Cialis recept

Several different VED products are available but all systems utilize a negative pressure vacuum chamber and elastic constriction ring at the base of the penis to facilitate and maintain an erection. Patient and partner success rates with VED therapy have been reported at 76% and 74%, respectively. 12 The most common side effect associated with VED therapy is minor penile pain.

Patients should only use VED products which contain a vacuum-limiting device to avoid injury to the penis due to excessive negative pressure. The surgically implanted penile device was the first treatment available for ED patients almost 40 years ago, and today the penile prosthesis remains a viable treatment

option

The more desirable 3-piece inflatable products typically consist of a prosthetic cylinder implanted within each corpora which is connected to a fluid-filled reservoir and a pump in the base of the scrotum.

The most common complications associated with the penile prosthesis are device malfunction and infection. Technological advances have decreased the rate of malfunction and a recent review found a

10-year

33 cialis recept Similar advances have led to the development of antibiotic-coated devices, which have resulted in decreased infection rates. Remarkable advances in the treatment of ED have been made over the past several years. In addition to the new PDE 5 inhibitors, several investigational agents with novel treatment targets and exciting strategies utilizing biotechnology, which may reverse the underlying disease pathology of ED, are in various phases of development. Several PDE 5 inhibitors are currently being evaluated in clinical studies.

Avanafil is an ultra short-acting agent that is rapidly absorbed (T max 35 min) and eliminated (T 1/2 35.

Novel treatment modalities currently being evaluated for ED include: topical alprostadil, dopamine agonists,

melanocortins

Bremelanotide is a melanocortin receptor agonist with known effects on erectile function originating within the CNS and has shown significant improvements in erectile response after intranasal administration.

36 The active form of Rho-kinase appears to augment the regulation of cavernosal smooth muscle contraction and detumesence, therefore, compounds that inhibit Rho-kinase are currently under development. 34 The potential application of genetic technology, although still in early development, holds the most promise for the future of ED management. In animal studies testing intracavernous injections of a 'naked' DNA plasmid genetically encoded with a potassium channel activator, hSlo, the treatment has slowed the natural decline and maintained erectile function in rats for several months. 36,37 A phase 1 study demonstrated a complete return of erectile function in 2 of 11 men with ED who received hSlo intracavernous therapy, which was well tolerated, as reported in a 2-year follow-up study.

ED encompasses several disorders related to problems with ejaculation, such as premature ejaculation, delayed ejaculation, and anorgasmia. 5 Of these, premature ejaculation is the most common and the focus of this discussion. Premature ejaculation can be subdivided into a cialis price no prescription primary or secondary disorder, and although the underlying etiology is not completely known, accumulating evidence supports the role of a neurophysiologic and/or behavioral disease component.

5,7,40 Patients with primary premature ejaculation (PPE) have features consistent with a neurophysiologic focus including family history of PE, penile hypersensitivity, excessive ejaculatory reflex, and serotonin receptor sensitivity. 40 Stress, anxiety, and emotional problems are consistent with a behavioral theory and have been more closely associated with secondary PE.

Several neurotransmitters have been implicated for their role in the complex process of the ejaculatory reflex, with serotonin exhibiting an inhibitory role during ejaculation. A complete assessment of sexual function should be evaluated in order to differentiate ED from PE, which has been reported to co-occur in approximately 30% of patients. 40 Complaints involving difficulties maintaining an erection as a result of early ejaculation in the absence of comorbid ED factors could be misdiagnosed as ED if a patient is not properly screened for PE.

A short intravaginal ejaculatory latency time (IELT), which is the time from vaginal penetration to ejaculation, can be helpful in establishing the underlying etiology of sexual dysfunction. Recently, the Premature Ejaculation Tool, a valid and reliable measure of premature ejaculation, was developed to capture patient concerns beyond a short latency time. Although several drugs have been evaluated in clinical trials to improve ejaculatory control and reduce personal distress, none of these agents are currently approved by FDA for the treatment of PE.

However, behavior modification strategies and pharmacologic agents such as the selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and topical preparations (eg, lidocaine/prilocaine cream) are all currently recommended by the AUA for the management of PE. 5 Topical anesthetics effectively desensitize the penis to tactile stimuli, improve latency time, and are associated with only minor local side effects. The SSRIs and TCAs have traditionally been used as antidepressants and some are associated with intolerable side effects and potentially significant drug interactions, therefore the chronic use of these drugs for the treatment of PE can be unappealing and may result in poor adherence by patients.

