All of these medicines work by relaxing smooth muscles and increasing blood flow in the penis during sexual stimulation. You should not take any of these medicines to treat ED if you are taking nitrates to treat a heart condition. Nitrates widen and relax your blood vessels. The combination can lead to a sudden drop in blood pressure, which may cause you to become faint or dizzy, or fall, leading to possible injuries.
Sildenafil is available as oral tablets at doses of 25 mg, 50 mg, and 100 mg. Patients should take sildenafil approximately one hour before sexual activity. In some men, the onset of action of the drug may be as early as 11-20 minutes. It's best for men to take sildenafil on an empty stomach for best results since absorption and effectiveness of sildenafil can be diminished if it is taken shortly after a meal, particularly a meal that is high in fat. Sildenafil and the other PDE5 inhibitors don't cause an immediate erection. Sexual stimulation is necessary for these medications to work.
As a starting point, consider the National Health and Social Life Survey, which was the first nationally representative sex survey conducted in the United States [1]. The data were collected in 1992 from thousands of Americans aged 18-59. As part of this survey, male participants were asked whether they’d had trouble maintaining or achieving an erection any time in the last year, to which they provided a simple yes/no answer.
Neurologic illnesses leading to ED have been recently reviewed (64). The most common of them (i.e., consequences of prostatic surgery, stroke and Parkinson’s disease) are not typical of younger age and, similarly to conditions less common but more typical of younger men, such as spinal cord injury, multiple sclerosis and spina bifida, the clinical features of the underlying disease are clearly apparent, being ED one of the multiple manifestations, rather than a harbinger of a subtle condition. Diagnosis of neurologic origin of ED is often quite simple, based on medical history and physical exam. The clinical management is a multidimensional and coordinated work of rehabilitation and medical therapy, which includes ICI injection of vaso-relaxant drugs, vacuum device and surgery (64).

The first is a vacuum erection device (VED).  The device, which can be purchased on line and used at home, is placed over the penis, then pumped up to create a vacuum around the penis. This draws blood into the penis, creating an erection. One study found that the dropout rate with the VED was quite high, with only 50% of couples finding the treatment satisfactory. 2

In most young men with ED, additional testing to assess for the origin of ED is unnecessary as the history gives you the information that you need. With this said, it may be therapeutic for the patient to know his laboratory assessments are normal, in which case additional testing does add significant value to the assessment. From the history alone, we find that most of these men will have situational erectile dysfunction that responds well to low dose oral PDE-5 inhibitors. If the patient does respond well to these medications, the diagnosis of neurogenic erectile dysfunction, clinically significant arterial insufficiency, or venous-occlusive dysfunction can efficiently be ruled out. If the patient responds inconsistently or does not respond to the oral medications, additional workup should be considered, dependent on the additional history provided.
If you answer “yes” to any of these questions, your ED may well have a psychological link. To confirm this diagnosis, you may want to complete a full psychological evaluation. This is particularly important if you suspect that your ED has something to do with a mental health issue like anxiety or depression that might require additional treatment, either medical or psychosocial.

Taking one of these tablets will not automatically produce an erection. Sexual stimulation is needed first to cause the release of nitric oxide from your penile nerves. These medications amplify that signal, allowing some men to function normally. Oral erectile dysfunction medications are not aphrodisiacs, will not cause excitement and are not needed in men who get normal erections.

