Impotence - Dictionary Definition and Overview
Impotence :  (noun)
1: the quality of lacking strength or power; being weak and feeble [syn: powerlessness, impotency] [ant: power, power]
2: an inability (usually of a male) to copulate [syn: impotency]

Based on WordNet 2.0
Impotence : \Im"po*tence\, Impotency \Im"po*ten*cy\, n. [L. impotenia inability, poverty, want of moderation. See Impotent.] 1. The quality or condition of being impotent; want of strength or power, animal, intellectual, or moral; weakness; feebleness; inability; imbecility.

Some were poor by impotency of nature; as young fatherless children, old decrepit persons, idiots, and cripples. --Hayward.

O, impotence of mind in body strong! --Milton.

2. Want of self-restraint or self-control. [R.] --Milton.

3. (Law & Med.) Want of procreative power; inability to copulate, or beget children; also, sometimes, sterility; barrenness.

Based on Webster's Revised Unabridged Dictionary
IMPOTENCE, med. jur. The incapacity for copulation or propagating the species. It has also been used synonymously with sterility. 2.Impotence : may be considered as incurable, curable, accidental or temporary. Absolute or incurable impotence, is that for which there is no known relief, principally originating in some malformation or defect of the genital organs. Where this defect existed at the time of the marriage, and was incurable, by the ecclesiastical law and the law of several of the American states, the marriage may be declared void ab initio. Com. Dig. Baron and Feme, C 3; Bac. Ab. Marriage, &c., E 3; 1 Bl. Com. 440; Beck's Med. Jur. 67; Code, lib. 5, t. 17, l. 10; Poyn. on Marr. and Div. ch. 8; 5 Paige, 554; Merl. Rep. mot Impuissance. But it seems the party naturally impotent cannot allege that fact for the purpose of obtaining a divorce. 3 Phillim. R. 147; S. C. 1 Eng. Eccl. R. 384. See 3 Phillim. R. 325; S. C. 1 Eng. Eccl. R. 408; 1 Chit. Med. Jur. 877; 1 Par. & Fonb. 172, 173. note d; Ryan's Med. Jur. 95. to 111; 1 Bl. Com. 440; 2 Phillim. R. 10; 1 Hagg. R. 725. See, as to the signs of impotence, 1 Briand, Med. Leg. c. 2, art. 2, Sec. 2, n. 1; Dictionnaire des Sciences Medicales, art. Impuissance; and, generally, Trebuchet, Jur. de la. Med. 100, 101, 102; 1 State Tr. 315; 8 State Tr. App. No. 1, p. 23; 3 Phillm. R. 147; 1 Hagg. Eccl. R. 523; Fodere, Med. Leg. Sec. 237.

Based on Bouvier's Law Dictionary, Revised 6th Ed (1856) [Bouvier_Law_Dictionary]:
Impotence :  What_is_erectile_dysfunction">Medical Author: Dennis Lee, M.D.
Medical Editors: Jay W. Marks, M.D., and Jacob Rajfer, M.D.

What is erectile dysfunction?

Erectile dysfunction (ED), also known as impotence, is the inability to achieve or sustain an erection for satisfactory sexual activity. Erectile dysfunction is different from other conditions that interfere with sexual intercourse, such as lack of sexual desire and problems with ejaculation and orgasm. This article focuses on the evaluation and treatment of erectile dysfunction.



How common is erectile dysfunction?

Erectile dysfunction (ED, impotence) varies in severity; some men have a total inability to achieve an erection, others have an inconsistent ability to achieve an erection, and still others can sustain only brief erections. The variations in severity of erectile dysfunction make estimating its frequency difficult. Many men also are reluctant to discuss erectile dysfunction with their doctors, and thus the condition is under-diagnosed. Nevertheless, experts have estimated that erectile dysfunction affects 30 million men in the Untied States.



