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The mean age of the study group was 59.6 11.2 y.13 54 24 had arteriogenic ED, 16 54 30 had mixed Hormone Treatment For Menopause And Low Libido vasculogenic ED, 9 54 17 Erectile Dysfunction Photos had cavernosal veno occlusive dysfunction, 11 54 20 had Erectile Dysfunction Clickbait Article post radical retropubic prostatectomy ED and 5 Us Hair Store 54 9 had psychogenic ED.13 54 24.1 responded to sildenafil at a median Us Hair Store maximal dose of 200 mg, 4 13 required 150 mg and 9 13 required Best Ginseng For Ed 200 mg.41 54 76 Erectile Dysfunction Clickbait Article failed to respond to sildenafil.Mean IIEF question 3 and 4 Erectile Dysfunction Clickbait Article scores were 1.5 and 1.4 at baseline, 2.2 and 1.9 with sildenafil Best Ginseng For Ed 100 mg, 2.8 and 2.5 with sildenafil 150 mg and 3..0 and 2.9 with sildenafil 200 mg, respectively.After 4 weeks, treatment was regarded as having improved their erections by 37 , 46.3 and 68 of patients with sildenafil 100 Hormone Treatment For Menopause And Low Libido mg, 150 mg and 200 mg, respectively.34 54 63 reported adverse effects with maximal dose sildenafil comprising headache 19 , facial flushing 32 Hormone Treatment For Menopause And Low Libido , dyspepsia 14 , nasal congestion 11 , dizziness 5 and visual disturbances 5.4 13 Hormone Treatment For Menopause And Low Libido 31 responders refused to continue treatment due to adverse effects.In conclusion, Hormone Treatment For Menopause And Low Libido sildenafil at doses of up to Best Ginseng For Ed 200 mg is an effective salvage therapy for 24.1 of previous sildenafil non responders but is limited by a significantly higher incidence of adverse effects and a 31 treatment discontinuation rate.IntroductionErectile dysfunction ED is the inability to Hormone Treatment For Menopause And Low Libido achieve and maintain an erection of sufficient rigidity Best Ginseng For Ed for satisfactory sexual intercourse.1 Community based epidemiological studies suggest that sexual dysfunction, particularly ED, is a common disorder in patients and is associated with Best Ginseng For Ed reduced quality of life.2,3,4,5Sildenafil citrate ViagraTM, Pfizer, Us Hair Store UK , a potent, competitive phosphodiesterase type 5 iso enzyme PDE 5 inhibitor, is the first oral medication to demonstrate significant and reliable efficacy in most patients with ED.6 Following activation of the nitric oxide cGMP pathway by sexual arousal, inhibition of PDE 5 isoenzyme by sildenafil results in increased corporal levels of cGMP and an augmented penile erection.7 Sildenafil appears effective in restoring erectile function and improving intercourse success rates in a wide range of patients, including those with hypertension, diabetes, spinal cord injury, other concomitant medical conditions, and in those patients taking a wide variety of concomitant medications.Its efficacy appears related to the extent and severity of ED, with significantly reduced efficacy Hormone Treatment For Menopause And Low Libido demonstrated in patients with severe vasculogenic ED, diabetic ED and post Erectile Dysfunction Photos radical prostatectomy ED.6,8,9,11Jarow Hormone Treatment For Menopause And Low Libido et al reported a sildenafil response rate of 65 , significant improvement in quality of life Erectile Dysfunction Clickbait Article and a 35 incidence of adverse effects.9 Virag reported similar results Erectile Dysfunction Photos Erectile Dysfunction Photos with a 60 response rate and a 26.75 incidence of Erectile Dysfunction Clickbait Article adverse effects.10 McMahon et al reported a similar response rate of 67.5 but a higher incidence of adverse effects of 53.6.11 These authors report a similar efficacy rate but a higher incidence of adverse effects compared to that reported by the Sildenafil Study Group.6The maximum dose of sildenafil recommended by the manufacturer is 100 mg.A study was designed to prospectively review a group of patients with chronic ED, unresponsive to sildenafil 100 mg, who were treated in a home setting with doses of sildenafil in excess of the recommended maximum dose Us Hair Store 150 mg and 200 mg.Treatment efficacy, safety