My Penis Stuff

Scientists once believed erectile dysfunction (ED)—was a problem only of the mind and not of the body. But recent data suggest a physical (or organic) cause in more than half of all cases, especially those involving older men. In any case, experts believe it affects up to 30 million American men. But what is involved in impotence and what is available to correct it? The following information should help you talk to your urologist about this frustrating issue, and some of the options—including vascular surgery—that may help solve it.

What happens under normal conditions?

The internal structure of the penis includes two cylinder-shaped chambers, the corpora cavernosa. Filled with spongy tissue containing smooth muscles, fibrous tissue, veins and arteries, these chambers run the length of the organ and are surrounded by a membrane cover, called the tunica albuginea. The urethra, the channel through which urine and semen exit the body, is located on the underside of the corpora cavernosa and is surrounded by spongy tissue. The longest part of the penis is the shaft, which ends in the glans. The meatus is the opening at the end of the urethra.

Erection is the culmination of a complex set of physical, sensory and mental events, involving both the nervous and vascular systems. It begins when physical or psychological stimulation (arousal) causes neurotransmitters or impulses in the brain (chemicals such as dopamine, acetylcholine and nitric oxide) to tell the muscles of the corpora cavernosa to relax, allowing blood to fill the organ’s tiny open spaces. As the tunica’s fibrous or elastic tissues trap the blood, the penis engorges, or increases, in an erection. When stimulation finally ends, usually after ejaculation, pressure inside the organ decreases, as the muscles contract. Blood then flows from the penis and the penis returns to its normal shape and size.

What is erectile dysfunction (ED)?

Erectile dysfunction refers to the inability of a man to attain and maintain an erection sufficient for intercourse. It occurs when there is reduced blood flow to the penis or nerve damage, both of which can be triggered by a variety of factors. Scientists once believed that ED was an emotional issue alone. But today they know that physical factors are just as important as psychological triggers—stress, marital/family discord, job instability, depression and performance anxiety—in provoking this problem. It is important to note that hundreds of medications can also contribute to impotence while they fight allergic reactions, high blood pressure, ulcers, fungal infections, anxiety, depression and psychoses.

Who is at risk for erectile dysfunction (ED)?

A man is at risk if they suffer from:

Vascular diseases: Hardening or narrowing of arteries, often associated with high cholesterol, can also restrict blood flow to the penis, particularly if you are over 60. Because smoking can lead to any of the factors responsible for vascular problems—such as high blood pressure—it is probably an important factor in both arterial disease (atherosclerosis) and ED.

Neurologic disorders: Spinal cord diseases or injuries, brain injuries, multiple sclerosis, Parkinson’s disease and other progressive diseases can interrupt nerve impulses to and from the brain. Diabetes poses both neurological and vascular problems because it damages small blood vessels and nerves throughout the body, impairing the impulses and blood flow necessary for an erection.

Other conditions/illnesses: In addition, other chronic illnesses such as cancer and well as hormonal imbalances and penile disorders can disrupt the nerve impulses and blood flow necessary for normal erections.

What are the symptoms of erectile dysfunction (ED)?

Failing to achieve and/or sustain an erection is the primary sign of ED. But diagnosing the specific cause and prescribing appropriate treatment usually require a variety of tests, beginning with a complete history and physical examination.

Your doctor may order additional laboratory tests to assess any conditions that may be interfering with normal erectile function, particularly arterial flow to the penis. A blood test, for instance, is normally used to reveal blood lipids and triglycerides, both of which indicate atherosclerosis if elevated. A urinalysis identifies protein and glucose levels that can suggest diabetes.

While these analyses focus on your chemical status, erectile function tests are the principal tools your doctor will use to tell how the blood vessels, nerves, muscles and other tissues of your penis and pelvic region are working. Among them, penile nerve function tests—squeezing the head of the penis and measuring various responses—can determine if there is sufficient sensation in the penis. Nocturnal penile tumescence (NPT), or healthy involuntary erections during sleep, may rule out psychological issues and instead suggest nerve function or blood supply problems.

An imaging technique called duplex ultrasound may also be used. It monitors the behavior of moving structures and might provide some of the best data since it can evaluate blood flow, vein leaks, scarring of erectile tissue and some signs of atherosclerosis. During the test, an erection may be produced by injecting the stimulator prostaglandin into the body and then measuring vessel expansion and penile blood pressures, both of which are compared to the limp penis. In either case, duplex ultrasound can illustrate a specific blood vessel disease that may rule out a need for vascular surgery.

How is erectile dysfunction (ED) surgically treated?

The past several decades have ushered in a new treatment era for ED. Because of the advent of many advances, today urologists are helping millions of impotent men perform better and longer.

