Early in the development of sildenafil, Pfizer recognized the need for better efficacy instruments for erectile and sexual dysfunction. After developing an initial version of the questionnaire that was successfully used in early Phase II trials, the company elicited the help of an international panel of experts to further refine and validate the questionnaire. Accordingly, the International Index of Erectile Function (IIEF) was developed and validated in 1996-1997 as an adjunct to the sildenafil clinical trial program.

The International Index of Erectile Function (IIEF) is a widely used, multi-dimensional self-report instrument for the evaluation of male sexual function. It is has been recommended as a primary endpoint for clinical trials of erectile dysfunction (ED) and for diagnostic evaluation of ED severity. The IIEF was developed in conjunction with the clinical trial program for sildenafil, and has since been adopted as the ‘gold standard’ measure for efficacy assessment in clinical trials of ED. It has been linguistically validated in 32 languages and used as a primary endpoint in more than 50 clinical trials.

It has demonstrated consistent and robust treatment responsiveness in studies in USA, Europe and Asia.

Rosen et al developed a shortened version of the 15-item International Index of Erectile Function (IIEF) that contained 5 items the IIEF-5. The items focus on erectile function and intercourse satisfaction. This was shown to be an excellent diagnostic test for erectile dysfunction.

The 5-Item Version of the International Index of Erectile Function (IIEF-5)

Calculate your ED score here and go here to get your score interpretation.

Interpretation:

• minimum score: 1

• maximum score: 25

• The higher the score the better the erectile function.

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This led to a heated debate since many colleagues argued that no one could give a medicine to treat erectile dysfunction for a "recreational or frivolous" purpose as some called it. The years have gone through, Viagra became one of the top selling drugs in the world, and now we see many men taking it to improve their performance, the amount of pleasure, even though they are not suffering from any sexual dysfunction.

Today this is still a heated debate among Viagra users who use it to increase the hedonism and eroticism in their loving relationships.

Sometimes sex is seen as work, as an everyday life obligation,  rather than seen it as a relation in which two people, enjoy, have fun,  take the greatest pleasure and possible bond. There are men who take it as a test, an exam and only look at how rigid their penis gets, how long the erection lasted and how many orgasms the couple had.

The pressure to perform and the goals we set for ourselves lead to high levels of anxiety, fear of not being able to achieve these objectives, such as anxiety tends to block the sexual response, and we enter a vicious circle.

On many occasions men give much more importance to work than to pleasure. It is common to see how men can get to work even the weekend but  "who do not have time to read, listen to music, exercise and even less time for eroticism." We call these people addicted to work: "workaholics". These men faced with sexual difficulties can always have the excuse of stress, work problems, lack of time, etc…

Men always wonder what is the right quantity of sexual relations they should have that "must have", because of competition and social pressure. There is no right or wrong answer or special goals to achieve or any need to be part of any kind of statistics. It should be what one wants, when one feels it is the right moment and that is enjoyable for both.

The refractory period is the time that it will take to get a new erection after an orgasm (the needed time is not the same for everyone). This differs from women who may have multiple orgasms. Almost all the young men have one or two orgasms per encounter, often being satisfied with the first, and while this is true there are some situations where some men can have more, this is not criteria to measure normality or abnormality. 

Remember that sexual relations are not merely just orgasms but also the time before (games, caresses, kisses, variations in the position), either with or without penetration. We often see men who say "yes, a little game is okay, but sex without penetration what for?" Perhaps it would be great to try new things, and this is an advise to men with or without sexual problems: erotic games without the imperative, unpostponable penetration.

Some physicians think that if someone needs to take medication to improve their erections is "because something was missing them," but the truth is that many want to take Viagra (sildenafil) only to achieve greater enjoyment and duration in their love encounters, to achieve more rigid and faster erections, in order to have more erections in their sexual encounters, to bring greater satisfaction to their partners. 

But if someone wants to take medicine to improve their quality of life, who could question it? If this person has been, at least controlled once by a doctor, well informed regarding the available dosages and its proper use, Viagra (sildenafil) is an effective solution to enjoy love and sex, to which now Cialis (tadalafil) and Levitra (vardenafil) have been added now.

