Herbal Treatment for Erectile Dysfunction

Mental Impotence Healer

Mike Millers Mental Impotence Healer is an eBook that utilizes guided imagery to help you cure your psychological impotence. In guided imagery, you will be guided into imagining a scenario to help you overcome physical and psychological issues. It commonly uses descriptive language and guidelines that have direct affects on the brain. Since the mind greatly influences the body, this approach helps you have rock-hard erections when you need them most. Simply listen to The Mental Impotence Healer Program for 2 months and completely annihilate your sexual fears and in next to immediately you will become a brand new You! Recharged with sexual energy, bursting with self-confidence, strong on command, and conditioned to be aware that your days of Psychological Impotence are gone, for all time! The Mental Impotence Healer Program gives you your confidence back and will maximize your self-esteem to amazing new heights. Listen to the beautiful, calm and relaxing Guided Imagery session and it will totally transform your sex life. You will have control over your erections without taking any harmful medication or dangerous pills. Grab a set of headphones and the recordings will go to work while you relax. The carefully mastered binaural beats and subliminal messages will reprogram your subconscious mind into a radically altered state of heightened sexual awareness and desire! More here...

Mental Impotence Healer Summary


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Author: Mike Miller
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Female Sexual Dysfunction

In 1966, Masters and Johnson21 first described the female sexual response consisting of four successive phases -excitement, plateau, orgasmic, and resolution. This was later modified to the phases of desire, arousal, orgasm, and resolution. It is well recognized today that the female sexual cycle is not just a sequence of events, but a very complex

The Female Sexual Response

The female sexual response, as described in the mid 1960s by Masters and Johnson,6 begins with excitement, leading to plateau, orgasm, and finally, resolution. In 2000, Dr. Rosemary Basson,7 a pioneering researcher in the field of FSD, proposed a new, nonlinear female sexual response cycle. Dr. Basson suggested that the sexual response is driven by the desire to enhance intimacy, and begins with a state of sexual neutrality8 (Table 5-1.2). As the woman seeks a sexual stimulus and responds to it, she becomes sexually aroused. Arousal leads to desire, thus stimulating a woman's willingness to receive or provide additional stimuli. Emotional and physical satisfaction are gained by an increase in sexual desire and arousal. Emotional intimacy is then ultimately achieved. Various biological and psychological factors can negatively affect this cycle, thus leading to FSD.

Coping With Msrelated Changes In Sexual Response

Coping with Altered Genital Sensations To enhance sexual response, increase stimulation to other responsive areas such as Coping with Erectile Problems A number of oral medications are available to treat erectile dysfunction. The FDA has approved several medicines called phos-phodiesterase-type-5 (PDE-5) inhibitors. PDE-5 inhibitors work by blocking a chemical in the erectile tissues that causes erections to become flaccid. These medicines include sildenafil (Viagra ), vardenafil (Levitra ), and tadalafil (Cialis ). To date, only sildenafil has been completed in clinical trials with men who have MS, although the other medicines are highly similar and can be prescribed for persons with MS. These medicines do not improve libido, but are helpful in maintaining erections when they occur. They are typically taken an hour before anticipated sexual activity. The effects of vardenafil and tadalafil are reported to last somewhat longer than sildenafil, although they have not been directly...

Model for understanding sexual response

For heuristic purposes, the sexual response cycle can be divided into four phases of functioning desire, arousal, orgasm, and satisfaction. Dysfunctions of sexual response found in both DSM-IV1,' and ICD-10(1.4) mirror this theoretical model, but also include another dimension, that of sexual pain disorders. These ideas are an elaboration of Masters and Johnson's psychophysiological research as well as the independent theoretical contributions of Kaplan (15> and LiefA16. Two assumptions underlie this model (1) each phase of sexual function has relatively discrete underlying psychophysiological mechanisms and (2) disturbances in one phase do not necessarily denote dysfunctions in another. This conceptualization, however, does not preclude a dysfunction in one area precipitating secondary impairments in another phase. For example, the loss of erectile capacity may eventually dampen a man's interest in engaging in any sexual activity. The strength of this four-phase model is that it...

Unresolved Issues With Viagra

Following its launch in 1998, sildenafil (Viagra) continued to attract a lot of interest in 1999. In August 1998, the American College of Cardiology (ACC) and the American Heart Association (AHA) issued interim recommendations for silde-nafil prescribing in patients with cardiovascular disease.717 2 Subsequently, in January 1999, an expert consensus document was released by the ACC and AHA reiterating their previously released recommendations.738 2 The ACC and AHA also stated that more research is needed into the effects of sildenafil in certain high-risk patients with significant cardiovascular disease. Other unresolved issues identified by the ACC and AHA included interactions with non-aspirin antiplatelet agents, interactions with other phosphodiesterase inhibitors, central nervous system (CNS) effects, hypotensive effects in high-risk cardiac patients (e.g. those with severe heart failure), and musculoskeletal effects (myalgia and chest pains) that may be mistaken for angina. In...

The EPOR modela human sexual response cycle model

Proposed a four-phase linear, sequential, and incremental model of the human sexual response cycle ( Fig 1). The phases were described as the excitation (E) phase (stimuli from somatogenic or psychogenic sources raise sexual tensions), the plateau ( P) phase (sexual tensions intensified), the orgasmic (O) phase (involuntary pleasurable climax), and finally the resolution (R) phase (dissipation of sexual tensions). The great success of this EPOR model was its wide compass it could characterize the sexual responses of women and men, both heterosexual and homosexual, ranging from simple petting to vaginal or anal coitus with orgasm. However, it had several weaknesses. Fig. 1 The development of the linear-sequence human sexual response model from (a) the original EPOR model of Masters and Johnson (29 through (b) the DEOR

Physiology Of Penile Erection

The physiology of penile erection involves an interplay of anatomical, hemodynamic, neurophysiological, and sex hormone interaction. Penile erection is the result of a complex interaction between the central nervous system and other local factors. This physical event also can be influenced by psychological factors. 5-Hydroxytryptamine (5-HT), dopamine, and nor-epinephrine play important roles as central neurotrans-mitters in the process of erection. Still other substances or hormones, such as endorphins, oxytocin, vasopressin, adrenocorticotropic hormone (ACTH) and related peptides, and prolactin, appear to participate in the complex and coordinated process of penile erection. Central nonadrenergic neurons also may influence male sexual behavior. Nitric oxide (NO) released during nonadrenergic, noncholinergic (NANC) neurotransmission and from the vascular endothelium is most likely the major neu-rotransmitter mediating penile erection. NO is a mediator of relaxation of the corpus...