Penile prostheses: Surgically implanted devices to ensure stiffness have become highly reliable therapeutic solutions. Vacuum erection devices have proven to be safe alternatives in stiffening the penis by drawing blood into the organ with a pump and holding it with an “occluding band.” Penile injection therapy is a relatively quick and effective way to send vasoactive drugs directly into the corpora cavernosa where they expand the vessels, relax the tissue and increase blood flow for an erection. Furthermore, the pills: sildenafil, tadalafil and vardenafil have become the treatments of choice for millions of men who have experienced the drugs’ ability to boost levels of cyclic guanosine monophosphate (cGMP), a chemical factor in metabolism responsible for relaxing blood vessels.

Vascular surgery: Although options are varied, not everything is for everyone. In fact, two vascular approaches developed over past decades to restore penile blood flow disrupted by disease or traumas are useful for only a select few.

Penile arterial revascularization: This procedure is designed to keep blood flowing by rerouting it around a blocked or injured vessel. Indicated only for young men (under 45) with no known risk factors for atherosclerosis, this procedure is aimed at correcting any vessel injury at the base of the penis caused by adverse events such as blunt trauma or pelvic facture. When such an event leaves a penile vessel too injured or blocked to transfer blood, the surgeon may microscopically connect a nearby artery to get around the site, clearing the pathway so enough blood can be supplied to the penis to enable an erection.

Venous ligation surgery: This procedure focuses on binding leaky penile vessels that are causing penile rigidity to diminish during erection. Because venous occlusion, necessary for sufficient firmness, depends on arterial blood flow and relaxation of the spongy tissue in the penis, this approach is designed to intentionally block off problematic veins so that there is enough blood trapped in the penis to create an appropriate erection. Since long-term success rates are less than 50 percent, this technique is rarely a choice for correcting ED.

In fact, you are not a candidate for either penile vascular surgery if you have insulin-dependent diabetes or widespread atherosclerosis. You are also not suited if you still use tobacco or experience consistently high blood serum cholesterol levels. Neither of these surgeries will work if you have injured nerves or diseased and/or generalized damaged blood vessels. Also, if you are a candidate, be aware that vascular surgeries are still considered experimental by some urologists and may also not be covered by your insurance.

What can be expected after surgical treatment for erectile dysfunction (ED)?

Most of the best known treatments for ED have excellent track records for being both effective and safe. But in making your choice, make sure to discuss the potential complications of each option with your doctor.

For instance, the good news about a penile prosthesis is that it does not usually affect urination, sex drive, orgasm or ejaculation. But on rare occasions, these semi-rigid, silicone-covered metal rods or hydraulic devices can cause pain or reduced sensation. While injections can initiate erections within 15 minutes to several hours, be aware that they also can produce prolonged or painful ones, not to mention a scarring of penile connective tissue (fibrosis).

At the same time, a vacuum erection device should take only one to three minutes to give an erection, usually with no serious side effects if used properly. However, the use of the erection device to maintain the erection is limited to 30 minutes.

Sildenafil, tadalafil and vardenafil have 75 percent success rates, primarily because they are a subtle solution that works within the hour. But on rare occasions they can cause headaches, flushing, indigestion or muscle aches. Also, if you have heart disease or low blood pressure, the Food and Drug Administration (FDA) cautions a thorough examination before getting a prescription. You cannot take these drugs if you are taking nitroglycerine or any similar drug.

Penile arterial revascularization can restore function in men, although only a small percentage of them undergo the procedure. While few patients experience postoperative complications, side effects can include penile scarring, numbness and shortening all of which can cause further impotence.

Venous ligation surgery, although rare, is also known to cause penile shortening, along with other problems. Also, improvements with venous ligation surgery may be temporary.

When is venous surgery for erectile dysfunction successful?

It has been most successful in young men with abnormally draining veins since birth who have never had a full erection. It has also been used in some patients with an injury to the covering tunica albuginea or the corpora cavernosa.

I am interested in vascular surgery, what should I be aware of?

Realize this is not a surgery for everyone. If you meet the criteria mentioned previously, you will want to find a specialist with a track record of having done these microsurgical techniques. Be aware, however, that penile vascular solutions are still experimental; few specialized urologists or vascular surgeons are trained to do either procedure. If your doctor is not one of them, you will need to ask for a referral. You will also want to get a second opinion if this treatment option is recommended, given that there are few patients who are good candidates.

If I choose vascular surgery, what should I ask my surgeon?

Once you have found a surgeon, ask about his or her experience and outcome record with penile arterial revascularization. Make sure that you understand the potential outcomes and possible complications. Also, ask how the particular approach stacks up against other treatment choices for you. For instance, vacuum devices and oral or injection therapies still work for some people. Penile prostheses, the most widely used surgical technique for ED, usually have a more favorable outcome than vascular techniques.

Is age a factor in impotence?

