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In order to establish whether normal erections are occurring overnight (nocturnal erections), the doctor may organise nocturnal penile tumescence (NPT) testing.

This involves wearing a monitor overnight in your own home.

The data from this monitor is then assessed to analyse how often erections occurred, how long they lasted, and how rigid and large the penis was during the erections.

If NPT testing is normal, the cause of erectile dysfunction is usually psychological. If not, further testing of the blood flow in the genital area may be required to see if there is blockage or leakage.

The doctor may also organise a blood test of levels of hormones such as testosterone, prolactin and thyroid stimulating hormone to see if these are contributing to the erectile dysfunction.

For the great majority of men, erectile dysfunction can be effectively treated.

It is essential that if you experience erectile dysfunction, you discuss it with your doctor.

Many treatment options are available, and your doctor can help you decide which one is most appropriate for you. Some causes of erectile dysfunction such as hormonal problems or anxiety may be cured completely with treatment and/or therapy. Even if the underlying cause cannot be cured, medication may still allow a satisfactory erection. Ignoring the problem tends not to make it better, and can have a significant impact on relationships and self-esteem. Treating Erectile Dysfunction — Without the Little Blue Pill.

Non-pharmaceutical alternatives may be more effective.

En espanol | If you watch TV or read magazines, you could easily conclude that men seeking treatment for erectile sildenafil 20 mg online dysfunction (ED) have but one option: pills. The three dominant brands — Cialis, Levitra and Viagra — are locked in an expensive battle for men’s allegiances, and have, through their suggestive advertising, triggered both satire and controversy in the 14 years since the Food and Drug Administration approved Viagra.

Think about improving your heart health first before pursuing ED treatments. But steamy commercials aside, what if the pills don’t work for you, as is the case in 25 to 30 percent of men with ED, or they stop working after a few years — a common problem for men whose ED is caused by an underlying cardiovascular condition? “A lot of patients think that pills will give them complete restoration,” says Ajay Nehra, M.D., a urology professor at the Mayo Clinic College of Medicine in Rochester, Minn. But many patients instead find that even if they take the pills, they are “not the same” sexually as they were before the onset of their ED, he says.

If you are among the men who want — or need — to try other therapies for ED, here are the three main options, some of which are cheaper and more effective than the pills. All costs stated below will vary, depending on your insurance plan. Join AARP today — Receive access to exclusive information, benefits and discounts.

Before pursuing ED treatments, though, bear in mind that improving heart health by losing weight, eating a healthier diet, exercising more and quitting smoking typically enhances erectile performance as well as one’s overall health. In addition, sex therapy counseling sessions can often ease or eradicate ED symptoms, if the underlying cause is psychological in nature, says Drogo Montague, M.D., director of the Center for Genitourinary Reconstruction at the Cleveland Clinic. Vacuum erection device (penis

pump

The devices consist of a cylindrical tube, 12 to 18 inches long, connected by a small air hose to a hand pump (on many models this resembles the squeeze mechanism on a blood pressure monitor). Users place the tube over the penis then pump to produce an erection.

They must then place an elastic band around the base of the penis to keep the blood there and maintain the erection. “Obviously this isn’t the most spontaneous thing,” says Tobias Kohler, M.D., assistant professor of urology at Southern Illinois University School of Medicine.

“You can imagine someone having sex with a partner for the first time and pulling out this lunch box.” While the pumps produce erections for 90 percent of users, most abandon it for other treatments, says Trinity J. Bivalacqua, M.D., assistant professor of urology and oncology at the Johns Hopkins Medical Institution.

The pumps are “very cumbersome and clumsy,” Bivalacqua says.

Despite reliably producing erections, pumps have the lowest satisfaction rate of any erectile dysfunction treatments.

“In my practice, most men who try it will say, ‘Not for me,’ ” he adds. Insurers typically cover 80 percent of the roughly $500 cost for a prescription pump, leaving consumers with around $100 in out-of-pocket expenses. If you opt for a pump, experts say it’s important to get one through a doctor’s prescription.

