Cialis Sublingual
"Generic 20 mg cialis sublingual with amex, erectile dysfunction treatment doctors in bangalore."
By: Paul Reynolds, PharmD, BCPS
- Critical Care Pharmacy Specialist, University of Colorado Hospital
- Clinical Assistant Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
http://www.ucdenver.edu/academics/colleges/pharmacy/Departments/ClinicalPharmacy/DOCPFaculty/Q-Z/Pages/Paul-Reynolds,-PharmD.aspx
Comparative cross-over study of sildenail and apomorphine for treating erectile The authors consider that several trials comparing dysfunction erectile dysfunction causes agent orange buy line cialis sublingual. An open- with other published studies suffering from design label erectile dysfunction drugs gnc buy 20 mg cialis sublingual free shipping, randomized erectile dysfunction medicine for heart patients generic cialis sublingual 20mg otc, lexible-dose erectile dysfunction treatment with diabetes order cialis sublingual online pills, crossover study to assess the comparative eficacy and safety of sildenail citrate and limitations [13-15]. All Level 1 studies were all open apomorphine hydrochloride in men with erectile dysfunc-- label studies, but all were otherwise well designed tion. Eficacy of apo-- morphine and sildenail in men with nonarteriogenic erectile dysfunction. Switching patients with erectile dysfunction from sildenail citrate to tadalail: results of a European multicenter, open-label study of patient The dawn of the age of pharmacologic treatment be-- preference. Clin Ther 2003; 25: 2724–37 gan 25 years ago with the recognition that vasoactive [4] Von KeitzA, Rajfer J, Segal Set al. A multicenter, randomized, drugs when injected in to the penile erectile tissue were double-blind, crossover study to evaluate patient preference capable of initiating and maintaining erection [1,2]. Comparing These were relegated to second line therapy after vardenail and sildenail in the treatment of men with erec-- tile dysfunction and risk factors for cardiovascular disease: the appearance of effective oral phosphodiesterase- a randomized, double-blind, pooled crossover study. J Sex Med 2006; 3: 650–61 to progression of their disease and thirdly are a small [8] Eardley I, Montorsi F, Jackson G et al. Several observational reports and extension examining the eficacy of intracavernosal two randomized clinical trials are available for review. In a second observational series, 52 men psychogenic, or mixed causes, alprostadil also dem-- received 30 micrograms vasoactive intestinal poly-- onstrated signiicant eficacy. In this label lexible dose self-injection study in 683 men, report all patients obtained erection suficient for 94 percent of patients had better erections after the penetration with a median duration of treatment was injections. This was followed with a placebo-controlled determine the optimal dose, these patients used al-- phase, during which 171 patients were subsequently prostadil (up to 40 µg) at home for up to 6 weeks. The combination of vasoactive intestinal polypeptide We are able to conclude, on the basis of this evi-- and phentolamine appears to be safe and well dence that intracavernosal prostaglandin E1 is an tolerated. Most commonly observed adverse effects effective treatment for men with erectile dysfunction were facial lushing and headache, characteristic (Grade of Recommendation = A). Some evidence exists to fective as intracavernosal pharmacotherapy for erec-- support the use of sympathomimetic drugs, such as tile dysfunction [2]. Both terbu-- en out of favor as monotherapy because of its high taline and pseudoephedrine performed better than rates of ibrosis. In one series 163,042 papaverine placebo, with detumescence resulting in 36%, 28% injections were administered to 1,748 patients. None re-- Priapism occurred in 106 (6%) of patients after 235 quired surgical intervention. Fibrosis or nodule forma-- (1994) showing detumescence in 42% of patients tion occurred in 187 (11%) of patients [12]. There is no treatment to reverse penile ibrosis, Combination therapies for intracavernosal injections though it sometimes regresses on its own. One dificulty encountered with change to more invasive methods of improving erec-- the use of combination agents is the need for the tile function, i. Concentrations of each alprostadil, 4% with papaverine, 12% with bimix [13] component vary widely in the literature, but ratios and 12-15% with trimix [14, 15] Signiicantly it has of 12-30mg papaverine: 10-20?g alprostadil:1mg been observed that pain decreases substantially phentolamine appear standard. Bechara et al reported a crossover study of alprosta-- dil versus trimix in a group of 32 men who had failed 6. These notably include men with sickle cell disease, Rates of pain for alprostadil was signiicantly higher multiple myeloma and leukemia. In a series multiple combinations of trimix ingredients versus al-- of 605 injections in 33 men using warfarin for prostadil in a 180 men with erectile dysfunction [15]. This rate of 9% of patients is fective and produce erections that are of equal fre-- comparable to the 14% (434/3143) of patients on quency and quality