While erectile dysfunction can occur at any age, it is uncommon among young men and more common in the elderly. By age 45, most men have experienced erectile dysfunction at least some of the time. According to the Massachusetts Male Aging Study, complete impotence increases from 5% among men 40 years of age to 15% among men 70 years and older. Population studies conducted in the Netherlands found that some degree of erectile dysfunction occurred in 20% of men between ages 50 to 54, and in 50% of men between ages 70 to 78. In 1999, the National Ambulatory Medical Care Survey counted 1,520,000 doctor-office visits for erectile dysfunction.






How does erection occur?

Erection begins with sexual stimulation. Sexual stimulation can be tactile (for example, by touching the penis), or mental (for example, by having sexual fantasies). Sexual stimulation generates electrical impulses along the nerves going to the penis and causes the nerves to release nitric oxide, which in turn increases the production of cyclic GMP (cGMP) in the smooth muscle cells of the corpora cavernosa. The cGMP causes the smooth muscles of the corpora cavernosa to relax, and allow rapid blood flow into the penis. The in-coming blood fills the corpora cavernosa, making the penis expand.



How is erection sustained?

The pressure from the expanding penis compresses the veins (blood vessels that drain the blood out of the penis) in the tunica albuginea, helping to trap the blood in the corpora cavernosa, thereby sustaining erection. Erection is reversed when cGMP levels in the corpora cavernosa fall, causing the smooth muscles of the corpora cavernosa to contract, stopping the inflow of blood and opening veins that drain blood away from the penis. The levels of the cGMP in the corpora cavernosa fall because it is destroyed by an enzyme called phosphodiesterase type 5 (PDE5)



What are the causes of erectile dysfunction?

The ability to achieve and sustain erections require:

  1. A healthy nervous system that conducts nerve impulses in the brain, spinal column, and penis,
  2. Healthy arteries in and near the corpora cavernosa,
  3. Healthy smooth muscles and fibrous tissues within the corpora cavernosa, and
  4. Adequate levels of nitric oxide in the penis.


Erectile dysfunction can occur if one or more of these requirements are not met. The causes of erectile dysfunction include:

  • Aging: There are two reasons why older men are more likely to experience erectile dysfunction than younger men. First, older men are more likely to develop diseases (such as heart attacks, sleep (a stage in the sleep cycle with rapid eye movements). Men with psychogenic erectile dysfunction (erectile dysfunction due to psychological factors such as stress and anxiety rather than physical factors) usually maintain these involuntary erections. Men with physical causes of erectile dysfunction (for example; atherosclerosis, smoking, and diabetes) usually do not have these involuntary erections.
  • Are there physical causes of erectile dysfunction? A prior history of cigarette smoking, heart attacks, strokes, and poor circulation in the extremities suggest atherosclerosis as the cause of the erectile dysfunction. Diminished sensation of the penis and the testicles, bladder dysfunction, and decreased sweating in the lower extremities suggest diabetic nerve damage. Loss of sexual desire and drive, lack of sexual fantasies, gynecomastia (enlargement of breasts), and diminished facial hair suggest low testosterone levels.
  • Is the patient taking medications that can contribute to erectile dysfunction?


    • Physical examination

    The physical examination can reveal clues for physical causes of erectile dysfunction. For example, if the penis does not respond as expected to touching, a problem in the nervous system may be the cause. Small testicles, lack of facial hair and enlarged breasts can point to hormonal problems such as hypogonadism with low testosterone levels. A reduced flow of blood as a result of atherosclerosis can sometimes be diagnosed by finding diminished arterial pulses in the legs or listening with a stethoscope for bruits (the sound of blood flowing through narrowed arteries). Unusual characteristics of the penis itself could suggest the root of the erectile dysfunction, for example, bending of the penis during erection could be the result of Peyronie's disease.