Treatment of erectile dysfunction

Sildenafil (Viagra) is the only oral medication available for erectile dysfunction. A type-5-phosphodiesterase inhibitor, the drug potentiates the effects of nitrous oxide on sinusoidal smooth muscle. It comes in 25, 50, and 100 mg tablets which should be taken about 1-1.5 hours prior to intercourse. Initial dose is 50 mg at a maximum frequency of one per day. The dose can be increased up to 100 mg. The drug can potentiate the hypotensive effects of nitrates therefore, nitrate us is an absolute contraindication. Adverse reactions include headache and changes in vision. Other oral medications awaiting FDA approval include phentolamine C. Vacuum constriction devices (VCD) are an effective treatment alternative for erectile dysfunction. The design involves a plastic cylinder that is placed on the penis with negative pressure created. A constriction band is placed at the base of the penis. Almost every patient can be a candidate for these devices. Contraindications include penile...

SEXuAl Response Cycle

Two pioneering researchers, William Masters and Virginia Johnson, identified four stages of sexual response. These stages excitement, plateau, orgasm, and resolution are known as the human sexual response cycle. Two basic processes occur during sexual response vasocongestion and myotonia. Vasocongestion refers to the concentration of blood in the blood vessels and in the tissues of the genitals and breasts. In men, vasocongestion occurs when arterial blood flow to the penis increases and venous outflow decreases. Erection is a result of increased blood flow to the spongy tissue (corpora cavernosa) of the penis, causing these tissues to expand. In women, this inflow of blood causes the clitoris to enlarge, the labia to swell, and the vagina to lubricate. Myotonia, or neuromuscular tension, refers to the increase of energy in nerves and muscles. During sexual activity, myotonia takes place throughout the body, affecting both involuntary and skeletal muscles. plateau phase of the sexual...

Antidepressants and Female Sexual Dysfunction

Although numerous medications can have an adverse impact on sexual function, few classes of medications have been demonstrated to have more impact on sexual function than antidepressants. Although many of the various classes of antidepressant agents can affect sexual function, the selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, sertraline, or fluoxetine, have been shown to adversely affect libido, arousal, as well as the ability to reach orgasm.27 Under a physician's care, options may include switching agents, dose reduction, or drug holiday. Bupropion (Wellbutrin) may be an effective alternative.28 In addition, studies have suggested that the use of sildenafil with

Causes of Female Sexual Dysfunction

Similar to its counterpart in the male, there are numerous causes of FSD (Table 5-1.3). In fact, any factors influencing normal physiology, or any step of the sexual response in women, may contribute to FSD. The etiologies can be grouped as being either psychogenic or organic in nature, although overlap often exists. components of the sexual response can cause FSD. Vascular causes of FSD include atherosclerosis, smoking, diabetes, dyslipidemia, peripheral vascular disease, hypertension, renal failure, and perineal or pelvic trauma, such as that seen with bicycle riding. Neurologic diseases associated with FSD may include stroke, multiple sclerosis, spinal cord injury,Alzheimer's disease, Parkinson's disease, pudendal nerve injury, and iatrogenic surgical changes during radical pelvic surgery, CRS, or hysterectomy. Hormonal or endocrinologic causes of FSD include hypogo-nadism, androgen insufficiency, menopausal changes and genital atrophy, hypothyroidism, hyperthyroidism, diabetes,...


Sildenafil (Viagra) was developed more than 10 years ago as an antihypertensive and antianginal drug. It Sildenafil is a selective inhibitor of cGMP-specific PD-5 and therefore inhibits the degradation of cGMP. PD-5, the predominant type in the corpus cavernosum, also is present in other tissues (e.g., lungs, platelets, and eye). The selective inhibition of this enzyme facilitates the release of nitric oxide and smooth muscle relaxation of the corpus cavernosa. Sildenafil enhances erection by augmenting nitric oxide-mediated relaxation pathways. It has been suggested that sildenafil's mechanism of action is due to cross-talk between cGMP- and cAMP-dependent transduction pathways within the cavernous muscles. Sildenafil is readily absorbed after oral administration and reaches peak plasma levels after about an hour. It undergoes hepatic metabolism and has a terminal half-life of about 4 hours. An initial dose of 50 mg is taken about an hour prior to sexual activity to induce penile...

A pAdrenergic receptor blockers

Common adverse effects of p-blockers include decreased exercise tolerance, cold extremities, depression, sleep disturbance, and impotence, although these side effects may be less severe with the p1-selective blockers (ie, metoprolol, atenolol, bisoprolol). The use of p1-selective agents also helps minimize adverse effects associated with

Supplemental Reading

A patient who has been a heavy smoker (2 packs of cigarettes per day for 30 years) comes to you for advice to quit smoking. You inform your patient that sudden cessation of smoking will result in withdrawal symptoms that may include restlessness, irritability, anxiety, tension, stress, intolerance, drowsiness, frequent awakenings from sleep, fatigue, depression, impotence, confusion, impaired concentration, gastrointestinal disturbances, decreased heart rate, and impaired reaction times. You advise your patient that successful cessation of tobacco use requires attention to both the positive and negative (withdrawal) reinforcement properties of nicotine and tobacco use. You plan, therefore, to combine both psychological and pharmacological treatment. What are some therapeutic approaches you can suggest

Biochemistry Hormones

Testosterone from blood is correlated with sensation seeking, particularly that of the experience seeking and disinhibitory types (Aluja & Torrubia, in press Daitzman & Zuckerman, 1980), although Bogaert and Fisher (1995) and Dabbs (2000) found only nonsignificant tendencies toward association using salivary testosterone. Hypogonadal men with very low testosterone referred for complaints of erectile dysfunction were lower on sensation seeking than men with normal levels of testosterone (O'Carroll, 1984). Testosterone in young males correlates with their sexual experience, as defined by the number of sexual partners they have had (Bogaert & Fisher, 1995 Dabbs, 2000 Daitzman & Zuckerman, 1980). Other corelates of testosterone in males include assertiveness, impulsivity, and low self-control. A history of antisocial behavior, beginning in childhood, is found in men with high testosterone levels (Dabbs, 2000).

Prolactinsecreting Tumors

Ninety percent of such tumors are in females with secondary amenorrhea as the common presenting feature. Galactorrhea is not always present, perhaps because a permissive level of estrogen may be required for milk production. In men, impotence with decreased sperm count is the endocrinological equivalent. Women, possibly owing to a greater awareness of the effects of hypersecretion, tend to present at a younger age with microadenomas, while men present later in life with visual field disturbances.

Presentation and Clinical Features

The three main presenting features are similar to pituitary adenomas endocrine disturbance, headache and visual impairment. In a recent large series of over 28 RCCs 1 , the mean age at presentation was 45 years. Clinically, endocrine disturbance was the most common presentation (50 ), including amenorrhea (37.5 of female patients), growth retardation, impotence and DI. Biochemically, hypopitu-itarism, hyperprolactinemia and gonadotrophin deficiencies were the common endocrine findings. Headache was a major feature in 32.1 and visual disturbance in14.3 . Patterns of visual disturbance included central field loss as well as the peripheral field loss expected in sellar region lesions. Four patients had pre-operative DI, a feature that, in the authors' opinion, excludes pituitary adenoma.

