Physical examination should include the assessment of male secondary sex characteristics, femoral and lower extremity pulses, and a focused neurologic examination including perianal sensation, anal sphincter tone, and bulbocavernosus reflex. More extensive neurologic tests, including dorsal nerve conduction latencies, evoked potential measurements, and corpora cavernosal electromyography lack normative (control) data and appear at this time to be of limited clinical value. Examination of the genitalia includes evaluation of testis size and consistency, palpation of the shaft of the penis to determine the presence of Peyronie's plaques, and a digital rectal examination of the prostate with assessment of anal sphincter tone.

Traditionally, erectile impotence (the classical definition of impotence) is the failure to achieve penile erection during intercourse. It may have either physical or psychological causes. Alcoholism, endocrine disease, and neurological disorders are typical physical causes. Psychological causes include anxiety over performance, hostility or other negative feelings toward the sexual partner, and stress, anxiety, depression, or other emotional conflicts outside of the relationship. Erectile impotence occasionally occurs with age and, although attributed by the individual to the aging process itself, it is usually secondary to disorders of aging, such as faulty blood circulation or prostate disease. In cases of impotence caused by blood vessel dysfunction, an insufficient supply of blood flows into the penis, or the blood diffuses out into adjacent tissues.


For many men, stopping smoking is an erectile dysfunction remedy, particularly when ED is the result of vascular disease, which occurs when blood supply to the penis becomes restricted because of blockage or narrowing of the arteries. Smoking and even smokeless tobacco can also cause the narrowing of important blood vessels and have the same negative impact. 

Organic impotence refers to the inability to obtain an erection firm enough for vaginal penetration, or the inability to sustain the erection until completion of intercourse. In contrast to psychogenic impotence, which is impotence caused by anxiety, guilt, depression, or conflict around various sexual issues, organic impotence, the more common of the two categories of erectile dysfunction, is caused by physical problems. Ten to 20% of middle-aged men and a much higher percentage of elderly men are impotent. Aside from its importance as a common and distressing sexual problem, organic impotence may herald important medical problems.
Organic impotence refers to the inability to obtain an erection firm enough for vaginal penetration, or the inability to sustain the erection until completion of intercourse. In contrast to psychogenic impotence, which is impotence caused by anxiety, guilt, depression, or conflict around various sexual issues, organic impotence, the more common of the two categories of erectile dysfunction, is caused by physical problems. Ten to 20% of middle-aged men and a much higher percentage of elderly men are impotent. Aside from its importance as a common and distressing sexual problem, organic impotence may herald important medical problems.
Several pathways have been described to explain how information travels from the hypothalamus to the sacral autonomic centers. One pathway travels from the dorsomedial hypothalamus through the dorsal and central gray matter, descends to the locus ceruleus, and projects ventrally in the mesencephalic reticular formation. Input from the brain is conveyed through the dorsal spinal columns to the thoracolumbar and sacral autonomic nuclei.
3. Are there physical causes of erectile dysfunction? Erectile dysfunction may be a symptom of underlying medical conditions, which if not detected may cause further medical problems. A prior history of cigarette smoking, heart attacks, strokes, and poor circulation in the extremities (for example, intermittent claudication or cramping in your leg[s] when you walk) suggest atherosclerosis as the cause of the erectile dysfunction. Loss of sexual desire and drive, lack of sexual fantasies, gynecomastia (enlargement of breasts), and diminished facial hair suggest low testosterone levels. A prior history of pelvic surgery or radiation and trauma to the penis/pelvis/perineum can cause problems with the nerves and blood vessels. Symptoms of intermittent claudication of the lower extremities with exercise may suggest a vascular problem as a cause of the erectile dysfunction.

