Abstract | Full Text | Full Text PDF | PubMed | Scopus (95) | Google ScholarSee all References Sildenafil has a 4000-fold increased selectivity for PDE-5 over PDE-3, has negligible effects on heart rate, and has only a modest effect on blood pressure level in healthy persons, with an average systolic pressure decrease of 10 mm Hg with a single dose of 100 mg.3x3Zusman, RM, Morales, A, Glasser, DB, and Osterloh, IH. Overall cardiovascular profile of sildenafil citrate. Am J Cardiol. 1999; 83: 35C–44C
Counselling or sex therapy (58% of people find this works for them) –mind-related causes of erectile dysfunction can affect anyone. They are more likely if you experience erectile dysfunction at a younger age. Talking to a counsellor or therapist can help some people overcome erectile dysfunction related to these problems, possibly for good. They can also help you if your erectile dysfunction is causing you stress, as this can make matters worse.
Erections also require neural input to redirect blood flow into the corpora cavernosae. Psychogenic erections secondary to sexual images or auditory stimuli relay sensual input to the spinal cord at T-11 to L-2. Neural impulses flow to the pelvic vascular bed, redirecting blood flow into the corpora cavernosae. Reflex erections secondary to tactile stimulus to the penis or genital area activate a reflex arc with sacral roots at S2 to S4. Nocturnal erections occur during rapid-eye-movement (REM) sleep and occur 3–4 times nightly. Depressed men rarely experience REM sleep and therefore do not have nocturnal or early-morning erections.
Since their introduction in the therapeutic field, more than a decade ago, PDE-5 inhibitors have revolutionized the treatment of sexual dysfunction. By blocking the activity of PDE-5 isoenzyme, localized throughout the smooth muscle cells of the vasculature (genital vessels included), PDE-5 inhibitors increase the levels of cyclic guanosine monophosphate thus exerting vasodilating properties and facilitating penile erection[40-42]. Due to these properties, sildenafil was the first drug of its class to receive wide acceptance. Its short half-life, food interactions and the associated visual disturbances however, paved the way for the development of newer PDE-5 inhibitors. As such vardenafil with its more rapid onset of action, and tadalafil with its longer half-life and the lack of food interactions or side effects, have offered significant alternatives to sildenafil[43-50].
Physical and emotional stress — whether over-exercising, under-sleeping or just dealing with everyday stressors like work and a busy schedule — causes an increase in “stress hormones,” including cortisol and adrenaline. Stress can lower desire for sex. This is because stress can contribute to fatigue or preoccupation with other tasks. It can also significantly affect blood flow by increasing inflammation.
Consider this:  penicillin, the first successful antibiotic, was derived from molds that inhibit bacterial growth.  Scientists had to figure out why the molds slowed bacteria, and refine the active ingredients.  Using herbal supplements is somewhat like putting mold on a wound.  It might help, a little, but it’s certainly not going to help as much as using penicillin.
A collection of risk factors that strongly predict heart disease—termed the metabolic syndrome—is also associated with erectile dysfunction. An increasingly prevalent condition, this syndrome includes low HDL, increased triglycerides, high blood sugar, and heightened inflammation and causes a three-fold or greater risk of heart attack, stroke, and diabetes. It is largely attributable to excess weight, poor diet, and inactivity and afflicts at least 47 million Americans, signaling that an epidemic of erectile dysfunction is sure to follow. Indeed, a survey of 2,400 men participating in a health screening revealed that metabolic syndrome increases the likelihood of erectile dysfunction by 48%.10
In Eastern medicine, animal products are commonly used for their perceived health benefits. The philosophy “like nourishes like”, suggests that consuming the organ of an animal will bring benefits to the corresponding organ in one’s body is a common belief. Men seeking greater potency have turned to eating penises from goats, bull, deer, horses, seals and other mammals in the form of cooked dishes or herbal preparations. While there is no scientific evidence supporting this practice, the cultural beliefs remain strong and supplements containing extracts from animal penises are readily available in the form of capsules, often mixed with herbal compounds pitching similar erectogenic properties. A significant proportion of these potency-inducing supplements in Asia have been found to contain PDE5-inhibitors substrates such as tadalafil and sildenafil (30). However uncontrolled use of illicit PDE5-inhibitors under the guise of natural supplements remains a health threat to the general public.
Yohimbe. Before Viagra and the other prescription erectile dysfunction drugs became available, doctors sometimes prescribed a derivative of the herb yohimbe (yohimbine hydrochloride) to their patients suffering from ED. But experts say the medication is not particularly effective, and it can cause jitteriness and other problems. "It's not a great drug," says McCullough. "And I suspect the herb is not as potent as the pharmaceutical version." What's more, evidence shows that yohimbe is associated with high blood pressure, anxiety, headache, and other health problems. Experts discourage its use.
When it comes to scientific development, in Western medicine, an analytic approach is often used to identify and resolve medical challenges. A hypothesis is first derived through general observations of a phenomenon. A research plan is then carefully designed and data collected. Once sufficient data is collected, critical statistical evaluations are done and conclusions are drawn (4). Every aspects of a disease entity are studied from macroscopic to microscopic views, down to the cellular and molecular levels. The deep understanding of the role of cGMP-specific phosphodiesterase type 5 enzymes in ED and the use of phosphodiesterase-5 inhibitors in treatment of ED exemplifies the success of this approach.