Adjusting to Changes in Sexual Function in MS

Normal sexual function changes throughout one's lifetime, but having multiple sclerosis (MS) can profoundly affect an individual's sexual experience in a variety of ways. The most frequently reported change in men is diminished capacity to obtain or maintain an erection (impotence), while the most frequent change reported by women is partial or total loss of libido (sexual desire).

The Brain And Spinal Cord And Ms

Sexual response is controlled by emotional responses in concert with the central nervous system the brain, and the spinal cord. The brain is involved in many aspects of sexual functioning, including sexual desire, the perception of sexual stimuli and pleasure, movement, sensation, cognition, and attention. Throughout the sexual response cycle, sexual messages are communicated between the brain, spinal cord, and the genitals. Because MS can cause lesions along myelinated pathways, it is not surprising that changes in sexual function are reported so frequently by people with MS.

Combination of Pharmacophores

Some highly specific mono-target drugs have clearly proven the usefulness of mono-target medicine. Examples are phosphodiesterase 5 inhibitors such as sildenafil, the a-1a antagonist drugs such as tamsulosine, selective COX-2 inhibitors such as celecoxib and kinase-specific anticancer drugs such as imatinib. However, in addition to one-target drugs, clinicians are more and more convinced that modulating a multiplicity of targets can be an asset in treating a range of disorders. An extreme example of a multi-target drug is clozapine, which exhibits nanomolar affinities for more than a dozen different receptors.

Preoperative Evaluation

Intraventricular tumors are often slow-growing and benign. These lesions frequently grow large before clinical manifestations and, ultimately, produce symptoms secondary to hydrocephalus, either by obstruction of the normal pathways of cerebrospinal fluid flow or by its overproduction. Most patients present with headaches 2 . Colloid cysts, which typically occur anteriorly and superiorly within the third ventricle, have a tendency to intermittently obstruct the foramen of Monro, resulting in acute lateral ventricular hydrocephalus with symptoms of intracranial hypertension. Visual loss, impotence and diabetes insipidus may be caused by tumors invading the floor of the third ventricle. Asymmetric bitemporal hemianopia, starting with inferior temporal field loss, may occur due to dilatation of the third ventricle with pressure on the optic chiasm from above. The extension of the tumor may cause a variety of visual field defects, including homonymous hemianopia, binasal field defects,...

Paradigm Shift Involving Patients in Healthcare Decisions

Many clinical decisions are not purely scientific matters, but also involve value judgments that vary from person to person. For example, the right choice, for a patient choosing between surgical and radiation treatment of his prostate cancer, depends on how much he thinks he would be bothered by surgical complications such as impotence or incontinence and on how important he feels it is to have the cancer physically removed from his body. Similarly, whether a woman should begin receiving annual mammography at age 40 or 50 depends on how she feels about the inconvenience and discomfort of mammography, the financial costs of screening, the consequences of false-positive testing, and the benefits of receiving more aggressive screening.

Emotional Mispredictions

Such mispredictions are common in health settings.49 For example, patients with inflammatory bowel disease expect that having a colostomy would make them miserable, and yet patients emotionally adapt to colostomies relatively quickly.50 People predict that they would be miserable if they had kidney failure, and yet most dialysis patients are happy.51 Such mispredictions could influence patients' healthcare decisions. If a prostate cancer patient overestimates how much he will be bothered by impotence or incontinence, he may forgo potentially beneficially treatments.

Psychotherapysexual counselling

Sex therapy today involves integrating medical and psychotherapeutic interventions. The conventional role of the mental health clinician in the treatment of erectile dysfunction had been to treat those with psychogenic erectile problems. Now with the advent of efficacious, reversible, and safe medical therapies the role of the Many men with erectile dysfunction can achieve a significant recovery in sex therapy those with acquired disorders typically fare better than those with lifelong problems. In an excellent review of the treatment studies for erectile dysfunction, Mohr and Beutler(44) wrote that the 'component parts of these treatments typically include behavioural, cognitive, systemic and interpersonal communications interventions. Averaging across studies, it appears that approximately two-thirds of the men suffering from erectile failure will be satisfied with their improvement at follow-up ranging from six weeks to six years.'

Sleepinduced respiratory disturbances

Clinical features include night-time and daytime symptoms. Night-time symptoms are represented by loud snoring, apnoeic episodes ending with sonorous breathing resumption, nocturia, severe fatigue upon awakening, and sometimes headache. Daytime symptoms are dominated by excessive sleepiness which varies in intensity among patients. Other symptoms include irritability, negligence, loss of concentration, loss of libido, impotence, and sometimes depression.

Autonomic and Endocrine Effects

All antipsychotics except clozapine and perhaps olanzapine produce hyperprolactinemia by removing the inhibitory actions of dopamine on prolactin secretion. This results in amenorrhea, galactorrhea, and infertility in women and in loss of libido and impotence in men. Inhibition of the release of follicle-stimulating and luteinizing hormones may also play a role. In addition, weight gain is common, and food intake must be monitored.

Treatment of acute mountain sickness

Which reduces the reabsorption of bicarbonate and sodium at the level of the renal tubules, leading to a metabolic acidosis within an hour of ingestion. An oral dose of acetazolamide 250 mg twice daily can be used for mild acute mountain sickness. Side-effects include peripheral paresthesias, polyuria, nausea, drowsiness, impotence, and myopia.

Injury to the L5 Segment

At L5, neural decompression is best achieved posteriorly via a laminectomy with a trans-pedicular approach. In the case of severe neural compression, an anterior decompression can be performed through a paramedian abdominal incision. The lower lumbar spine can then be exposed via a transperitoneal or retroperitoneal approach. The transperitoneal approach provides more extensive exposure but it also entails mobilization of the great vessels and the hypogastric nerve plexus. Mobilization of the latter structure is associated with an increased risk of impotence.

Comparison With National Data

Where appropriate, comparisons are made between event rates in PEM studies and other data resources, e.g. national statistics. An example is the analysis of cardiovascular events of the PEM study on sildenafil (Shakir et al., 2001) (the product used for erectile dysfunction). Reported deaths from myocardial infarction and ischaemic heart disease in users of sildenafil in the PEM study were found to be no higher than expected according to national mortality statistics. The precautions with regard to possible sources of bias and confounding also apply to external comparisons.

Measuring Outcomes Of Care

The ideal situation is when a therapy intervention improves all three of the above-mentioned health outcomes (clinical, economic, and humanistic) (Table 9.1, Scenario 1). A major ethical issue surfaces when one or more of these outcomes does not improve, but rather worsens as a result of treatment (Table 9.1, Scenarios 2-6). For example, suppose a drug reduces the incidence of myocardial infarction, but negatively affects patient quality of life due to side-effects such as depression, erectile dysfunction, and insomnia. In the total view, this drug is less cost-effective than alternative treatments to prevent myocardial infarction (Table 9.1, Scenario 2). In other words, it provides a negative economic outcome. Although it achieves the targeted clinical outcome (prevention of myocardial infarctions), one must ask whether treatment with this medication is ethical. This is an example where the three outcomes (clinical, economic, humanistic) are not affected in the same direction,...

