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By: Randolph E. Regal, BS, PharmD
- Clinical Associate Professor, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan
- Clinical Pharmacist, University of Michigan Health System, Ann Arbor, Michigan
https://pharmacy.umich.edu/people/reregal
Rate: Administerasa min–4hrbeforesexualactivity);notmorethanoncedaily;Concurrentusewithal- bolus three times daily. For erectile dysfunction, take ap- taken 1 hr before sexual activity (range 25–100 mg taken 30 min–4 hr before sex- proximately 1 hr before sexual activity and not more than once per day. If chest pain occurs after taking sildena?l, Revatio(forpulmonaryarterialhypertension) instruct patient to seek immediate medical attention. Counsel patient that protection against sexually transmitted diseases and ? Viagra: Determine erectile dysfunction before administration. Dr Kumaran Ramakrishnan, Honorary Fellow, Rehabilitation Studies Unit, Sydney Medical School Northern, the University of Sydney, and Consultant Rehabilitation Physician & Senior Lecturer, Department of Rehabilitation Medicine, University Malaya. Dr Ian Cameron, Head of the Rehabilitation Studies Unit, Sydney Medical School Northern, the University of Sydney. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. Reproduction for purposes other than those indicated above, requires written permission from the Agency for Clinical Innovation. We wish to acknowledge Dr Stella Engel, Dr Sue Rutkowski, Dr Bon San Bonne Lee, Dr Douglas Brown, Prof Anne Tonkin, Dr Mary-Clare Waugh and Dr Komal Adarkar for their contribution to the original and/or subsequent factsheet/s. Individual therapeutic decisions must be based on clinical judgment with a detailed knowledge of the individual patient’s unique risks and medical history, in conjunction with this resource. Following stimulation, overactivity of sympathetic ganglia remains uncontrolled due to isolation of the spinal cord below the injury from normal regulation by vasomotor centres in the brainstem (refer to Figure 1). Flushing due to dilatation of blood vessels, which is probably also responsible for headache, and profuse sweating above the level of injury also occur (via sympathetic inhibitory outfow from vasomotor centres). However, both of these mechanisms are insuffcient to satisfactorily control paroxysmal hypertension due to massive sympathetically- mediated vasoconstriction of the splanchnic bed. Impulses travelling intercourse, labour or severe menstrual through the vagus nerve cause secondary cramping. Typically, the patient will complain of a pounding • bradycardia headache with fushing and profuse sweating above the level of spinal lesion, with or without other symptoms such • fushing/blotching of skin above spinal injury level as nasal congestion (stuffness), blurred vision, shortness of • profuse sweating above spinal injury level breath and/or anxiety. Skin pallor and piloerection (goose • skin pallor and piloerection below spinal bumps) can be seen below the level of spinal lesion. Women with spinal cord injury above the mid thoracic region (T6 level) who are pregnant may experience autonomic dysrefexia as the frst sign of the commencement of labour. To help determine if bladder is empty or not, consider patient’s fuid intake and • Ask patient and carer if they suspect a cause. This is certainly true when performing the If bladder is distended and patient is unable to void in procedure of manual evacuation and autonomic dysrefexia their usual manner, lubricate the urethra with a generous will be exacerbated during prolonged nociceptive (6) amount of lignocaine 2% gel, wait 2 to 3 minutes and stimulus to remove faecal matter. Drain urine which medication is given prior to more straightforward and be alert for sudden hypotension due to rapid procedures, such as catheterisation, may vary (e. Dosage may be titrated by removing the If you are sure the bladder is empty and symptoms persist, transdermal patch or by spitting out residual spray or apply a generous amount of lignocaine gel onto the anal tablet with hypotensive effect being shorter lasting. Where control of the noxious stimulus is diffcult, regional epidural anaesthesia may be appropriate. An acute episode of autonomic dysrefexia can lead to an increased susceptibility to further episodes due to excess circulating catecholamines. These may be precipitated by activities which would not normally do so, such as performing muscle stretches, bowel care, or other activities. The patient must be alerted to this possibility and monitored appropriately for 48 to 72 hours. Perform thorough survey of the patient to • Episode of autonomic dysrefexia will not resolve until determine cause of autonomic dysrefexia. Beginning with urinary system: • the urinary tract, particularly bladder distension, is the If catheter is in situ: commonest cause of autonomic dysrefexia. Large volume of fuid • If catheter appears to be blocked attempt to instilled in bladder may further exacerbate autonomic unblock catheter by pulling back on the syringe. If block persists, gently irrigate catheter with 10 to 15 mls of normal saline at body temperature. Lignocaine gel may decrease sensory input lignocaine gel (if readily available) into the urethra and relax sphincter for catheterisation. Commence systematic