Yes. Data suggest that while not an inevitable part of aging, the risk of impotence increases as we grow older. About 5 percent of men at age 40 complain of the problem, while between 15 and 25 percent at age 65 experience it. Some experts suggest the numbers may be underreported since men are still embarrassed by this physical and psychological issue. However, the reassuring news is that it is treatable in all age groups.

What should I remember about erectile dysfunction?

Also called impotence, ED is the consistent inability to sustain and maintain an erection, is a widespread problem. It may affect as many as 50 percent of men between ages 40 and 70. Luckily, doctors can identify physical causes involving blood flow, nerves or other mechanical issues involving the penis, which can also be addressed with modern technology. In fact, oral drugs, vacuum devices, injectable medications, psychotherapy and even surgery have made impotence very treatable. The promising news is that new drugs are sure to join existing non-invasive treatments while other experimental options, such as gene therapy, are on the horizon. In addition, ongoing modifications of today’s standard treatments will eventually improve the picture for impotent men.

Erectile dysfunction (ED) is the inability of a man to attain and/or maintain an erection sufficient for sexual activity. Fortunately, most men who have ED only lose the ability to have satisfactory erections. In other words, for most of these men, penile sensation is normal and the ability to have an orgasm and ejaculate (The fluid that is expelled from a man’s penis during sexual climax (orgasm). To release semen from the penis during an orgasm.) remains. Today, there are several treatment options available to men suffering from this disorder. Lifestyle changes are the first line of treatment with weight loss, smoking cessation and exercise associated with improved erections. For most men, the initial medical treatment will be an oral medication such as sildenafil citrate. If this treatment is unsuccessful, second-line treatment options are ordinarily considered. These include using a vacuum erection device (A device used for treatment of impotence that features a pump that draws air from a plastic cylinder placed over the penis and creates a vacuum that allows increased blood flow to the penis which causes and erection.), intraurethral medication (Medication administered via the urethra, the tube that carries urine outside the body from the bladder.) or penile injection therapy (Treatment for impotence that utilizes a combination of drugs that are injected into the side of the penis. The drugs relax the muscles and increase blood flow to create an erection.). If these second-line treatments fail or if the patient and his partner reject them, then the third-line treatment option, penile prosthesis implantation, is considered.

What are penile prostheses?

Penile prostheses are devices that are implanted completely within the body. They produce an erection-like state that enables the man who has one of these implants to have normal sexual intercourse. Neither the operation to implant a prosthesis nor the device itself will interfere with sensation, orgasm, ejaculation or urination. What are the different types of penile prostheses?

There are two erection chambers (corpora cavernosa) in the penis. All penile prostheses have a pair of components that are implanted within both of these erection chambers. The simplest penile prostheses consist simply of paired flexible rods that are usually made of medical-grade silicone, and produce a degree of permanent penile rigidity or firmness that enables the man to have sexual intercourse. These devices are either malleable (Able to be shaped or bent.) or inflatable. A malleable rod prosthesis can be bent downward for urination or upward for intercourse. Inflatable penile prostheses are fluid-filled devices that can be inflated for erection. They are the most natural feeling of the penile implants, as they allow for control of rigidity and size.

The inflatable devices have fluid-filled cylinders that are implanted within the erection chambers. Tubing connects these cylinders to a pump that is implanted inside the scrotum (Also referred to as the scrotal sac. The sac of tissue that hangs below the penis and contains the testicles.), the sac that contains the testicles (Also known as testis. Either of the paired, egg-shaped glands contained in a pouch (scrotum) below the penis. They produce sperm and the male hormone testosterone.). In the simplest of these inflatable devices, the pump transfers a small amount of fluid into the cylinders for erection, which then transfers out of the cylinders when erection is no longer needed. These devices are often referred to as two-component penile prostheses. One component is the paired cylinders and the second component is the scrotal pump.

Three-component inflatable penile prostheses have paired cylinders, a scrotal pump and an abdominal fluid reservoir. With these three-component devices, a larger volume of fluid is pumped into the cylinders for erection and out of the cylinders when erection is no longer needed.

What does penile prosthesis implantation involve?

Penile prostheses are usually implanted under anesthesia. Usually one small surgical cut is made either above the penis where it joins the abdomen or under the penis where it joins the scrotum. No tissue is removed, blood loss is small and blood transfusion (The transfer of blood from a healthy donor into the bloodstream of somebody who has lost blood or has a blood disorder.) is almost never required. A patient will typically spend one night in the hospital.

Most men have pain after penile prosthesis implantation for about four weeks. Initially, oral narcotic pain medication is required and driving is prohibited. If men limit their physical activity while pain is present, it usually resolves sooner. Men can often be instructed in using the prosthesis for sexual activity one month after surgery, but if pain and tenderness are still present, this is sometimes delayed for another month.

What are the complications of penile prosthesis surgery?