ED is common among patients with cardiovascular diseases (CVD). Sexual problems usually precede the onset of CVD, and should, therefore, be considered as a risk factor for cardiac events. Similarly, patients with preexisting CVD are at increased risk of experiencing ED. Therefore, ED and CVD might be considered as two different clinical manifestations of the same systemic disease.19
ED is often the result of atherosclerosis, and as a result, men with ED frequently have cardiovascular disease. Sexual activity is associated with increased physical exertion, which in some men may increase the risk of having a heart attack (myocardial infarction or MI). The major risk factors associated with cardiovascular disease are age, hypertension, diabetes mellitus, obesity, smoking, abnormal lipid/cholesterol levels in the blood, and lack of exercise. Individuals with three or more of these risk factors are at increased risk for a heart attack during sexual activity. The Princeton Consensus Panel developed guidelines for treating ED in men with cardiovascular disease. Thus, if you have ED and cardiovascular disease (for example, angina or prior heart attack), you should discuss whether or not treatment of ED and sexual activity are appropriate for you.
Although few studies specifically evaluated the clinical characteristics of ED in younger men, this problem is increasingly frequent. Healthcare professionals both inside and outside of Sexual Medicine are likely to deal with young men complaining for ED and it is important that basic knowledge on this topic is available. In fact, young men reporting ED risk being dismissed without any specific medical assessment, including medical history or physical exam, owing to the assumption that ED in younger is a self-limiting condition, without any clinical consequence. However, evidence shows that, similar to middle-aged or older men, ED can be the consequence of the combination of organic, psychological and relational factors and all these components must be assessed for a correct clinical management. In particular, ED in younger, even more than in older men, can be considered a harbinger of CVD and it offers the unique opportunity to unearth the presence of CV risk factors, thus allowing effective and high quality preventive interventions.
Like all diabetic complications, ED can occur even when you have followed your doctor’s advice and carefully managed your diabetes. Also like all diabetes complications, ED is less likely to occur with good blood sugar control. Poorly controlled diabetes and high cholesterol increase the chances of vascular complications, which may lead to ED or other circulatory problems. In addition, regular smoking and alcohol use can contribute to ED.
If this treatment approach fails, it is useful, however frustrating, to start again from the beginning. Reassess the history to ensure that nothing was missed originally. Obtain labs and perform a PCDU. This will give the objective information that you might need in order to make a diagnosis of a known etiology for ED and to provide the patient reassurance that your evaluation has been thorough.
Fully restoring sexual health with treatment of a medical condition (such as high blood pressure with diet and/or exercise or by controlling diabetes or other chronic diseases) may not be possible. Identification and treatment of these conditions may prevent the progression of ED and affect the success of various ED therapies. Nutritional states, including malnutrition, obesity, and zinc deficiency, may be associated with erectile dysfunction, and dietary changes may prove a sufficient treatment. Masturbation and excessive masturbation are not felt to cause ED, however, if one notes weak erections with masturbation, this may be a sign of ED. Some men who masturbate frequently may have troubles with achieving the same degree of stimulation from their partner, but this is not ED.
“With the success of Viagra-type drugs, there has been a tendency to start all patients with ED on one of these drugs and not look much further for a medical cause. But we now know that ED may be an early warning for heart and blood vessel disease, so it is important to look for common risk factors. These include high blood pressure, diabetes, medications, smoking, drinking, and drugs,” said Dr. Wang.
Not only can guilt affect your ability to perform sexually, but so can low self-esteem. The correlation between erectile dysfunction and low self-esteem seems obvious from one direction – an inability to perform in the bedroom can cause you to feel bad about yourself. But how does low self-esteem cause ED? Self-esteem is defined as, “confidence in one’s own worth or abilities.”

Total testosterone levels: Health care professionals should obtain a patient's blood samples for total testosterone levels in the early morning (before 8 a.m.) because the testosterone levels go up and down throughout the day. If you have a low testosterone level, a health care professional should check it again to confirm that it is truly low. In some men, a specialized test measuring the active form of testosterone (free or bioavailable testosterone) may be recommended.
Rates of erectile dysfunction have significantly increased over the last 15 years, especially in men younger than 40. In 2002, a review of 23 studies from Europe, the United States, Asia and Australia found that the rate of erectile dysfunction in that age group was two per cent. More recent studies suggest that erectile dysfunction is becoming more prevalent in younger men, with as many as 15 per cent of men in that age group battling it.
Diabetes can cause nerve, blood vessel, and muscle damage that results in problems like pain, numbing or loss of sensation in the hands and feet.12 These issues can also result in ED problems, because nerve signals and blood flow are necessary to the process of getting an erection.6 And as men with diabetes get older, ED problems become even more common.13
Patient can inject medications directly into the corpora cavernosa to help attain and maintain erections. Medications such as papaverine hydrochloride, phentolamine, and prostaglandin E1 (alprostadil) can be used alone or in combinations to attain erections. All of these medications are vasodilators and work by increasing blood flow into the penis. Prostaglandin E1 (Caverject, Edex) is easier to obtain; however, it is associated with penile pain in some individuals. The use of combinations of two or three of these medications can decrease the risk of having penile pain.
Once you have talked to your partner about your issues, you may want to consider taking things one step further with psychosexual therapy. This is a form of therapy in which both you and your partner see a therapist together. The therapist will help you and your partner break out of the cycle of stress and disappointment that has been coloring your sex life and contributing to your ED. Going to a therapist with your partner may also help you work out any relationship issues that have been affecting your sex life so the both of you will be more satisfied.
Though stress and anxiety are two different things, they are closely related when it comes to issues of erectile dysfunction. In many cases, stress is the underlying factor, but it causes anxiety which then triggers more stress – it is a vicious cycle. If you take a look at the physical side of things, however, you’ll see that stress and anxiety are even more closely related than you may realize.
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.
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