Spinal cord and root compression neurological effects

The lower sacral roots are involved early, producing loss of motor and sensory bladder control with detrusor paralysis. Overflow incontinence ensues. Impotence and faecal incontinence may be noted. A l.m.n. weakness is found in the muscles supplied by the sacral roots (foot plantarflexors and evertors), the ankle jerks are absent or impaired and a sensory deficit occurs over the 'saddle' area.

Clinical premotor symptoms

Female PD patients mainly report difficulties with arousal, whereas males complain about erectile dysfunction and premature ejaculation, all of which result in difficulties reaching orgasm and or attaining sexual satisfaction in half of the patients (Bronner, 2004).

S Evidence statements

Four systematic reviews which included men with erectile dysfunction were identified.432-435 All were of good quality (Ia). Two reviews examined the effects of sildenafil (Viagra), one looked at yohimbine (a herbal preparation) and the fourth looked at a variety of interventions including both yohimbine and sildenafil. There was overlap in the trials included in these reviews. All three reviews which looked at the effectiveness of sildenafil reported that it was significantly better than placebo in the treatment of sexual dysfunction in men.432,433,435 One review also reported that sildenafil was effective in all subgroups investigated.433 Both the review which looked exclusively at yohimbine434 and the review which also looked at a variety of other treatments432 found that yohimbine was significantly better than placebo in the treatment of erectile dysfunction. The side effect profile of both drugs was reported to be good. The review which looked at a large variety of interventions...

Special Issues For The Transplant Patient

The hypothalamic-pituitary-gonadal (HPG) axis is markedly disturbed by chronic renal failure, and this is manifest in diminished testosterone levels and impaired spermatogenesis. These patients often present with complaints of diminished libido, erectile dysfunction (ED), and infertility. Upon evaluation, they have low serum testosterone levels and elevated follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels.1 Interestingly, these patients usually retain a normal response to clomiphene citrate stimulation. Clomiphene citrate has antiestrogenic properties which result in a decrease in negative feedback by

Route of Administration

In general, it is recommended that both the substrate and interacting drug be administered in the same way these drugs are used (or going to be used clinically). However, if multiple routes of administration are possible, it might be necessary in some cases to investigate the possibility of drug interactions with the different routes of administration. This is particularly true for drugs that undergo gut wall metabolism whereby the amount of metabolism will differ between the oral and intravenous routes. Therefore it is thought that the differences in exposure that result from a drug interaction will be different depending on the route of administration (viagra interaction with erythromycin), which will consequently result in different dosing adjustment recommendations, then in such cases one is better off obtaining the true magnitude of interaction for the different routes of administration.

Causes of ageing effects

Found that sexual activity correlated more with age than with levels of free testosterone. Rowland et al.(22) studied 39 healthy males aged 21 to 82, assessing questionnaires and erectile response to visual stimuli. Erection decreased with age and this reduction was related to decreased penile threshold to electrical and vibrotactile stimulation. However, these latter measures correlated with age, so that cause could not be distinguished from effect. In a definitive study of male ageing, Feldman et a .(23) incriminated vascular disease as the cause of elderly erectile failure but did not assess neurological factors. Ford and Kellett(24) compared 28 elderly men with erectile failure with 26 age-matched controls who were potent using 40 measures covering vascularity, autonomic control, collagen, hormone, and psychological factors. The groups were distinguished by only two measures the number of sweat glands that responded to pilocarpine stimulus (p < 0001) and a composite vascular...

Chapter References

Masters, W. and Johnson, V. (1966). Human sexual response. Churchill, London. 23. Feldman, H.A., Goldstein, I., Hatzichristou, D., Krane, R., and McKinlay, J. (1994). Impotence and its medical and psychological correlates results of the Massachusetts male aging study. Journal of Urology, 151, 54-61 28. Schiavi, R., White, D., Mandeli, J., and Levine, A. (1997). Effect of testosterone administration on sexual behavior and mood in men with erectile dysfunction. Archives of Sexual Behavior, 26, 231-8

Symptomatology of Urogenital Atrophy

Typical symptoms of vaginal atrophy include vaginal dryness, vaginal irritation, as well as loss of vaginal caliber and depth in more advanced degrees of atrophy. The initial symptoms of vaginal atrophy can be promptly reversed with local estrogen therapy. However, the more long-term effects of urogenital atrophy such as loss of vaginal caliber and depth are less likely to be readily reversible. This has recently become a clinically important issue, because male erectile dysfunction can be treated pharmacologically, whereas the female partners' advanced urogenital atrophy has not been taken into account. Any attempt at sexual intercourse after a long hiatus of inactivity in a post-menopausal woman can result in sexual dysfunction and even vaginal trauma including lacerations upon attempted penetration. It is thus critical that both partners be considered when initiating erectile dysfunction therapy in the male.

Carbonic Anhydrase Inhibitors

Common systemic effects are depression, stomach discomfort, tingling of the extremities, kidney stones, and impotence. A substantial metallic, chalky taste is also common. The tingling of the extremities is so pronounced that it has been suggested that you can judge a patient's compliance by asking if this sensation is present. Ocular effects with systemic therapy are rare. All CAIs, topical or systemic, are contraindicated in patients with sulfonamide allergies, severe kidney or heart diseases, and adrenocortical insufficiency.

Chemical Name Papaverine papavereen

Description Papaverine belongs to a group of medicines called vasodilators, which cause blood vessels to expand, thereby increasing blood flow. Papaverine is used in MS to treat erectile dysfunction. When papaverine is injected into the penis, it produces an erection by increasing blood flow to the penis.

Interaction With Protease Inhibitors

Concerns were also raised in 1999 of a probable interaction between sildenafil and protease inhibitors leading to a potentiation of the effects of sildenafil and an increased likelihood of adverse effects.742 3 In Europe, Pfizer and European Union regulators agreed to a sildenafil labelling change that concomitant treatment with ritonavir is not advised, and planned to expand the drug interaction precaution to include other protease inhibitors.751 2 Similarly, in the United States, the FDA and Pfizer discussed updating the labelling of sildenafil to include a warning about possible interactions with protease inhibitors.751 2 In September, the Japanese Ministry of Health and Welfare issued another warning against unregulated use of sildenafil without proper consultation with a physician.769 2 At the time, a total of 33 adverse reactions associated with sildenafil had been reported in Japan, including 2 deaths sildenafil had been prescribed by a doctor in only 8 of the 33 cases. Also,...

AReductase Inhibitors

Finasteride (Proscar) is a 5a-reductase inhibitor that blocks the conversion of testosterone to DHT in target tissues. Since DHT is the major intracellular androgen in the prostate, finasteride is effective in suppressing DHT stimulation of prostatic growth and secretory function without markedly affecting libido. It is approved for the treatment of benign prostatic hyperpla-sia. Although there is usually some regression in the size of the prostate gland following administration of finasteride, clinical response may take 6 to 12 months. If the obstructive symptoms are severe, there is often not enough time to allow this compound to work. The principal adverse effects of finasteride are impotence, decreased libido, and decreased volume of ejaculate. The compound is generally well tolerated in men.