Infection occurs in 1 to 5 percent of cases. This is a significant complication because in order to eliminate the infection, it is almost always necessary to remove the prosthesis. In 1 to 3 percent of cases, erosion (The wearing away of surface tissue by disease, ulceration, cancer or the chemical processes associated with inflammation.) occurs when some part of the prosthesis protrudes outside the body. Erosion often is associated with infection and removal of the device is frequently necessary.

Mechanical failure is more likely to occur with inflatable than with rod prostheses. The fluid present inside the inflatable prosthesis leaks into the body; however, these prostheses contain normal saline (Containing salt.) that is absorbed without harm. After mechanical failure, another operation for prosthesis replacement or repair is necessary if the man wants to remain sexually active. Today’s three-component inflatable penile prostheses have about a 10 to 15 percent likelihood of failure in the first five years following their implantation.

Frequently asked questions:

Is penile prosthesis implantation covered by insurance?

Although all third-party payers do not cover penile prosthesis implantation, most including Medicare do if the prosthesis is implanted to treat erectile dysfunction caused by an organic disorder.

Will a penile prosthesis interfere with urination?

It normally does not.

Generic name: Vardenafil
Brand names: Levitra

Levitra is an oral drug for male impotence, also known as erectile dysfunction (ED).

Levitra is a phosphodiesterase inhibitor. It works by helping to increase blood flow into the penis during sexual stimulation. This helps you to achieve and maintain an erection.

Levitra causes erections only during sexual excitement. It does not work in the absence of arousal and does not increase sexual desire.

Take one Levitra tablet about one hour before sexual activity, with or without food.

Take Levitra only before sexual activity, but no more than once a day. Do not take two doses at once.

Store Levitra at room temperature.

Do not take Levitra if you are also using a nitrate drug for chest pain or heart problems. Levitra with a nitrate medicine can cause a serious decrease in blood pressure, leading to fainting, stroke, or heart attack.

Levitra can decrease blood flow to the optic nerve of the eye, causing sudden vision loss. This has occurred in a small number of people taking Levitra, most of whom also had heart disease, diabetes, high blood pressure, high cholesterol, or certain pre-existing eye problems, and in those who smoke or are over 50 years old. It is not clear whether Levitra is the actual cause of vision loss.

Stop using Levitra and get emergency medical help if you have sudden vision loss.

Before taking Levitra, tell your doctor if you are allergic to any drugs, or you have:

• heart disease or heart rhythm problems;
• a recent history (in the past 6 months) of a heart attack, angina (chest pain), or congestive heart failure;
• a recent history of stroke or blood clots;
• a personal or family history of “Long QT syndrome”;
• high or low blood pressure;
• liver disease;
• kidney disease (or if you are on dialysis);
• a blood cell disorder such as sickle cell anemia, multiple myeloma, or leukemia;
• a bleeding disorder such as hemophilia;
• a stomach ulcer;
• retinitis pigmentosa (an inherited condition of the eye);
• a physical deformity of the penis (such as Peyronie’s disease); or
• if you have been told you should not have sexual intercourse for health reasons.

If you have any of these conditions, you may need a dose adjustment or special tests to safely take Levitra.

Seek emergency medical attention if you think you have used too much of Levitra. Overdose symptoms may include back pain, muscle pain, or vision problems.

Avoid drinking alcohol, which can increase some of the side effects of Levitra.

Grapefruit and grapefruit juice may interact with Levitra. Discuss the use of grapefruit products with your doctor. Do not increase or decrease the amount of grapefruit products in your diet without first talking to your doctor.

Do not use any other drug to treat impotence, such as alprostadil (Caverject, Muse, Edex) or yohimbine (Yocon, Yodoxin, others), unless your doctor tells you to.

Stop using Levitra and call your doctor at once if you have any of these serious side effects:

• sudden vision loss;
• ringing in your ears, or sudden hearing loss;
• chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;
• irregular heartbeat;
• swelling in your hands, ankles, or feet;
• shortness of breath;
• vision changes;
• feeling light-headed, fainting; or
• penis erection that is painful or lasts 4 hours or longer.

Less serious side effects may include:

• warmth or redness in your face, neck, or chest;
• stuffy nose;
• headache;
• upset stomach; or
• back pain.

This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.

Vardenafil is available with a prescription under the brand name Levitra.

You may buy/order Levitra (Vardenafil) online here.

Erectile dysfunction (ED) is a medical term that describes the inability to achieve and or maintain an erect penis adequate for sexual function. This condition is one of the most common sexual problems for men and the number of men suffering from ED increases with age. Approximately 25 million American men suffer from ED, although not all men are equally distressed by the problem.

What happens under normal conditions?