and tolerance was evaluated using serial physician interviews and the patient self administered IIEF questionnaire.Materials and methodsFifty four fully evaluated patients Hormone Treatment For Menopause And Low Libido with chronic ED who had previously failed to respond to a home trial of sildenafil 100 Best Ginseng For Ed mg with erections suitable Best Ginseng For Ed for sexual intercourse were studied.All patients had received focussed sildenafil usage education and had been re titrated to confirm their non responder status.The mean number of sildenafil uses prior to enrolment in this study was 7 tablets range 5 C16.All patients had been previously assessed using a standardised protocol and the etiology of their ED determined.This protocol included a history and physical examination, determination of fasting lipids, glucose and free testosterone, vibratory penile biothesiometry and penile Erectile Dysfunction Clickbait Article colour duplex Doppler ultrasonography CDU before and after intracavernous vasoactive drug challenge 20 mg alprostadil.Rigiscan nocturnal penile tumescence testing, dynamic infusion cavernosometry and cavernosography DICC and Hormone Treatment For Menopause And Low Libido phallopharmacoangiography were performed where clinically indicated.Patients with unstable coronary artery disease, low output congestive cardiac failure, hypertension treated with three or more drugs, currently prescribed organic nitrate medication or those with any other contraindication to renewed sexual intercourse or sildenafil were excluded from the study.Each man was treated at home with escalating doses of sildenafil citrate 100 mg, 150 mg and 200 mg taken 1 Erectile Dysfunction Clickbait Article hour before planned sexual activity until either maximal response or intolerable adverse effects occurred.The Us Hair Store primary efficacy end point was the response to the questions 3 and Us Hair Store 4 of the erectile function domain of the International Index of Erectile Function IIEF after a trial of each dose of sildenafil.The secondary efficacy end point was the response to the global assessment question Has this treatment improved your erections after 4 weeks of treatment.Results were analysed using standard statistical analysis including descriptive statistics and Student s t test.ResultsFifty four Hormone Treatment For Menopause And Low Libido patients with chronic ED and a mean Best Ginseng For Ed age of Erectile Dysfunction Photos 59.6 11.2 y were enrolled in the study group.The etiology of ED was psychogenic in 5 patients 9 , arteriogenic in 13 patients 24 , cavernosal veno occlusive dysfunction CVOD in 9 patients 17 , MVED in 16 patients 30 and post radical retropubic prostatectomy Erectile Dysfunction Photos ED in 11 patients 20.The mean duration of ED was 16..6 months range 4 C32.Twenty Erectile Dysfunction Clickbait Article four patients had diabetes mellitus, 27 Best Ginseng For Ed had hypertension, 26 had dyslipidaemia and 20 smoked cigarettes.Two or more vascular risk factors were present in 46 patients Table 1.Table 1 Patient demographics, intercurrent illness and life style factors overall and according to aetiology of EDFull size tableErections of sufficient rigidity and Erectile Dysfunction Clickbait Article duration for satisfactory sexual intercourse Erectile Dysfunction Photos occurred in 13 patients 24.1 at a median maximal dose of 200 mg.Four patients 7.4 required 150 mg and comprised 2 patients with psychogenic ED and 2 patients with arteriogenic ED.The remaining 9 patients 16.7 required 200 mg and comprised 2 patients with psychogenic ED, 3 patients with arteriogenic ED, 2 patients with cavernosal veno occlusive dysfunction Hormone Treatment For Menopause And Low Libido and 2 patients with post radical prostatectomy ED.Nine of the 13 patients 69 Erectile Dysfunction Clickbait Article who responded chose to continue therapy with Best Ginseng For Ed sildenafil.Overall, high dose sildenafil was effective in Erectile Dysfunction Clickbait Article 4 out of 5 patients 80 Best Ginseng For Ed with psychogenic ED and 9 out of 49 patients 18.4 with organic ED Table 2.Of the 11 patients with post radical prostatectomy ED, 2 patients had