survey of patient for Autonomic dysrefexia will not resolve without fnding and other causes of autonomic dysrefexia, which remediating the underlying cause. If no cause can be found and symptoms persist obtain assistance from Spinal Unit Consultant. Episode is considered to be resolved when: • Cause of autonomic dysrefexia has been identifed. Table continues on page 11 10 Treatment of Autonomic Dysrefexia for Adults & Adolescents with Spinal Cord Injuries Table continued from page 10 Action/Intervention Rationale - Educate patient, carers, signifcant others. Additional education may be required to help recognition of symptoms, treatment and strategies to avoid further episodes as much as possible. It is important to also alert the patient and carers to the possibility of increased susceptibility to further episodes over following few days. A Cardiovascular consequences of loss of supraspinal systematic review of the management of Autonomic control of the sympathetic nervous system after spinal Dysrefexia after spinal cord injury. Part D sponsors are responsible for making appropriate coverage determinations and ensuring that covered Part D drugs meet the requirements in this section. Additionally, Part D sponsors must recognize a physician’s authority to delegate prescribing where authorized by State law. Generally, in retail pharmacy, standing orders and protocols are methods used by physicians to delegate and define their prescribing authority to non-physician providers such as pharmacists. Standing orders are typically pre-approved documents for a specific drug or vaccine, contain a set of required clinical criteria and permit administration of the drug without physician examination, as long as the required clinical criteria are met. A protocol is similar to a standing order but is generally broader in scope and may include multiple drugs and extensive clinical criteria. A Part D sponsor may only provide benefits for Part D drugs that require a prescription if those drugs are dispensed upon a valid prescription, as required by §423. For the applicable drugs of a manufacturer to be covered under Part D, the manufacturer must participate in the Medicare Coverage Gap Discount Program. An applicable drug is a Part D drug that is approved under a new drug application under section 505(b) of the Federal Food, Drug, and Cosmetic Act or a biologics license application under section 351 of the Public Health Service Act (other than a product licensed under subsection (k) of such Act). Thus the definition of applicable drugs excludes biological products approved under the abbreviated licensure pathway (biosimilars). Extemporaneously compounded prescription drug products (addressed separately in this chapter in section 10. Approved commercially available combination products include those with multiple active ingredients combined in a single drug product and those products with multiple drugs that remain separate but are co-packaged together and intended for dispensing as a single entity. Only costs associated with those components that satisfy the definition of a Part D drug are allowable costs under Part D because the compounded products as a whole do not satisfy the definition of a Part D drug. For a Part D compound to be considered on-formulary, all ingredients that independently meet the definition of a Part D drug must be considered on-formulary. For any non-Part D ingredient of the Part D compound, the Part D sponsor’s contract with the pharmacy must prohibit balance billing the beneficiary for the cost of any such ingredients. Sponsors treating compounds as non-formulary products should be applying the cost sharing associated with an exceptions tier, regardless of whether the compound contains brand name or generic products. For a Part D compound considered off-formulary, transition rules apply such that all ingredients that independently meet the definition of a Part D drug must become payable in the event of a transition fill and be covered if an exception under §423. For compounds containing all generic products, the generic cost-sharing should be applied. If a compound contains any brand name products, the Part D sponsor may apply the higher brand name cost-sharing to the entire compound. However, test strips, lancets and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. Insulin syringes equipped with a safe needle device, in their entirety (syringe and device), are also Part D drugs and should be managed like any other Part D drug the sponsor places on its formulary. Part D sponsors must make safety enabled insulin syringes available on their formularies for all of their institutionalized beneficiaries. The definition of medically accepted indication also means, in the case of a covered Part D drug used in an anticancer chemotherapeutic regimen, the definition of medically accepted indication in section 1861(t)(2)(B) of the Act. Thus, Part D sponsors will be required to thoroughly understand and apply Part B’s definition of an anti-cancer chemotherapeutic regimen, utilize Part B compendia, and consider peer reviewed medical literature when necessary. Part D sponsors are responsible for ensuring that covered Part D drugs are prescribed for medically-accepted indications using the tools and data available to them to make such determinations.