Androgens Testosterone

Androgen deficiency can lead to decreases in nocturnal erections and libido. Hypogonadism is associated with impotence, yet erection in response to visual stimulation is preserved in men with hypogonadism, suggesting that androgens are not essential for erection. Although androgens can enhance male sexual function, testosterone therapy for the treatment of ED should be discouraged unless the cause is clearly related to hypogo-nadism. Androgen therapy in normal men may enhance sexual behavior but is without significant effect upon erectile function. Usefulness of oral methyltestosterone is limited in men with hypogonadal impotence. Improvement following transdermal testosterone may require several months of therapy. Androgen replacement regimens for treating male hypogonadism include long-acting intramuscular injections (e.g., testosterone enanate, testosterone cypi-onate) and oral preparations (e.g. methyltestosterone, fluoxymesterone). Transdermal patches (Testoderm, Androderm) and...

Adverse Reactions Contraindications and Interactions

Headache and GI symptoms are the most frequently reported side effects. It is possible to reduce GI side effects, such as nausea, abdominal discomfort, and diarrhea, by taking the extract with food. Theoretically, decreased libido or erectile dysfunction could also occur. Because of saw palmetto's possible hormonal effects (and lack of indications for use), pregnant and nursing women should avoid it. It is important to rule out prostate cancer in those taking saw palmetto for BPH, since the symptoms are similar. The effect of saw palmetto on prostatic cancer would likely be beneficial but not curative. No drug interactions have been reported.

The Evolutionary Neurodevelopmental Perspective

The last personality with which the narcissist shares some resemblance is the sadistic. The passive exploitation of the narcissist is often mistaken for the active exploitation of the sadist. In the narcissist, however, exploitation is incidental to egocentricity. In contrast, the sadist dominates others self-consciously and deliberately constructs scenarios that demean others to force their inferior status to consciousness. The narcissist wants your worship the sadist wants to inflict impotence on others. Further, whereas the sadistic personality is characteristically destructive and cruel and enjoys watching others suffer, narcissists become rageful only when their sense of specialness is compromised. Otherwise, narcissists are content to go forth with benign insouciance, surveying their dominion and soaking up tributes and comforts owed to them by lesser others. If Leonardo returns to Spain, he will do so with just this mentality. Given narcissists' image of strength, ability, and...

Antiparkinsonian Therapy And Hypersexuality

Sexual awareness or activity was reported in 3 to 4 instances. The authors noted that the 5 men in the 40 to 60 year age group, with a relatively mild form of parkinsonism and 1 to 2 year history of impotence, demonstrated improved motor function with therapy but did not report a change in sexual function.

Drugs That Interfere With Norepinephrine Storage

Peripheral nervous system side effects are the result of a reserpine-induced reduction of sympathetic function and unopposed parasympathetic activity symptoms include nasal congestion, postural hypotension, diarrhea, bradycardia, increased gastric secretion, and occasionally impotence. Because of the increased gastric secretion, reserpine is contraindicated for patients

Erection the conversion of the flaccid urinary penis to the rigid sexual penis

The vasodilatation of the arterial supply by VIP together with the relaxation of the vessels of the cavernosal tissue allows them to fill under arterial pressure stretching the chambers until they become stiff against their covering of unyielding tunica albuginea, and the veins (emissary) that pass obliquely through the tunica become occluded greatly reducing penile vascular drainage The flaccid urinary penis has been converted into the erect rigid sexual penis some 7 to 8 cm longer. The rigidity is essential for successful vaginal penetration and to stimulate its walls (especially the anterior) during penile thrusting. The striated muscles of the pelvic region, namely the ischiocavernosus and bulbocavernosus, are not normally involved in creating penile erection, (39) although they can be voluntarily contracted in bursts to aid its rigidity. The engorged corpus spongiosum is less rigid than the cavernosal chambers making the glans of the penis softer and less damaging to the female...

Syndromes related to a cultural emphasis on fertility and procreation Genital shrinking syndrome koro suoyang

The 'genital shrinking' syndrome is a transient state of acute anxiety associated with vegetative symptoms, in which the affected male subjectively experiences a shrinking of his penis and the affected female a shrinking of her breasts and or labia the sufferers anticipate not only impotence or sterility but, in the case of complete genital retraction, certain death. Moreover, the immediate human environment of the sufferers is convinced of the same outcome and this explains the 'life saving' measures commonly taken, such as holding on to the sufferer's genitals manually or with special instruments. The 'genital shrinking' syndrome came to the attention of European psychiatry in the late nineteenth century through reports of colonial physicians working in Southeast Asia and through the growing interest in traditional Chinese medicine. Chinese traditional medicine interprets suo-yang as yin-yang imbalance due to a deficiency of the 'warm' male principle yang and an excess of the 'cold'...

Levels of explanation and the reduction of mental processes

Many recent authors have also argued against the reduction of mental processes (e.g. Davidson 1980 Fodor 1983), but as we have seen the accompanying danger is that mental processes are stranded without a causal story, or one that separates them from other biological processes. However once the case for the pervasiveness of intentional processes in biology is presented then explanations of psychological processes are no more stranded than those of molecular biology. Nevertheless we do need to be quite specific about what can and cannot be reduced, and how far. We need also to be clear about levels of causal processes, for we are not referring to distinctions such as those of mental versus non-mental, or neuroscience versus biochemistry. That would be to create a dualism (or multilevelism) that is totally at odds with our analysis. For instance a rapid heart beat is part of the intentional response of fear, and an erection is part of male sexual excitement. These physiological responses...

Psychophysiological assessment

Patients use a variety of tactics to conceal their sexual interest. There are a number of drawbacks to using penile plethysmograpy for the clinical assessment of deviant sexual response. One central issue is whether or not arousal responses seen in the laboratory are equal to similar arousal in the real world. Individuals undergoing psychophysiological assessment often deny any and all deviant sexual interest, and so penile plethysmography frequently involves measuring possible sexual interest that the patient has absolutely denied. This can be problematic when attempting to delineate deviant sexual interests through penile plethysmography. Recently, penile plethysmography has come under greater scrutiny because slides depicting nude children are frequently used to assess paedophilic interest. The use of nude slides is considered unethical and illegal in some countries such as the United States. Another problematic issue is the necessity of obtaining two separate rooms to complete...

Autonomic nervous system specific diseases

Automatic Nerves The Penis

In the latter disorder, features of extrapyramidal system involvement arc also found. Both disorders are characterised by postural hypotension anhidrosis (absent sweating) impotence Symptoms of autonomic dysfunction are common in long-standing insulin-dependent diabetics Impotence retrograde ejaculation. Autonomic involvement with orthostatic hypotension, impotence, diarrhoea and bladder involvement may accompany sensimotor neuropathy in the primary and hereditary forms. Amyloid infiltration affects autonomic ganglia. pressure rise, bradycardia, sweating, reflex penile erection (priapism).