to those produced by alprostadil. How-- is advisable that the physician stress the need, in ever, duration of erections was longer than alprosta-- anticoagulated patients, to place pressure on the dil and a larger number of episodes of priapism (5% injection site for ive full, uninterrupted minutes of vs. Side Notable in this study, 995/1511 patients had in-ofice effect rates are noted in Table 12. To There have been several advances in the under-- date no suficiently effective product exists.. In this regard there are several issues worth mentioning: 1) High systemic levels are A large trial of topical alprostadil without a skin pen-- undesirable as they may result in an unacceptable etration enhancer was also published by Padma- level of adverse events. This study used 100, 200 and the corpora cavernosa in a timely fashion with the 300?g doses of alprostadil and achieved successful effective (highest) concentration. A criticism of this study is that its Topical penile therapy has a unique set of anatomic high initial function rates do not adequately represent and physiologic issues that are important to consider. There are several anatomic/fascial layers between the penile skin and the corpus cavernosa. Therefore, topical Since the introduction by Virag in the early 1980s of treatment trials have empathized exposure to the injection of papaverine in to the corporal bodies for glans penis as it has direct venous communication the treatment of sexual dysfunction has become a to the corpora cavernosa [27,28]. It use as a a relatively impermeable tissue due to the stratum topical therapy has a much shorter experience and corneum. The horny cells at the stratum corneum one that has not moved beyond preliminary clinical are bonded with a very tight intercellular lipid matrix trials. Serum papaverine levels after topical adminis-- bilayer that makes the passage of drugs challenging tration have been measured in a single study with a [29]. To overcome this barrier investigators have high performance liquid chromatography assay [35]. Fortunately, the suggesting that absorption did occur, but not signii-- penis and scrotum are unique in that their stratum cantly over baseline values. The papaverine levels corneum is the most permeable of all anatomic in this study indicated that topical absorption is less locations tested. Relaxation of vascular of the excipients in topical formulations have been smooth muscle is the principle pharmacologic action reported [27,28,31,32]. Nitroglycerin produces, in a dose is to: 1) Disrupt the stratum corneum lipid bilayer, dependent manner, dilation of both arterial and 2) Interact with the membrane keratin, 3) Produce venous beds, dilatation of the post-capillary vessels a weak interaction with the drug molecule, and 4) including large veins and decreases in venous return. The available evi-- Contraindications to the use of topical nitroglycerin dence indicates that this agent enhances skin pen-- include those who have allergic reactions to organic etration by altering the luidity of lipids in the stratum nitrates. These are extremely rare, but they do corneum, without any interaction with the chemical occur. Intra-cavern-- safe in patients with erectile dysfunction after failing silde-- ous Alprostadil-A Comparative Study in 103 Patients With nail (Viagra). Multicenter, intestinal polypeptide and phentolamine mesylate adminis-- double-blind, placebo-controlled evaluation of the erectile tered by autoinjector in the treatment of patients with erec-- response to transurethral alprostadil in men with chronic tile dysfunction resistant to other intracavernosal agents. Dermal and transdermal with intracavernosal vasoactive intestinal polypeptide and drug delivery: new insights and perspectives. Prostate cancer represents the second most common As with all areas of sexual medicine, the literature has solid malignancy diagnosed in adult men in many areas of great strength and signiicant weaknesses, Western societies. These dysfunctions injury has on cavernous smooth muscle content and include reduction in libido, anejaculation, alterations function as well as potentially the tunica albuginea[6- in orgasm, penile size alterations and possibly 8]. Anejaculation The concept of penile rehabilitation, the use of has several implications: irstly, it may interfere with any intervention or combination of interventions subject’s self perception of his manhood and body (medications, devices or actions) whose goal is image. Then as ejaculation and orgasmic sensations broadly thought of as being aimed at restoring erectile are closely related at least in some men, anejaculation function to pre-treatment levels, is believed to be may be associated with reduced orgasmic quality, based on three inter-related concepts: (i) improving and inally, it renders men infertile. Prostate cancer is cavernosal oxygenation, (ii) promoting endothelial perceived as a disease of old men, to whom infertility protection and (iii) preventing cavernosal nerve is no longer an issue. Most diagnosis may actually increase the motivation for patients (55%) had orgasm-associated pain for less