You get to decide what is normal for you. That might include him still experiencing pleasure from you touching his penis even if he’s not hard. Some men can still orgasm without an erection. Or he may prefer not to have any touching while he is dealing with his erection problems. It is okay for you to orgasm even if he doesn’t. Reading about what might bring you pleasure, or considering how you think about sex can make this something enjoyable to explore together.
Ejaculatory incompetence, erectile difficulty, erectile dysfunction, erectile failure, frigidity–female Medtalk The inability to achieve or maintain a penile erection adequate for the successful completion of intercourse, terminating in ejaculation; penile erection is mediated by nitric oxide Epidemiology Prevalence of minimal, moderate, and complete impotence in the Massachusetts Male Aging Study was 52%; age is the most important factor; complete impotence ↑ from 5%–age 40 to 15%–age 70; for an erection to achieve a successful outcome, it requires
Before delving into the causes and solutions to erectile dysfunction, it’s first important to understand how erections work. The penis is mostly comprised or fibrous tissue that fills with blood upon arousal. This is what causes an erection, and after arousal is finished, blood drains back out into the body and the penis becomes flaccid. Men can have erections for no discernible reason throughout the day, but when sexual stimulation occurs, rather through contact, visual, audible, or mental stimulation, the potential for achieving an erection increases.
There are treatments available to help you to get and maintain an erection. In addition, making healthy changes to your lifestyle could help with impotence. Switching to a healthier balanced diet, taking more exercise and cutting down on or giving up alcohol and cigarettes could help you to see an improvement in sexual function. If you think that the problem may be related to stress or anxiety, counselling can also help.
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I know it’s awkward to talk about money like you’re business partners but partners is just what you are: You’re fiancés who share finances. So you need to be very clear about what this merger means. Right now, it doesn’t sound like you’re being very transparent with each other. Why were you surprised to find he was making more and contributing less than you feel he should? Do you not know how much he makes? Does he not know how much you expect him to pay back?
The inability to achieve or sustain a sufficiently firm penile erection (tumescence) to allow normal vaginal sexual intercourse. The great majority of cases are not caused by organic disease and most men experience occasional periods of impotence. It is often related to anxiety about performance and is usually readily corrected by simple counselling methods which prescribe sensual massage but forbid coitus. Organic impotence may be caused by DIABETES, MULTIPLE SCLEROSIS, spinal cord disorders and heart disease. Many cases can be helped by the drug SILDENAFIL (Viagra).
This is a completely legitimate and rational fear that disrupts a man’s ability to become aroused. If a man is not ready for a child and you are not on birth control, there is always a chance you could conceive. If you are new to one another, he doesn’t know for certain if you are a carrier of a disease. This is where the physiological and the psychological partner up and shut it down, to protect their dude.
Causes of impotence are many and include heart disease, high cholesterol, high blood pressure, obesity, metabolic syndrome, Parkinson's disease, Peyronie's disease, substance abuse, sleep disorders, BPH treatments, relationship problems, blood vessel diseases (such as peripheral vascular disease and others), systemic disease, hormonal imbalance, and medications (such as blood pressure and heart medications).

The 1985 National Ambulatory Medical Care Survey indicated that there were about 525,000 visits for erectile dysfunction, accounting for 0.2 percent of all male ambulatory care visits. Estimates of visits per 1,000 population increased from about 1.5 for the age group 25-34 to 15.0 for those age 65 and above. The 1985 National Hospital Discharge Survey estimated that more than 30,000 hospital admissions were for erectile dysfunction.
Although not indicated for routine use, nocturnal penile tumescence (NPT) testing may be useful in the patient who reports a complete absence of erections (exclusive of nocturnal "sleep" erections) or when a primary psychogenic etiology is suspected. Such testing should be performed by those with expertise and knowledge of its interpretation, pitfalls, and usefulness. Various methods and devices are available for the evaluation of nocturnal penile tumescence, but their clinical usefulness is restricted by limitations of diagnostic accuracy and availability of normative data. Further study regarding standardization of NPT testing and its general applicability is indicated.
The National Institutes of Health Consensus Development Conference on Impotence was convened to address (1) the prevalence and clinical, psychological, and social impact of erectile dysfunction; (2) the risk factors for erectile dysfunction and how they might be used in preventing its development; (3) the need for and appropriate diagnostic assessment and evaluation of patients with erectile dysfunction; (4) the efficacies and risks of behavioral, pharmacological, surgical, and other treatments for erectile dysfunction; (5) strategies for improving public and professional awareness and knowledge of erectile dysfunction; and (6) future directions for research in prevention, diagnosis, and management of erectile dysfunction. Following 2 days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement.
Men who wear tight underwear may also experience the same problems. Because of the constriction, feeling may be lost, and even if unnoticed actively, the brain will notice. This is part of the complication with erectile dysfunction between the brain and the body. While you may be in the mood, if the proper electrical signals are not sent back and forth, nothing will happen.
But if the blood flow is weak here, it is highly likely that it is also weak in arteries supplying the heart, raising the risk of a heart attack. In fact, some studies suggest that women with heart disease may also suffer sexual dysfunction: the clitoris, like the penis, is a vascular organ, and also relies on healthy blood flow for successful orgasms.
Me? I'm in my 60's and never had ED, not even once. And never failed to have a good orgasm with sexual activity. Unfortunately, I think it has created too much of a contrast to my wife, who has never had an orgasm, and now in menopause has given up and won't even let me touch her sexually (hugging and kissing is fine, but that's as far as she'll let me go).
It appears that testosterone has NOS-independent pathways as well. In one study, castrated rats were implanted with testosterone pellets and then divided into a group that received an NOS inhibitor (L-nitro-L-arginine methyl ester [L-NAME]) and a control group that received no enzyme. [24] The castrated rats that were given testosterone pellets and L-NAME still had partial erections, a result suggesting the presence of a pathway independent of NOS activity.

