Besides PDE5 inhibitors and among second-line therapies are VCDs which are clear plastic chambers placed over the penis, tightened against the lower abdomen with a mechanism to create a vacuum inside the chamber. This directs blood into the penis. If an adequate erection occurs inside the chamber, the patient slips a small constriction band off the end of the VCD and onto the base of the penis. An erection beyond 30 min is not recommended. These devices can be a bit cumbersome, but are very safe.40
The bad news: Men with diabetes are three times more likely to report having problems with sex than non-diabetic men. The most common sexual problem is Erectile Dysfunction, or ED, sometimes called impotence. Even worse, because ED is such a private issue, many men feel embarrassed to discuss the problem with their doctor, or even their partner, so the problem is never addressed.
Metabolic syndrome, comprising central obesity, hypertension, increased fasting blood glucose levels and dyslipidaemia, has been linked with erectile dysfunction.15 While the worldwide prevalence of metabolic syndrome is increasing, erectile dysfunction has been reported in up to 80–95% of patients with metabolic syndrome.15 There are several pathways in which metabolic syndrome may impair erectile function, including hormonal changes, inflammation, endothelial dysfunction and atherosclerosis. Patients with metabolic syndrome may benefit from lifestyle modifications, pharmacological interventions or surgery. Treatment of metabolic syndrome may result in improvement in erectile function.
All of these medicines work by relaxing smooth muscles and increasing blood flow in the penis during sexual stimulation. You should not take any of these medicines to treat ED if you are taking nitrates to treat a heart condition. Nitrates widen and relax your blood vessels. The combination can lead to a sudden drop in blood pressure, which may cause you to become faint or dizzy, or fall, leading to possible injuries.
Traditionally, the aetiology of erectile dysfunction is classified into organic, psychogenic or mixed. Organic causes include anatomical, vasculogenic (ie arterial or venous), neurogenic, endocrinological and drug-related side effects. Psychogenic aetiology may be generalised or situational. In reality, however, anxiety and depression commonly accompany erectile dysfunction, irrespective of the original aetiology.4 Consequently, nearly all organic erectile dysfunction will eventually become ‘mixed’. Risk factors for erectile dysfunction are listed in Table 1.
A psychological reaction to persistent erectile failure is almost inevitable and universal. This complicates the identification of primarily psychogenic impotence so it is essential to have an insightful and empathetic manner to manage erectile dysfunction effectively. Even when erectile dysfunction is primarily organic, appropriate counselling provided by the patient's doctor can be reassuring if adequate time is made available. Psychogenic impotence can be improved with the help of an experienced psychiatrist or psychologist. This psychotherapy requires a supportive and understanding partner willing to participate in couple-oriented behavioural sessions.

Does diabetes cause erectile dysfunction? Diabetes can lead to lower levels of testosterone, and this can result in erectile dysfunction. Controlling blood sugar levels, maintaining a healthy weight, getting exercise, and reducing stress are all ways of reducing this problem. Hormone therapy, Viagra, and counseling are some ways that medicine can help. Read now
The success of most commonly-used therapies will depend on co-operation of the partner. It is important to determine the partner's attitudes to the problem and involve them in discussions of treatment options. Men who do not have a regular or supportive partner rarely do well with therapies which necessitate treatment at the time of intended intercourse.
Epileptic seizures occur in a relatively small number of patients with multiple sclerosis, but can have serious consequences. Because the cause of epileptic seizures in patients in MS may be different from that in other forms of epilepsy, it is uncertain whether patients with MS should be treated differently. We searched for studies on the treatment of epileptic seizures in patients with MS, but found none. Well designed studies that address this issue are needed.

Improving lifestyle factors such as diet, exercise, smoking, excessive alcohol, and maintaining an active lifestyle has shown improvement in ED in men of all ages. Apart from the general benefits of a healthy lifestyle, studies show improvement in erectile dysfunction symptoms and a reduced need for tablets. ED also shares risk factors with a range of other medical conditions including diabetes, heart disease, and circulatory problems, all of which are also likely to benefit from lifestyle modification.
The usual starting dose of prostaglandin E1 is 2.5-5 micrograms. Generally, men with vasculogenic impotence require higher doses than those with neurogenic or psychogenic impotence. The starting doses should be adjusted accordingly. The optimal dose for each patient varies considerably and must be individually titrated by progressively increasing the dose (up to a maximum of 30 micrograms) with successive test injections until an adequate response is achieved. In practical terms, this is defined as an erection firm enough for penetration and lasting from 20-60 minutes. The first injection (at least) should be given under the direct supervision of a doctor and the patient subsequently taught how to self-inject. It is not sufficient just to send the patient home with a prescription and diagram on how to self-inject any more than it is appropriate to ask a diabetic to start insulin self-injection without careful instruction and supervision. Intracavernosal therapy should generally be supervised by a doctor with appropriate experience. Regular monitoring is essential.
In a 2005 study, three months of twice-daily sets of kegel exercises combined with biofeedback and advice on lifestyle changes, such as quitting smoking, losing weight, and limiting alcohol, worked far better than just giving the participants advice. “Wearing tight pants will affect impotence along with some other medical conditions like diabetes and heart disease,” which can also affect a man’s degree of impotence, Dr. Jennifer Burns, specializing in family practice with an emphasis on gastrointestinal health at the BienEtre Center, told Medical Daily.
If you can't take one of these oral medications, your physician may have you try Caverject (alprostadil for injection), a hormone that you inject into your penis using a fine needle, or Muse (alprostadil urogenital), a tiny suppository that you insert into the tip of the penis. Both of these will bring on an erection within five to 15 minutes without sexual stimulation.