Syndromes
- Heart bypass (CABG) surgery or angioplasty to improve blood flow to the damaged or weakened heart muscle
- Rheumatoid factor
- Carcinoid syndrome
- As during the infancy period, place the toddler in a safety restraint (toddler car seat) when riding in a car.
- Migraine headache
- Throat tightness or difficulty swallowing
- Arteriosclerosis of the arms or legs
- Be consistent. Meals and snacks should be eaten at the same times each day. Do not skip meals and snacks. Keep the amount and types of food (carbohydrates, fats, and proteins) consistent from day to day.
Peak systolic velocity in behavioral correlations in the medial prefrontal cortex and patients with arterial erectile dysfunction and peripheral nucleus accumbens during cocaine self-administration by arterial disease. Chronic administration 2007; 52: 555-63 of an oral Rho kinase inhibitor prevents the development of vasculogenic erectile dysfunction in a rat model. Models to Function and Enhances Sexual Behavior in Atherosclerotic study atherosclerosis: a mechanistic insight. The limitations have included the possible changes over the decades, standard biochemical principles in the tissue / cellular integrity due to stages of pro-- have been used in all branches of clinical scienc-- cessing and some intricate differences attributable es and sexual medicine research is no exception. On the other hand, has been a useful tool for the understanding of the iNoS could be induced in response to bacterial lipo-- cellular mechanisms relating to the neurotransmit-- polysaccharide (Hung A et al. Furthermore, the rent awareness of lifestyle modiication, attempts at in vitro culture systems can be used for the primary calorie restriction and exercise seemed to instigate evaluation of newer drugs or agents for their thera-- molecular prevention, seen as limited interaction of peutic potentials in male and female sexual medicine. In many respects, breakthrough information was What more can be said about the value of molecu-- provided by way of advanced cell culture techniques lar and biochemical techniques? Although analysis and ture holds for these moieties by way of translational interpretation of such protein modiications still pres-- application. Although After all, genital tissue reconstruction is now a pos-- the complexities are yet to be completely unraveled, sibility both in the male and female. Quantiica-- tion of prostaglandin E1 receptors in cavernous tissue of outcome regulation. Looking at the neuromodulators, in addition to func-- Al-Hijji J, Larsson B, Batra S. Nitric oxide synthase in the rab-- tional adrenergic alpha-1 and -2 receptor subtypes bit uterus and vagina: hormonal regulation and functional signiicance. Am J Physiol Regul Integr this context and in further studies, tissue oxygen and Comp Physiol. Smooth muscle myosin heavy chain and caldesmon expression in the an-- tools to aid in the hemodynamic evaluation of sexual terior vaginal wall of women with and without pelvic organ functioning (Min K et al. The higher expression of oxide synthase in the male reproductive tract of the rat. Fer-- myosin heavy chain isoform in the proximal vagina til Steril 1995; 63:1101-7. Culture tics compared to the tonic type in the distal vagina and identiication of human and rabbit corpus cavernosum (Basha M et al. However, threat to structural integrity channels and gap junctions: their role in erectile physiology, is also an important factor in the female. Isolation of two isoforms of phosphodies-- muscle and endothelial cells seeded on collagen matrices. Proteomic analysis of rat penile tissue in a model of erec-- Garban H, Marquez D, Magee T, Moody J, Rajavashisth T, Ro-- tile dysfunction after radical prostatectomy. Effect smooth muscle cells by vardenail, a novel, selective phos-- of muscle-derived stem cells on the restoration of corpora phodiesterase type 5 inhibitor. Reconstitu-- of functional muscarinic acetylcholine receptor subtypes in tion of human corporal smooth muscle and endothelial cells human corpus cavernosum and in cultured smooth muscle in vivo. Sildenail corporeal smooth muscle cell tone: diabetes and relaxation inhibits phosphodiesterase type 5 in human clitoral corpus of human corpus cavernosum smooth muscle by adenosine cavernosum smooth muscle. Phosphodiesterase type 5 is not upregulated endothelial and ibroblastic cells after exposure to papaver-- by tadalail in cultures of human penile cells. Evidence that osteogenic progenitor of gene expression proiles between Peyronie>s disease cells in the human tunica albuginea may originate from and Dupuytren>s contracture. Rabbit corpus cavernosum smooth muscle shows a different phosphodiesterase proile Waldkirch E, Uckert S, Sigl K, Imkamp F, Langnaese K, Richter than human corpus cavernosum. Effects of estrogen on nitric oxide synthase and histological composition in the rabbit clitoris and vagina. Development of human and rabbit vaginal smooth muscle cell cultures: effects of vasoactive agents on intracellular levels of cyclic nucleotides. Role of andro-- gens in female genital sexual arousal: receptor expression, structure, and function. Sex steroid hormones differentially regulate nitric oxide synthase and arginase activities in the proximal and distal rabbit vagina. Testosterone increases blood low and expression of androgen and estrogen