Tadalafil (Cialis) is the third oral medicine approved by the U.S. FDA for the treatment of erectile dysfunction. Like sildenafil (Viagra) and vardenafil (Levitra), tadalafil inhibits PDE5 (as described earlier). Unlike the other PDE 5 inhibitors, patients should take tadalafil once daily and is approved for the treatment of BPH (benign enlargement of the prostate).

Kimberly Hildebrant, ARNP is a board certified Family Nurse practitioner. She graduated with a Bachelor of Science in Nursing from the University of Pittsburgh and a Masters in Nursing from Duquesne University. She has practiced as a nurse practitioner in the field of Infectious Disease as well as HIV for 4 years. She has over 13 years of experience as a critical care nurse. Kimberly is passionate about providing affordable healthcare to all individuals to ensure that all can live their best life. She is an advocate for preventative care and early treatment to avoid lasting illness.
Her remark was entirely destructive of poetry, since it was to the effect that poetry had nothing whatever to do with her; all her friends spent their lives in making up phrases, she said; all his feeling was an illusion, and next moment, as if to taunt him with his impotence, she had sunk into one of those dreamy states which took no account whatever of his existence.
Erosion of the prosthesis, whereby it presses through the corporal tissue into the urethra, may occur. Symptoms and signs may include pain, blood in the urine, discharge, abnormal urine stream, and malfunction. If the prosthesis erodes into the urethra, a physician must remove it. If the other cylinder remains intact, it can be left in place. A physician leaves a catheter in place to allow the urethra to heal.
Another potential new treatment consists of penile low-intensity shock wave lithotripsy. This consists of 1500 shocks twice a week for 3–6 weeks. The purpose is to stimulate neovascularisation to the corporal bodies with improvement in penile blood flow and endothelial function. The use of low-intensity shock wave lithotripsy may convert PDE5 inhibitor non-responders to responders.47
Penile prostheses are very effective, and most patients who have a prosthesis placed are satisfied with the prosthesis. However, placement of a prosthesis causes scarring of the tissue within the corpora cavernosa, and if the prosthesis requires removal, other forms of therapy, except for the vacuum device, are often not effective. Thus, most physicians reserve placement of a prosthesis for men who have tried and failed or have contraindications to other therapies.
Because there's no word better than "love," where do you go from "I love you"? I really, really love you? I love you so much? With a cherry on top? Ugh. Pretty soon, you're in Hallmark territory, quoting bad pop lyrics. Since "I love you" is as good as it gets, maybe you feel you've peaked. You might be wondering: Is this it? Do you just say the same thing, over and over, for the rest of your days? "I love you" can be scary when it seems to be a plateau and the end of something. But that's bullshit. Hopefully, "I love you" is just the beginning.
Additionally, the physiologic processes involving erections begin at the genetic level. Certain genes become activated at critical times to produce proteins vital to sustaining this pathway. Some researchers have focused on identifying particular genes that place men at risk for ED. At present, these studies are limited to animal models, and little success has been reported to date. [4] Nevertheless, this research has given rise to many new treatment targets and a better understanding of the entire process.
Dr. Matthew Walvick, D.O. is a board certified Internal Medicine physician. He completed his undergraduate education at UCLA. He received his medical degree from Touro University College of Osteopathic Medicine in Vallejo, California. He completed his Internal Medicine residency at UCSF's Fresno Medical Education Program. Prior to joining Lemonaid Health, Dr. Walvick was a practicing primary care physician at John Muir Health and then doing house calls with the start-up Heal. Dr. Walvick is excited to be a part of the Lemonaid Health team making healthcare refreshingly simple.
The motivation and expectations of the patient and his partner and education of both are critical in determining which therapy is chosen and in optimizing its outcome. If single therapy is ineffective, combining two or more forms of therapy may be useful. Penile prostheses should be placed only after patients have been carefully screened and informed. Vascular surgery should be undertaken only in the setting of clinical investigation and extensive clinical experience. With any form of therapy for erectile dysfunction, long-term followup by health professionals is required to assist the patient and his partner with adjustment to the therapeutic intervention. This is particularly true for intracavernosal injection and vacuum constriction therapies. Followup should include continued patient education and support in therapy, careful determination of reasons for cessation of therapy if this occurs, and provision of other options if earlier therapies are unsuccessful.
Some may use alcohol as a way to get into the mood and overcome some of the nerves associated with having sex, but too much of a good thing can actually backfire. In fact, having a long history of alcohol abuse may lead to long-term erectile dysfunction. As many as 70 percent of men with chronic erectile dysfunction also have a history of alcohol abuse.
The U.S. FDA (Food and Drug Administration) has a list of 29 OTC products that claim to treat erectile dysfunction. Patients should avoid these because many contain harmful ingredients. Other natural or herbal remedies such as DHEA, L-arginine, ginseng, and yohimbe are supplements that have been used but have not been proven safe and effective according to some researchers. Before using such compounds, individuals should consult their doctor. According to some experts, acupuncture does not effectively treat erectile dysfunction. Other home remedies for reducing ED symptoms include diet changes such as eating blueberries and citrus fruits and drinking red wine.
The history can be useful in distinguishing organic from psychogenic impotence (Table 187.1). The patient with organic impotence describes problems with erection that progress over months to years. At first, the patient will have partial erections or seemingly firm erections that become flaccid during intercourse. With time, total erectile failure ensues. Organic impotence is constant and nonselective, meaning it is not better or worse with any specific partner or any type of stimulation.