Achieving a normal erection is a complex process involving psychological impulses from the brain, adequate levels of the male sex hormone testosterone (Male hormone responsible for sexual desire and for regulating a number of body functions.), a functioning nervous system, and adequate and healthy vascular tissue in the penis. The simplest way to describe the process of erection is to think of a washing machine. The “on-off” switch (the brain) initiates the process; the wires in the washing machine (the nerves) carry the electrical signal to the pipes (the blood vessels), when an appropriate signal arrives a valve opens to allow water to flow in (the arteries carry blood into the penis) and the drain shuts (the penile veins close). Water flows in and fills the tank (the penis fills with blood and becomes erect) and the wash cycle begins (enjoys sexual activity). At the end of the wash cycle this process reverses, the switch goes to the off position (the brain terminates erection), the valve closes (the arteries markedly decrease blood inflow) and the drain opens draining the wash tank of water (the veins open, blood leaves the penis and erection subsides).

What are the risk factors for ED?

There are risk factors for the development of ED. As men age, the level of circulating testosterone decreases, which may interfere with normal erection. While a low testosterone level itself is rarely the cause of ED (5 percent or less), low testosterone can be an additional contributing factor in many men who have other risk factors for ED. Low levels of sexual desire, lack of energy, mood disturbances and depression can all be symptoms of low testosterone. A simple blood test can determine if the testosterone level is abnormally low, and testosterone can be replaced using a number of different delivery systems (e.g., shots, skin patches, gels, pills placed under the tongue).

What are some causes of ED?

By far, the most important cause of the development of ED is the presence of illnesses like high blood pressure, diabetes mellitus (A condition characterized by high blood sugar resulting from the body’s inability to use sugar (glucose) as it should. In type 1 diabetes, the pancreas is not able to make enough insulin; in type 2 diabetes, the body is resistant to using available insulin.), high cholesterol levels and cardiovascular disease. These processes, acting over time, can lead to a degeneration of the penile blood vessels, leading to restriction of blood inflow through the arteries and also to leakage of blood through the veins during erection.

The choices we make in life can lead to degeneration of the erectile tissue and the development of ED. Smoking, drug or alcohol abuse, particularly over a long period of time, will compromise the blood vessels of the penis. Lack of exercise and a sedentary lifestyle will contribute to the development of ED. Correction of these conditions will contribute to overall health and may in some individuals correct mild ED. Treatment of many medical conditions can interfere with normal erections. Drugs used to treat these risk factors listed above may also lead to or worsen ED. Patients undergoing surgery or radiation therapy for cancer of the prostate (In men, a walnut-shaped gland that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.), bladder, colon (Large intestine.) or rectum (The lower part of the large intestine, ending in the anal opening.) are at high risk for the development of ED.

How is ED diagnosed?

For most patients, the diagnosis will require a simple medical history, physical examination and a few routine blood tests. Most patients do not require extensive testing before beginning treatment. The choice of testing and treatment depends on the goals of the individual. If erection returns with simple treatment like oral medication and the patient is satisfied, no further diagnosis and treatment are necessary. If the initial treatment response is inadequate or the patient is not satisfied,then further steps may be taken. In general, as more invasive treatment options are chosen, testing may be more complex.

What are some non-surgical treatments?

The first line of therapy for uncomplicated ED is use of oral medications known as phosphodiesterase-5 inhibitors (PDE-5)  - sildenafil citrate, vardenafil HCl or tadalafil. Men with ED take these pills before beginning sexual activity and the drugs boost the natural signals that are generated during sex, thereby improving and prolonging the erection itself. These medications are safe and fairly effective, with improvement in erection in nearly 80 percent of patients using these drugs. Early concerns about possible bad effects on the heart have not proven true; after extensive testing and five years of use, sildenafil citrate can be used safely by all heart patients except those using medications called nitrates because of an interaction between these two classes of drugs. The side effects of PDE-5 inhibitors are mild and usually transient, decreasing in intensity with continued use. The most common side effects are headache, stuffy nose, flushing and muscle aches. In rare cases, sildenafil can cause blue-green shading of vision due to high blood levels of sildenafil exerting a brief effect on the retina of the eye. This is of no long-term risk and is gone within a short time as the amount of sildenafil in the blood decreases. It is important to follow the instructions for using these medications in order to get the best results. Tests have shown that 40 percent of men who do not respond to sildenafil will respond when they receive proper instruction on medication use.

For men who do not respond to oral medications another drug, alprostadil, is approved for use in men with ED. This drug comes in two forms: injections that the patient places directly into the side of the penis and a transurethral suppository. Success rates with self-injection can reach 85 percent. Modifying alprostadil to allow transurethral delivery avoids the need for a shot, but reduces the effectiveness of the agent to 40 percent. The most common adverse effects of alprostadil use are a burning sensation in the penis and the risk of over correcting the problem, resulting in a prolonged erection lasting over four hours and requiring medical intervention to reverse the erection.