parenting[20]. Though advanced sperm extraction than a minute, a third reported pain for 1–5 minutes and fertilization techniques are available, the issue and pain lasting more than 5 minutes was reported of anejaculation and its implication on future fertility by 12%; only 2. No consensus exists assume this to be non-relevant and semen should as to the etiology of orgasmic pain, however it is be cryopreserved for men who may potentially postulated that bladder neck/pelvic loor spasm plays bmay desire future fatherhood[21]. Based on this assumption, a prospective, the application of assisted reproductive technologies non-placebo controlled study was conducted to to couples whose male partner cannot deliver assess the use of tamsulosin, an alpha-adrenergic sperm in an antegrade fashion. Alternatively use of an analgesic taken physiological and psychogenic elements contribute prior to sexual activity has been described may be a to the genesis of orgasm. Schover et al, in a study a few drops in 58% of the subjects but 16% reported of 1236 men treated for localized prostate cancer a loss of more than 1 ounce. Treatment the sample reported a problem with their orgasms was bladder emptying in 84% and condoms use in including 31% who no longer tried to reach orgasm, 11% [27]. At present, there is no effective treatment presence or absence of orgasm, orgasm quality to restore the nature of preoperative orgasm. Pain to sexual activity) or mechanically (using a rubber during orgasm occurred in 14% of the patients, constriction ring or condoms, if the leakage amount located in the penis (63%), abdomen (9%), rectum is small).
Corona flattening can occur on occasion and may require revision surgery done at the same time of the 2nd stage surgery (typically penile and testicular implantation) Erectile implants Roughly nine months after the penis is created erectile dysfunction treatment herbs discount cialis sublingual 20mg visa, the patient can have a penile implant placed to impotent rage man order 20mg cialis sublingual free shipping allow rigidity for penetration erectile dysfunction drugs online generic cialis sublingual 20 mg online. As such erectile dysfunction pills sold at gnc buy cheap cialis sublingual 20mg line, implants created for non-transgender males with erectile dysfunction are rigidly fixed to the pubic bone. Pre and post op antibiotics reduce the risk, as well as intraoperative sterile technique. Erosion is when the implant protrudes through the skin of the phallus or the urethra. The presence of sensation in the phallus, and avoiding an excessively large implant reduce the risk of erosion. Dysuria Should a recently postop phalloplasty patient have dysuria, the best approach is to obtain a urine culture. Urinalysis is of little value as white and red cells can be detectable in normal post op patients for months after reconstruction. If a urine culture is positive, the infection should be treated with culture specific antibiotics. If it is negative, the most likely culprit is a urethral stricture, which should be evaluated by the surgeon who performed the phalloplasty, or if unavailable, a local urologist. Metoidioplasty Metoidioplasty (metaoidioplasty) is a Greek word that means “towards male genitalia. Patients may opt to have a urethra placed in the phallus, but not all patients choose to do this. A scrotum can also be created from the labia majora and a vaginectomy may be performed. Because metoidioplasty is a shorter procedure, occasionally hysterectomy is performed at the same time as metoidioplasty. Some surgeons may use tissue expanders to create the scrotum, while others do not find this necessary. Testicular implants are typically placed at a second stage approximately 4 months later. While the phallus is not large enough to accept a penile implant, erections are possible since the procedure involves the use of natal clitorial and other genital tissues. Complications associated with metoidioplasty are very similar to free flap phalloplsaty, except for flap loss since no flap is used. Wound breakdown, infection, urethral stricture and fistula are all seen in similar anatomic sites to that of free flap phalloplasty, although the incidence is lower in metoidioplasty. Risks such as coronal flattening do not occur in metoidioplasty, as the corona does not require sculpting in metoidioplasty. Management of complications similar to as is detailed in the phalloplasty section. Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. June 17, 2016 150 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 2. June 17, 2016 151 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 31. In the National Transgender Discrimination Survey, 21% of trans men surveyed had undergone hysterectomy. Also unclear is how reproductive desires may play in to decisions about hysterectomy and or oophorectomy. Furthermore, it is unclear from this study what proportion of these hysterectomies were due to a medically pathologic condition rather than gender dysphoria, since hysterectomy is one of the most common non-obstetrical surgical procedures. A study of 134 transgender men reported a diversity of indications for hysterectomy, though most procedures were performed for gender affirmation. In that study, 58% underwent hysterectomy because organs were incongruent with current gender identity, 47% for further physical masculinization, 43% to facilitate a change in legal documents, and 37% to avoid future gynecological appointments. However, this same study also noted that for many this procedure was seen as “preventive” in 59%, was performed because of pre-existing medical problems in 26%, specifically for “tumors, cysts, fibroids or endometriosis” in 22% or to stop extreme bleeding and cramping in 22%. Surgical approaches Best practice for the surgical approach to hysterectomy in transgender men has not been studied. Based on existing evidence, the American Congress of Obstetricians and Gynecologists has stated that for patients in whom the approach is appropriate, a vaginal approach has the fewest complications and blood loss, quickest recovery, and is the most cost-effective. Initial data [5,6] support the notion that vaginal hysterectomy is appropriate for transgender men. Many other studies have noted that laparoscopic hysterectomy, the second least invasive form of hysterectomy, is also possible and can successfully be accomplished without additional complications. For example if a transgender man undergoing hysterectomy has no plans for penetrative vaginal intercourse in the future, the vaginal cuff closure could be much more exterior, such that less of a vaginal orifice remains. Similarly, vaginectomy (removal of vaginal mucosal tissue) and colpocleisis (closure of the vaginal canal) could be performed if no vaginal orifice is desired, as long as there is no desire for future genital reconstructive surgery that would make use of the vaginal mucosa (for urethral lengthening etc). Finally, consideration of whether to retain or remove the ovaries and fallopian tubes at the time of surgery is also a personal decision and will be based on considerations of patient desire, future fertility, plans for exogenous (steroid) hormone administration, and other pathology that may be aided or exacerbated by ovarian removal (e. Hysterectomy and oophorectomy experiences of female-to-male transgender individuals. Vaginal hysterectomy as a viable option for female-to-male transgender men: Obstet Gynecol. June 17, 2016 153 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 6. Vaginectomy and laparoscopically assisted vaginal hysterectomy as adjunctive surgery for female-to-male transsexual reassignment: preliminary report. Hysterectomy and bilateral salpingoovariectomy in a transsexual subject without visible scarring. Combined hysterectomy/salpingo-oophorectomy and mastectomy is a safe and valuable procedure for female-to-male transsexuals. June 17, 2016 154 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 32. In this practice, the testicles (if present) are moved in to the inguinal canal, and moving the penis and scrotum posteriorly in the perineal region. Tight fitting underwear, or a special undergarment known as a gaffe is then worn to maintain this alignment. In addition to local skin effects, this practice could result in urinary trauma or infections, as well as testicular complaints, which are covered elsewhere. Packing is the placing of a penile prosthesis in one’s underwear, giving both an outward appearance as well as reducing gender dysphoria. Binding involves the use of tight fitting sports bras, shirts, ace bandages, or a specially made binder to provide a flat chest contour. In some people with larger breasts, multiple garments may be used, and breathing may be restricted. Prolonged binding may result in breast pain, local skin irritation, or fungal infections. June 17, 2016 155 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 33. Barriers include access to trans-experienced aesthetic providers, transportation, affordability, and confusion regarding the options, risks and benefits. Transgender woman typically seek hair removal on the face, neck, as well as in the genital area in the case of pre-operative preparation for vaginoplasty. Methods: pros and cons of each The hair growth cycle consists of three successive stages that include the anagen (growth) phase, the catagen (transitional) phase, and the telogen (resting) phase. Time in each phase can vary by location, from an anagen phase of one to two months on the body, to two to six years on the scalp. Treatments are typically every 4-8 weeks, depending on the treatment location, as the hair growth cycles vary by area. Treatments should be avoided when photosensitizing medications are being used (see table [18]). Flashing lights have been known to induce seizures in susceptible patients, so patients should be screened for this risk. Protective, wavelength specific, eye-ware is used during non-facial body treatments. John’s wort in the last year, autoimmune diseases such as lupus, scleroderma, vitiligo. There are three types of electrolysis; galvanic (direct electrical current produces a chemical reaction), thermolysis (diathermy: short-wave which produces heat) and blend (combination of galvanic and thermolysis).
