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Jiang Yunhao, who was so calm and mens ed drugs Extend Pills Natural calm, suddenly stood up from the stone chair and asked, You said you are already a fourth order inscription master His eyes were fixed on Qi Wenshan. 1 Department of Neurology and Psychiatry, Assiut University Hospital, Assiut, Egypt. 2 Department of Neurology and Psychiatry, AL-Azhar University Hospital, Assiut, Egypt.

3 Department of Clinical Pathology, Assiut University Hospital, Assiut, Egypt. *Corresponding Author: Sherifa Ahmed Hamed M.D, Department of Neurology and Psychiatry, Assiut University Hospital, Assiut, Egypt Telephone: +2 088 2374904 Fax: +2 088 23333227 E-mail: [email protected] Abstract. We aimed to determine the frequency of ED in epileptic adults and its related variables. Included were 100 epileptic men treated with conventional antiepileptic drugs (AEDs).

Patients were assessed using International Index of Erectile Function questionnaire-5 items version (IIEF-5), psychiatric interview, Beck Depression Inventory (2nd edition) (BDI-II) and Hamilton Anxiety Rating Scale (HAM-A).

Free testosterone and sex hormone binding globulin (SHBG) were measured to assess endocrinal status. Compared to controls (n=50), patients had higher rates of ED (37%), lower IIEF-5 scores (P=0.053), particularly with frontal lobe epilepsy, left foci, carbamazepine (CBZ) and uncontrolled seizures. A high frequency of depression (51%) and scores of BDI-II were reported with frontal lobe epilepsy, right foci, CBZ, polytherapy and lack of control on AEDs. Lower free testosterone and higher SHBG levels were also reported.

Patients with ED were older in age, had higher rates of uncontrolled seizures (58.19%) and higher scores of BDI-II and HAM-A.

A significant negative correlations were identified between ED and age, age at onset, scores of BDII and HAM-A.

We concluded that psychiatric comorbidity and endocrine abnormalities appear to be related to ED and seizure intractability to AED medications. Attention should be paid to optimize seizure control. In addition, psychotherapy and modalities such as medications for ED are sometimes needed. Erectile dysfunction; epilepsy; antiepileptic drugs; depression; anxiety.

GTC: Generalized tonic-clonic; AEDs, antiepileptic drugs; CBZ: carbamazepine; VPA: valproate; EI-AEDs: enzyme inducer antiepileptic drugs; TLE: temporal lobe epilepsy; SHBG: sex hormone binding globulin; IIEF-5: International Index of Erectile Function questionnaire – 5 items version; BDI-II: Beck Depression Inventory (2nd edition); HAM-A: Hamilton Anxiety Rating Scale. Epilepsy is one of the most common chronic medical illnesses [1]. Men with epilepsy have an approximately five-folds increase in risk of sexual dysfunction compared to general population [2].

In general, sexual disorders are common in people with epilepsy, occurring in up to 1/2-2/3 of patients [3-6].

Various aspects of sexual functions are affected in men with epilepsy including sexual interest and poor sexual performance (as diminished Libido, potency, or satisfaction of erection or orgasm and premature ejaculation) [7]. Erectile dysfunction (ED) is defined as a failure to persistent or recurrent partial or complete obtaining and/or maintaining penile erections until the end of sexual activity. The etiology of ED in patients with epilepsy is multifactorial, involving neurological, endocrine, iatrogenic and psychosocial.

ED may be due to disturbance of sex hormones, hypothalamic-pituitary axis and testicular function by epileptic discharges [3, 8,9], or may result as adverse effect of antiepileptic drugs (AEDs) [10-12]. Reduced serum levels of free testosterone and/or albumin bound testosterone and free androgen index (FAIs) and increased levels of estradiol (E2), sex hormone binding globulin (SHBG), follicle stimulating hormone (FSH), luteinizing hormone (LH) and prolactin were reported in men with epilepsy [3-6].

Enzyme inducer AEDs (EI-AEDs) as carbamazepine (CBZ), phenytoin (PHT) and phenobarbitone (PB) elevate SHBG and reduce bioactive testosterone levels and may result in impotence in men [13, 14]. Epilepsy signifies anxiety and depression, low self-esteem and immaturity and this could lead to avoid situations that call for affective sexual involvement [15-18].

