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Neurophysiologic testing (vibrometry; bulbocavernosus reflex latency; cavernosal electromyography; somatosensory evoked potential test; pudendal and sphincter electromyography) Nocturnal penile tumescence and rigidity assessment.

Specialized endocrinologic testing (hypothalamic-pituitary-gonadal function studies; magnetic resonance imaging of the sella turcica) Vascular diagnostics (duplex ultrasonography; penile pharmacocavernosometry and pharmacocavernosography; penile arteriography; computed tomography or magnetic resonance imaging; nuclear imaging) Adapted with permission from Jardin A, Wagner G, Khoury S, et al.

Recommendations of the 1st International Consultation on Erectile Dysfunction. Plymouth, U.K.: Health Publication Ltd, 2000:718–719 . Abstract Prevalence Pathophysiology Diagnosis and Evaluation Treatment Link to Cardiovascular Disease References. First-line therapy for ED is aimed at lifestyle changes and modifying pharmacotherapy that may contribute to ED8 ( Table 2 6). Sedentary lifestyle, a significant risk factor for cardiovascular disease, may also be a modifiable risk factor for ED.15 Obesity nearly doubles the risk of ED3; one study determined that one third of men who were obese improved their ED with moderate weight loss and an increase in the amount and duration of regular exercise.14 The risk of moderate or total ED is almost double in men who smoke compared with nonsmokers.16 Patient education should be aimed at increasing exercise, losing weight to achieve a body mass index (BMI) less than 30 kg per m 2 , and stopping smoking. Psychological causes (e.g., anxiety, depression, guilt, history of sexual abuse, marital or relationship problems, stress) Decreased appearance and volume of ejaculate. Chronic prostatitis, normal aging process, obstruction of ejaculatory duct(s), retrograde ejaculation. Chronic fatigue syndrome, hypogonadism, hypothyroidism, psychological conditions. Impaired quality and timing of orgasm, including anorgasmia.

Alcohol abuse, Cushing syndrome, hyper- or hypothyroidism, medications (e.g., antihistamines, antipsychotics, beta blockers, selective serotonin reuptake inhibitors, thiazides, tricyclic antidepressants), psychological causes, surgery of the pelvis or prostate. History of sexual abuse, genital piercings, sexually transmitted infections (e.g., genital herpes) Assessment of body habitus for central obesity. Cushing syndrome, diabetes mellitus, metabolic syndrome. Cauda equina syndrome, spinal stenosis, surgery of the pelvis or prostate, trauma. Atherosclerotic vascular disease, cerebrovascular disease. Peyronie disease, ruptured corpora

cavernosum

Chronic fatigue syndrome, hypogonadism, hypothyroidism, psychological conditions. Impaired quality and timing of orgasm, including anorgasmia.

Alcohol abuse, Cushing syndrome, hyper- or hypothyroidism, medications (e.g., antihistamines, antipsychotics, beta blockers, selective serotonin reuptake inhibitors, thiazides, tricyclic antidepressants), psychological causes, surgery of the pelvis or prostate. History of sexual abuse, genital piercings, sexually transmitted infections (e.g., genital herpes) Assessment of body habitus for central obesity.

Cushing syndrome, diabetes mellitus, metabolic syndrome. Cauda equina syndrome, spinal stenosis, surgery of the pelvis or prostate, trauma. Atherosclerotic vascular disease, cerebrovascular disease. Peyronie disease, ruptured corpora cavernosum, venous leakage. Anxiety, hyperthyroidism, stimulant abuse, underlying cardiovascular disease. Epididymitis, hypogonadism, testicular cancer, varicocele. Phosphodiesterase type 5 (PDE5) inhibitors are the most effective oral drugs in the treatment of ED,9 , 12 and should be considered first-line therapy.8 , 14 , 17 Retail sales of sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) approached $1.48 billion in 2007.18 Sildenafil has been found to be effective and safe in cases of ED associated with diabetes mellitus17 , 19 and spinal cord injury,20 and in men with sexual dysfunction secondary to antidepressant therapy.21 Compared with placebo, sildenafil has been shown to improve erections (74 versus 21 percent; number needed to treat [NNT] = 2)22 and results in more frequent intercourse attempts (57 versus 21 percent; NNT = 3).23 Approximately one third of men with ED do not respond to therapy with PDE5 inhibitors. These agents are not effective for improving libido.24. The three PDE5 inhibitors are considered to be relatively similar in effectiveness, but there are differences in dosing, onset of action, and duration of therapeutic effect ( Table 6 ).25 There are no rigorous data to suggest that one PDE5 inhibitor is superior to another.

An open-label trial found that patients preferred tadalafil and vardenafil over sildenafil,26 yet most evidence supports equal effectiveness between sildenafil and vardenafil.27 PDE5 inhibitors are generally well tolerated, with mild transient adverse effects of headache, flushing, dyspepsia, rhinitis, and abnormal vision.