Buy cialis sublingual with a mastercard. 🥒 12 Simple Ways To Cure Weak Erection | Erectile Dysfunction Cure and Treatment (Updated 2019).
In the first trial erectile dysfunction pills in south africa generic cialis sublingual 20mg without prescription, patients in the gel testosterone group experienced slightly greater sexual enjoyment compared with those receiving the testosterone patch (p = 0 erectile dysfunction diabetes reversible buy discount cialis sublingual 20mg on line. Similarly erectile dysfunction symptoms causes purchase cialis sublingual 20 mg on line, all three groups significantly improved from baseline impotence exercise purchase cialis sublingual 20 mg mastercard, but without between- group differences for the domains of sexual motivation and sexual desire. Although spontaneous erections were significantly increased in frequency compared with baseline in both gel testosterone groups, and not in the patch testosterone group, there were no significant between- treatment group differences. At day 30, among men with sexual partners for whom these data were reported (61 percent of randomized men), 31 percent of 50 mg gel testosterone men reported an increase from baseline in the number of days in the past week with sexual intercourse versus 39 percent of 100 mg gel testosterone men (versus 50 mg, p ? 0. One trial compared the efficacy and 231 harms of gel testosterone versus gel testosterone plus tadalafil. Men were randomized to 50 mg gel testosterone (Testogel) 96 daily for 4 weeks followed by concurrent treatment with tadalafil 20 mg twice weekly for 9 weeks versus 50 mg gel testosterone (Testogel) daily for 10 weeks followed by concurrent treatment with tadalafil 20 mg twice weekly for 3 weeks. The men, refractory to prior sildenafil therapy were randomized to 1 percent gel testosterone daily plus 100 mg sildenafil once daily for each day with sexual activity as needed for 12 weeks versus 100 mg sildenafil as needed. One subject in gel testosterone plus sildenafil arm withdrew due to adverse events. There were no withdrawals due to adverse events among patients receiving sildenafil alone. In men receiving gel testosterone plus sildenafil, the mean number of successful sexual attempts (per week) ranged from 1. Cream testosterone versus cream testosterone plus isosorbide dinitrate plus co dergocrine. One trial compared the efficacy and harms of cream testosterone versus cream 322 testosterone plus isosorbide dinitrate plus co-dergocrine. Each treatment was to be applied daily at bedtime to the penile shaft and glans; if intercourse was going to occur then the cream was applied 15 minutes before intercourse. Five men who received combination therapy reported a mild transient headache versus none who received cream testosterone alone. Among all men with complete responses, those who received cream testosterone plus isosorbide dinitrate plus co-dergocrine reported a mean of 6. One trial compared the efficacy and harms of cream testosterone plus isosorbide dinitrate plus co 329 dergocrine versus placebo. Of men who received combination therapy, 40 percent reported at least one full erection with successful intercourse during followup versus 0 percent of those who received placebo. Men who received combination therapy also reported improved enjoyment with partner and satisfaction with intercourse. The efficacy and harms of patch testosterone versus 317,330 placebo were evaluated and reported in two trials. The design and study population of the 317 first trial are described elsewhere in two other sections: Gel Testosterone versus Placebo and 330 Gel Testosterone versus Patch Testosterone. In the second trial, 39 “borderline” hypogonadal men (total testosterone <10 nmol/l or a free androgen index <30 percent) aged 40–77 years (mean: 62 years) were randomized to 6 months of treatment either with 5 mg patch testosterone (Testoderm) once daily or placebo. Withdrawals due to a skin reaction occurred in 15 percent of patch testosterone subjects, but not in placebo subjects. In the first trial,, among men with sexual partners (62 percent of randomized men), 24 percent of men receiving placebo reported an increase from baseline in the number of days in the past week with sexual intercourse, compared with 21 percent of men receiving patch testosterone (p ? 