receptors in the rat vagina. It is ine to study normative sexual function in animals, but “ceil-- For sexual desire and reward, it is vitally important to ing effects” may well prevent the ability to observe use models that have predictive validity. To have a model circumstances, solicitations perhaps the display of of dysfunction, one must use animals that are hy-- high-intensity lordoses, are augmented by drugs pofunctional. For example, albino male rats do not (dopamine or melanocortin agonists) or conditioned readily show psychogenic erections, whereas pig-- cues associated with sexual reward. Likewise, the number of psychogenic erections in pigmented conditioned partner or place preferences can be Long-Evans males, but facilitated erections in albino used to infer reward states that feed back positively Wistar males. The lack of reward, induced by early neous erections by bremelanotide was always ob-- sexual experience that is not accompanied by opioid served consistently in albino Sprague-Dawley rats, transmission, diminishes the desire of female rats but not consistently in pigmented rats (A. Shadiack, to initiate sexual activity, and abolishes conditioned personal communication). Because of their unique place and partner preferences in both male and physiology that may well suppress erection due to female rats. A similar effect is observed in long- higher than normal serotonin turnover, albino rats term castrated rats given subthreshold hormone provide a lower baseline of erection that allows for priming. Castration, nonreward, administration of low doses of estradiol to female and satiety diminish the display of those responses, rats (e. Indeed, the induction of estrus termination ously with sexually nonresponsive partners, or with by high amounts of distributed vaginocervical a lack of sexual reward induced by concurrent treat-- stimulation is masked by estradiol priming at 4- or ment with naloxone), are likely to increase in use. This indicates that the timing possess low hormone levels, thus it is likely that ex-- and dose of hormone priming is critical in generating periential factors have played a role in the etiology a reliably low baseline upon which facilitative effects of the disorder. This is also such a clinical situation may well be one of low de-- true of males, and will depend critically on the level sire induced by sexual nonreward. Again, the most of sexual experience and the amount of time since important requirement of the preclinical model will be castration has occurred. For sexual arousal, both behavioral and vascular models exist to examine mechanisms of erection, ejaculation, and vaginal/clitoral blood low. This can be expressed naturally in chasing or pur-- Animals possess appetitive and consummatory suit, or in other behaviors that maximize the desired aspects of sexual behavior that are homologous rate of genital contact and stimulation. Control is an and analogous to our own and that are controlled important aspect of sexual function in both men and by similar or identical neurochemical and hormonal women, and problems with locus of control may form systems. They experience sexual arousal, desire, an important part of the etiology of different sexual reward, and inhibition. Female rats that require some form of courtship or pursuit, and display proceptive and receptive sexual behaviors will work hard to obtain even small sexual rewards. Although female with experience, making them less vulnerable to primates, including humans, can have sex through-- treatments that disrupt sexual responding. From an evolutionary female-initiated solicitation and sexual activity dur-- perspective, sexual behavior appears to have similar ing their periovulatory periods (Wallen, 1982, 1995). This and human sexual behaviors is the primary chal-- makes the study of sexual behavior in animals, and lenge for researchers. If the process and endpoints of sexual response are We believe that animal models will continue to be the same (even if the outward expression of appeti-- indispensable for studies of the neurobiology of sexual tive behaviors or copulation is species-speciic), then behavior. We need the knowledge that lesion and animals can indeed be used as models of human drug studies, neurochemical and neuroanatomical sexual response provided the homology or analogy analyses, and molecular approaches, provide is speciied unambiguously, and that treatments or in animals to guide our emerging work in the experiences have similar effects between the spe-- neuroanatomy of sexual responding in humans using cies, giving the animal model predictive validity. This functional magnetic resonance imaging or positron requires that we understand the particular behaviors emission tomography. We need animal models to of both species as best we can, which in turn re-- further understand the hormonal processes that lead quires that we be careful and creative in how we ask to changes in sexual arousability (e. For example, it was once hormone replacement therapy in postmenopausal or believed that male rats lack the cognitive capacity hypogonadal individuals). The kind of invasive and and sophisticated cultural conditioning for sexual direct studies of brain or organ function in animals inhibition, thereby making them unsuitable models simply cannot be conducted in human subjects.
