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admin | Category: Electile Dysfunction 2016 | 07.04.2015
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Search Can Stock Photo for royalty free illustration, royalty free clipart, digital artwork, EPS vector clip art, stock illustrations, stock images, logo icon graphics, and cheap EPS format line art drawings. See related patient information handout on erectile dysfunction, written by the author of this article. Erectile dysfunction is defined as the persistent inability to attain or maintain penile erection sufficient for sexual intercourse. Bio: Derek is an active blogger for the website Erectile Doctor, an online directory connecting licensed physicians and patients seeking erectile dysfunction treatment. Can Stock Photo has the royalty free illustration, line art drawing, EPS vector graphic, or stock clipart icon that you need.
The majority of cases have an organic etiology, most commonly vascular disease that decreases blood flow into the penis. The corpora cavernosa are composed of a mesh-work of interconnected cavernosal spaces lined by vascular endothelium. Normal erectile function requires a complex set of dynamic neural and vascular interactions. Most causes of erectile dysfunction were once considered to be psychogenic, but current evidence suggests that up to 80 percent of cases have an organic cause.1 Organic causes are subdivided into vasculogenic, neurogenic and hormonal etiologies. Aging is an independent risk factor, and although the incidence of erectile dysfunction increases steadily with age, it is not an inevitable consequence of aging.
Information from references 7 and 8.Excessive and long-term use of a number of substances may also cause erectile dysfunction. In all instances, medical conditions having an impact on erectile function should be corrected or their progression controlled.
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Our designers and illustrators provide royalty free stock images, clip art, clipart graphics, and pictures for as little as 1 dollar. Regardless of the primary cause, erectile dysfunction can have a negative impact on self-esteem, quality of life and interpersonal relationships. An estimated 10 to 20 million American men have some degree of erectile dysfunction.1,2Increased understanding of the male erectile process and the development of several agents to improve erectile function have generated great public interest among men and their sexual partners. Penile erection can be elicited by at least two distinct mechanisms, central psychogenic and reflexogenic,3 which interact during normal sexual activity. Vasculogenic etiologies represent the largest group, with arterial or inflow disorders being the most common. Several studies have indicated that patients and providers are reluctant to address sexual topics. The initial step in evaluation is a detailed medical and social history, including a review of medication use.


These advances are expanding the treatment options available to primary care physicians in the management of erectile dysfunction. 3 Blood flow is provided primarily by the cavernosal branches of the internal pudendal artery. Psychogenic erections are initiated centrally in response to auditory, visual, olfactory or imaginary stimuli. Consideration should be given to discontinuation of any medication suspected of contributing to the erectile problem or, if required, switching to an alternative medication less likely to interfere with erectile function.
Each branch divides into numerous terminal branches that open directly into the cavernous spaces.
Reflexogenic erections result from stimulation of sensory receptors on the penis which, through spinal interactions, cause somatic and parasympathetic efferent actions.3On arousal, parasympathetic activity triggers a series of events starting with the release of nitric oxide and ending with increased levels of the intracellular mediator cyclic guanosine monophosphate (cGMP). Regardless of the primary etiology, a psychologic component frequently coexists.5The severity of erectile dysfunction is often described as mild, moderate or complete, although these terms have not been precisely defined. Increases in cGMP cause penile vascular and trabecular smooth muscle relaxation.3,4 Blood flow into the corpora cavernosa increases dramatically.
First, provide information about conditions that are commonly associated with sexual dysfunction, then follow with a question about the individual's concerns. Laboratory tests are useful to screen for common etiologic factors and, when indicated, to identify hypogonadal syndromes.
The rapid filling of the cavernosal spaces compresses venules resulting in decreased venous outflow, a process often referred to as the corporeal veno-occlusive mechanism. The male sexual response cycle consists of four major phases: (1) desire, (2) arousal (erectile ability), (3) orgasm and (4) relaxation.
Before the initiation of testosterone therapy, the patient should be evaluated for the possibility of an occult prostate malignancy, which may be stimulated by supplemental testosterone.
Appropriate evaluation of erectile dysfunction leads to accurate advice, management and referral of patients with erectile dysfunction. This information may help assess the patient's sexual problems as well as identify high-risk behaviors and other concerns affecting the patient's overall health.Once a concern with the patient's sexual function is identified, the next step is to differentiate erectile dysfunction from other sexual problems, such as loss of libido or ejaculatory problems. The physician should use appropriate vocabulary, avoiding slang or excessively technical terminology.
Patients with suspected vasculogenic or neurogenic causes can be considered for a trial of therapy in the primary care setting. Having the patient define the terms in his own words will help the physician and patient communicate more effectively.13 The International Index of Erectile Function (IIEF)14 is a valuable tool for defining the area of sexual dysfunction (Figure 4).
Patients with a suspected psychogenic etiology should be considered for sexual counseling or psychiatric referral as well.Patients requesting a more comprehensive evaluation or those not responding to initial therapy should be referred for further evaluation and treatment. The IIEF is designed to be a self-administered measure of erectile dysfunction, but it also assesses a patient's function in other phases of sexual function.
As such, it should be viewed as an adjunct to, rather than a detailed sexual history.Reprinted with permission from Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A.