Causes Of Hypersexual Behavior

Different mechanisms have been suggested to explain hypersexuality in response to antiparkinsonian therapy. The dopaminergic system, which is widely distributed in the central nervous system (CNS) and pelvic organs, is necessary for male sexual arousal and ejaculation, as documented in animal experiments and human studies.65 The serotonergic system, which is also widely distributed in the CNS, has an inhibitory role in the sexual response cycle. Dopaminergic agents such as levodopa, bromocrip-tine, and pergolide may promote sexual behavior by activating the dopaminergic system and lowering serotonin concentrations at postsynaptic sites.25

Disorders of sexual behaviour

Impotence or reduced libido Reduced sexual activity and interest is the most common disorder of sexual behaviour associated with dementia, though it is the least likely to come to the attention of the clinician. It probably plays a part in the high rates of divorce seen, for example, in young couples after one partner has sustained a brain injury. Psychological effects, in particular the change in the patient's role in the partnership as a result of dementia, as well as the physiological effects of brain injury on erectile function, contribute to impotence and reduced libido.

Current Medical Treatments For Hypertension

Possible new drugs are constantly on trial, for instance, vasopeptidase inhibitors.9 Sildenafil specializes in pulmonary vasodilation while it increases blood flow out of the heart, it has no effect on wedge pressure.35 One group of researchers attempted to determine whether benazepril or nitrendipine produced a greater reduction in left ventricular mass. The results were close benazepril had greater effect on diastolic pressure and nitrendipine decreased systolic pressure more.32

Differentiation Of Pd From Multiple System Atrophy

Among the males with MSA in Chandiramani et al's series, 93 had erectile dysfunction (ED), including 48 where this complaint preceded the diagnosis of MSA. However, ED can also be seen in PD, although the proportion of early ED is less.32 One would also expect poor response to urological surgery targeting prostatism, even poorer than with PD. All 11 men with MSA in Chandiramani et al.'s series9 who had a TURP were incontinent postoperatively. See the section below, Effects of Urologi-cal Surgery.

Other Agents Of The Same Pharmacological Class

Specific chemical class usually associated with one therapeutic area but have later been developed or used clinically in an entirely different therapeutic area. Terfenadine is another typical example. It was discovered through a central nervous system programme aimed at synthesising new neuroleptic agents but because of its potent secondary pharmacological effects at the -antihistamine receptor, it was developed as the first non-sedating -antihistamine. It was a highly successful and popular drug until withdrawn due to reports of torsade de pointes resulting from drug interactions. Like all neuroleptics, it attracted considerable regulatory attention because of its effect on the QT interval. Sildenafil, originally intended for development as an antianginal drug, was developed instead for male erectile dysfunction and it is not surprising that at high concentrations, it has been shown to prolong cardiac repolarisation by blocking the rapid component of the delayed rectifier potassium...

Adr Headlines From 1999

In 1999, confidence in vaccinations received another blow following the withdrawal of rotavirus vaccine (RotaShield) because of reports of intussusception, and there was misleading press coverage regarding the safety of the measles, mumps and rubella (MMR) vaccine. Investigations continued into the link between anorectic agents and valvular heart disease, the safety of sildenafil, and metabolic disorders associated with protease inhibitors. Fluoroquino-lones came into the spotlight when marketing of trovafloxacin and its IV formulation alatro-floxacin was suspended in Europe because of hepatotoxicity, and grepafloxacin was withdrawn worldwide later in the year following reports of fatal cardiovascular events.

Ganglionic Blocking Agents

The ganglionic blocking agents are extremely potent antihypertensive agents and can reduce blood pressure regardless of the extent of hypertension. Unfortunately, blockade of transmission in both the sympathetic and parasympathetic systems produces numerous untoward responses, including marked postural hypotension, blurred vision, and dryness of mouth, constipation, paralytic ileus, urinary retention, and impotence. Owing to the frequency and severity of these side effects and to the development of other powerful antihypertensive agents, the ganglionic blocking agents are rarely used.

Early Historical Forerunners

Eventually, the glory of ancient Greece and Rome disappeared. In the Middle Ages, the world was viewed through a religious paradigm. Faith in God offset hard times for humanity, including mass starvation, disease, pestilence, and war. By some estimates, a third of the population of Europe was killed by the Black Death alone. Humans naturally sought explanations to such paradoxical calamities. How could such horrors occur if God were just and loving Again, women were to blame. Those who ran afoul of social standards became natural scapegoats, being diagnosed according to the standard of the times as witches, in league with Satan. Through their sorcery, these evil beings could summon famine, plague, bad luck, and worst of all, impotence. Eventually, the widespread dread of witches found religious sanction in the Malleus Maleficarum, or Witches' Hammer, written by two German monks in 1496, a kind of Stephen King version of our modern DSM, complete with its own form of therapy burning at...

Consequences of Cigarette Smoke Induced Microvascular Dysfunction

Most smoke-related diseases point toward effects on the microcirculation. For one, the development of pulmonary emphysema occurs at the microcirculatory level of the delicate alveolar membranes, presumably due to a dysbalance between aggressive factors such as tissue degrading mediators and reactive oxygen species released from smoke-activated neutrophils (i.e., elastase, hydrolytic enzymes) and protective factors such as a-1 antiprotease, which are inactivated by cigarette smoke. Also, the association of cigarette smoking and chronic inflammatory conditions such as periodontal disease is a largely microcirculatory phenomenon that involves phagocyte dysfunction and other pathomech-anisms. Another important problem related to cigarette smoking-induced microcirculatory dysfunction is of major concern to plastic surgeons. There is an impressive literature on the adverse effects of cigarette smoking on the outcome after surgical interventions, such as (i) a significantly higher incidence...

Spinal Dysraphism in Adults

Adult patients with spinal dysraphism include those with new symptomatic onset of a previously unsuspected occult dysraphic condition and those with a known dysraphic lesion in childhood but with symptom onset only in adulthood. In both groups, unlike in childhood, pain is the most frequent presenting symptom. This may be poorly localized and bilateral, and coupled with weakness in the legs as well as sensory disturbance. Problems with bladder control, as well as erectile dysfunction, also occur frequently. Not infrequently, the problem only comes to light as a result of excessive stretching of the conus, as may occur in childbirth or trauma 25 . In those with a known dysraphic lesion, presentation in adulthood may be with a progressive scoliosis or foot deformity, although these features are generally not seen in an adult with a previously unsuspected dysraphism.


Sphincter Disturbance Disturbances of micturition are the presenting feature in approximately 5 of cases of MS, but problems with bladder function eventually affect the majority of patients to some extent. In view of the common etiology within the spinal cord, bowel and sexual function problems often co-exist few male patients who have significant micturition problems do not have erectile dysfunction. The occurrence of sexual dysfunction correlates closely with bladder impairment. It is a major cause of distress, relationship strain, misunderstanding, and marital breakdown. Although not commonly a feature at presentation, again, apart from those with primary progressive disease, it is a significant issue even in the relatively able-bodied patient. Erectile dysfunction has been found to affect up to 91 of men, and between 56 and 72 of women with MS report sexual difficulties. The problems experienced do not simply reflect the autonomic disturbances that occur in MS but are...