To address these concerns, several clinical trials have utilized lower doses and on-demand versus continuous daily dosing of these agents, but an advantage associated with this dosing strategy has not been clearly established.

Paroxetine, sertraline, and fluoxetine have been the most studied SSRIs and are commonly recommended agents for the management of PE within their class. Based on results from several randomized controlled trials, paroxetine seems to have the greatest effect on improving IELT and delaying ejaculation from 1.5

min

Some of the more commonly reported side effects predominantly occurring in patients on continuous dosing include: nausea, fatigue, headache, confusion, and diarrhea. To minimize potentially serious adverse reactions, patients taking SSRIs should be instructed to avoid taking other serotonergic drugs and advised against abruptly discontinuing therapy.

Furthermore, healthcare providers should monitor patients closely for drug interactions, because several SSRIs are highly protein bound and metabolized through the cytochrome P450 system. Clinical trials evaluating the TCAs for the treatment of PE have focused primarily on clomipramine which has been shown to have favorable effects on IELT in several studies.

5 In a randomized crossover design involving 36 men with PE who were treated with fluoxetine, sertraline, clomipramine, and placebo, clomipramine had the greatest effect on IELT (from 46 sec at baseline to 5.75 min, P 43 Anticholinergic side effects such as drowsiness, dizziness, dry mouth, and fatigue have been reported in clomipramine-treated

patients

Despite these challenges, several agents are being investigated for PE including: SSRIs, serotonin receptor (5-HT 1A ) antagonists, opioid receptor agonists, PDE 5 inhibitors, and topical preparations.

Dapoxetine, a rapidly absorbed SSRI with a short half-life, has received the most attention of the investigational agents for PE. Despite receiving a non-approvable letter from FDA in 2005, dapoxetine is in phase 3 studies and is currently available in several

European

44 The proposed rationale behind the development of the 5-HT 1A antagonists for PE is that the coadministration of these agents with the SSRIs may improve the onset of effect in patients who are utilizing on-demand treatment. Combination treatment with pindolol (a non-selective beta blocker with known 5-HT 1A antagonist properties)

and

The prompt recognition and management of underlying organic, neurogenic, and psychogenic conditions associated with ED are necessary to improve

treatment-related

Phosphodiesterase inhibitors have now replaced older agents such as alprostadil, phentolamine, and papaverine for the first-line treatment of ED. The convenience of these oral dosage forms, which have been available for the past decade, has also generated the willingness of more men to seek earlier treatment for their symptoms. Although premature ejaculation remains one of the most common sexual disorders, the lack of FDA-approved treatments has proven to be a significant challenge for the management of this condition. Despite this obstacle, several agents are currently recommended by the AUA for the treatment of PE such as SSRIs, TCAs, and topical lidocaine/prilocaine.

Several investigational drugs for the management of ED and PE are also in various phases of development.

Douglass is assistant clinical professor, Northeastern University School of Pharmacy, Adult Internal Medicine, Boston Medical Center, Mass. Lin is a urologist at Massachusetts Bay Urologic Associates, Dorchester Center, Mass.

Disclosure Information: The authors report no financial disclosures as related to products discussed in this article. Management of erectile dysfunction: diagnosis and treatment guideline.

Feldman, HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. The worldwide prevalence and epidemiology of erectile dysfunction. Montague DK, Jarow J, Broderick GA, et al; AUA Erectile Dysfunction Guideline Update Panel. AUA guideline on the pharmacologic management of premature ejaculation.

An evidence-based definition of lifelong premature ejaculation: report of

the

Diagnosis and management of erectile dysfunction in the primary care setting.

Clinical guidelines panel on erectile dysfunction: summary report on the treatment of organic erectile dysfunction.

The contribution of common medical conditions and drug exposures to erectile dysfunction in adult males. Montague DK, Jarow JP, Broderick GA, et al; Erectile Dysfunction Guideline Update Panel. Chapter 1: The management of erectile dysfunction: an AUA update. Chapter 3: Detailed outcomes analyses of treatments for erectile dysfunction.