undergone a bilateral nerve sparing radical retro pubic prostatectomy NSRRP and one had undergone a unilateral procedure and the remainder non nerve sparing procedures.The mean interval between surgery and treatment was 5.2 months.High dose sildenafil was effective in 1 man treated with bilateral NSRRP and in 1 Erectile Dysfunction Clickbait Article man treated with a unilateral NSRRP.Table Us Hair Store 2 Response rate for sildenafil 150 mg, sildenafil 200 mg and sildenafil overallFull size table.Mean responses to questions 3 and 4 of the IIEF erectile function domain, the primary end point, were 1.5 and 1.4 at baseline, 2.2 and 1.9 with sildenafil 100 mg, 2.8 and 2.5 with sildenafil 150 mg and 3.0 and 2.9 with sildenafil 200 mg.The mean score for Q3 and Q4 for sildenafil was statistically superior to baseline, overall, in all etiological groups Hormone Treatment For Menopause And Low Libido and at all doses P 0.001.The overall mean score for Q3 and Q4 for Best Ginseng For Ed sildenafil 200 mg was statistically superior to sildenafil 100 mg P 0.05 but not to sildenafil 150 mg.The mean score for Q3 and Q4 for Erectile Dysfunction Photos sildenafil 200 mg was statistically superior to sildenafil 100 mg P 0.05 for all etiological groups except post radical prostatectomy ED Figures 1 and 2.The global assessment by patients whether treatment improved their erections, the secondary end point, was answered in the Erectile Dysfunction Photos affirmative at week 4 by 37 on 100 mg, 46.3 on 150 mg and 68 on 200 mg Figure 3.The incidence of affirmative responses was statistically superior at sildenafil 200 mg compared to 100 mg P 0.05.Viagra is taken as a single tablet, 1 hour before sexual activity.Only 1 dose should be Erectile Dysfunction Photos taken in any 24 hour period.The onset of the Erectile Dysfunction Photos effect may be delayed Erectile Dysfunction Photos if taken with food.Viagra is supplied in boxes of 4 Erectile Dysfunction Photos Us Hair Store Erectile Dysfunction Clickbait Article tablets..THE PRICES LISTED ARE FOR MEDICATION DISPENSED ON A PRIVATE PRESCRIPTION.SOME PATIENTS,HOWEVER, MAY BE ELIGIBLE TO OBTAIN THIS MEDICATION ON AN NHS PRESCRIPTION.YOUR Erectile Dysfunction Photos DOCTOR WILL Hormone Treatment For Menopause And Low Libido BE ABLE TO ADVISE YOU WHICH TYPE OF PRESCRIPTION YOU REQUIRE.VIAGRA sildenafil citrate is a cGMP specific phosphodiesterase type 5 PDE5 inhibitor, used for the treatment of male erectile dysfunction.The physiological mechanism responsible for erection of the penis involves Erectile Dysfunction Clickbait Article the release of nitric oxide NO in the corpus cavernosum in response to sexual stimulation.Nitric oxide then activates the enzyme guanylate cyclase, which results in increased levels of cyclic guanosine monophosphate cGMP , producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood.Sildenafil has no direct relaxant effect on isolated human corpus cavernosum, but enhances the effect Best Ginseng For Ed of NO by inhibiting PDE5, which is responsible for the biodegradation of cGMP in the corpus cavernosum.When sexual stimulation causes local release of NO, Us Hair Store inhibition of PDE5 by sildenafil produces increased levels of cGMP in the Hormone Treatment For Menopause And Low Libido corpus cavernosum, resulting in smooth muscle relaxation and increased inflow of blood to Erectile Dysfunction Photos the corpus cavernosum.Sildenafil, at recommended doses, has no effect in the absence of sexual stimulation.Studies in vitro have shown that sildenafil has between 10 and 10,000 fold greater selectivity for PDE5 than for other phosphodiesterase isoforms namely PDEs 1, 2, 3, 4, and 6 and greater than Erectile Dysfunction Photos 700 fold effect on PDE7 PDE11.In particular, sildenafil has greater than 4,000 fold selectivity for PDE5 over PDE3, the cAMP specific phosphodiesterase isoform involved in the control of cardiac contractility.Sildenafil is about 10 fold as Best Ginseng For Ed Us Hair Store potent for Hormone Treatment For Menopause And Low Libido Erectile Dysfunction Photos PDE5 compared to PDE6, an isoenzyme found Us Hair Store in the retina this lower Us Hair Store selectivity is thought to be the