    Laboratory tests

    Common laboratory tests to evaluate erectile dysfunction include:

    • Complete blood counts
    • Urinalysis: An abnormal urinalysis may be a sign of diabetes mellitus and kidney damage
    • Lipid profile: High levels of LDL cholesterol (bad cholesterol) in the blood promotes atherosclerosis.
    • Blood glucose levels: Abnormally high blood glucose levels may be a sign of diabetes mellitus.
    • Blood Hemoglobin A 1c: Abnormally high levels of blood hemoglobin A 1c in patients with diabetes mellitus establish that there is poor control of blood glucose levels.
    • Serum creatinine: An abnormal serum creatinine may be the result of kidney damage due to diabetes.
    • Total testosterone levels: Blood samples for total testosterone levels should be obtained in the early morning (before 8 am) because of wide fluctuations in the testosterone levels throughout the day. A low total testosterone level suggests hypogonadism. Measurement of bio-available testosterone may be a better measurement than total testosterone, especially in obese men and men with liver disease, but measurement of bio-available testosterone is not widely available.
    • PSA levels: PSA (prostate specific antigen) blood levels and prostate examination to exclude prostate cancer is important before starting testosterone treatment since testosterone can aggravate prostate cancer.


    Other tests

    Monitoring erections that occur during sleep (nocturnal penile tumescence) can help distinguish between erectile dysfunction of psychological and physical causes. If nocturnal erections do not occur, then the cause of erectile dysfunction is likely to be physical rather than psychological, however, tests of nocturnal erections are not completely reliable. Scientists have not standardized the tests and have not determined in whom they should be done.



    Psychosocial examination

    A psychosocial examination using an interview and questionnaire may reveal psychological factors contributing to erectile dysfunction. The sexual partner also may be interviewed to determine expectations and perceptions encountered during sexual intercourse.



    What are the treatments for erectile dysfunction?

    Treatments for erectile dysfunction in 2004 include:
    1. Working with doctors to select medications that do not impair erectile function,
    2. Making life style improvements (for example; quitting smoking, and exercising more),
    3. Drugs such as tadalafil (Cialis),
    4. Inserting medications into the urethra (intraurethral suppositories),
    5. Injecting medications into the corpora cavernosae (intracavernosal injections),
    6. Vacuum constrictive devices for the penis,
    7. Penile prostheses, and
    8. Psychotherapy.


    Adjusting medications

    Many common medications for treating hypertension, depression, and high blood lipids can contribute to erectile dysfunction (see above). Treatment of hypertension is an example. There are many different types (classes) of anti-hypertensive medications (medications that lower blood pressure); these include beta-blockers, valsartan (Diovan), may actually increase sexual appetite, improve sexual performance, and decrease erectile dysfunction. Therefore, choosing an optimal anti-hypertensive combination is an important part of treating erectile dysfunction



    Lifestyle improvements

    Quitting smoking, exercising regularly, losing excess weight, curtailing excessive alcohol consumption, controlling hypertension, and optimizing blood glucose levels in patients with diabetes are not only important for maintaining good health but also may improve erectile function. Some studies suggest that men who have made lifestyle improvements experience increased rates of success with oral medications.



    Intraurethral suppositories


How effective is testosterone in treating erectile dysfunction?

In patients with hypogonadism, testosterone treatment can improve libido and erectile dysfunction, but the response of erectile dysfunction in men with hypogonadism to testosterone is not complete; many men still may need additional oral medications such as sildenafil, vardenafil or tadalafil.



In men 40 years of age or older, a breast examination, digital examination of the prostate and a PSA level (prostate specific antigen) should be done to exclude breast and prostate cancer before starting testosterone treatment since testosterone can aggravate breast and prostate cancers. Patients who have breast and prostate cancers or are suspected of having them should not use testosterone.



Sildenafil (Viagra)

What is sildenafil (Viagra)?

Sildenafil (Viagra) was the first oral phosphodiesterase type 5 (PDE5) inhibitor approved by the FDA in the United States for the treatment of erectile dysfunction (it is not approved for women). Sildenafil inhibits PDE5, which is an enzyme that destroys cGMP. By inhibiting the destruction of cGMP by PDE5, sildenafil allows cGMP to accumulate. The cGMP in turn prolongs relaxation of the smooth muscle of the corpora cavernosa. Relaxation of the corpora cavernosa smooth muscle allows blood to flow into the penis resulting in increased engorgement of the penis. In short, sildenafil increases blood flow into the penis and decreases blood flow out of the penis.