For men who cannot or do not wish to use drug therapy, an external vacuum device may be acceptable. This device combines a plastic cylinder or tube that slips over the penis, making a seal with the skin of the body. A pump on the opposite end of the cylinder creates a low-pressure vacuum around the erectile tissue, which results in an erection. To keep the erection once the plastic cylinder is removed a rubber constriction band goes around the base of the penis, which maintains the erection. With proper instruction 75 percent of men can achieve a functional erection using a vacuum erection device.

There are some men who have severe degeneration in the tissues of the penis, which makes them unable to respond to any of the treatments listed above. While this is a small number of men, they usually have the most severe forms of ED. Patients most likely to fall into this group are men with advanced diabetes, men who suffered from ED before undergoing surgical or radiation treatment for prostate or bladder cancer and men with deformities of the penis called Peyronie’s disease (A plaque (hardened area) that forms on the penis, preventing that area from stretching. During erection, the penis bends in the direction of the plaque, or the plaque may lead to indentation and shortening of the penis.). For these patients reconstructive prosthetic surgery (placement of a penile prosthesis or “implant”) will restore erection, with patient satisfaction rates approaching 90 percent. Surgical prosthetic placement normally can be performed in an outpatient setting or with one night of hospital observation. Possible adverse effects include infection of the prosthesis or mechanical failure of the device.

What can be expected after treatment?

All of the treatments above, with the exception of prosthetic reconstructive surgery, are temporary and meant for use on demand. The treatments compensate for but do not correct the underlying problem in the penis. So it is important to follow-up with your doctor and report on the success of the therapy. If your goals are not reached, if your erection is not of sufficient quality or duration and you are still distressed, you should explore the alternatives with your doctor. Because the medications used are not correcting the problems leading to ED, your response over time may not be what it once was. If such should occur again, have a repeat discussion with your physician about the remaining treatment options.

Frequently Asked Questions

How do I know my ED is not in my head?

Many years ago most men with ED were thought to have psychological problems. This was the result of our ignorance of the normal mechanism of erection and the causes of ED. We now realize that most men have underlying physical causes.

If I worry about my ability to get an erection can I make a bad condition worse?

Nothing happens in the body without the brain; worrying about your ability to get an erection can itself interfere with the process. This condition is called performance anxiety and can be overcome with education and treatment.

Can I combine treatment options?

This is often done but because of the risk of prolonged erections with drug therapy it should only be performed under physician supervision. Ask your doctor for proper instructions.

I was fine until I began taking this new drug, what should I do?

Many drugs can cause ED, but some cannot be changed because the benefits outweigh the adverse effects. If you are fairly certain that a specific drug has caused the problem, discuss the possibility of a medication change with your doctor. If you must remain on the specific medication causing the problem, the treatment options outlined above can still be used in most cases.

Generic name: Tadalafil
Brand names: Cialis

Cialis is an oral drug for male impotence, also known as erectile dysfunction (ED). It works by dilating blood vessels in the penis, allowing the inflow of blood needed for an erection. Cialis relaxes muscles and increases blood flow to particular areas of the body.

Cialis causes erections only during sexual excitement. It does not work in the absence of arousal and does not increase sexual desire.

Do not take Cialis if you are also using a nitrate drug for chest pain or heart problems. This includes nitroglycerin (Nitrostat, Nitrolingual, Nitro-Dur, Nitro-Bid, and others), isosorbide dinitrate (Dilatrate-SR, Isordil, Sorbitrate), and isosorbide mononitrate (Imdur, ISMO, Monoket). Nitrates are also found in some recreational drugs such as amyl nitrate or nitrite (“poppers”). Taking Cialis with a nitrate medicine can cause a serious decrease in blood pressure, leading to fainting, stroke, or heart attack.

Do not take Cialis more than once a day. Allow 24 hours to pass between doses.

Contact your doctor or seek emergency medical attention if your erection is painful or lasts longer than 4 hours. A prolonged erection (priapism) can damage the penis.

Cialis can decrease blood flow to the optic nerve of the eye, causing sudden vision loss. This has occurred in a small number of people taking Cialis, most of whom also had heart disease, diabetes, high blood pressure, high cholesterol, or certain pre-existing eye problems, and in those who smoke or are over 50 years old. It is not clear whether this medication is the actual cause of vision loss.

Before taking Cialis, tell your doctor if you are allergic to any drugs, or if you have:

• heart disease or heart rhythm problems;
• a recent history a heart attack (within the past 90 days);
• a recent history of stroke or congestive heart failure (within the past 6 months);
• angina (chest pain);
• high or low blood pressure;
• liver disease;
• kidney disease (or if you are on dialysis);
• a blood cell disorder such as sickle cell anemia, multiple myeloma, or leukemia;
• a bleeding disorder such as hemophilia;
• a stomach ulcer;
• retinitis pigmentosa (an inherited condition of the eye);
• a physical deformity of the penis (such as Peyronie’s disease); or
• if you have been told you should not have sexual intercourse for health reasons.