The pumps sold in sex shops tend to be novelty

items

These produce erections by injecting or inserting into the penis a drug that increases blood flow. Urethral suppositories, the size of a grain of rice, are inserted via the head of the penis; injections are self-administered near the base of the penis. The

actual

The frequency, intensity and duration of that side effect vary by method and user but can, in some cases, be bad enough, Montague says, that “a man will get an erection but be too uncomfortable to use it.” Suppositories “were developed so men wouldn’t have to use needles,” Bivalacqua says.

They contain the drug alprostadil (also known as prostaglandin E1) and are sold under the brand name Muse.

If they are going to work, it takes about five to 10 minutes. However, Muse produces erections in only 30 to 40 percent of patients, usually those with mild ED, because some of the drug is absorbed systemically and diverted from its function of opening penile arteries to allow more blood to flow in. The out-of-pocket cost is around $20 to $30 per suppository.

For men who don’t mind needles, injections come in various formulations: alprostadil alone; a two-drug combo called bi-mix, which can either be alprostadil mixed with phentolamine or phentolamine mixed with papaverine; and tri-mix, a three-drug mixture of phentolamine, papaverine and a low dose of alprostadil. Of these formulations, alprostadil alone carries the highest reported rate (50 percent of users) of burning and pain; in bi-mix users the rate of burning is around 10 percent, and in tri-mix users it drops to less than 3 percent of users, says Nehra. “And that improves dramatically over time as men get used to the injection,” he adds . Because the burning side effect is triggered by alprostadil, the formulations with the least alprostadil — tri-mix and certain versions of bi-mix — could work for men who experience burning with the single-drug formula.

But some men might choose alprostadil alone because the multi-drug cocktails can cost more and must be dispensed by a compounding pharmacy — one that is authorized to mix medications on site — which could mean the added hassle of a long drive to pick up the drug.

Some injectable formulations need to be refrigerated — yet another reason many men steer away from the needle option.

Among ED treatments, injections are also the most common cause of extended erections — rigidity lasting more than four hours, also called priapism — which afflict about 3 to 7 percent of users, Kohler says. That condition, while easily treated with an adrenaline shot, requires urgent attention at a clinic or hospital.

The cost of this ED treatment is $2 to cialis super active 100mg $5 per injection.

Join AARP today — Receive access to exclusive information, benefits and discounts. A surgically implanted prosthesis can virtually guarantee erections on demand.

“Overall, these have the highest satisfaction for both the patient and his partner,” Nehra says. Ninety-five percent of prostheses implanted in men in the United States are pump-and-chamber devices in which the man activates a pump — via a discrete subdermal push button in the scrotum — that fills his penis with sterile saline from a reservoir implanted along with the pump.

The other 5 percent of prostheses are either pump devices in which the saline is permanently in the prosthesis, not in a separate reservoir (urologists may recommend this for men who have had multiple surgeries); or a pair of semi-rigid, malleable rods implanted in the penis, which render it hard at all times. The patient manually shifts the penis into an erect position for sex. With the pumps, erections last until the user hits the deflate button, which Kohler says “doesn’t happen” accidentally .

He adds that pump

prostheses

The downside to these prostheses includes the standard risks of surgery,

the

The cost for surgical options varies, and insurance coverage is typically good. All of the above treatments preserve men’s sensation in the penis and ability to achieve orgasm. Choosing the treatment that is best for you comes down to preference and efficacy.

Montague cites a study that surveyed three groups of men, all of whom were successfully using an ED treatment. One group was on oral medications, one was using injections and a third had surgically implanted pumps.

The most satisfied users were those with the implanted prostheses.

Once implanted, the pumps become “part of their sildenafil 100mg price walgreens body,” Montague explains. Works every time.” Pills, even when they work, might be less effective if you’ve had more than a couple drinks or are out of sorts for other reasons.

Injections are slightly more reliable than pills but, Montague says, are still subject to variability. Erectile Dysfunction – Symptoms and Treatment Options for ED.

Erectile Dysfunction – Symptoms and Treatment Options for ED. Erectile dysfunction, also known by the acronym ED, is a rarely-discussed but very common medical condition that affects men worldwide. In fact, approximately 1 in 5 men in the United States over the age of 20, roughly 30 million men, suffer from ED.