In this work, we aimed to determine the frequency rate of ED in a cohort of adult men with epilepsy and its relation to demographic-, clinical-, epilepsy-, psychosocial- hormonaland treatment- related variables.

This study was conducted on 100 adult males with epilepsy, with age ranges between 20 to 48 years and total time of illness ranged from 3 to 35 years.

Patients were on regular treatment with one or combined therapy of the conventional AED(s) for at least 6 months before participation in our study.

Patients were free from other neurological or medical diseases and had normal computer tomography (CT) or magnetic resonance imaging (MRI) of the brain. Their seizure types’ were diagnosed according to the International League Against Epilepsy (ILAE) [19].

Patients were recruited from the out-patient epilepsy clinics of the departments of Neurology and Psychiatry of Assiut and Al-Azhar University Hospitals, Assiut, Egypt.

Fifty healthy males matched for age, sex, educational level and socioeconomic status were included as controls for comparison.

Controls were recruited from the healthy general population matched for age- (range: 20-48 years; mean: 30.36±7.59), sex-, educational level and socioeconomic status. Excluded were subjects (patients and controls) with: 1) history of neurological disorder other than epilepsy, 2) history of clinically significant genitourinary disease, pelvic trauma, pelvic surgery, or radiation therapy, 3) concomitantly known vascular risks (e.g., heavy smoking, diabetes mellitus (DM), coronary artery disease) , systemic illness (e.g.

gout, active gastrointestinal disease, renal failure, serum creatinine concentration >150 mmol/l, chronic hepatic illness) likely to affect erectile function, 4) alcoholism or diagnosed substance abuse and/or previous hospitalization for substance abuse), 5) use of regular medication(s) in addition to AEDs (e.g. drugs for high blood pressure, heart medications, antidepressants, tranquilizers, and sedatives), and 6) current or recent treatment of ED with intracorporeal injection or application of vasoactive drugs. The study protocol was approved by the ethical committee of the faculties of medicine of Assiut and Al-Azhar, Assiut, Egypt and all patients and control subjects gave their informed consent to participate in this study as follow: Methods.

All patients and healthy control subjects underwent the same research protocol.

Patients’ evaluation was done interictally, 1) Medical, neurological, endocrinological, psychiatric, vascular and urological history and examination: Seizure variables included age at onset, precipitating factors, duration of illness, type, frequency, family history of epilepsy, type of utilized AED(s) (monotherapy or polytherapy), duration of treatment, degree of patients’ control on AED(s) and side effects from medications.

The frequencies of seizures were defined as described before [20] into: a) very frequent: occuring several times a day or at intervals shorter than 7 days, b) frequent: occuring at intervals longer than 7 days but shorter than 30 days, c) occasional: occuring at intervals longer than 30 days but shorter than one year, and d) rare: occuring at intervals longer than one year. Regarding the degree of control on AEDs, patients were considered controlled on AEDs treatment, when seizure free for ?1 year, partially controlled when seizure frequencies were occasional and uncontrolled when seizures were frequent or very frequent.

Physical and urological examinations included examination for the presence of secondary sexual character, genitalia, other tissues of the penis and pelvic region, rectal and prostate examination and examination of perianal and penile sensation.

Bulbocavernosal reflex was done to test the integrity of the sacral arc, performed by squeezing the glans (head) of the penis, which immediately cause the anus to contract if nerve function is normal. The latency between squeeze and contraction was assessed by observing the anal sphincter or by filling it with a gloved finger inserted past the anus.

All patients underwent standard electroencephalography (EEG) and neuroimaging [as computed tomography (CT) or sildenafil teva 50 mg cena magnetic resonance imaging (MRI)].

2) Assessment of erectile function: Assessment of erectile function was done using the Arabic translated version [21] of International Index of Erectile Function questionnaire 5-items version or IIEF-5 [22]. Each item of IIEF-5 is scored from 0 to 5 on 4 items and 1 to 5 on 1 item.

The 4 of the 6 items includes questions regarding maintenance ability, erection confidence, maintenance frequency, and erection firmness, while the single item includes question about intercourse satisfaction and overall satisfaction. A cutoff value of 21 is chosen so that patients with IIEF-5 scores of ?21 are classified as having ED while scores >21 are not.