If you have any of these conditions, you may need a dose adjustment or special tests to safely take Cialis.

Take one Cialis tablet before sexual activity, with or without food. The best time to take Cialis depends on how and when the drug works for you, but some men are able to have an erection 30 minutes after taking it. Others are able to wait up to 36 hours after taking Cialis before engaging in sexual activity.

Take Cialis only before sexual activity, but no more than once a day. Do not take two doses at once.

Seek emergency medical attention if you think you have used too much of Cialis. Overdose symptoms may include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

Store Cialis at room temperature.

Avoid drinking alcohol, which can increase some of the side effects of Cialis.

Avoid using other medicines to treat impotence, such as alprostadil (Caverject, Muse, Edex) or yohimbine (Yocon, Yodoxin, others), without first talking to your doctor.

Stop using Cialis and call your doctor at once if you have any of these serious side effects:

• sudden vision loss;
• ringing in your ears, or sudden hearing loss;
• chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;
• irregular heartbeat;
• swelling in your hands, ankles, or feet;
• shortness of breath;
• vision changes;
• feeling light-headed, fainting; or
• penis erection that is painful or lasts 4 hours or longer.

Less serious side effects may include:

• warmth or redness in your face, neck, or chest;
• stuffy nose;
• headache;
• upset stomach; or
• back pain.

This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.

You may buy/order Cialis (Tadalafil) online here.

Erectile dysfunction (ED), or the inability to get an erection, is a complex condition with many possible causes. The cardiovascular system, specifically the thin layer of cells lining the blood vessels called the endothelium, is believed to play a major role in some cases of ED.

The presence of ED can often be one of the earliest signs of problems in endothelial function that may later progress to heart disease. In such cases of ED, the vascular endothelium loses its capacity to form nitric oxide, which is necessary to dilate the blood vessels in the penis that cause an erection.

If this hypothesis is correct, then a drug designed to treat this damaged vascular endothelium, such as a statin, should help men with ED who do not respond to treatment with Viagra.

One small but promising study involved men who previously failed treatment with Viagra alone. The men were given 80 mg daily of the statin Lipitor or a placebo. Both groups also received 100 mg tablets of Viagra to use for sexual purposes. After 12 weeks, the Viagra-plus-Lipitor group had statistically significant improvement in erectile function, while the placebo group showed no such improvement.

Although the number of men in the study was small, the results nonetheless are promising enough for the authors to call for larger trials to be done.

You may be able to avoid erection problems (erectile dysfunction) related to anxiety and stress by taking a more relaxed approach to lovemaking. Talk to your partner about your problems and concerns. Sexual intimacy is a form of communication. If you and your partner talk about your lovemaking, it will help reduce your stress and anxiety and you may become more relaxed.

Erections may gradually become more difficult to get and maintain as you get older. However, foreplay—erotic stimulation before intercourse—and the right environment can help increase your ability to have an erection, regardless of your age.

Other things you can do that may reduce your risk for developing an erection problem include:

• Quitting smoking.
• Avoiding use of excess alcohol and illegal drugs.
• Keeping your cholesterol level low to reduce the risk of hardening of the arteries (atherosclerosis).
• Treating high blood pressure.
• Keeping your blood sugar in a safe range if you have diabetes.
• Exercising regularly.
• Lowering stress in your life.

Seek care immediately if you use medication to treat an erection problem (erectile dysfunction) and the erection lasts longer than 4 hours.

Seek care immediately if you have taken phosphodiesterase-5 inhibitors (such as Viagra, Levitra, Cialis) in the past 24 hours and are having chest pain. Tell your health professional you are taking this medication. Do not use any form of nitroglycerin if you have chest pain and have taken Viagra, Levitra, or Cialis in the past 24 hours.

Call a health professional if erection problems occur with:

• Any type of injury to the back, legs, buttocks, groin, penis, or testicles.
• A loss of pubic or armpit hair and an enlargement of the breasts.

Make an appointment to see a health professional within 1 to 2 weeks if an erection problem occurs more than 25% of the time and the problem:

• Occurs with a persistent backache.
• Occurs after you start taking a new medication or change the dose of a medication.
• Is affecting your self-image or sense of well-being.
• Has not improved despite self-care.

If your erection problem is occasional, there is no reason to call your health professional. If it occurs frequently but does not bother you or your partner, you may or may not choose to call your doctor. However, an erection problem that develops suddenly may be a sign of a disease; it is recommended that you see your doctor.

Watchful Waiting

Watchful waiting is a period of time during which you and your health professional observe your symptoms or condition without using medical treatment. A single episode of an erection problem is often a temporary and easily reversible problem. Do not assume it will happen again. If possible, forget about it and expect a more successful experience the next time. If you or your partner is concerned about it, talk about the problem and openly discuss your fears and anxieties.