To understand erectile dysfunction, it is important to understand how erections occur. Under

normal

If the arteries are calcified or diseased such as someone with heart disease or vascular disease, blood flow may be compromised. It is important to see your doctor if you have new onset erectile dysfunction as it may be an indication of cardiovascular disease. The causes of ED are often multifactorial and include such common conditions such as diabetes and heart disease. Sometimes the condition can be an early warning sign of heart problems and up to 40 percent of ED cases are the result of vascular problems such as atherosclerosis, or plaque buildup in your arteries. ED can have broad implications on a man’s quality of life and can include difficulties with depression, intimacy, anxiety and self-esteem.

Treatments for ED usually can be classified into five categories. Medications – The most common treatment for ED are the oral prescription medications.

These medications are phosphodiesterase-5 inhibitors and are the Viagra’s of the world.

They work by bringing more blood to the penis to improve the rigidity of erections. Most people are candidates but care should be taken with some medications and cannot be taken with nitrates. Vacuum erection devices (VED) – These devices work by using negative pressure to the penis and keeping in the penis with an elastic tension ring.

VEDs have been around since the 1980’s and can help most people but can be uncomfortable. Injectable Medication & Intraurethral Suppositories – The next line of treatments work by placing medications directly into the penis through an injectable or intraurethral suppository.

One such option is MUSE, a small pill that is placed directly into the urethra and gives medication locally.

Self-injections work by injecting medication directly into the corporal bodies to induce an erection. Injections work well for most people but the man or his partner must be willing to inject the medication into the penis.

Prosthesis – For those men who wish to achieve an erection but have failed the previous treatments, a penile prosthesis is

the

Penile implants have been used since the 1970s and typically consist of inflatable cylinders that are placed into the corporal bodies of the penis in the operating room.

Patient satisfaction is high with penile prostheses and can be a life-changing event for many

men

Talk to your partner, talk to your friends, or talk to your doctor – just know that you are not alone when it comes to this condition. Options are out there so find out if there is a treatment option right for you!

Jason Phillips is a specialist in men’s urological health and is available to discuss your options is you suffer from erectile dysfunction.

Jason Phillips is a Board Certified Urologist specializing in men’s and women’s urologic health. Dedicated to providing patients superior care, he has a special interest in treating BPH, urologic cancers, kidney stones, overactive bladder, incontinence, bladder prolapse, and erectile dysfunction. He is trained in minimally invasive technologies including ureteroscopy, Greenlight laser, Urolift, laparoscopic surgery and the da Vinci

robotic

The treatment of erectile dysfunction in patients with neurogenic disease. Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: AN Shridharani; (IV) Collection and assembly of data: AN Shridharani; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Abstract: Erectile dysfunction (ED) related to compromise of the nervous system is an increasingly common occurrence. This may be due to the multifactorial nature of ED, the myriad of disorders affecting the neurotransmission of erectogenic signals, and improved awareness and diagnosis of ED.

Nevertheless, neurogenic ED remains poorly understood and characterized. Disease related factors such as depression, decreased physical and mental sildenafil 100mg price walgreens function, the burden of chronic illness, and loss of independence may preclude sexual intimacy and lead to ED as well.

The amount of data regarding treatment options in subpopulations of differing neurologic disorders remains scarce except for men with spinal cord injury. The treatment options including phosphodiesterase inhibitors, intracavernosal or intraurethral vasoactive agents, vacuum erection devices (VED) and penile prosthetic implantation remain constant.

This review discusses the options in specific neurologic conditions, and briefly provides insight into new and future developments that may reshape the management of neurogenic ED. Keywords: Erectile dysfunction (ED); neurogenic; treatment. Neurogenic erectile dysfunction (NED) is a traditional classification of erectile dysfunction (ED) encompassing disorders impairing erections via neurologic compromise or dysfunction. The disorders compromising erections may act centrally, peripherally or both. The prevalence of neurogenic ED has been suspected to be between 10% and 19% of all causes of ED (1,2). However, several classically defined neurogenic processes may affect several components of the normal pathway to achieve erection e.g., multiple sclerosis (MS), diabetes mellitus, iatrogenic surgical and spinal cord injury.

Each disease state has its own unique characteristics that require acknowledgement to fully understand their effect on ED.