They is not adressed in other chapters and a short section conclude that cultural factors in combination with is therefore added to this chapter. The most frequently cited moderator of concordance is gender, such that men show signiicantly greater concordance than women. Until now the chapter has focused on physiology and pathophysiology of women’s sexual response, but it First, agreement between actual genital arousal and is clear there is an interaction between physiology self-reported arousal in women is not zero; the aver-- and psychology in the sexual response, and recently age correlation reported by Chivers and colleagues growing evidence has shown a gender difference in was +. This of sexual response are examples of the relative suggests that women’s experience of sexual arousal independence between physiological, psychological, is not primarily related to experience of physiological and behavioral aspects of women’s sexuality. This responding and is mediated by additional cognitive section of the chapter examines current research and emotional mechanisms. It is not clear how much on concordance and nonspeciicity of women’s appraisal of subjective sexual arousal is inluenced sexual arousal within the broader context of by perception of genital responding, or vice versa, implications for psychophysiological assessment of but these measures are highly positively correlated women’s sexuality and sexual functioning, and for in women [264]. That these two self-report measures understanding the development and expression of differ in their relationship with physiologically-mea-- female sexual orientation. Sexual arousal is an of interoceptive awareness, that is, the psychological emotional state [261] and, similar to other emotions, capacity to perceive internal physiological changes. The greater reliance on the degree to which the individual’s experience of external information suggests that women’s experi-- sexual arousal corresponds with her physiological ence of sexual arousal is more inluenced by their response (concordance) is a matter of interest to re-- attitudes, beliefs, and values regarding sexuality, as searchers and practitioners in sexual medicine, since well as immediate contextual factors such as sexual 0 comitte 22. This vari-- physiological sexual response, and psychological ability in women’s concordance estimates may re-- traits, like sexual orientation, also shows marked dis-- lect the multitude of psychological factors that inlu-- cordance in women. Gender differences have been ence women’s experience of sexual arousal more so observed in the relationship between self-reported than physiological factors, suggesting a role for in-- sexual attractions (toward males or females) and pat-- dividual differences in moderating concordance be-- terns of genital and self-reported sexual arousal to tween self-reported and genital sexual arousal. This female and male sexual stimuli; men’s sexual arous-- raises fascinating questions as to the origins of con-- al patterns are very strongly associated with their cordance among women and whether concordance self-reported sexual orientation, whereas women’s is a desired state (see next section). Cognitive models suggest that concordant sexual response is a desirable, or even necessary, state Women report increased sexual arousal to both pre-- for satisfactory sexual functioning [268]. The po-- ferred and non-preferred sexual stimuli [288,290- tential for concordance to vary with sexual function-- 292], which suggests that their cognitive and affec-- ing has been demonstrated in studies of sexually tive responses to sexual stimuli are not dependent dysfunctional women; women with sexual arousal upon their sexual preferences, such as sexual orien-- problems report lower subjective sexual arousal to tation. Sexual desire, as evidenced by masturbation sexual stimuli in the laboratory, but typically do not and partnered sexual behaviors, is also kindled by show signiicantly lower genital responses when exposure to both preferred and non-preferred sexual compared to women without sexual arousal prob-- stimuli [290] suggesting that, among heterosexual lems [269,270]. Studies comparing the concordance women, motivation for engaging in sexual behavior of sexual responses of sexually functional and dys-- is also less dependent upon sexual preferences. Using may be related to better sexual functioning, such still pictures of female and male nudes, Sylva et al. While orgasm fre-- heterosexual and lesbian women’s brain responses quency, particularly during heterosexual coitus, is an showed speciicity in areas associated with process-- inadequate means of determining women’s sexual ing of visual stimuli and motivation, that is, greater function, these studies do indicate an association response to stimuli matching a woman’s sexual ori-- between concordance and orgasmic frequency that entation. Hypothalamic response, however, did not suggests concordance may be a useful index of in-- show category-speciic response for either group. Flexibility bian women only; heterosexual