According to this scale, ED is classified into four categories: severe ED (1–7), moderate ED (8–11), mild-to-moderate ED (12–16), mild (17–21), and no ED (22–25). 3) Psychiatric evaluation: Standardized psychiatric interview was done by applying the Diagnostic and Statistical Manual of Mental Health Disorders, fourth edition (DSM–IV) criteria for the diagnosis of depression and anxiety [23].

A standardized psychiatric interview was chosen as the primary method for obtaining data.

A differentiation between behavioral disorders and behavioral symptoms was made throughout the work. In patients with coexisting symptoms, assessment of the severity of the symptoms was undertaken by an experienced psychologist using the Arabic translated versions of Beck Depression Inventory (2nd edition) (BDI-II) [24, 25] and Hamilton Anxiety Rating Scale (HAM-A) [26,27]. BDI-II is the revised version of the original BDI (1st edition) [28].

In BDI-II, the items reflecting somatic disease and consequences of a medical illness which overlap with depressive symptoms were eliminated (as fatigue, work disability, weight loss, loss of energy, sleep loss, appetite loss, changes in body image, and somatic preoccupation).

The BDI–II consists of 21 items to assess the intensity of depression. Each of the 21 items corresponding to a symptom of depression is summed to give a single score for the BDI-II. According to summation of scores from all 21 parameters, the score of 0-13 is considered minimal range, 14-19 is mild, 20-28 is moderate, and 29-63 is severe.

The HAM-A consists of 14 items to measure the severity of a patients’ anxiety. Each of the 14 items is scored on a 5-point scale, ranging from 0 = not present to 4 = severe. According to summation of scores from all 14 parameters, the total score of 14-17 is considered as mild in range 18-24 as moderate while 25-30 as severe. 15-20 minutes to complete the interview and score the result.

4) Laboratory investigations: Standard laboratory tests included: complete blood count (CBC), measurement of serum creatinine, liver enzymes and fasting blood glucose level. For analysis of serum free testosterone, prolactin, free thyroxin (FT4), thyroid stimulating hormone (TSH) and sex hormone binding globulin (SHBG), blood samples were drawn at (8.00-10.00 am) after an overnight fast and patients were seizure free for at least 72 hours, as any postictal central hormonal dysfunction is recognized to reverse within hours. Assessment protocols were done according to the recommendations of the manufacturers. The concentrations of serum prolactin, FT4 and TSH were measured by IMMULITE reproductive hormone assays from Diagnostic Product Cooperation (Los Angeles, USA). The concentrations of free testosterone were buy sildenafil teva measured by enzyme immunoassay method (ELISA) (BioSource Europe S.A.

Rue de I`Industrie, 8 – B-1400 Nivelles – Belgium) and SHBG concentrations were measured by ELISA kits (IBL international GMBH, Hamburg, Germany). For confirmation, the serum hormone levels were obtained and assessed twice at two different days. The hormonal levels were combined with the cross sectional assessment while clinical evaluation and interviewing with patients and control subjects. Compliance to antiepileptic medications was confirmed by assessment of the serum drug level at least once during the period of the study. The serum levels of AEDs were determined in the Therapeutic Drug Monitoring (TDM) lab, Assiut University Hospital, Assiut, Egypt, using fluorescence polarization immunoassay system of Abbott (EPIA), TDxFLX apparatus (Abbott Lab, Wiesbaden, Germany) as described before [29].

The serum levels of AEDs were measured as part of the investigation in batched assays. The approximated therapeutic serum level of CBZ is 4-10 ?g/ ml and that of VPA is 50-100 ?g/ml.

Calculations were done with the statistical package SPSS, version 12.0.

Data were presented as mean ± SD (standard deviation) when normally distributed and mean (quartiles) when not normally distributed.

Kolmogorov-Simirnov test was used to test the parameter distributed.

Unpaired two-sided Student’s t test was used for comparison of mean of normally distributed parameters.

In all other cases Mann-Whitney U test was used for comparison. Correlations must be assessed using Pearson’s for normally distributed data and Spearman’s methods for non-normally distributed data. What was once acknowledged solely as impotence and smilingly mentioned barely behind closed doors has within the recent years gained immense recognition for the most part partially to the microscopic blue pill created for this?

It absolutely was within the late '90s and was the speak the city thus to talk. Anyone laid low with it

wished

Its name is dysfunction and because of some early research will be treated with not solely the microscopic blue pill referred to as Fildena however additionally different similar to Vidalista 60 , and Valif 20 . These medications have helped scores of men laid low with dysfunction and their scope in the world. There don't seem to be too several educated those that wouldn't have detected of this.