Viagra (sildenafil citrate) is a drug that changed the history of Pharmacology, Sexology and Medicine. Knowing the intimate mechanism of an erection and the specific action of Viagra (sildenafil) on men (who should not neglect other essential factors of eroticism) will enjoy a pleasurable and satisfying sex life.

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In men with ED, testing to see whether sleep erections are occurring can help to determine the cause of ED.

The presence of normal sleep erections usually implies that the ED is due to a psychological cause (called psychogenic ED). Patients with a psychological cause for their ED will generally have normal sleep erection cycles.

Men who have a physical cause (organic) for their ED will usually have some abnormality of the frequency, intensity or duration of their sleep erections.

If sleep erections do not occur, or are poor in number and quality, then it is appropriate to look for another cause of the erection problems, such as a problem with the nerves or blood vessels supplying the penis.

Erections on awakening and nocturnal erections are signals establishing that anatomical and physiological regulating mechanisms are generally intact.

Dr. Frank Sommer (Cologne, Germany) says that it seems that taking Viagra every night improves erections. In addition to inhibiting the enzyme phosphodiesterase-5-responsible for the loss of erection (Viagra, by inhibiting the enzyme inhibitory, helps achieve and maintain the rigidity of erections) Viagra also has beneficial effects on arterial endothelial cells (cells lining the inside of the arteries). 

We know that erections are due to the opening of small arteries and to the relaxation of the cavernous smooth muscle thanks to the nitric oxide, vasodilator gas, which is produced in certain neurons and in arterial endothelial cells. 

These studies suggest that, an intake of 50 to 100mg of Viagra (sildenafil), at bedtime (nightly), could be an effective treatment to "cure or prevent impotence" or, simply, improve erectile physiological response for those patients suffering from ED caused by psychological causes. 

Past and recent studies related to men without erectile dysfunction, also suggests that men could improve their erections by taking Viagra every night. 

Nevertheless more studies are needed to confirm these results that have been presented by Dr. F. Sommer at American Urological Association’s 99th Annual Meeting, San Francisco, May 8-13, 2004.

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At first sales were not what was expected and patients accepted it with some reluctance and fear. Ignorance of many general practitioners and specialists did not help its introduction.

Viagra (sildenafil) was a medicine, both in stages of research and in clinical use, but it demonstrated a high efficiency (the response in patients is amazing) with few side effects. 

It needs to be noted that this is a medicine developed to treat a specific medical and psychological condition: erectile dysfunction. Unfortunately now there are people who use it to improve their sexual performance. Today it has also being studied for its use in women and used for pulmonary insufficiency.

Back then we started to hear things like: "it affects the heart and the sight", " you could become blind if you use it … or even die", "the elderly are going to take it and increase health risks", "he will cheat on his wife or even leave her for another woman " so that what wished first became for both partners the most feared. Even today, in 2008, there are patients asking whether it "will do harm to them because they have hypertension or heart disease."

The false beliefs about the problems induced by the Viagra (sildenafil) were introduced then, in the social imagination. 

But nobody though that, between erectile dysfunction and its resolution by taking an oral medication some essential steps needed to be taken. 

Men suddenly needed to be encouraged to seek for a sexual consultation, go to it, go through the inevitable and unavoidable diagnostic stage and then having to go through another feared scene, go to the pharmacy and overcome the shame of buying the prescription drug itself.

It is very common to hear patients tell us: "I am not going to buy Viagra (sildenafil) without going through a medical exam to find out the causes of my erectile dysfunction" which clearly shows that many men want to "make things right."

Nevertheless men needed time to adapt to this new reality and their consumer behavior had to change what was helped by its effectiveness. Let us not forget that at some point we started hearing things like "magic pill" or "the pill of happiness” which helped a lot men to change their beliefs about Viagra (sildenafil). 

Some pharmacists, were used to sell some prescription drugs without having patients presenting the prescription itself but very fast they realized that dispensing Viagra (sildenafil) without seeing the prescription was not a good idea. Men had to change their mindset and assume their impotence. In addition it is not ethical to dispense a prescription drug without a prescription.

Even the doctor had several levels of conflict: not knowing how or when to inquire about the sex lives of their patients, not been seeing as intrusive, inappropriate or be suspected of seducing its patient. In addition we know that patients do not always share their sexual difficulties. 

Sometimes they have problems with the issue (prejudice, ignorance and lack of training, values and beliefs, their own modesty) and do not dare to ask or even talk about it. 