In their extensive review, Bassil and coworkers summarise the benefits and risks, with benefits such as improvement of sexual function, bone density, muscle strength, cognition and overall improvement in quality of life. Among the risks that have been suggested include erythrocytosis, liver toxicity, worsening of sleep apnoea and cardiac function, possibly increasing symptoms of benign prostatic hyperplasia (BPH). They also note that although a possibility of stimulation of prostate cancer has been hypothesised, no scientific or clinical evidence exists to this possible risk.38
Poor sleep patterns can be a contributing factor for erectile dysfunction, Mucher says. One review published in the journal Brain Research emphasized the intricate relationship between the level of sex hormones like testosterone, sexual function, and sleep, noting that testosterone levels increase with improved sleep, and lower levels are associated with sexual dysfunction. Hormone secretion is controlled by the body’s internal clock, and sleep patterns likely help the body determine when to release certain hormones. 
The usual starting dose of prostaglandin E1 is 2.5-5 micrograms. Generally, men with vasculogenic impotence require higher doses than those with neurogenic or psychogenic impotence. The starting doses should be adjusted accordingly. The optimal dose for each patient varies considerably and must be individually titrated by progressively increasing the dose (up to a maximum of 30 micrograms) with successive test injections until an adequate response is achieved. In practical terms, this is defined as an erection firm enough for penetration and lasting from 20-60 minutes. The first injection (at least) should be given under the direct supervision of a doctor and the patient subsequently taught how to self-inject. It is not sufficient just to send the patient home with a prescription and diagram on how to self-inject any more than it is appropriate to ask a diabetic to start insulin self-injection without careful instruction and supervision. Intracavernosal therapy should generally be supervised by a doctor with appropriate experience. Regular monitoring is essential.

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Some men may order ED drugs online for convenience, even if they have a prescription for the medication. In one French study, 12% of men with prescriptions for PDE-5 inhibitors reported buying their medicine online, which creates a significant risk of purchasing a counterfeit version of the medicine. Another European study reported that 60% of men who purchased prescription-only medicines online believed that they would be able to access the same medicines online as they would get from a real pharmacy or doctor.
Since endothelial dysfunction, CVD and ED are closely associated in epidemiological studies, the question for clinicians is whether to recommend the man presenting with ED undergo a cardiovascular (CV) evaluation. Clearly, based on numerous studies, ED can be considered at least a ‘marker’ for possible further vascular disease or CVD.15 In their report, Vlachopoulos and coworkers make the point that the man presenting with ED, the clinician, is offered an opportunity to attempt to improve the health of the man by addressing lifestyle modification, and consider further vascular evaluation owing to the clear relationship between endothelial dysfunction, ED and CVD.19
Drugs causing your erectile dysfunction can be checked during your assessment – during your medical assessment, your doctor will assess your full medical history including any drugs you are currently taking. This is to work out whether your ED is a side effect of a medication, and also to work out which types of ED treatment are safe for you to use.
Penile injections can be a useful treatment for those who do not respond to a PDE5 inhibitors. It allows a ‘natural’ erection to occur within 10–15 minutes of administration and, with the correct dosage, should last for under an hour. Alprostadil is the only widely available commercial product in Australia. Alternatives are compounded medications, which are cheaper, but require refrigeration. Structured training of patients in how to administer penile injections (especially with compounded medications) and monitoring for efficacy and side effects can help increase the success of penile injection therapy. The side effects of penile injections include pain (10%, especially with alprostadil), prolonged erections (5%) and fibrosis (2%).22
Erectile dysfunction is a common multi-factorial complication of diabetes mellitus. Newer medications, like the so-called PDE-5 inhibitors result in enhancement of penile erection. The introduction of sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis), have altered the management of erectile dysfunction. In this review we assessed the effect of these agents on erectile dysfunction in diabetic people. Eight studies with 976 men randomised to PDE-5 inhibitor therapy and a duration of mainly 12 weeks were evaluated. Compared to placebo treatment, these agents showed favourable effects in scores estimating sexual life, with an increased rate of adverse effects like headache and flushing after PDE-inhibitor therapy. Mortality was not reported in any of the included trials. Quality of life, with the exception of scores for sexual life, was not relevantly affected. If taken as prescribed, PDE-5 inhibitors comprise a valuable treatment option for erectile dysfunction in men with diabetes.
Antidepressants can have numerous effects on sexual function including altered sexual desire, erection difficulties and orgasm problems. This systematic review investigated different ways to manage such sexual dysfunction. We included 23 randomised studies, with a total of 1886 participants who had developed their sexual problems while taking antidepressant medication. Twenty-two of these studies looked at the addition of further medication to the ongoing treatment for depression. For men with antidepressant-induced erectile dysfunction, the addition of sildenafil (Viagra; three studies, 255 participants) or tadalafil (Cialis; one study, 54 participants) appeared to improve the situation. For women with antidepressant-induced sexual dysfunction the addition of bupropion (Wellbutrin, Zyban; three studies, 482 participants) at higher doses appears to be the most promising approach studied so far, but further data from randomised trials are likely to be required before it can be recommended confidently. We did not find evidence that any intervention led to a worsening of psychiatric symptoms; however, we cannot be confident of this for many of the interventions studied, as only small numbers of participants have been studied so far.
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