Obesity and metabolic syndrome can cause changes in blood pressure, body composition, and cholesterol which may lead to ED. Other conditions that may contribute to erectile dysfunction include Parkinson’s, multiple sclerosis, Peyronie’s disease, sleep disorders, alcoholism, and drug abuse. Taking certain medications can also increase your risk for ED.


To reach the largest audience, communications strategies should include informative and accurate newspaper and magazine articles, radio and television programs, as well as special educational programs in senior centers. Resources for accurate information regarding diagnosis and treatment options also should include doctors' offices, unions, fraternal and service groups, voluntary health organizations, State and local health departments, and appropriate advocacy groups. Additionally, since sex education courses in schools uniformly address erectile function, the concept of erectile dysfunction can easily be communicated in these forums as well.
This penile tumescence monitor is placed at the base and near the corona of the penis. It is connected to a monitor that records a continuous graph depicting the force and duration of erections that occur during sleep. The monitor is strapped to the leg. The nocturnal penile tumescence test is conducted on several nights to obtain an accurate indication of erections that normally occur during the alpha phase of sleep.
When sexually stimulated there is a release of a chemical, nitric oxide (NO) in the blood vessels of the corpus cavernosum. The NO stimulates the production of a compound called cGMP, which causes relaxation of the smooth muscle in the blood vessels supplying the corpus cavernosum. PDE 5 is an enzyme that breaks down cGMP. By inhibiting the breakdown of cGMP by PDE5, these medications allow cGMP to build up in the penis. cGMP causes muscles in the corpora cavernosa of the penis to relax. When the muscle is relaxed, more blood can flow into the penis and fill the spaces in the penis. As the penis fills with blood, the veins in the penis are compressed, and this results a hard erection. When the effect on PDE5 decreases, the cGMP levels go down and the muscle in the penis contracts, causing less blood to flow into the penis and allowing the veins to open up and drain blood out of the penis.
Experts often treat psychologically based impotence using techniques that decrease anxiety associated with intercourse. The patient's partner can help apply the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety during treatment of physical impotence. If these simple behavioral methods at home are ineffective, a doctor may refer an individual to a sex counselor.
Long-term predictions based on an aging population and an increase in risk factors (eg, hypertension, diabetes, vascular disease, pelvic and prostate surgery, benign prostatic hyperplasia, and lower urinary tract symptoms) suggest a large increase in the number of men with ED. In addition, the prevalence of ED is underestimated because physicians frequently do not question their patients about this disorder.