Not solely have these medications helped millions, however they need additionally created their revered manufacturing firms a bigger quantity of cash than the common person would ever even win in an exceeding lottery.

Thus it's not too stunning to ascertain that there's analysis occurring for a subsequent generation or a minimum of a new product which will be marketed. Two such medications within the works are that of Vidalista 40 and Kamagra Gold or Zydena®. Sildenafil is AN experimental medication that has shown nice promise, particularly within the speed within which it claims to figure.

The manufacturers are oral communication that it starts operating in as very little as quarter-hour once taking it and this might undoubtedly spell competition for different current products on the market.

Quarter-hour is concerning 0.5 the time that presently prescribed Kamagra Oral Jelly 100mg impotence treatments begin to figure once being taken.

Thus there undoubtedly may well be a marketplace for such a pill if it ever becomes offered.

But what abundant even be observed is that there's a once each day Cialis that may negate such a fast-acting medication. different problems to stay in mind but are facet effects, The other medication within the works is called Udenafil or proprietary name is Zydena®. This medication is truly presently being prescribed in each Chosen and Russia as a once each day formula. One needs to surprise if it's solely a matter of your time before it involves North America and Europe. It will but ought to be approved by the FDA before ever coming back to the USA and Dong-A Partech Co, its producer is running tests within the USA to do to prove its effectiveness and safety to sometime create a debut in the US. Is there an area for these medications within the world market? I'd say affirmative, the prescriptions that are written or refilled day by day for this condition are staggering and it is sensible that some new ones on the market would undoubtedly succeed on some level.

However can this happen, solely time can tell and if it will the speculation on what medication will take high spot within the market is smooth out.

Nothing works for my Erectile Dysfunction; am I currently cursed with this condition for life?

Quite merely, the solution to the present is an unequivocal no. In today's world, with a good vary of treatment strategies offered, nobody ought to ever feel that there's no answer for his or her own specific variety of dysfunction. In younger men, it will typically be that their performance anxiety is thus entrenched that even giant doses of Cenforce drug, Malegra , or Vilitra won't offer a cure.

However, for these men, there are six ways that they'll adopt that, with a small amount of following, will yield terribly satisfactory results. Wherever this is often impractical, there are different, lesser-known medications that will induce a satisfactory erection regardless of however anxious they'll be.

The situation will be terribly similar in older men. Let's say in post-prostatectomy cases, Cenforce 150 drug and similar medication can rarely work.

However, these men can also have the benefit of various medications within the kind of gels or via painless injections.

This additionally applies to men with neural structure injury, advanced induration, Parkinson's sickness, and stroke or artery sickness. The main message here is that despite your natural and, utterly intelligible issues, there's invariably an answer and everyone that's needed is that the right specialist with a dedication and a disposition to assist you to discover the correct one for you.

You want to totally perceive your own dysfunction and what's inflicting it and this is often wherever a specialist skilled comes in.

You would like to own the precise reason for your distinctive impotence pinpointed and solely a doctor with a specialist interest and coaching during this subject will try this for you.

Understanding your own erection issues is a component of the cure and designation the cause is central to correct treatment. Erection may be a sexual state that corresponds to the enlargement of pennies in males. The easy reason for an erection is taken into account to be the enhanced blood flow within the pennies that creates it grow giant and thence get erected.

The complete method of erection is de facto vital for a person to own a contented sexual life.

Allow us to currently perceive the varied aspects of male erection downside. The primary players that management the complete erection method embrace the male internal secretion androgen, the pituitary body, and also the prostate. Currently, the blood enters the erectile organ space into the hollow structures that are parallel to the penis on each side, referred to as corpora cavernous.

This enhanced blood flow will be a result of psychological input. Once the erection reaches its extreme the seed is ejaculated via a tube, corpus spongiosum, out of the erectile organ.

The correct functioning of the erectile organ is important to urge a correct erection. If thanks to any physical reason the blood flow isn't optimum to cause an erection the state are termed as erection pathology.

Erection difficulties are ordinarily seen in those people who have unhealthy habits like alcoholism and chain-smoking. Medical science has developed a cure for dysfunction.

Dysfunction or impotence will be treated to some extent with the employment of medical aid medication offered within the market.