Much of the emphasis on erectile pathophysiology has been placed on penile smooth muscle function and cavernosal hemodynamics. The neuroanatomy and neurophysiology of erection can be characterized but its full extent is poorly understood.

Neurologic disease does not always reproducibly affect erections in a uniform manner compared to other types of sexual dysfunction (SD).

This offers many obstacles to understanding the role the nervous systems plays in SD and consequently obscures what treatment options readily optimize erections specific to the neurologic insult. Treatment strategies for sildenafil 100mg price walgreens ED usually target the corporal smooth muscle to augment its relaxation or replace its function via prosthesis implantation.

Nevertheless, to treat ED related to a neurologic disorder, assessments of function and disease related factors are recommended, as ED in these men is often multifactorial in origin. A comprehensive understanding of the neural pathways for erection is necessary for assessing whether neurogenic ED exists and how to appropriately address the ED.

As stated previously, neurologic disease may affect multiple neural pathways leading to ED, sensation deficits and ejaculatory dysfunction. Nerves originating in the spinal cord and peripheral ganglia

innervate

They merge to form the cavernous nerves that travel alongside the prostate, enter the corpora cavernosa and corpus spongiosum to

affect

The somatic nerves send sensory information from the penile skin, glans, and urethra via the dorsal penile nerve and pudendal nerve to the spinal cord.

The somatic nerves also initiate contraction of the ischio- and bulbocavernosus muscles.

The sympathetic pathway originates from the 11 th thoracic to the 2 nd lumbar spinal segments and goes via the white rami to enter the sympathetic chain ganglia. Subsequently nerves travel through the lumbar splanchnic to inferior mesenteric and superior hypogastric nerves to the pelvic plexus. The T10 through T12 segments are most often the origin of sympathetic fibers, and the sympathetic chain ganglia that innervate the penis are located in the sacral and caudal ganglia (3). Parasympathetic pathways originate from the intermediolateral cell columns of the 2 nd , 3 rd and 4 th sacral spinal cord segments. Preganglionic fibers pass through the pelvic plexus where they coalesce with sympathetic fibers from the superior hypogastric plexus. The cavernous nerves that innervate the penis arise from the portion of the pelvic plexus. The pelvic plexus also contains nerves that innervate the rectum, bladder and urinary sphincter and the nerve projections can be damaged during radical excision of the bladder, prostate and rectum, leading to iatrogenic ED (4). Induction of erection occurs after stimulation of the cavernous and pelvic nerve plexus.

Conversely, stimulation of the sympathetic trunk leads to detumescence. The reflex erectile response requires that the sacral reflex arc remain intact.

Tactile and sensory signals are received by the somatic sensory pathways and integrate with parasympathetic nuclei within the sacral spinal cord (S2-4) leading to induction of erection via cholinergic signaling. These reflexogenic erections remain intact with upper motor neuron injuries.

Psychogenic erections do not require that the sacral reflex arc remain intact. In a cat models, spinal cord removal below L4/L5 led to absence of a reflexogenic erection but stimulation of the medial preoptic area (MPOA) or placement near a female cat in heat led to erection (5,6).

Psychogenic erections occur sildenafil 100mg price walgreens via induction of central pathways traveling from the brain through the sympathetic chain.

Non-penile sensory pathways induced by sight, sound, touch and smell travel through the MPOA to the erection centers within the cord T11-L2, and S2-S4 to induce erections (7). When a sacral lower motor neuron injury is present in men, below T12 these types of erections are more likely to occur (8).

Spinal cord lesions above T9 are not associated with psychogenic erections (9).

Rigidity of erections is less with psychogenic erections because the thoracolumbar sympathetic outflow may contain a decreased concentration of neurons compared to the parasympathetic outflow from the sacral spinal cord. The somatosensory pathways for erections originate in the penile skin, glans and urethra. Glans afferent sensory free nerve endings are 10-fold

more

The nerve endings coalesce to form the dorsal penile nerve along with other sensory nerve fibers.

Through the pudendal nerve they enter the S2-4 nerve roots to terminate on spinal neurons and interneurons. Nerve bundles within the dorsal nerve contain nitric oxide (NO) synthase, found typically in autonomic nerves, and stimulation of the sympathetic chain can leak to evoked potentials from the dorsal nerve and vice versa (10-12).