At the prevalence of FSD in the partners of men with ED. One hundred fifty women were evaluated, aged 25 to 82 years. The study revealed that 56 of these women had FSD, and demonstrated specific vascular risk factors, including cigarette smoking, hypercholesterolemia, hypertension, and prior pelvic surgery. Based on population surveys, this would suggest that more than 30 million women in the United States might have FSD. Unfortunately, despite this high prevalence, it has been estimated that less than 5 of women with FSD are being treated.

Free Will

People lose their freedom when they cease to believe that their decisions depend on their deliberations. If you fall out of an airplane without a parachute, you may debate all you like about whether to go down or up, but you know your deliberation has no effects. More subtly, an alcoholic or drug addict may go through the motions of deciding whether to indulge in his vice, but he doesn't really believe the decision is a real one. What's the use, he might think, I've decided every other morning to have a drink I know I'm just going to make the same decision I might as well have one. In this case the belief in one's own impotence might be delusional, but it's self-fulfilling. One can contrast the addict's situation with the decision of whether to take a breath. You can postpone breathing only so long at some point the question whether to breathe or not seems to be taken out of your hands. The alcoholic classes his decision to take

Oral treatments

The introduction of sildenafil citrate (Viagra ) in the United States could best be characterized as 'a happening'. In the first 90 days after its approval it became the most prescribed medication with 3 million prescriptions written 5 months later approximately 90 per cent of those prescriptions had been refilled. Sildenafil acts by inhibiting the enzyme that breaks down cyclic guanosine monophosphate (cGMP). It enhances the man's ability to achieve a natural erection, providing that he is being adequately stimulated mentally and physically. Unlike other medical treatments such as self-injection, transurethral or vacuum therapy, sildenafil does not induce an erection irrespective of the man's degree of arousal. Taken on an empty stomach, sildenafil works in approximately 1 h. The only contraindication to sildenafil is the concomitant use of nitrate medications or a diagnosis of retinosa pigmentosa. Depending on the aetiology of the dysfunction, the efficacy of sildenafil ranges...

Vacuum systems

Vacuum pump systems are manufactured by numerous companies (UroHealth, Mission, Post-t-Vac) and consist of several components a clear plastic cylinder, a hand pump, a lubricant, and tension rings. Battery operated systems are available for men who are unable to manually pump the device. To create an erection the man places the clear plastic tube over his lubricated penis. Pumping creates an erection by producing a negative pressure 'vacuum' to draw blood into the corpora. The tension band is positioned on the base of the penis to maintain the erection. Approximately 90 per cent of men are able to achieve erections sufficient for intercourse with the vacuum pump drop-out rates are approximately 20 per cent. (4Z>

Sexual Dysfunction

Erectile dysfunction management has changed dramatically in the past 15 years. A decade or so ago, the only clearly effective treatment was the implantation of a penile prosthesis. This is a very rigorous surgical procedure with a mechanical end result. The erection is firm and controlled by the patient without much psychological input. In the past decade and a half, the role of vasodilat-ing agents injected into the penis became practical. Prostaglandin, when injected into the shaft of the penis, gives a good workable erection but is fraught with complications and can result in priapism. It also requires good hand coordination to do the injection. The use of vacuum-induced erections, caused by a tube being placed over the penis and a vacuum induced by pumping air out of the tube, never became popular among those with MS. Placement of the prostaglandin in the urethral opening became available the medicated urethral system for erection (MUSE) this method can work for many patients, but...

Sexual function

A diminution in sexual interest, a decrease in activity, and impaired performance are the most common aspects of sexual dysfunction in epilepsy. Men have been studied more thoroughly than women. Erectile impotence is a common complaint. The levels of free testosterone, the biologically active male hormone, is diminished in treated male epileptics due to the action of anticonvulsant drugs. Hyposexuality may be more pronounced in patients with partial epilepsy, but this may simply reflect the refractory nature of partial epilepsy and the greater amount of drugs prescribed. (15>


GI disturbances, including nausea, vomiting, and intense gastric irritation, are frequent. In addition, ethion-amide may cause a wide range of neurological side effects, such as confusion, peripheral neuropathy, psychosis, and seizures. Neurological effects can be minimized by pyridoxine supplementation. Other rare side effects include gynecomastia, impotence, postural hypotension, and menorrhagia.


Also been used in combination with other agents, such as papaverine. The injection does not appear to produce any long-term side effects on penile smooth muscle. Transurethral therapy with alprostadil, such as MUSE (alprostadil urethral suppository or medicated urethral system for erection) is also an effective therapeutic technique, and there may be a role for this form of administration in selected patients with ED. The intracav-ernosal injection of alprostadil (e.g., alprostadil alfadex Edex, Viridal) is safe and effective in patients with ED when sildenafil is ineffective. Both of these delivery systems have been used in the treatment of ED. MUSE can also be used in conjunction with a penile constrictor device (e.g., ACTIS).

Other Agents

Many other drugs and herbals exhibit varying degrees of potency with respect to penile erection. Some have undergone limited clinical trials, while others are associated with anecdotal reports. Generally, these agents are not particularly effective and are not widely used among mainstream therapeutic options for ED. tric oxide. Injected intracavernosally it can produce penile erections, but its clinical usefulness has not been fully established. Minoxidil, an antihypertensive agent, produces arte-riolar vasodilation by an unknown mechanism. In limited clinical studies, minoxidil increases penile rigidity and has been used in the long-term treatment of organic impotence. Naltrexone, an orally active opioid receptor antagonist, restores erectile function in some patients with id-iopathic ED. Calcitonin gene-related peptide (CGRP) induces a dose-related increase in penile arterial inflow, cavernous smooth muscle relaxation, cavernous outflow occlusion, and an erectile response. CGRP plus...

Current Problems

As has been said above, it is unlawful to advertise prescription only'' medicines to the public. However, as the recent launch of Viagra has shown, it is easy to evade this restriction. The company, quite lawfully, can hold a press conference stating that a marketing authorization has been obtained for the product and that it will be available on prescription from a stated date. The media then ask a variety of questions, all of which are answered carefully and truthfully. Radio and television reports carry the news to the nation to be followed up the next day by a variety of stories in the newspapers. Should some of these newspaper articles contain false or misleading statements, the company would not be responsible. The interesting fact is that the newspaper cannot be prosecuted for the inaccuracy because in English law it is not a commercially interested party'' as defined in the Medicines Act. A similar situation could arise without any prompting from the company. An alert...

Prostate Problems

Impotence is often a psychological problem more than a physical one. Drugs, tobacco, diabetes, and atherosclerosis can affect blood circulation which influences erectile ability. The herb yohimbe has been shown to improve erectile and ejaculatory activity. Hypnotherapy may also be beneficial. Ginseng and the Ayurvedic herb ash-waganda can enhance sexual energy.