0. One open label trial compared the 77 efficacy and harms of patch testosterone plus sildenafil versus sildenafil. Men were randomized to 5 mg patch testosterone daily plus 100 mg sildenafil, as needed for one month versus placebo patch daily plus 100 mg sildenafil, as needed. One trial compared the efficacy and harms of 321 dihydrotestosterone gel versus placebo. Of men who received dihydrotestosterone gel, 5 percent reported mild headache (versus 3. At baseline and 6-month followup, participants rated their ability to maintain erection during intercourse on a scale of 1–6, in which 2 = “75 percent of intercourses” and 3 = “50 percent of intercourses. Quantitative Synthesis There was a large degree of clinical heterogeneity in the eligible testosterone trials with regard to patient characteristics (e. Overview of Trials The trials evaluated the following treatments: phentolamine (one additional trial of 124 333,338 336,337,339,341,344 phentolamine is described in the Sildenafil section ), trazodone, 162,350 340,343,345,349 cabergoline, pentoxifyling (in 4 reports), and miscellaneous medications. Two trials investigated the effect of phentolamine in comparison to 333,338 333 placebo. One of the trials was used a crossover design (n = 5) and the other a parallel 338 design (n = 44). The trial 338 333 outcomes were patient diary and RigiScan measures on nocturnal erectile activity. Forty to 50 percent of patients improved their erections with higher doses of phentolamine (40 and 60 mg) compared with 30 and 20 percent with lower dose (20 mg) or 338 placebo respectively. Oral phentolamine (40 mg, 3 consecutive nights) administered before sleep increased the number of erectile events with rigidity of at least 60 percent lasting at least 10 minutes (p = 0. Five trials reported on the effect 336,337,339,341,344 of treatment with trazodone (n = 333, range: 34-100 participants). Trazodone was 337,344 339,341 336 341 administered at doses of 50 mg, 150 mg, or 200 mg per day. Subjective measures such as self reported questionnaires to address improvement in erection 336,337,341,344 with treatment were used in four trials. In one trial, numerically more patients in the trazodone group reported dry mouth (25. Another study reported 50 percent more 339 withdrawals due to adverse events in trazodone group versus the placebo group. In the trazodone arm of one trail, five patients experienced sedations; no information on adverse events 339 for other groups (i. In a trial comparing 344 the efficacy and harms of trazodone to mianserin, two patients (8 percent) withdrew due to adverse events from the mianserin treatment group and two patients (8 percent) in the trazodone group developed serious adverse events (priapism and sedation). Improvement in erection measured by Index of Sexual Satisfaction was 19 and 24 337 percent in trazodone and placebo groups, respectively. One study reported minor improvement from baseline in trazodone group but the between-group (versus placebo) difference for base rigidity (> 60 percent), nocturnal erection, or morning erection, was not statistically 336 significant. For one trial, improved erections were observed in 66, 60, 80, and 39 percent of 341 the patients treated with trazodone, testosterone, hypnosis, and placebo, respectively. The proportions of patients with positive response (3 or more successful intercourse attempts during 30 days and rigidity ? 30 minutes) at the end of 30 days of treatment with 50 mg trazodone, 20 mg ketanserin, 10 mg mianserin, and placebo were 65. Two trials were identified with a total of 452 participants 162,350 randomly assigned to treatment with cabergoline (n = 225) or placebo (n = 222). The number of patients with any adverse events was greater in cabergoline group 162 (12. Withdrawals due to adverse events were higher in the active arm versus placebo in the study which reported this information (5. Both trials reported numerically or statistically significant improvements in the results with cabergoline 0. The improvement in Q3 (frequency of penetration), and Q4 (ability to maintain the erection after sexual penetration) was 45. Full erection (sufficient for penetration) was achieved in 10 versus 0 percent, and 345 343 in 78 versus 0 percent. One trial reported a slight decrease in average percent rigidity after 3 months of treatment with pentoxifylline. Eight trials 334,335,342,346,348,351-353 were placebo controlled and one trial used active medication as 347 comparator. Other self-reported outcomes 334,335,342,352 related to erection were assessed in four trials One trial assessed and reported only 353 rigidity measures (RigiScan). These records were seven case 354-359,363 361,362 360 reports, two case series, and one retrospective cohort study. In all cases except for one, the administered minimum dose of sildenafil was 50 mg. Injection Treatments Penile Fibrosis (Non-randomized studies: observational studies and clinical trials) In total, 20 non-randomized studies (retrospective observational cohort, and clinical trials) reporting the absence or presence of penile fibrosis in long-term followup (at least 6 months) met 364-383 the eligibility criteria for inclusion in the review (in 20 publications). Of these, 13 were 364-366,368-371,376-378,380,381,383 clinical trials of prospective design and seven were retrospective 367,372-375,379,382 cohort studies. The majority of the study subjects were middle aged (mean age range: 50-62 years).