The international index of erectile dysfunction (IIEF): a multidimensional scale for assessment of erectile dysfunction.
Because erectile dysfunction is frequently caused by medication, a review of the patient's drug therapy is essential and should include prescription and over-the-counter medications. Life stressors such as change in social status, divorce, death of spouse, loss of job, or family problems may have an effect on erectile function. Difficulty in erectile function affects the patient and his partner, so it is important to assess whether the erectile problem is troubling one partner more than the other, and if so, who and why. Finally, the physician should determine the patient's and the partner's level of understanding of sexual anatomy and function, as well as what expectations each has with regard to treatment outcome. Men with erectile dysfunction and their partners often lack a full understanding of sexual processes or have unrealistic expectations regarding sexual performance and satisfaction.5PHYSICAL EXAMINATIONThe physical examination should assess the patient's overall health. Particular attention should be given to the cardiovascular, neurologic and genitourinary systems, as these systems are directly involved with erectile function. The cardiovascular examination should include assessment of vital signs (especially blood pressure and pulse) and signs of hypertensive or ischemic heart disease.
Abdominal or femoral artery bruits and asymmetric or absent lower extremity pulses are indicative of vascular disease. Skin and hair pattern evidence of vascular insufficiency should be noted.The patient's demeanor, dress, speech and overall appearance should be noted for signs suggestive of anxiety or depressive disorders. The superficial anal reflex, indicative of normal somatic function of sacral cord levels S2–4, is assessed by touching the perianal skin and noting contraction of the external anal sphincter muscles.
It is performed by placing a finger in the rectum and noting contraction of the anal sphincter and bulbocavernosus muscle when the glans penis is squeezed. External anal sphincter tone can be assessed during this maneuver as well.The genital evaluation should assess for local abnormalities, such as hypospadias or phimosis, and evidence of hypogonadism.
The penis should be palpated to determine the presence of local abnormalities such as fibrous plaques of the fascial covering (Peyronie's disease). The prostate gland should be assessed for size, consistency and symmetry.ADDITIONAL STUDIESIf not previously done, some basic studies should be considered to identify unrecognized systemic conditions that may predispose to erectile dysfunction. The specific testosterone assay to be obtained is debated.15,17 Testosterone is predominately protein-bound and is influenced by a variety of clinical conditions. An age-adjusted, first-morning, free testosterone level is probably the most accurate measure.17 If the initial testosterone level is low, follow-up studies should include luteinizing hormone and follicle-stimulating hormone levels to differentiate testicular from hypothalamic-pituitary dysfunction.
These tests are not usually performed in the family physician's office and are not necessary before the initiation of therapy for most patients. Many of these tests are subject to significant variation in interpretations and are most appropriate for use in refractory cases.



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