basis for colour vision abnormalities observed with higher doses or plasma levels of sildenafil see WARNINGS AND PRECAUTIONS, Hormone Treatment For Menopause And Low Libido DETAILED PHARMACOLOGY.PDE5 is also Erectile Dysfunction Clickbait Article found in lower concentrations in platelets, vascular and Us Hair Store visceral smooth Hormone Treatment For Menopause And Low Libido muscles, and skeletal muscle.The sildenafil induced inhibition Erectile Dysfunction Clickbait Article of PDE5 in these tissues appears to be the basis for the enhanced platelet antiaggregatory activity of Us Hair Store nitric oxide observed in vitro, Hormone Treatment For Menopause And Low Libido and inhibition of platelet thrombus formation in vivo, and peripheral arterial venous dilation in vivo see WARNINGS AND PRECAUTIONS.PharmacodynamicsEffects of VIAGRA on Blood Pressure BP Single oral doses of sildenafil 100 mg administered to healthy volunteers produced decreases in supine blood pressure mean maximum decrease of 8.3 5.3 mm Hg.The decrease in blood pressure was most notable approximately 1 2 hours after dosing.The effects are not related to dose or plasma levels.Larger effects were recorded among patients receiving concomitant nitrates see CONTRAINDICATIONS.Effects of VIAGRA on Cardiac Parameters Single oral doses of VIAGRA Best Ginseng For Ed up to 100 mg in healthy volunteers produced no clinically relevant effects on ECG.Effects of VIAGRA on Erectile Response VIAGRA was studied in Us Hair Store clinical trials of various designs.In fixed dose clinical trials, 62 , 74 , and 82 of patients on 25 mg, 50 mg and 100 mg of VIAGRA, respectively, reported an improvement in their erections, compared to 25 on placebo p 0.0001, Best Ginseng For Ed see CLINICAL TRIALS.In eight double blind, placebo controlled, cross over studies using RigiScan a device used to objectively measure penile rigidity and duration of erections , erections during sexual stimulation improved significantly on VIAGRA compared to placebo.These studies included patients Erectile Dysfunction Photos with organic etiologies such as spinal cord injury and diabetes mellitus , and patients without an established organic cause.Most studies assessed the efficacy of VIAGRA approximately 60 minutes post dose.All eight studies investigating the effects of sildenafil on penile plethysmography RigiScan after visual sexual stimulation VSS under laboratory conditions, consistently showed that doses of up to 100 mg resulted in statistically significant improvements in duration of erections of 60 rigidity considered hard enough for penetrative sexual intercourse , compared with placebo.In patients who respond, the median time to onset of erections 60 rigidity in response to VSS, was 25 minutes after an oral dose of 50 mg sildenafil.The mean total duration of erections 60 rigidity at the base of the penis was 3, 24 and Hormone Treatment For Menopause And Low Libido 32 minutes for subjects receiving placebo, 25 mg and Us Hair Store 50 mg doses, respectively, when exposed to VSS for 2 hours.VIAGRA increases couples ability to have sexual intercourse see CLINICAL TRIALS.Pharmacokinetics.Absorption Sildenafil is rapidly absorbed.Maximum observed plasma concentrations are reached within 30 to 120 minutes median 60 minutes of oral dosing in the fasted state.The mean absolute bioavailability is 41 range 25 63.The oral pharmacokinetics of VIAGRA is proportional over the recommended dose range studied 25 mg to 100 mg.Sildenafil inhibits the human PDE5 enzyme in vitro by 50 at a concentration of 3.5 nM.In man, the mean maximum free plasma concentration of sildenafil following a single oral dose of 100 mg is approximately 18 ng mL, or 38 nM.When VIAGRA was administered with a high Best Ginseng For Ed fat meal, the rate of absorption was significantly decreased, with a 29 reduction in Cmax and a 60 minute delay in Tmax..The patient may find that it takes Best Ginseng For Ed longer Us Hair Store to work Erectile Dysfunction Clickbait Article if taken with a high fat meal.However, although it was statistically significant AUC decreased by 11 , the decrease in the extent of absorption was not clinically Hormone Treatment For Menopause And