Approximately 75% of one clinical sample [365] Persistence of a small remnant of the Mullerian duct could reach orgasm through masturbation, while the may lead to a cyst forming between the ejaculatory remainder either would not or could not. Interestingly, ducts which can become obstructed and cause correlational evidence suggests that masturbatory diminution of the volume of the ejaculate and infertility. Both vasa are palpable and the epididymes usually Similar to men with other types of sexual dysfunction, feel distended. Local sion includes primarily the bladder neck or extends Wolfian duct abnormality involves loss of a variable to the level of the verumontanum. The importance amount of the vas deferens, seminal vesicle, and/or of contraction of the urethral smooth muscle at the ejaculatory duct, and sometimes part of the ipsilateral level of the verumontanum has been hypothesized urinary system as well. This may be associated with to be important in preventing retrograde ejaculation maldevelopment of the bladder neck and trigone, [383]. After radical Patients with prune belly syndrome have normal prostatectomy, ejaculation is bound to be lost since libido, erections, and orgasms. Most have abnormal the seminal vesicles are removed with the prostate ejaculation and probably emission. Erectile impotence was common until detailed involving nine patients, seven had retrograde anatomical studies showed where the parasym-- ejaculation and two produced ejaculates [379]. Post Retrograde ejaculation can be surgically treated masturbation urine specimens were of normal urinary with bladder neck reconstruction but results remain appearance. Drug treatment is the sperm and no mention was made of the fructose most promising approach. Abnormal ejaculation thus appears to be alpha-adrenergic sympathetic nerves mediate present in the vast majority of patients with prune both bladder neck closure and emission. Whether the primary abnormality is sympathomimetic agents have been described retrograde ejaculation or lack of emission is not clear. These drugs include pseudoephedrine and ephedrine, and b) Traumatic damage phenylpropanolomine. The pull through procedure pass-- useful is pseudoephedrine which is administered es close to the posterior aspect of the prostate, and at a dose of 120 mg 2-2. The damage is most likely if there has been closure of a tricyclic antidepressant, Imipramine, which blocks recto urethral istula. Analysis of 20 subfertile males the reuptake of noradrenaline by the axon from the who had repair of imperforate anus in infancy indi-- synaptic cleft, is also occasionally useful [388]. The cated that 7 had no ejaculate, 11 were azoospermic, usual dose is 25mg twice daily. Current thinking is 1 was severely oligozoospermic, and only 1 had a that long-term treatment with imipramine is likely normal sperm concentration in a very small volume to be more effective. Both vasa were blocked in 5 men not always produce normal ejaculation, it may and one vas in a further 8 patients, apparently as a result in some prograde ejaculation. The basic Antegrade (normal) ejaculation requires a closed method of sperm retrieval involves recovery of urine bladder neck (and proximal urethra). Surgical pro-- by either catheter or voiding after masturbation, and cedures that compromise the bladder neck closure then centrifugation and isolation of the sperm. Urinary infection, especial-- to a 60% risk of autonomic dysrelexia, especially in ly if complicated by epididymitis, can also produce men with injuries above the T5 level [393, 394]. Vi-- obstruction that may be situated at ejaculatory duct bratory stimulation is successful in obtaining semen level. Routine vasography in subfertile men with in up to 70% of men with spinal cord injury [395]. The is endemic in large parts of Africa and is seen with use of electro-ejaculation to obtain semen by electri-- increasing frequency in tourists returning from Af-- cal stimulation of efferent sympathetic ibers of the rica who have contracted the disease while enjoy-- hypogastric plexus is an effective and safe method ing water sports: Lake Malawi has acquired an evil of obtaining semen. The disease may present 71% of men with spinal cord injury who underwent with haemospermia [389], and ibrosis and calciica-- electro-ejaculation achieved ejaculation [396]. Genito urinary ever, both are associated with a signiicantly higher tuberculosis can cause great damage to the male risk of autonomic dysrelexia than electro-ejaculation. Plain X nifedipine minimizes the risk of severe hypertension, ray will often show the extent of the disease. Haemospermia is seldom as ominous a symptom as haematuria, but this complaint should not be Several authors have reported the use of midocrine ignored. In recent studies, vealed that an inlammatory cause could be deined antegrade or retrograde ejaculation occurred in 22- in most men under 30 years of age; however, there 64. It should tion, following treatment with midodrine 30–120 