How effective is sildenafil (Viagra)?

Sildenafil is used for the treatment of erectile dysfunction of either physical or psychological cause. It has been found to be effective in treating erectile dysfunction in men with coronary artery disease, diabetes mellitus, hypertension, depression, coronary artery bypass surgery, and men who are taking antidepressants and several classes of anti-hypertensives.



In randomized controlled trials, an estimated 60% of men with diabetes, and 80% of men without diabetes experienced improved erections with sildenafil.



How should sildenafil (Viagra) be administered?

Sildenafil is available as oral tablets at doses of 25, 50, and 100 mg. It should be taken approximately one hour before sexual activity. In some men, the onset of action of the drug may be as early as 11-20 minutes. Sildenafil should be taken on an empty stomach for best results since absorption and effectiveness of sildenafil can be diminished if it is taken shortly after a meal, particularly a meal that is high in fat.



What is the dose of sildenafil (Viagra)?

In prescribing sildenafil, a doctor considers the age, general health status, and other medication(s) the patient is taking. The usual starting dose for most men is 50 mg, however, the doctor may increase or decrease the dose depending on side effects and effectiveness. The maximum recommended dose is 100 mg every 24 hours, however, many men will need 100 mg of sildenafil for optimal effectiveness, and some doctors are recommending 100 mg as the starting dose.



Metabolism (breakdown) of sildenafil is slowed by aging, liver and kidney dysfunction, and concurrent use of certain medications (such as erythromycin--an antibiotic, and protease inhibitors, for HIV). Slowed breakdown allows sildenafil to accumulate in the body and potentially may increase the risk of side effects. Therefore in men over 65, in men with substantial kidney and liver disease, and in men who also are taking protease inhibitors, the doctor will initiate sildenafil at a lower dose (25 mg) to avoid accumulation of sildenafil in the body. A protease inhibitor ritonavir (Norvir) is especially potent in increasing the accumulation of sildenafil, thus men who are taking Norvir should not take sildenafil doses higher than 25 mg and at a frequency of no greater than once in 48 hours.



What are the side effects of sildenafil (Viagra)?

Sildenafil has been found to be well tolerated without important side effects. The reported side effects are usually mild, and include diarrhea , and abnormal vision (seeing a bluish hue or brightness).



Sildenafil can cause hypotension (abnormally isosorbide mononitrate . Other nitrates such as amyl nitrate and butyl nitrate also are found in some recreational drugs called "poppers".



Sildenafil should be used cautiously in men on alpha blockers such as doxazosin (Cardura), tamsulosin (Flomax). There have been occasional reports of low blood pressure in men who have taken the two classes of drugs simultaneously and therefore it is recommended that there be at least a span of 4-6 hours between the ingestion of sildenafil and alpha blockers.



There have been rare reports of priapism (prolonged and painful erections lasting more than 6 hours) with the use of PDE5 inhibitors such as sildenafil, vardenafil, and tadalafil, especially when sildenafil is used in combination with injection of medications into the corpora cavernosa or intraurethral suppositories. Patients with blood cell diseases such as sickle cell multiple myeloma have higher than normal risks of developing priapism. Priapism untreated can cause injury to the penis and lead to permanent impotence. Therefore, sildenafil should not be used in combination with intraurethral suppositories and corpora cavernosa injections. If there is prolonged erection (longer than 4 hours), immediate medical assistance should be obtained.



Is it safe for men with heart disease to use sildenafil (Viagra)?

Sildenafil has been found to be effective and safe in the treatment of erectile dysfunction in men with stable heart disease due to atherosclerosis of the coronary arteries, provided that they are not on nitrates. The real concern is not as much the safety of sildenafil but the risk of sexual activity in triggering heart attacks or abnormal heart rhythms in patients with heart disease.



The risk of developing heart attacks or abnormal heart rhythms during sex is low in men with well controlled hypertension, mild disease of the heart's valves, well controlled heart failure, mild and stable angina (with a favorable treadmill stress test), successful coronary stenting or bypass surgery, and a remote history of heart attack (more than 8 weeks previously). Sildenafil can be used safely in men in these low risk groups.