Low Libido relevant.The relative bioavailability fed fasted was 89 90 CI 84 94 see DRUG INTERACTIONS.Distribution Us Hair Store The mean steady state volume of distribution Vss for sildenafil is 105 litres, indicating distribution into the tissues.Sildenafil and its major circulating N desmethyl metabolite are both approximately Erectile Dysfunction Photos 96 bound to plasma proteins.Protein binding is independent of total drug concentrations.Based upon measurements of sildenafil in the semen of healthy volunteers, less than 0.001 of the ingested dose may appear in the semen of patients 90 minutes after drug intake.Metabolism Sildenafil is cleared predominantly by the CYP3A4 major route and CYP2C9 minor route hepatic microsomal isoenzymes.The major circulating metabolite results from N demethylation of sildenafil at the N methyl piperazine moiety.This metabolite has a PDE selectivity profile similar to sildenafil and an in vitro potency against PDE5 approximately 50 that of the parent drug.Plasma concentrations Hormone Treatment For Menopause And Low Libido of this metabolite are approximately 40 of those seen for sildenafil.The N desmethyl metabolite is further metabolised, with a terminal half life of approximately 4 Erectile Dysfunction Photos hours.Excretion The total body clearance of sildenafil is 41 L h with a resultant terminal phase half life of Erectile Dysfunction Photos 3 5 hours.After either oral or intravenous administration, sildenafil is excreted as metabolites predominantly in Erectile Dysfunction Clickbait Article the feces approximately 80 of administered dose and to a lesser extent in the urine approximately 13 of Erectile Dysfunction Photos the administered dose.Special Populations and ConditionsGeriatrics Healthy elderly subjects 65 years or older had a reduced clearance of sildenafil, resulting in approximately 90 higher plasma concentrations of sildenafil and the active N desmethyl metabolite compared to those seen in healthy younger volunteers 18 45 years.Due to age differences in plasma protein binding, the corresponding increase Erectile Dysfunction Clickbait Article in free sildenafil plasma concentration was approximately 40.Hepatic Insufficiency In volunteers with hepatic cirrhosis Child Pugh Erectile Dysfunction Clickbait Article A and B , sildenafil clearance was reduced, resulting in increases in AUC 85 and Us Hair Store Hormone Treatment For Menopause And Low Libido Cmax Erectile Dysfunction Clickbait Article 47 compared to age matched volunteers with Best Ginseng For Ed no hepatic impairment.The pharmacokinetics of sildenafil in patients with severe hepatic impairment Erectile Dysfunction Clickbait Article Child Pugh class C have not been studied.Since sildenafil clearance is reduced in geriatric patients 65 years or older , patients with renal impairment or patients with hepatic impairment, a Erectile Dysfunction Photos starting dose of 25 mg Best Ginseng For Ed should be considered.Based on efficacy and toleration, the dose Best Ginseng For Ed may be increased to 50 mg or 100 Erectile Dysfunction Clickbait Article mg see WARNINGS AND PRECAUTIONS, DOSAGE AND ADMINISTRATION.Renal Insufficiency In volunteers with mild CLcr Erectile Dysfunction Clickbait Article 50 80 mL min and moderate CLcr 30 49 mL min renal impairment, the pharmacokinetics of a single oral dose of VIAGRA 50 mg were not altered.In volunteers with severe CLcr 30 mL min renal impairment, sildenafil clearance was reduced, resulting in increases in AUC 100 and Cmax 88 compared to age matched volunteers with no renal impairment.In addition, N desmethyl metabolite AUC and Cmax values were significantly increased by 200 and 79 respectively in subjects with severe renal impairment compared to subjects with normal renal function.Sildaforce 100mg Generic Viagra Tablets are a very popular, successful and widely accepted treatment for erectile dysfunction.Sildaforce 100mg is produced to a high quality standard to ensure safety and effectiveness.Patients using Sildaforce 100mg regularly report successful intercourse and generally continue to use the treatment.The effective treatment time of Sildaforce 100mg is 4 6 hours but many GPs report longer effective times