After adjusting for cardiovascular risk factors including diabetes, heart failure and stroke, those taking PDE5 inhibitors were found to be markedly less likely to die than those taking alprostadil or no erectile dysfunction drugs. Filling more prescriptions for PDE5 inhibitors appeared to be associated with a greater benefit, although Andersson said that trend should be interpreted with caution because the study was not large enough for a definitive dose-response analysis.

"The answer to the question, 'Can patients with heart disease safely have sex?' is almost always 'Yes,' unless they have such bad heart failure or severe artery disease that even a moderate amount of exertion will cause terrible chest pain," says Richard Stein, MD, who is director of preventive cardiology at New York City's Beth Israel Hospital. "And if that is the case, sex is probably the last thing on their minds anyway."
Abstract | Full Text | Full Text PDF | PubMed | Scopus (46) | Google ScholarSee all References The Princeton Consensus Panel provided guidelines (Table 4) for physicians regarding patients who are being evaluated for their level of risk in resuming sexual activity.51x51DeBusk, R, Drory, Y, Goldstein, I et al. Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel. Am J Cardiol. 2000; 86: 62F–68F
Crossref | PubMed | Scopus (42) | Google ScholarSee all References Apomorphine does not appear to have any notable cardiovascular adverse effects and has been used successfully in Europe. However, apomorphine use has been associated with other unpleasant adverse effects such as nausea and emesis, and the drug has not been approved by the US Food and Drug Administration (FDA) for use in the United States.
The causes of ED are numerous but generally fall into two categories: organic or psychogenic. The organic causes can be subdivied into five categories: vascular, traumatic/postsurgical, neurological, endocrine-induced, and drug-induced. Examples of the psychogenic causes are depression, performance anxiety, and relationship problems. In people with diabetes, the main risk factors are neuropathy, vascular insufficiency, poor glycemic control, hypertension, low testosterone levels, and possibly a history of smoking.

When dealing with certain medical conditions, it is important to focus treatment toward the root of the problem. If you were to properly manage your high blood pressure without the use of any confounding medications and instead employ a lifestyle change, both ailments would likely disappear. While this would be the ideal case, it isn’t the reality for most patients. Medications are great for controlling high blood pressure, but it’s important to speak with your doctor about any concerns before taking them.
The second way relates to the risk associated with the sexual activity in a patient with either overt or occult CVD. In this case, the diagnosis of ED should prompt an initial cardiovascular assessment based on the history and clinical examination in order to define the baseline risk according to (i) the likelihood of silent CAD18,31 (especially since ED patients have a high probability to have silent CAD) or to the stage of clinically evident CAD, (ii) other cardiovascular conditions either unrelated, or related to ED (e.g. heart failure, peripheral arterial disease).
PubMed | Google ScholarSee all References As with sildenafil, use of nitrate or NO-donor medications is contraindicated while taking tadalafil because of the potential for marked hypotensive interactions.74x74Gresser, U and Gleiter, CH. Erectile dysfunction: comparison of efficacy and side effects of the PDE-5 inhibitors sildenafil, vardenafil and tadalafil—review of the literature. Eur J Med Res. 2002; 7: 435–446
Erectile dysfunction usually precedes cardiovascular events by 3 to 5 years. Therefore, sexual function should be incorporated into cardiovascular disease risk assessment for all men. Recently, algorithms for the management of patients with erectile dysfunction according to the risk for sexual activity and future cardiovascular events were proposed[91]. A comprehensive approach to cardiovascular risk reduction (comprising of both lifestyle changes and pharmacological treatment) will result in significant benefits on overall vascular health, including sexual function. Proper sexual counselling will exert beneficial effects on the quality of life of hypertensive patients with erectile dysfunction and will improve adherence to antihypertensive drug therapy[91].
Get your diabetes under control. According to Dr. Nehra, the most important number you need to stay on top of is your A1C, which is a blood test that lets you know how well your blood sugar has been controlled for the past few months. Lifestyle changes can help and so can medications. Diabetes medications do not add to your risk for erectile dysfunction, says Nehra.

In some cases, however, these drugs may be unsuitable for patients with heart disease. If you are considering one of these drugs and you have heart disease, as many diabetics do, be sure to tell your doctor. In rare cases, the pills may create “priapism,” a prolonged and painful erection lasting six hours or more (although reversible with prompt medical attention).

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