The risk of heart attack or abnormal heart rhythms during sex is higher in men with unstable angina (angina that occurs at rest or with minimal exertion), poorly controlled hypertension, moderate to severe heart failure, moderate to severe disease of the heart's valves, recent heart attack (less than 2 weeks previously), potentially life threatening disorders of heart rhythm such as recurrent ventricular tachycardia, and moderate to severe disease of the heart's muscle. In these men, doctors usually stabilize or treat the heart conditions before prescribing sildenafil.



Before starting sildenafil for erectile dysfunction, a doctor may need to determine whether the heart can safely achieve the workload necessary for sexual activity. For example, in men with coronary artery heart disease, a doctor may perform a treadmill stress test to determine whether there is adequate blood supply to the heart muscle while exercising at levels comparable to sexual activity.



Vardenafil (Levitra)

What is vardenafil (Levitra)?

Vardenafil (Levitra) was the second oral medicine approved by the United FDA in the US for the treatment of erectile dysfunction. Like sildenafil (Viagra), vardenafil (Levitra) inhibits PDE5 which destroys cGMP (as discussed earlier).



How effective is vardenafil (Levitra)?



Vardenafil was evaluated in four multicenter, randomized, placebo-controlled trials involving more than 2400 men (78% white, 7% black, 2% Asian, 3% Hispanic) with erectile dysfunction. Two of these trials were conducted in special erectile dysfunction populations; one in men with diabetes mellitus, another in men who developed erectile dysfunction after prostate surgery. The doses of vardenafil in the four studies were 5 mg, 10 mg, and 20 mg.



In all four studies, vardenafil was significantly better than placebo in improving men's ability to achieve and maintain erections in all age categories (less than 45, 45-65,and greater than 65 years of age) and in all races.



How should vardenafil (Levitra) be administered?

The recommended starting dose of vardenafil is 10 mg taken orally approximately 1 hour before sexual activity. The dose may be adjusted higher or lower depending on efficacy and side effects. The maximum recommended dose is 20 mg, and the maximum recommended dosing frequency is no more than once per day. Vardenafil can be taken with or without food.



What are the side effects of vardenafil (Levitra)?

Vardenafil is generally well tolerated with only mild side effects. These side effects include headache, flushing, nasal congestion, dyspepsia, body aches, dizziness, nausea, and increased blood levels of the muscle enzyme creatine kinase.



There have been rare reports of priapism (prolonged and painful erections lasting more than 6 hours) with the use of oral PDE5 inhibitors such as vardenafil, sildenafil and tadalafil. Patients with blood cell diseases such as sickle cell anemia, leukemia, and multiple myeloma have higher than normal risks of developing priapism. Priapism untreated can cause injury to the penis tissue and lead to permanent loss of potency. If there is prolonged erection (longer than 4 hours), immediate medical assistance should be sought.



Who should not use vardenafil (Levitra)?

Vardenafil (Levitra) can cause hypotension (abnormally low blood pressure, which can lead to fainting and even shock) when given to patients who are taking nitrates. Patients taking nitrates daily, even patients taking nitrates only once a day, should not take vardenafil. Most commonly used nitrates are medications to relieve angina (chest pain due to insufficient blood supply to heart muscle because of narrowing of the coronary arteries). These include nitroglycerine tablets, patches, ointments, sprays, pastes, and isosorbide dinitrate and isosorbide mononitrate. Other nitrates such as amyl nitrate and butyl nitrate are found in some recreational drugs called "poppers".



Vardenafil should not be used with alpha-blockers, medicines used to treat high blood pressure and benign prostate hypertrophy (BPH), because the combination of vardenafil 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 (Uroxatrol), and prazosin (Minipress).