women showed refers to a pattern of intraindividual variability in sex-- nonspeciic amygdalar responses. With tern of results from these different lines of research respect to sexual orientation and identity, women demonstrates that speciicity and nonspeciicity of are more likely than men to experience and express peripheral sexual responses are mirrored in central same-gender attractions and less likely to engage aspects of sexual functioning in women. Therefore, a woman’s sexual desire Figure 19: Heterosexual women’s and men’s mean genital responses, in standardized z-scores (top panel), and self-reported sexual responses, in percentage increase from baseline (bottom panel), to various categories of stimuli. The stimulus category “Intercourse” in the male and female panels represents responses to depictions of two men and two women, respectively, engaged in intercourse. Self-report data on the de-- velopment of female sexual orientation support this Gender differences exist in the relationships among proposition; women report that social and emotional psychological, behavioral, and psychophysiological factors are more salient than sexual arousal to the aspects of sexuality, with greater lexibility observed development of their sexual interests in either the in women. Low concordance between genital and same gender [305, 306] or opposite gender [309]. Nonetheless, there is some patterns of sexual arousal do not constrain women’s evidence that higher concordance may be associ-- sexual behavior, feelings, or identity. The potential for discordance the potency of stimuli depicting any sexual activity between physiological sexual response, psycho-- to evoke genital response, regardless of the actors logical states of sexual arousal, and psychological portrayed or context of the sexual activity [288] traits, such as sexual orientation, strongly suggests (figure 19) is also highlighted in studies where that objective measures of sexual response should women show physiological sexual responses to not be used in isolation to draw conclusions about other clearly nonpreferred sexual stimuli, such as women’s sexuality. Genital response precedes subjective between physiological and psychological sexual arousal [316], is evident within seconds of aspects of sexual response the onset of a sexual stimulus [317], and can occur in the absence of subjective experience of sexual • Gender difference in speciicity of sexual arousal [287]. Reports of women’s genital lexibility in women’s sexual attractions response and orgasm during sexual assault [182] and research showing that women experience genital • Female genital response is a relexive responses to sexual threat stimuli suggests that response to exposure to any sexual stimulus genital response under conditions of nonpreferred depicting sexual activity, whether preferred sexual stimuli may be typical in women. For this or not reason, inferences regarding a woman’s sexual • Nonspeciic genital vasocongestion suggests desire and relative sexual attractions based solely that genital response is not a valid indicator on her genital responding would very likely be of sexual desire or sexual orientation inaccurate. Multi-subject studies will show which sites have high reproducibility and • Integration of central and are likely to be connected to the (sexual) peripheral mechanisms task, thus enhancing the power of the study. However, there are many limitations and potential • Validate the effectiveness of the chosen pitfalls that one should be aware of when planning stimuli (and the paradigm) outside the a study using these tools or even when reading a scanner in a separate group of subjects. Sexual consummation • Know your signal characteristics • Decide the type of genital stimulation to comitte 22. Requires Linux or Linux level of sexual arousal that may be used virtual machine (Vmware). Helen o’Connell, Prof Norm and rotational head motion can be easily Eizenberg and Anatomedia for the permission to measured and can be used to remove use their anatomical pictures. Helen O’Connell for her comments to correction software should be used to align the chapter. The evolution of human reproduction: a pri-- matological perspective Am J Phys Anthropol 2007;Suppl were nevertheless important during the 45:59-84. Mol Reprod Dev 1994 octo-- each other (network) rather than with the ber;39(2):184-93. Cellular and molecular mechanisms of female reproductive Analysis software behaviors. J Sex Med 2008 nisms mediating oestradiol modulation of the developing July;5(7):1559-71. Sexual differentiation of pheromone pro-- human brain activity during primary sensory stimulation. Sexual differences in visual attention to sexually explicit videos: a Differentiation of the Brain. Sex-speciic content preferences for vi-- diol mediates developmental masculinization of sex be-- sualsexualstimuli. Female sexual hancing glutamate release: a mechanism for organiza-- arousal: a behavioral analysis. Neuroanatomical correlates of visually evoked sexual [20] Pfaus J, Giuliano F, Gelez H. A rapid neuromodulatory