Back then doctors did not have tools as effective, safe and easy to use to treat the erectile dysfunction such as Viagra (sildenafil) and now Cialis (tadalafil) and Levitra (Vardenafil). 

Doctors feared that Viagra (sildenafil), as well as the pathology itself, not yet well known, would bring severe or fatal side effects. They decided to wait for a more widespread use and let the specialists to treat their patients with this medication. 

This was probably the safer way to proceed to help Viagra (sildenafil) to become the most used treatment of erectile dysfunction in men living with frustration, embarrassment and anxiety. Men did not need to suffer anymore in silence and could expose their sexual life to their doctors. 

It has to be noted that Viagra (sildenafil) is not an aphrodisiac. Viagra (sildenafil) does not act in the brain or the heart, but only in the corpora cavernosa of the penis in the presence of sexual desire and stimulation. 

Ten years after its emergence it can be said that many of the ghosts, prejudices and false beliefs disappeared and that both doctors and patients know much more about Viagra (sildenafil).

Viagra (sildenafil citrate) has become one of the most commonly used prescription drugs today. What encouraged other pharmaceutical companies like Lilly to developed Cialis (tadalafil) and Bayer which introduced Levitra (vardenafil). Cialis (tadalafil) has a longest duration (36hs) and Levitra (vardenafil) has a more specific action. 

Currently in Argentina, sales of all oral drugs to treat impotence exceeded 29,000,000 tablets in 2007. Viagra sold more than 10 tablets per second in the countries where it is registered (not counting Cialis or Levitra sales).

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• That sildenafil (Viagra) acts within 25 minutes once ingested?
• That it is best taken 1 hour prior to sexual intercourse and preferably not taken with food?
• That to act there must be a preliminary stage of erotic stimulation and excitement?
• That it remains active until 5 hours after ingestion?
• That it can be taken up to once per day but never more than once a day and always under medical prescription?
• That it is effective for patients with impotence due to psychological and physical factors?
• That since its launch in 1998 only in the U.S. more than 100 million doses have been administered?
• That can it can be used in people who are medicated with antihypertensive, beta blockers, antidepressants or sedatives?
• That exhaustive research is being conducted to know the possible use in women with problems with excitation and suffering among others problems of lubrication and anorgasmia?
• That it resulted in a study presented by two Argentinean researchers (Dr. Sapetti A. Dr. Comesaña E. Diaz) presented in the American Congress of Psychiatry (Chicago, 2000) demonstrating that sildenafil is most effective when there are no risk factors (smoking, hypertension, diabetes, high cholesterol, sedentary life, obesity) than when there are, indicating that the reduction of these adverse factors is essential both to increase the response of Viagra as to improve the response upright?
• That it increases their effectiveness and shortens treatment when combined with Sex therapies?

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Erectile Dysfunction is a very common problem in men with diabetes and associated with diabetic neuropathy and peripheral vascular disease. 50% of men with diabetes develop this disease within 10 years of diagnosis. The prevalence is between 50% and 70% in men and diabetes increases with age, becoming 95% in diabetic men aged 70. 

According to the MMAS study, the prevalence of impotence was 3 times higher for patients suffering from diabetes than patients not having it.

According to an epidemiological study with 15,770 diabetic patients, that have been diagnosed recently, 22% of patients already had Erectile Dysfunction. The prevalence for type I diabetes increased the risk from 6% for patients between 30 and 40 years old to 55% for patients between 60 to 70 years old. Likewise, for type 2 diabetes the risk increased from 4% to 48% for the same age groups.

In diabetics, erectile dysfunction can occur because of neuropathy (ex.: Polyneuritis), decreased blood flow (today we know that there are alterations in the endothelium, inner layer of blood vessels) and psychological factors. 

In addition, when implanting a prosthesis to treat the Erectile Dysfunction, it has been found a loss of smooth muscle in the penis, more specifically in the cavernous tissue, in patients with diabetes. 

We also know that levels of nitric oxide synthase, (enzyme responsible for transforming the L-arginine in nitric oxide, a gas vasodilator involved in one of the steps of both the erection of the penis and the clitoris, in the cavernous body) are decreased in diabetics, smokers and people with testosterone deficiency.