If self-care has not helped after 2 weeks and you are concerned about your inability to have an erection, see a health professional who has experience in dealing with erection problems.

Who To See

Some health professionals, including doctors and mental health professionals, may not feel comfortable discussing sexuality and erection problems. Ask your health professional if he or she feels comfortable with and has experience in working with men who have erection problems.

The following health professionals can evaluate symptoms of erection problems:

• Family medicine doctor
• Internist
• Nurse practitioner
• Physician assistant
• Urologist

If it is possible that a psychological problem is contributing to your erection problem, your doctor may refer you to a health professional such as a:

• Psychiatrist.
• Psychologist.
• Certified licensed social worker.
• Counselor with special training in sexuality or relationship problems.

Symptoms of erection problems (erectile dysfunction) include being unable to:

• Have an erection at any time, either with masturbation or with a sex partner.
• Maintain an erection firm enough for sexual intercourse.
• Maintain an erection long enough to complete sexual intercourse.

Even with an erection problem, a man may still have sexual desire and be able to have an orgasm and to ejaculate.

What is erectile dysfunction?

Erectile dysfunction, sometimes called impotence, refers to a man’s consistent inability to get or maintain an erection sufficient to have satisfactory sex. It does not mean a lack of sexual interest or desire or the occasional difficulty achieving or maintaining an erection that affects all men at some time in their life.

Normally, an erection occurs when your imagination or one or more senses (vision, hearing, touch, smell, taste) are stimulated and you become aroused. Your central nervous system sends nerve impulses that increase blood flow to your penis. Four requirements for a normal erection are:

• A properly functioning nervous system that sends the necessary signals to the penis.
• An intact system of blood vessels to allow blood to flow into and out of the penis.
• Normal smooth muscle in the penis, which must relax so the penis can fill with blood and enlarge.
• The ability to trap the blood in the penis so that it stays firm.

See an illustration of the male reproductive system below.

Illustration copyright 2000, 2003 Nucleus Communications, Inc. All rights reserved.

The male reproductive system consists of the penis, two testicles, two epididymides, two vas deferentia, two seminal vesicles, and the prostate gland.

Erectile dysfunction can occur at any age but is more common in older men, who often have additional health problems or who may be taking medications that may interfere with normal erectile function. Treatment of erection problems in older men can be as effective as in younger men.

Doctors prefer to use the term erectile dysfunction instead of impotence. A man’s sexual function involves more than an erection, and the term impotence often carries negative implications. For ease of reading, this post uses the term erection problems to refer to erectile dysfunction.

Erection problems can affect your sexual life and your relationship. Discussing the issue with your partner and exploring other forms of intimacy can help improve your relationship and the erection problem.

What causes erection problems?

The cause of erection problems may be physical (such as injury to nerves or loss of blood supply to the penis) or psychological (such as anxiety or depression). Medications you are taking for other conditions, alcohol consumption, smoking, or illegal drug use also can cause erection problems.

Certain conditions may affect the nervous system or blood flow to the penis, increasing the risk for erection problems. These include diabetes, high blood pressure, high cholesterol, atherosclerosis, multiple sclerosis, and Parkinson’s disease.

What are the symptoms?

The only symptom of an erection problem is the inability to have or maintain an erection that is firm enough to consistently have sexual intercourse. This inability may or may not be related to sexual interest or the ability to have an orgasm and to ejaculate.

How are erection problems diagnosed?

A health professional can diagnose an erection problem using a medical and sexual history and a physical examination. Your health professional will want to know whether the erection problem occurs all the time or occasionally. The initial exam, laboratory tests, and possibly psychological tests can help determine whether the problem is physical, psychological, or a combination of the two.

How are they treated?

Treatment often includes lifestyle changes, such as avoiding tobacco, drugs, and alcohol. Discussing the issue with your partner, participating in sensual exercises, and seeking counseling may help. Further treatment may include oral medications (such as Viagra, Levitra, or Cialis), vacuum devices, or injection of medications into the penis. Surgery to place an implant in the penis also is an option.

Do not take Viagra, Levitra, or Cialis if you are taking nitrate medications—such as nitroglycerin—for heart problems. The combination of nitrates and any of these medications can lower your blood pressure to a dangerous level. You also should not take certain alpha-blockers (used to lower blood pressure and to treat an enlarged prostate) with these medications because of the risk of a dangerous drop in blood pressure. Check with your health professional to see whether you can take Viagra, Levitra, or Cialis with your alpha-blocker.

Can I prevent erection problems?

To reduce your risk of developing an erection problem, avoid smoking, drinking too much alcohol, and using illegal drugs.

Because erection difficulties are most often caused by a physical problem, maintaining good health through diet and exercise is very important. A relaxed approach to lovemaking and good communication with your partner can help prevent erection problems caused by psychological factors.

Author: Marianne Flagg