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Once upon a time, I’m going to put on my physician’s hat and give you the view from the other side.

Viagra so dominates the public consciousness that many men seem have never even heard about Cialis or Levitra, let alone all the other treatments that are available and may be necessary. Still that doesn’t matter, my patients still trying to get treatment i still can give them by only one method. The world is a better place thanks to Pfizer Inc.

Well, my first step was to review the medical records to see if there were any immediate clues. If I found some similar diceases, I should let you in on a small medical secret. About a quarter of all the cases that we see are drug-related. Usually, we simply change the medication and the ED goes away. Alternatively, we have to counsel lifestyle changes because the excessive alcohol consumption or recreational drug of choice is not doing the patient any favors.

Next step I take is take into account dyabetes. This is growing more common but this patient isn’t complaining about any increase in thirst or appetite, his weight looks much as it was the last time we met. During the physical, I’ll look for acanthosis nigricans which are darker patches of skin in the arm pit or round the neck. I may also do a blood sugar test just to be thorough. Blood pressure tests out in the normal range, so that’s another good sign.

The questions are designed to establish whether we’re dealing with problems of desire (which could be psychological or physical), whether it’s purely ED or there are also problems with ejaculation and orgasm, and to check up on those lifestyle choices which could be the real problem.

The physical examination tries to cover as many possibilities as possible in as short a time as possible. Most men find an examination deeply embarrassing so keeping it short is a “good thing”. I’m looking for anything that might suggest a systemic problem. So, I’m obviously going to start with the penis. Some of my questions have probed whether the penis has changed shape in any way or perhaps the erection is painful. A physical examination could find evidence of lumps or the answers to the questions may reveal that the penis now bends or curves when erect, all of which could suggest Peyronie’s disease. Similarly, if the penis is not sensitive when I touch it, this may indicate possible problems in the peripheral nervous system.

So the quick and easy explanations do exist, ant in most cases there is little to suggest the need to go on to further tests and I can then get into a discussion of the medication options. This is when the patient finally begins to look more comfortable again. We have finally come back to his original questions, except that I’m also telling him about Cialis and Levitra. Viagra may have the name, but Cialis in particular does have some interesting characteristics.

As long as I wear physician’s cap, ED is one of the main problem for a fifty-aged man.

I suppose I’m coming to Diabetes slightly later than I should. Erectile Dysfunction is quite a common early symptom of Type 2 Diabetes, cardiovascular disease or both. Checking through the literature, you’ll find that about 12% of patients who are later confirmed as diabetic first appear in the consulting rooms complaining of ED. The evidence is that treating ED in cardiovascular patients who are also diabetic significantly reduces the mortality rate. So some good can come out of treating ED, usually with Viagra, Cialis or Levitra although, given that these drugs may not always be allowed as treatment, it is better to prevent the onset of the Diabetes if at all possible, say, by reducing excess weight.

A few years back, the Massachusetts Male Aging Study (MMAS) of men aged between forty and seventy years found that 28% of men with diabetes had ED - about three times the incidence in the general population. Averaging out the later surveys over the age range, ED develops between ten and fifteen years earlier in men with diabetes. Above the age of 50 years, between 50-60% of men with diabetes will have difficulties with an erection. Above 70 years, it is almost certain that diabetic men will have some difficulty with erectile function.

The cause of ED in diabetic men usually has both organic and psychological elements. Even if the first cause is not psychological, the onset of organic disfunction almost inevitably produces serious performance anxiety and, if not treated, depression. The combination inevitably affects the libido and this reinforces the disability.

An increasing body of research indicates that half of all ED cases in diabetic men over 50 years are caused by arteriosclerotic disease resulting in a thickening, hardening and loss of elasticity in the arterial walls.

So that leaves us with the question of how we treat both the ED and the diabetes.

• This is the main problem of ED.
• Smoking and other uses of tobacco, (a) constrict and may block your blood vessels; and (b) can also reduce nitric oxide levels, both of which which may limit the flow of blood into your penis.
• Drinking too much alcohol can damage your blood vessels and make ED more likely.
• Performance anxiety and depression can cause ED. To keep your stress levels under control, you should review your current tasks, and set more reasonable goals and deadlines.
• Regular physical exercise can keep your arteries clear and boost your stamina. .
• If you sleep well, you are less likely to suffer from ED.

Thus, there are well-established systems for treating both diabetes and ED. There is no need to suffer in silence. Your sex life can be restored in most cases, albeit that sometimes, you cannot rely on a simple pill to solve the problems.

As your physician, I can also consider Viagra, Cialis or Levitra, but these drugs are not safe if you are taking nitrates to treat heart disease or alpha blockers to treat high blood pressure or prostate enlargement This takes us into new territory for these articles. The vacuum constriction device works no matter what the cause of the ED. If you find the idea of using this piece of equipment off-putting, there is the possibility of intracavernosal injections to the penis to help stimulate an erection. Surgery and penile prostheses implantation are highly successful, but there are greater risks of infection when operating on diabetic men.

Any man who is experiencing problems of erection is likely to feel angry, frustrated and afraid of rejection. In other words, he feels exactly the same way that you do. This underlines the basic truth that, when there are sexual problems in a relationship, both parties are affected. If you do not deal with these problems, they fester and may ultimately destroy your relationship.

How to begin

There is no right way to begin the discussion with your partner. If you have read the rest of the information on this website, you have actually taken a vital first step because you have begun to learn about the problem and its causes. You should have a better understanding of how your partner feels. You now understand not only that impotence is physically and emotionally complicated, but also that it is usually treatable, often using a drug like Cialis.