Men with a rare heart condition known as long QT syndrome should not take vardenafil since this may lead to abnormal heart rhythms. The QT interval is the time it takes for the heart's muscle to recover after it has contracted. The QT interval is measured with an electrocardiogram (EKG). Some patients have longer than normal QT intervals, and they may develop potentially life-threatening abnormal heart rhythms, especially when given certain medications. Since long QT syndrome can be inherited, men with a family history of long QT syndrome should not take vardenafil. Furthermore, vardenafil is not recommended for men who are taking medications that can affect the QT interval such as amiodarone (Cordarone), and sotalol (Betapace).



There is insufficient information on the safety of vardenafil in men with the following conditions:

  • Unstable angina (chest pain due to coronary artery disease that occurs at rest or with minimal physical exertion)
  • Low blood pressure (a resting systolic blood pressure less than 90mm Hg)
  • Uncontrolled high blood pressure (greater than 170/110 mm Hg)
  • Recent { aortic stenosis
  • Retinitis pigmentosa


Therefore, men with these conditions should not use vardenafil without having these conditions evaluated and stabilized first. For example, men with uncontrolled high blood pressure should have their blood pressure controlled; and men with potentially life-threatening abnormal heart rhythms should have these rhythms controlled.



When there is angina or heart failure, the doctor may need to determine whether the heart has enough reserve to safely carry out the work necessary for sexual activity by performing cardiac treadmill stress testing.



What precautions should be taken when using vardenafil (Levitra)?

Metabolism (breakdown) of vardenafil can be slowed by aging, liver disease, and concurrent use of certain medications (such as indinavir (Crixivan ) should not take more than 2.5 mg of vardenafil in a 24-hour period.
  • Men taking another protease inhibitor ritonavir (Norvir) should not take more than 2.5 mg of vardenafil every 72 hours.


    • Tadalafil (Cialis)

    What is tadalafil (Cialis)?

    Tadalafil (Cialis) is the third oral medicine approved by the United FDA in the US for the treatment of erectile dysfunction. Like sildenafil (Viagra) and vardenafil (Levitra), tadalafil inhibits PDE5 (as described earlier).



    How effective is tadalafil (Cialis)?

    The safety and efficacy of tadalafil in the treatment of erectile dysfunction was evaluated in 22 clinical trials involving more than 4,000 men. Seven of these trials were randomized, prospective, placebo-controlled studies of 12 weeks' duration. Two of these studies (involving 402 men) were conducted in the Untied States, and the other five studies (involving 1112 men) were conducted outside the Untied states. Two of these trials were conducted in special erectile dysfunction populations; one in men with diabetes mellitus, another in men who developed erectile dysfunction after nerve-sparing prostate cancer surgery.



    Effectiveness of tadalafil in these studies was assessed using a sexual function questionnaire. Study participants also were asked if they were able to achieve vaginal penetration and to maintain erections long enough for successful intercourse.



    In all seven trials, tadalafil was significantly better than placebo in improving men's ability to achieve and maintain erections. Improvements in erectile function was observed in some patients at 30 minutes after taking a dose; and improvements can last for up to 36 hours after taking Cialis when compared to placebo.



    How should tadalafil (Cialis) be administered?

    The recommended starting dose of tadalafil for most patients is 10 mg taken orally approximately 1 hour before sexual activity. The dose may be adjusted higher to 20 mg or lower to 5 mg depending on efficacy and tolerability. The maximum recommended dosing frequency is once per day, although for many patients tadalafil can be taken less frequently since the improvement in erectile function may last 36 hours. Tadalafil may be taken with or without food.



    What are the side effects of tadalafil (Cialis)?

    Tadalafil is generally well tolerated with only mild side effects. The most common side effects reported include headache, indigestion, back pain, muscle aches, facial flushing, and nasal congestion.



    Back pain and muscle aches occurred in less than 7% of patients, and usually occurred at 12 to 24 hours after taking tadalafil. The back pain and muscle aches associated with tadalafil were characterized by mild to moderate muscle discomfort in the lower back, buttocks and thighs, often aggravated by lying down. The back and muscle aches resolved in most patients without treatment within 48 hours. When treatment was necessary, { non-steroidal antiinflammatory drugs (NSAIDs) such as Motrin, Advil, or Aleve were effective. Approximately 0.5% of all the patients using tadalafil discontinued the drug due to back pain or muscle aches.