Blood-oxygenation-level-dependent functional mag-- role for steroid hormones in the control of reproductive netic resonance imaging for evaluating cerebral re-- behavior. Evolutionary changes in physiological control of Hum Brain Mapp 2002 May;16(1):1-13. Brain processing Neurological control of human sexual behaviour: insights of visual sexual stimuli in human males. Attentional modulation of neural processing of [63] Lotze M, Wietek B, Birbaumer N, Ehrhardt J, Grodd W, shape, color, and velocity in humans. Neuropsychologia stimulation elicits left-hemisphere dominant activation in 1997 November;35(11):1437-44. Proc Natl Acad Sci U S A [66] Redoute J, Stoleru S, Pugeat M, Costes N, Lavenne F, 2002 January 8;99(1):523-8. A review of the effect of traumatic brain [51] Stark R, Schienle A, Girod C, Walter B, Kirsch P, Blecker injury on the human sexual response. Erotic and disgust-inducing pictures--differences in the hemodynamic responses of the brain. Speciic cerebral activation due Prominent differences during tactile genital stimulation, but to visual erotic stimuli in male-to-female transsexuals not during orgasm. Acute Hakun J, Jens W, Suh J, Listerud J, Marquez K, Franklin effects of cocaine on human brain activity and emotion. Biol Psychiatry 2000 May blood low changes associated with clitorally induced 1;47(9):769-76. The sensory cortical representation of the human penis: Proc Natl Acad Sci U S A 2001 January 16;98(2):676-82. Nat Rev Neurosci 2005 tion of cortical ields in the lateral sulcus of Homo sapiens: September;6(9):691-702.
These implants consist of either inflatable or semirigid rods made from silicone or polyurethane erectile dysfunction ed drugs order fildena 100mg fast delivery. The inflatable devices allow you to erectile dysfunction and diabetes treatment generic fildena 50mg mastercard control when and how long you have an erection erectile dysfunction radiation treatment purchase fildena 150mg on-line. This treatment can be expensive and is usually not recommended until other methods have been tried first doctor for erectile dysfunction in delhi generic fildena 150mg. In rare cases, a leaking blood vessel can cause erectile dysfunction and surgery is necessary to repair it. If your erectile dysfunction is caused by stress, anxiety or depression, your doctor may suggest that you, or you and your partner, visit a psychologist or counselor. Even if it is caused by something physical, erectile dysfunction can create stress and relationship tension. Try nicotine replacement (such as gum or lozenges), available over-the-counter, or ask your doctor about prescription medication that can help you quit. This can help with underlying problems that play a part in erectile dysfunction in a number of ways, including reducing stress, helping you lose weight and increasing blood flow. Drinking too much or taking certain illicit drugs can worsen erectile dysfunction directly or by causing long-term health problems. It is increasingly older men, and can significantly impair quality of life both recognised that even for men with an obvious organic for the man and his partner. Physiology of erection Sexual stimulation, both physical and mental, directs the penis engorges, the penile veins are passively the release of nitric oxide from the penile nerves. Physical examination may guide further investigations: Specific treatment options for erectile ? If unexplained low libido or suspected hypogonadism, dysfunction measure testosterone and prolactin at 0800hrs. Psychotherapy should be considered in all men who have a psychogenic component to their erectile dysfunction. Gynaecomastia, increased haematocrit, alterations in lipid profile, hypertension, and infertility are some side N. Hyperprolactinaemia of any cause may result in effects associated with exogenous testosterone therapy. Adverse effects include pain, numbness, bruising, a cold blue penis and difficulty with ejaculation. Intracavernosal injections These agents act by directly relaxing smooth muscle in the corpora cavernosum and result in an erection. Side effects include pain at the injection site and priapism, and long term use can result in scarring of the tunica albuginea with potential curvature and shortening of the penis. Other injectable agents include; an aviptadil and phentolamine combination (Invicorp) and papaverine. Papaverine is associated with a higher incidence of priapism and scarring of the tunica albuginea and should only be used as a second-line therapy by experienced practitioners. Penile devices may be suitable for men who fail to respond to other therapies Vacuum constriction devices and penile prosthetic devices are options for men who fail to respond to other therapies. Penile devices are usually reserved for men who fail to A detailed history is essential to identify the possible respond to all other therapies. Consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. The Canadian Study of Erectile high potential for patient and partner treatment satisfaction. To help the patient and partner establish their objec- longstanding