medicines called alpha-blockers such as Hytrin (terazosin
HCl), Flomax (tamsulosin HCl), Cardura (doxazosin
mesylate), Minipress (prazosin HCl), Uroxatral (alfuzosin HCl),
 Jalyn (dutasteride and tamsulosin HCl), or Rapaflo (silodosin).
Alpha-blockers are sometimes prescribed for prostate
problems or high blood pressure. In some patients, the use
of Sildenafil with alpha-blockers can lead to a drop in blood pressure or to fainting


It is important that all erectile dysfunction is reported to your doctor, as sometimes it can be an indicator of something physically wrong with you that has to be treated. Also, your doctor is in the best position to find the reason for your erectile dysfunction. Routine questions and tests will provide a guide to the cause and allow your doctor to decide what kind of treatment you might need to deal with it. This may involve referral to a specialist. Detailed information can be found at the website of the Impotence Association – www.sda.uk.net
Erectile dysfunction is clearly a symptom of many conditions, and certain risk factors have been identified, some of which may be amenable to prevention strategies. Diabetes mellitus, hypogonadism in association with a number of endocrinologic conditions, hypertension, vascular disease, high levels of blood cholesterol, low levels of high density lipoprotein, drugs, neurogenic disorders, Peyronie's disease, priapism, depression, alcohol ingestion, lack of sexual knowledge, poor sexual techniques, inadequate interpersonal relationships or their deterioration, and many chronic diseases, especially renal failure and dialysis, have been demonstrated as risk factors. Vascular surgery is also often a risk factor. Age appears to be a strong indirect risk factor in that it is associated with an increased likelihood of direct risk factors. Other factors require more extensive study. Smoking has an adverse effect on erectile function by accentuating the effects of other risk factors such as vascular disease or hypertension. To date, vasectomy has not been associated with an increased risk of erectile dysfunction other than causing an occasional psychological reaction that could then have a psychogenic influence. Accurate risk factor identification and characterization are essential for concerted efforts at prevention of erectile dysfunction.
Erection dissatisfaction can actually enhance lovemaking. The dark cloud of erection changes has a silver lining. Young couples often have problems because young men become aroused faster than young women. Young men are often all finished before young women have even started to get aroused. Post-50 erection changes slow men’s arousal process so their erotic pace more closely matches women’s. A slower pace allows plenty time for kissing, cuddling, and whole-body massage, all essential to most women’s enjoyment of sex. Seen in this light, for many older couples, erection dissatisfaction can be a gift.

Unfortunately, some patients may have an overly simplified understanding of the role of PDE5 inhibitors in ED management. Such patients may not expect or be willing to undergo a long evaluation and testing process to obtain a better understanding of their sexual problem, and they may be less likely to involve their partner in discussing their sexual relationship with the physician. They may expect to obtain medications through a phone call to their doctor or even over the Internet, with minimal or no physician contact at all.