    Reports of abnormal vision were rare, it occurred in less than 0.1% of patients using tadalafil.



    There have been rare reports of priapism (prolonged and painful erections lasting more than 6 hours) with the use of oral PDE5 inhibitors such as vardenafil, sildenafil and tadalafil. Patients with blood cell diseases such as sickle cell anemia, leukemia, and multiple myeloma have higher than normal risks of developing priapism. Priapism untreated can cause injury to the penile tissue and lead to permanent loss of potency. If there is prolonged erection (longer than 4 hours), immediate medical assistance should be sought.



    Who should not use tadalafil (Cialis)?

    Tadalafil can cause hypotension (abnormally low blood pressure, which can lead to fainting and even shock) when given to patients who are taking nitrates. Patients taking nitrates daily, even patients taking nitrates only once a day, should not take tadalafil. Most commonly used nitrates are medications to relieve angina (chest pain due to insufficient blood supply to heart muscle because of narrowing of the coronary arteries). These include nitroglycerine tablets, patches, ointments, sprays, pastes, and isosorbide dinitrate and isosorbide mononitrate. Other nitrates such as amyl nitrate and butyl nitrate are found in some recreational drugs called "poppers".



    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 (Uroxatrol), and prazosin (Minipress). The only alpha-blocker that can be used safely with tadalafil is tamsulosin (Flomax). 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 that has not been tested with tadalafil is alfuzosin (Uroxatrol) and no recommendations can be made regarding the interaction between the two.



    Tadalafil is not recommended for men with the following conditions:

    • Unstable angina (chest pain due to coronary artery disease that occurs at rest or with minimal physical exertion)
    • Low blood pressure (a resting systolic blood pressure less than 90mm Hg)
    • Uncontrolled high blood pressure (greater than 170/110 mm Hg)
    • Recent stroke or heart attack (within 6 months)
    • Uncontrolled, potentially life-threatening abnormal heart rhythms
    • Severe liver disease
    • Severe heart failure or disease of the heart's valves, for example, aortic stenosis
    • Retinitis pigmentosa


    Therefore, men with these conditions should not use tadalafil without having these conditions evaluated and stabilized first. For example, men with uncontrolled high blood pressure should have their blood pressure controlled; and men with potentially life-threatening abnormal heart rhythms should have these rhythms controlled.



    When there is angina or heart failure, the doctor may need to determine whether the heart has enough reserve to safely carry out the work necessary for sexual activity by performing cardiac treadmill stress testing.



    What precautions should be taken when using tadalafil?

    In most healthy men, some of the drug will remain in the body for more than 2 days after a single dose of tadalafil. Metabolism (clearing of the drug from the body) of tadalafil can be slowed by liver disease, kidney disease, and concurrent use of certain medications (such as erythromycin, ketoconazole, and protease inhibitors). Slowed breakdown allows tadalafil to stay in the body longer and potentially increase the risk for side effects. Therefore, the dose and frequency of tadalafil has to be lowered in the following examples:

    • Medications such as erythromycin, ketoconazole (Nizoral), itraconazole (Sporanox), ritonavir (Norvir), and indinavir (Crixivan) can slow the breakdown of tadalafil. Therefore men taking these medications should not take more than 10 mg of tadalafil and should not take tadalafil more frequently than every 72 hours.
    • No tadalafil dose adjustment is necessary for men with only mild kidney disease. Men with moderately severe kidney impairment should start tadalafil at 5 mg every 24 hours, and not to exceed the maximum dose of 10 mg taken every 48 hours. In men with severe kidney disease and on dialysis, the maximum dose should not exceed 5 mg.
    • Men with severe liver disease should not take tadalafil. Men with mild to moderate liver disease should not exceed tadalafil dose of 10 mg once daily.


    Intracavernosal injections

    What are intracavernosal injections?