relationships exist between the couple and tives of treatment. To select diagnostic tests based on presenting com- tic alliance which may translate in to improved clinical plaints and goals of therapy. To offer treatment choices with comprehensive infor- remain an essential resource for several important reasons: mation on cost, likelihood of success and common 1. Second-line intracavernous and intraurethral vasoac- which would satisfy the patient and partner goals tive therapy may be outside of the practice pattern of treatment. To choose approaches which are reversible when- severe vascular disease or poorly controlled diabe- ever possible. Determine the timing of onset, nature of the prob- • Dynamic infusion cavernosography and caver- lem, and signifcance to the partner (if applicable). Establish a likely underlying etiology based on his- A monogamous, heterosexual relationship should not be tory, physical exam, and lab testing. Focused physical examination (directed at anatomic, vascular and neural systems essential for erections). The greatest utility of these questionnaires not add signifcantly to duration of the doctor-patient may be in establishing a response to therapy and determin- encounter. The primary goals of psychotherapy are ment or discomfort for some patients; therefore, every effort to reduce or eliminate performance anxiety, to understand the should be made to ensure privacy and personal comfort. Nocturnal penile tumescence may include fasting glucose, lipid profle and, in select cases, and rigidity testing using Rigiscan should take place for a hormone profle. Hormone profles are used to identify or at least 2 nights, measuring 2 to 5 overnight erections. Vascular testing suggested as a valuable addition to the evaluation and good general practice. This test is Diabetes Association guidelines)2 testing and potential treat- performed less frequently in Canada since the advent of ment for low levels of testosterone is appropriate. In the appropri- sound is normal, as indicated by a peak systolic blood fow ate patient, once treatment with exogenous testosterone is >30 cm/sec and a resistance index >0. If the ultrasound initiated, ongoing follow-up is mandatory according to pub- is abnormal, however, arteriography and dynamic infusion lished guidelines. Patients and partners are made aware of reserved generally for cases of high-fow priapism or planned effcacy, risks and benefts of appropriate treatments, taking vascular bypass. A penile angiogram allows visualization in to consideration preferences and expectations. Oral ther- of the penile circulation and directs embolization for the apy failure may often be salvaged by patient re-education unusual case of penile injury induced high-fow priapism. Neuro-physiological testing Success, Unsuccessful This form of testing generally continue consider third-line allows us to measure the sacral treatment therapy refex arc, an indirect measure of the perineal neural integrity, and Penile implant surgery has limited clinical availability and utility. Basic screening tests include the identifcation of car- umented hypogonadism is an option. Local therapy (intracavernous or intraurethral treatment or investigations may be appropriate. Bella is a member of the advisory boards for Lilly, Actavis, American Medical Systems, and Coloplast. There is a Use with alpha blockers potential risk of signifcant hypotension when using non-selective alpha blockers. Side effects (5 most common Headache, dyspepsia, Headache, fushing, dyspepsia, nasal Headache, fushing, rhinitis, in order of frequency when backpain, myalgia, nasal congestion, alteration in colour vision dyspepsia, sinusitis compared to placebo) congestion Please consult the individual product monographs for additional information. The assessment of vascular risk with erectile dysfunction: the role of the cardiologist and general physician. Diagnostic tests for male erectile dysfunction revis- received payment for talks from Abbott, Astellas, Pfzer, Lilly, Paladin, and Actavis. J Sex Med investments in many pharmaceutical companies through his diversifed retirement plan. Combination of psychological intervention and phosphodisterase-5 inhibitors for erectile dysfunction: A narrative review and meta-analysis. Standardization of vascular assessment of erectile dysfunc- tion: Standard operating procedures for duplex ultrasound. Standard operating procedures for neurophysiologic assessment of male sexual setting: Importance of risk factors for diabetes and vascular disease. Brock G, Harper W; for Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Guidelines on male sexual dysfunction: Erectile dysfunction and in hypogonadal men with erectile dysfunction: A systematic review. Oral phosphodiesterase-5 inhibitors and hormonal treatments for erectile dysfunction: A systematic review 2002;9:1583-87. Impact of a frst treatment with phosphodiesterase inhibitors 9-200911030-00150 on men and partners’ quality of sexual life: Results of a prospective study in primary care.
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