Tadalafil should not be used with alpha-blockers (except Flomax), medicines used to treat high blood pressure, and benign prostate hypertrophy (BPH) because the combination of tadalafil and an alpha-blocker may lower the blood pressure greatly and lead to dizziness and fainting. Examples of alpha-blockers include tamsulosin (Flomax), terazosin (Hytrin), doxazosin (Cardura), alfuzosin (Uroxatral), and prazosin (Minipress). Tamsulosin (Flomax) is the only alpha-blocker that patients can use safely with tadalafil. When tadalafil (20 mg) was given to healthy men taking 0.4 mg of Flomax daily, there was no significant decrease in blood pressure and so patients on this dose of tamsulosin (Flomax) can be prescribed tadalafil. The only alpha-blocker not tested with tadalafil is alfuzosin (Uroxatral), and no recommendations can be made regarding the interaction between the two.
He can follow the common general physical advice: Sleep well, eat well, exercise, and moderate or abstain from drinking and drugs. He can also visit the doctor to see if there’s any medical reason for his condition (anything from heart disease to diabetes and obesity). Sometimes, impotence is a side effect of prescription drugs. If his anxiety is extreme, it never hurts to see a professional therapist. Whenever there’s even a chance of a medical problem, my advice is always: Why not check with a professional?
Circulatory problems: An erection occurs when the penis fills with blood and a valve at the base of the penis traps it. Diabetes, high blood pressure, cholesterol, clots, and atherosclerosis (hardening of the arteries) can all interfere with this process. Such circulatory problems are the number one cause of erectile dysfunction. Frequently, erectile dysfunction is the first noticeable symptom of cardiovascular disease.
Watts and coworkers, in their review article, make several points about this ED/CAD nexus. Endothelial dysfunction is present in both CVD and ED, and is linked through the NO mechanism. The authors note that PDE5 inhibitors improve endothelial function and have a salutary effect on both CVD and ED. Both ED and cardiac disease respond to modifications in lifestyle as well as pharmacologic manipulation. These authors also report that the presence of ED gives the clinician an opportunity to assess CVD and prevention as well.20
Under normal circumstances, when a man is sexually stimulated, his brain sends a message down the spinal cord and into the nerves of the penis. The nerve endings in the penis release chemical messengers, called neurotransmitters, that signal the corpora cavernosa (the two spongy rods of tissue that span the length of the penis) to relax and fill with blood. As they expand, the corpora cavernosa close off other veins that would normally drain blood from the penis. As the penis becomes engorged with blood, it enlarges and stiffens, causing an erection. Problems with blood vessels, nerves, or tissues of the penis can interfere with an erection.
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Patients receiving penile prostheses should be instructed in the operation of the prosthesis before surgery and again in the postoperative period. The prosthesis usually is not activated until approximately 6 weeks after surgery, so as to allow the edema and pain to subside. The prosthesis is checked in the office before the patient begins to use it.
Another study compared the response of surgically and medically castrated rabbits to vardenafil with that of control rabbits. [22] Castrated rabbits did not respond to vardenafil, whereas noncastrated rabbits did respond appropriately. This result suggests that a minimum amount of testosterone is necessary for PDE5 inhibitors to produce an erection.
Alprostadil should not be used in men at higher risk for priapism (erection lasting longer than six hours) including men with sickle cell anemia, thrombocytopenia (low platelet count), polycythemia (increased red blood cell count), multiple myeloma (a cancer of the white blood cells), and is contraindicated in men prone to venous thrombosis (blood clots in the veins) or hyperviscosity syndrome who are at increased risk for priapism.
It can also help to tell your partner (either before you start or when it happens) that hey, sometimes it takes your penis a while to warm up or sometimes it comes and goes as it pleases — and that they shouldn't take it personally and you won't let it ruin the moment. When it happens, take a few deep breaths, focus on your partner, and go back to doing whatever was feeling good before. "If they approach that with authentic confidence, the partner is usually like 'OK, cool,'" says Skyler. "Remember, you're more than just your penis."

When you become aroused, your brain sends chemical messages to the blood vessels in the penis, causing them to dilate or open, allowing blood to flow into the penis. As the pressure builds, the blood becomes trapped in the corpora cavernosa, keeping the penis erect. If blood flow to the penis is insufficient or if it fails to stay inside the penis, it can lead to erectile dysfunction.
Patients receiving penile prostheses should be instructed in the operation of the prosthesis before surgery and again in the postoperative period. The prosthesis usually is not activated until approximately 6 weeks after surgery, so as to allow the edema and pain to subside. The prosthesis is checked in the office before the patient begins to use it.
In fact, one common reason many younger men visit their doctor is to get erectile dysfunction medication. Often, men with erectile dysfunction suffer with diabetes or heart disease, or may be sedentary or obese, but they don’t realize the impact of these health conditions on sexual function. Along with erectile dysfunction treatment, the doctor may recommend managing the illness, being more physically active, or losing weight.
Whenever I am prescribing a medication to a patient, I’m always asking myself, what can the patient do before requiring the medication? What changes do they have to make in order to reduce the amount of medication or preclude their even needing it? So a good candidate is somebody who has an understanding of a healthy lifestyle, about physical activity, about sleep, about nutrition, alcohol, smoking. So patients, individuals, have to do their share before they’re a candidate for anything. All right?
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