Headache is the most commonly reported adverse effect, occurring in approximately 10 percent of patients. Rare but important adverse effects include dizziness, syncope, and nonarteritic anterior optic neuropathy (predominantly from crossover phosphodiesterase type 6 inhibition).

PDE5 inhibitors should not be taken concomitantly with nitrates because this may lead to a synergistic effect, resulting in a potentially serious, even fatal, decrease in blood pressure.

PDE5 inhibitors are metabolized by the cytochrome P450 3A4 and may affect metabolism of protease inhibitors and antifungal medications.

Phosphodiesterase Type 5 Inhibitors for Erectile Dysfunction.

*— Maximum recommended dose per 24 hours is the maximum strength dose for each agent . † — Duration during which successful erections may be achieved following a dose of medication .

Phosphodiesterase Type 5 Inhibitors for Erectile Dysfunction. *— Maximum recommended dose per 24 hours is the maximum strength dose for each agent .

† — Duration during which successful erections may be achieved following a dose of medication .

Intracavernosal

pressure

The prevalence of hypogonadism (defined as a morning serum total testosterone level less than 300 ng per dL [10.41 nmol per L]) in men with ED is estimated to be 5 to 10 percent.13 , 28 In men with hypogonadism, testosterone supplementation is superior to placebo in improving erections and sexual function.

Response rates are higher in primary versus secondary testicular failure, and with transdermal versus oral or intramuscular testosterone.13 Supplementation is also associated with improved satisfaction with erectile function and sexual desire.29 Men with hypogonadism who failed a trial of sildenafil were found to have significant improvement in erectile function with the addition of testosterone supplementation.30 Testosterone supplementation may result in erythrocytosis, elevated serum trans-aminase levels, exacerbation of untreated sleep apnea, benign prostatic hyperplasia, and an increased

risk

Men receiving testosterone supplementation require more frequent monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels, and prostate examinations.31. Alprostadil (Caverject) is a viagra online no prior prescription viable second-line therapeutic option for the treatment of ED.

It should initially be administered in the physician's office at the lowest dose and sequentially titrated to an adequate erectile response while monitoring for syncope.

The physicians should also provide education on self-administration.8 Intra-cavernosal alprostadil is more effective, better tolerated, and preferred by men over the intraurethral form.32 Common adverse effects of intraurethral alprostadil include local penile pain, urethral bleeding, dizziness, and dysuria.

Common adverse effects of intracavernosal alprostadil include penile pain, edema and hematoma, palpable nodules or plaques, and priapism. Patients should be informed about the potential for occurrence of prolonged erections and should seek emergent medical evaluation for rigid erections lasting longer than four hours. Priapism is most commonly treated with aspiration of blood from the corpus cavernosum under local anesthetic. If this treatment is insufficient, then intra-cavernosal injections of phenylephrine should be performed with hemodynamic monitoring to watch for severe hypertension, tachycardia, or arrhythmia.

Vacuum pump devices are a noninvasive second-line option ( Figure 2 ) . They are contraindicated in men with sickle cell anemia or blood dyscrasias, and in those taking anticoagulants. If used properly, adverse effects and potential risks are negligible, yet there may be a substantial learning curve. When first- and second-line therapies have failed, surgical implantation of an inflatable penile prosthesis can be considered in consultation with a urologist ( Figure 3 ) .

Patients should be counseled regarding risks, benefits, and expectations of this procedure. The AUA does not endorse penile venous reconstructive surgery or surgeries to limit venous outflow from the penis. Penile arterial reconstructive surgery is controversial and more rigorous trials are needed to prove short- and long-term effectiveness.16. If you

are

The bad news: Men with diabetes are three times more likely to report having problems with sex than non-diabetic men. The most common sexual problem is Erectile Dysfunction, or ED, sometimes called impotence.

Even worse, because ED is such a private issue, many men feel embarrassed to discuss the problem with their doctor, or even their partner, so the problem is never addressed. The good news: ED is one of the most treatable complications of diabetes. In fact, over 95 percent of cases can be successfully treated.

With proven treatments available, diabetic men with ED have options. It isn’t something you—or your partner—should have to live with.

What ED Is—and What It Isn’t ED means the repeated inability to achieve or sustain an erection sufficient for sexual intercourse.

Although sexual vigor generally declines with age, a man who is healthy, physically and emotionally, should be able to produce erections, and enjoy sexual intercourse, regardless of his age. ED does not mean: • An occasional failure to achieve an erection.

The adage is true: It really does happen to everyone. All men experience occasional difficulties with erection, usually related to fatigue, illness, alcohol or drug use, or stress. ED occurs when a man is interested in sex, but still cannot achieve or maintain an erection.

Many men with diabetes also experience a decreased sex drive, often as a result of hormone imbalances or depression. Decreased sex drive is quite treatable, but it is treated differently from ED. Such problems often indicate a structural problem with the penis.

How Diabetes Causes ED Human sexual response requires several different body functions to work properly and together: nerves, blood vessels, hormones, and psyche.