    Medications can be injected directly into the corpora cavernosa to attain and maintain erections. Medications such as papaverine hydrochloride, phentolamine, and prostaglandin E1 can be used alone or in combinations to attain erections. Combining small amounts of each drug is preferred over using a single drug because of increased efficacy and fewer side effects. Even though such injections can be effective, they are not widely used because the injections are painful, there may be scarring of the penis, and there is a risk of developing priapism.



    Intraurethral suppositories

    What are intraurethral suppositories?

    Prostaglandin E1 can be inserted in a pellet (suppository) form into the urethra to attain erections. This technique also is not popular because of occasional side effects of pain in the penis and sometimes in the testicles, mild urethral bleeding, dizziness, and vaginal itching in the sex partner. Men also need to remain standing after inserting the pellet in order to increase blood flow to the penis, and it may take 15-30 minutes to attain an erection. Prostaglandin can cause uterine contractions and should not be used by men having intercourse with pregnant women unless condoms or other barrier devices are used.





    One variation of the vacuum device involves a semirigid rubber sheath that is placed on the penis and remains there after attaining erection and during intercourse.

    Surgery for erectile dysfunction

    Surgery for erectile dysfunction may have as its goal:
    1. To implant a device that causes the penis to become erect;
    2. To reconstruct arteries in order to increase the flow of blood to the penis, or
    3. To block veins that drain blood from the penis.


    Implantable devices, known as prostheses, can cause erections in many men with impotence.



    Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa, the twin chambers running the length of the penis. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.



    Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid (see figure 3). Tubes connect the cylinders to a fluid reservoir and pump, which also are surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis somewhat. They also leave the penis in a more natural state when not inflated.



    Possible problems with prostheses include mechanical breakdown and infection. Mechanical problems have diminished in recent years because of technological advances.



    Inflatable Implant Illustration - Erectile Dysfunction (ED)


    Surgery to repair arteries can reduce impotence caused by obstructions that block the flow of blood to the penis. The best candidates for such surgery are young men with discrete blockage of an artery because of a physical injury to the pubic area or a fracture of the pelvis. The procedure is less successful in older men with widespread blockage of arteries.

    What about psychological therapy?

    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 when physical impotence is being treated.



    Erectile Dysfunction At A Glance
    • Erectile dysfunction (ED), also known as impotence, is the inability to achieve or sustain an erection for satisfactory sexual activity.
    • Erectile dysfunction is common; experts have estimated that erectile dysfunction affects 30 million men in the Untied States.
    • The causes of erectile dysfunction include aging, high blood pressure, diabetes mellitus, cigarette smoking, atherosclerosis, depression, nerve or spinal cord damage, medication side effects, alcoholism or other substance abuse, and low testosterone levels.
    • Erectile dysfunction is treatable in all age groups.
    • Treatments include psychotherapy, adopting a healthy lifestyle, oral PDE5 inhibitors (Viagra, Levitra, and Cialis), intraurethral medications, intracavernosa injections, vacuum devices, surgery, and working with doctors to avoid medications that can impair erectile function.


    Based on University of Miami School of Medicine [Medical_Dictionary]:
    Impotence :  ejaculation , or both. Impotence can vary. It can involve a total inability to achieve an erection or ejaculation, an inconsistent ability to do so, or a tendency to sustain only very brief erections.

    The risk of impotence increases with age. It is four-fold higher in men in their 60s compared with those in their 40s according to a study published in the Journal of Urology (2000;163:460-463). Men with less education are also more likely to experience impotence, perhaps because they tend to have less healthy lifestyles, eat a less healthy diet, drink more and exercise less. Physical exercise tends to lessen the risk of impotence.

    Impotence can have emotional causes but most often it is due to a physical problem. The physical causes of impotence include diseases (such as penis . Impotence is treatable in all age groups. Treatments include psychotherapy, vacuum devices, surgery and, most often today, drug therapy.

    Advertising for drugs for the treatment of impotence has greatly popularized the problem better known in the ads by its other name, erectile dysfunction .



    Based on University of Miami School of Medicine [Medical_Dictionary]:
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