min be remembered, also, that schistosomiasis and tu-- before a new stimulation. Percutaneous tory ducts, which may be associated with obstruction aspiration of semen from the vas deferens has also and dilatation of the seminal vesicles. Such stones been reported as a means of harvesting semen for usually pass spontaneously. Unlike erectile capacity, the ability to prolonged sitting, and stasis of prostatic luid. Testic-- ejaculate increases with descending levels of spinal ular biopsies in spinal cord injured men demonstrate injury. Less than 5% of patients with complete upper a wide range of testicular dysfunction including hypo-- motor neuron lesions retain the ability to ejaculate. Approximately 22% prostatitis secondary to prolonged catheterization, of patients with an incomplete upper motor neuron epididymitis, and epididymo-orchitis can precipitate lesion and almost all men with incomplete lower mo-- obstructive ductal lesions and testicular damage. In et al reported that sperm density and motility were those patients capable of successful ejaculation, the higher in those with incomplete lesions [402]. In a sensation of orgasm may be absent and retrograde recent collective analysis of 40 paraplegic patients, ejaculation often occurs. Early studies showed that up to ing in particular have become very important in the three quarters of patients lost antegrade ejaculation well being of cancer patients. Due to modern sur-- after full bilateral retroperitoneal lymph node dissec-- gical techniques, improved quality of drugs for che-- tion. As a result of careful anatomical studies, the tech-- motherapy, and modern radiation techniques, more nique of retroperitoneal lymph node dissection has patients can be successfully treated without largely been modiied with nerve sparing so that antegrade compromising sexual functioning. Nevertheless, such was related to the size of the excised mass (<4 cm instruments are highly variable and largely unvali-- 4%; 4 8 cm 19%; >8 cm 60%). These questionnaires elicit limited informa-- It is important to anticipate this complication in young tion about aspects of sexuality other than erectile men with testicular tumors who may need chemother-- function. Although a deterioration of sexual activity apy or node dissection, and arrangements should be has been associated with the severity of ejaculatory made for sperm storage before treatment commenc-- dysfunction, particularly a decrease in volume or es. Excellent results can be obtained with artiicial in-- absence of semen [410], only a few questionnaires semination using cryopreserved spermatozoa [407]. Pathological dilatation of the seminal vesicles Herr [414] reported already in 1979 on 51 patients in the absence of obstruction has been described treated with retropubic Iodium-125 seeds, with loss previously, although the etiology remains obscure of ejaculate experienced by 6% of the patients. Caffo et al testesareverysensitivetoradiation,spermatogenesis evaluated toxicity and qoL of 143 patients treated is more easily affected than androgen productions. However, exit bilaterally at the inferior pole of the superior numbers were too small to draw inal conclusion. Damage of the young men in their sexual and fertile life, sexual sympathetic nerves could be caused by radiation, functioning and ejaculatory disorders are particularly but the dose does not seem enough to completely important. It is important and fear have been hypothesized, including fear of to anticipate this complication in young men with death and castration, fear of loss of self resulting testicular tumors who may need chemotherapy or from loss of semen, fear of castration by the female node dissection. Arrangements should be made genitals, fear that ejaculation would hurt the female, for sperm collection and storage at the earliest fear of being hurt by the female, performance anxiety, opportunity before treatment commences. Excellent unwillingness to give of oneself as an expression of results can be obtained with artiicial insemination love, fear of impregnating the female, and guilt sec-- using cryopreserved spermatozoa [407]. Appropriate necessary for learning to ejaculate or may result assessment requires an appreciation of how these in an inhibition of normal function. Regardless of factors combine to determine the inhibited ejaculatory speciic religion involved (Muslim, Hindu, Jewish, response for any particular individual. Some of these men Among those factors that are psychogenic and/or masturbated for a period of years like their secular behavioral, a number of possibilities have been counterparts, but guilt and anxiety about “spilling proposed. These men explanations have received more support than oth-- often had little contact with women prior to marriage ers, and some appear more plausible than others. Many different manifestations of anxiety women often relected a «Madonna-whore» split. And inally, the evaluative/performance aspect a relative absence of subjective arousal [367].