A common and troublesome side effect is postural hypotension. Sexual impotence does occur, and male patients may have difficulty ejaculating. Symptoms of unopposed parasympathetic activity include such gastrointestinal disturbances as diarrhea and increased gastric secretion.

Male orgasm

The intensity of orgasm varies with the duration of the sexual arousal (the longer it is maintained the greater the subsequent orgasm), the erotic excitement and novelty of the arousing stimuli, and previous ejaculation, especially the interval from the last one (initial ejaculations have usually better orgasms than subsequent ones). Males have a refractory period after ejaculation and usually cannot have an erection or another ejaculation until some time has passed. This varies with age and can be anything from minutes, when young, to hours or days when older.(20) It is not known where this inhibitory mechanism resides but animal work suggests that it may be in the brain rather than the spinal cord. Some men claim to be able to learn to inhibit ejaculation and yet have repeated serial orgasms. (40)

Chris Good

The system has now been reinforced in the form of the National Institute for Clinical Excellence (NICE), set up by government to advise on best medical practice. This Institute tells medical practitioners what therapeutic guidelines they should follow and which medicines they may prescribe on the National Health Service. It thus basically decides which medicines will be reimbursed by the government and which will not. It is difficult to understand how on the one hand the government can license a medicine as safe and effective and then decide on the other hand that it is not therapeutically justified and refuse to pay for it. There are many examples of medicines not being prescribable on the National Health Service (NHS). Sildenafil was licensed by Pfizer for treatment of male impotence. NICE decided that this use was not justified on the NHS. Strong protests caused NICE to change its mind and allow it for certain patients with a chronic underlying disease such as diabetes mellitus....


The vasodilators decrease total peripheral resistance and thus correct the hemodynamic abnormality that is responsible for the elevated blood pressure in primary hypertension. In addition, because they act directly on vascular smooth muscle, the vasodilators are effective in lowering blood pressure, regardless of the etiology of the hypertension. Unlike many other antihypertensive agents, the vasodilators do not inhibit the activity of the sympathetic nervous system therefore, orthostatic hypotension and impotence are not problems. Additionally, most vasodilators relax arterial smooth muscle to a greater extent than venous smooth muscle, thereby further minimizing postural hypotension.


The frotteur rubs up against the buttocks, thighs, breasts, or vaginal area with his hand, his leg, his pelvic area, or with a newspaper or some other object. Despite being in a crowded public setting, while rubbing a complete stranger, he finds it easy to fantasize a close sexual relationship with the victim and can get an erection in seconds. Sometimes he will push his erect penis, underneath his clothes, up against the woman's thighs or buttocks.


Flutamide (Eulexin) is a nonsteroidal antiandrogen (see Chapter 63) compound that competes with testosterone for binding to androgen receptors. The drug is well absorbed on oral administration. It is an active agent in the hormonal therapy of cancer of the prostate and has been shown to complement the pharmacological castration produced by the gonadotropin-releasing hormone (GnRH) agonist leuprolide. Flutamide prevents the stimulation of tumor growth that may occur as a result of the transient increase in testosterone secretion after the initiation of leuprolide therapy. The most common side effects of flutamide are those expected with androgen blockade hot flashes, loss of libido, and impotence. Mild nausea and diarrhea occur in about 10 of patients.


Human prolactin is similar in structure to human growth hormone, and both are good lactogens. In women, pro-lactin acts with other hormones on the mammary gland during pregnancy to develop lactation and after birth to maintain it. Hyperprolactinemia causes impotence in men and amenorrhea and infertility in women. Chronically elevated levels of circulating prolactin are associated with suppression of 17-p-estradiol and testosterone production in the ovaries and testes.


The extent of sexual responsivity with the neovagina is anecdotal. Many patients report the subjective experience of orgasm but describe it in a different form from that experienced prior to surgery as a male. No physiological measures of the sexual response cycle have been reported with postoperative transsexual patients. (23)


Other a-adrenoceptor receptor antagonists include yohimbine, phenoxybenzamine, and thymoxamine. Yo-himbine is an a2-adrenoceptor antagonist, and thymox-amine is a competitive and relatively selective blocking agent for a1- adrenoceptors. Phenoxybenzamine blocks both a1- and a2-adrenoreceptors, although it has a greater affinity for the a1-subtype. All three of these a-receptor blocking drugs can induce penile erection, but their effects are generally less consistent and less effective than those of phentolamine. Yohimbine is only moderately effective in treating patients with organic impotence, and side effects may include postural hypotension, heart palpitations, fine tremors, and cavernosal fibrosis, especially following intracavernosal injections.


Testicular failure may occur before puberty and present as delayed puberty and the eunuchoid phenotype, or after puberty, with the development of infertility, impotence, or decreased libido in otherwise fully virilized males. The source of hypogonadism can be testicular, as occurs in primary hypogonadism, or it may result from abnormalities of the hypothalamic-pituitary axis, as in secondary hypogonadism.


Improvement in esophageal dysphagia has been reported with apomorphine administration,108,109 although extensive testing has not been undertaken. It has been suggested that sildenafil might be of benefit in the treatment of spastic esophageal motor disorders110 because of its effect on nitric oxide, but there have been no published reports of its use for this purpose in PD. It is worth noting that transient esophageal obstruction has been attributed to levodopa, with resolution following drug discontinua-tion.111


Increased risk for foot infections, foot ulcers, and amputation. 2. The feet should be evaluated regularly for sensation, pulses and sores. Semmes-Weinstein 10-g monofilament testing may be performed to accurately assess sensation. D. Autonomic neuropathy is found in many patients with long-standing diabetes. This problem can result in diarrhea, constipation, gastroparesis, vomiting, orthostatic hypotension, and erectile or ejaculatory dysfunction. Initial management of diarrhea consists of sugar-free psyllium e.g., Metamucil, Sugar Free), loperamide (e.g., Imodium), 2.0 mg twice day, or diphenoxylate atropine sulfate (e.g., Lomotil)2.5 mg twice day. Sildenafil (Viagra) is beneficial in patients with erectile dysfunction IV. Pharmacotherapy of diabetes A. Insulin

Individual Agents

TABLE 64.2 Classification by Mode of Action for Treatments of Erectile Dysfunction that result in coordinated signaling that results in the initiation of a penile erection (e.g. apomorphine) that result in a penile erection (e.g. PGEj) nile erection is enabled or enhanced, they do not on their own initiate an erection (e.g. trazodone) that penile erection is enabled or enhanced (e.g. sildenafil) Reprinted with permission from Heaton JP, Adams MA, and Morales A. A therapeutic taxonomy of treatment for erectile dysfunction An evolutional imperative. Int J Impot Res 1997 9 115-121. Dept of Urology, Queen's University, Kingston, Ontario. nosal injection of a vasoactive agent or a systemic mode of drug administration. Local injections or dermal applications were frequently required for satisfactory pharmacological actions upon the vascular smooth muscles of the penis. Compounds with relatively short duration of action were found to be less than satisfactory in maintaining penile erections....

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