To talk or not to talk

You now need to bring your partner “up to speed”. How you do this will depend on the nature and strength of your relationship. Whatever you do should appear non-threatening. He already has considerable worry and anxiety about his inability to perform consistently (or at all). If you come over as confrontational, he will retreat even further into his shell. So you need to think about him as a person.

• What reaction you obtain in different cases?
• Is there a preferable way to raise this issue with alarming him?
• What can you offer to do to help him overcome the problem?

Whatever the approach you devise, should help to relieve the stress he is feeling and to build a spirit of co-operation between the two of you.

There is one further reason for opening the discussion. Impotence may be a symptom of more serious medical problems. If he only focuses on what he perceives to be his current sexual inadequacy, he may completely fail to take early steps to address the more serious underlying cause.

So many treatments for cancer and other serious conditions are effective because they are an early intervention. So many men find that more drastic measures are required because they delayed seeking diagnosis until it was almost or actually too late.

Support

Talking about the risks of not seeing a doctor may separate the emotional overtones from the physical issues. Hopefully, you still love him even though he is having sexual problems and you do not want to lose him to a disease. Even if the worst should be confirmed, the quality of your relationship during the difficult days of treatment will be far better. Ignoring the problem will only lead to you feeling guilty because you failed to take action and resentment from him that his problems were undiagnosed. Supporting each other openly and honestly is always the best foundation for a relationship.

Talking positively

That means talking positively about the different options that may have to be explored. Rather than focusing on all the things that may be wrong, concentrate on taking early action to restore good health, which if everything else is all right, may just be the simple decision to buy Cialis. By giving him encouragement, you stand a better chance of being able to work together to solve the problems as they come along. If all you do is to hold up a mirror to his negative feelings, you will both lose out.

This is an emotional minefield for both of you so approach it with care and a commitment to be patient even if his first response if very defensive and dismissive. By whatever means it takes, you need to manoeuvre him towards your family doctor and access to diagnostic services and treatment. This may be the usual case that can be treated with Cialis.

Just to repeat the general message running through these articles: if you are aged between forty and seventy years, you have a fifty/fifty chance of experiencing some degree of erectile dysfunction (ED). Some 10% of you will have a complete failure of erections - more often, this affects older men. Alongside this news is the equally significant evidence of depressive illnesses. Researchers estimate that about a quarter of men will suffer some degree of anxiety or depression at some point during their lives. When this happens, the symptoms may not appear too serious and you will probably not seek treatment. But you are twice as likely to suffer decreased libido and ED than someone not depressed, leading you to reduce or avoid sexual contract for a while. Many of you will leave the depression, if such it is, untreated and buy Viagra, Cialis or Levitra online. This is an entirely understandable reaction. But it is always better to get a professional opinion before self-medicating.

The ED may have been caused by the anxiety or depression itself, or there may have been an independent cause. But what began as a small problem can be aggravated as a side effect of the antidepressant medications you are prescribed. It is somewhat ironic that one of the factors depressing you may be your declining sexual performance, but the treatment for that depression can complete deprive you of your desire to have sex. As if it could get worse, the selective serotonin reuptake inhibitors (SSRIs) antidepressants not only affect sexual performance, but may also disturb sleep patterns and cause weight gain. Not surprisingly, this prompts many patients to stop taking the medication. Thus, although treatment using one or more antidepressants is usually successful in 90% of all cases, less than one third of patients complete the course of medication, and the incidence of relapse is high.

This creates real problems for the physicians trying to balance treatments for both the depressive illnesses and the ED. Because there may be adverse reactions between the different medications, you should not take Viagra, Cialis or Levitra on your own initiative if you are already taking any other medications. Your physician has a number of options:

• The first and most obvious possibility is to change to another antidepressant with fewer side effects. In a number of clinical double-blind studies, Serzone (Nefazodone) and Wellbutrin (bupropion) were shown to cause fewer problems on sexual function than SSRIs. If you respond well to either of these, you may find that you feel less depressed and your sexual performance improves. Wellbutrin is also less likely to cause weight gain which may aid your choice of medication.
• It may be possible to lower the dose of the current antidepressant so that you still get some relief from the depression and your sexual performance improves. For example, in one clinical trial of Prozac (fluoxetine hydrochloride) some people responded as well to a dosage of 5-10mg as the more usual 20mg.
• With some drugs, e.g. Zoloft (sertraline) and Anafranil (clomipramine), it may be possible to change the medication regime. If you have a fairly consistent time when you engage in sexual activity, this should be timed when the drug’s level in your body would be at its lowest, i.e. you would take your daily dose after sexual intercourse.
• There are some case reports and small clinical studies that have found some additional medications can modify the effect of the antidepressant. For example, in an off-label test, Amantadine has been shown to relieve the SSRI-induced inability to reach an orgasm in some but not all people.
• Then your physician may authorise you to take one of the specific ED medications such as Viagra, Cialis or Levitra. In a 2003 randomised study of ninety men suffering from antidepressant-induced ED, 54% of those treated with Viagra (sildenafil citrate) as against the placebo showed improvement. Note that only slightly over half the sample showed improvement. There are limits to the effectiveness of Viagra, Cialis and Levitra.
• If you are taking Zoloft (sertraline) and Paxil (paroxetine), it may be possible to change your schedule to include a two-day break each week. During this time, your sexual function should return without losing the effectiveness of the antidepressant.

All this has assumed that the ED was in fact caused by the depression or the medication to treat that depression. If there are alternative explanations for the ED, those should also be thoroughly investigated. It would compound the irony if the true cause of your ED should prove not to be the antidepressants but a condition requiring a different treatment.