Diabetes is associated with loss of quality of life. According to a study published in the journal Diabetes Care, erectile dysfunction in diabetics is associated with an increase in stress caused by diabetes, worse metabolic control and very significant increase in depressive symptoms. 

According to this study, 63% of patients reported that their doctors never diagnosed potential sexual problems, while the incidence increases a lot with the length and severity of diabetes.

The evaluation of patients with impotence is necessary to conduct a thorough medical history, considering surgery, endocrine disease, neurological, psychiatric or sexually transmitted infections (STIs). 

We must look for evidence of cardiovascular disease and study the genitourinary system, and in particular seek signs of gynecomastia (enlarged breasts), pathology of the penis (like Peyronie) or testicles. 

As for laboratory tests, an exhaustive exam has to be done to test for blood, testosterone, prolactin, TSH and prostate specific antigen (PSA). Other tests include penile Doppler, RigiScan, cavernosography and pelvic arteriography. 

Several substances can induce erectile dysfunction: antihypertensives, antiarrhythmics, beta-blockers, antidepressants, antiandrogens (finasteride, now also used in alopecia, cyproterone), H2 blockers for ulcers (cimetidine, ranitidine), alcohol, illegal drugs and tobacco.

Treatments

• Specific treatment of diabetes (oral medications, insulin, diet)
• Treatment of other mayor risk factors: depression, hypertension, high cholesterol, smoking, sedentary life, alcoholism
• Sildenafil (Viagra) and other inhibitors of phosphodiesterase like Cialis (tadalafil) and Levitra (vardenafil)
• Apomorphine
• Intracavernosal injection therapies (papaverine, phentolamine, PGE1)
• B-complex vitamins (B1, B6, B12, folic)
• L-arginine, Damiano, yohimbine (a laboratory is in Phase III of its research, and is testing a combination of yohimbine and L-Arginine to stimulate the production of nitric oxide synthase with very good results)
• Testosterone and DUS (when they are low)
• Increase physical activity
• Sexual therapy

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Technorati Tags: cardiovascular disease, Cialis, diabetes, diabetic, Erectile Dysfunction, impotence, Levitra, sildenafil, tadalafil, vardenafil, vascular disease, viagra

The best known are high levels of cholesterol, diabetes, smoking, hypertension and injuries in the pelvic region. Which make the arteries become rigid and decline in size, generating a hardening of the arteries. Also on ageing persons, and therefore the ageing of tissues helps arteries lose elasticity. 

Less often the main failure of the erection is the inability to store blood into the penis, as a result of a chronic failure filling, which does not allow the tissue of the penis to be properly oxygenated and eventually deteriorating the tissues of penis.

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Technorati Tags: Erectile Dysfunction, erection, impotence, vascular disease

Most men may suffer occasionally isolated difficulties in achieving an erection, but around one and a half million men in Spain between 25 and 70 years have a permanent or chronic disorder of the erection. It is, therefore, a very common disease, which affects more than 100 million men worldwide and more than a million and a half in Spain, although it is estimated that only 10 of the affected men ever consult a physician about this condition.

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Impotence is the persistent inability to achieve or maintain an erection sufficient to permit a satisfying sexual relationship. Speaking of Impotence does not refer to the lack of sexual desire, or the lack of orgasm or pleasure in the relationship. Nor are synonymous of Erectile Dysfunction Early or delayed Ejaculation, or bends of the penis when it is in erection. This involves only a disorder unique to the rigidity of the penis. Impotence should not be under any circumstances related to excessive sexual activity or masturbation, and there is no link with infertility.

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Erectile dysfunction ED is a problem that exists since the beginning of mankind. There is evidence of empirical treatments which have been used since immemorial times, but only in the past 40 years we have developed treatments that have changed the management of  this disease effectively and to which urologists have to adapt.

Because of scientific advances both in knowledge of the pathophysiology, and the new modalities of therapy, this problem has shown its true magnitude by the increase in the number of patients who go to the urologist solve this disease.

Traditionally it has been noticed that much of what we consider a truth in a given moment, it is not anymore in a very short short period of time, this is why qualified professionals should reevaluate their skills and not depend only on their experience. 

Many studies have shown that ED is a major public health problem affecting men’s quality of life worldwide and should be taken into account in health policies, because this disease has a great impact and has negative consequences as well for the couple, the family as for the society itself.

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