as well. Before you take Viagra or one of the others, tell your doctor: If you are allergic to any medications, including other ED medications About any prescription or nonprescription medications you take, as well as any herbal and dietary supplements If you are scheduled for surgery, even dental surgery If you take

alpha-blockers

If you’ve had a heart attack, stroke, or life-threatening irregular heart rate within the past 6 months, you should discuss other options with your doctor.

You should also avoid these medications if you have uncontrolled high or low blood pressure or if you get chest pain while having sex.

You may get: • A headache • Upset stomach or heartburn • Feeling of warmth • Nasal congestion • Changes in vision (lights tinged with color, glare) Warnings. You may need emergency treatment if you get an erection that lasts for more than 4 hours and happens without any sexual excitement. You may hear a doctor call it a “priapism.” Blood becomes trapped in the

penis

Also get emergency treatment with any of the following: A rash Painful erection Fainting Chest pain Itching or burning during urination.

If you’re having chest pain and have taken Viagra in the past 24 hours or Cialis in the past 48 hours, don’t take nitroglycerin. Call for an EMS and make sure you or someone with you tells them viagra without doctor which ED medicine you took.

You should also stop these medications and call your doctor right away if you have vision loss. A rare vision problem called NAION -- short for “nonarteritic anterior ischemic optic neuropathy” -- has been reported by a few men using these drugs. The condition causes a sudden loss of eyesight because blood flow is blocked to the optic nerve.