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Diagnosis of erectile dysfunction

The proper goal-oriented evaluation of a man proactive and complaining of erectile dysfunction requires a sympathetically elicited history, a focused physical examination and various carefully selected special investigations.
HISTORY

To obtain a clear history, it is important that the patient himself understands the distinction between loss of libido, erectile dysfunction and ejaculatory disturbance. This often may require some preliminary explanation. The onset, consistency and severity of the complaint need to be established. Recently, the development of self-administered symptom scores by O’Leary and colleagues and Rosen and colleagues have facilitated quantitative history-taking for erectile online pharmacy viagra.






Because sexual function is intimately related to the appropriate response of the sexual partner, tactful enquiries need to be made concerning previous and on-going relationships, and the attitude of the partner towards the problem.
Underlying relationship problems are a common cause of erectile dysfunction, and this possibility needs to be tactfully explored in all cases. Although, by tradition, the question concerning the presence or absence of early morning erections has been proposed as a means to distinguish between psychogenic and organic erectile dysfunction, the value of this enquiry has recently been questioned.
Many normal individuals do not regularly wake up with early morning erections, although the presence of a positive history of a firm erection on waking would make organic erectile dysfunction less likely. Although these symptom scores are admirable in their own way, they in fact tend to focus on the functional component of erectile dysfunction rather than its impact on the quality of life of the sufferer. This issue has recently been addressed by Wagner and colleagues, who have attempted to quantify the impact of erectile dysfunction on the sufferer (Table III).
Table III Quality of life and erectile dysfunction
1. I feel frustrated because of my erection problem

2. My erection problem makes me feel depressed

3. I feel like less of a man because of my erection problem

4. I have lost confidence in my sexual ability

5. I worry that I won’t be able to get or keep an erection

6. My erection problem is always on my mind

7. I feel that I have lost control over my erections

8. I blame myself for my erection problem

9. I feel angry because of my erection problem

10. I worry about the future of my sex life

11. I have lost pleasure in sex because of my erection problem

12. I am embarrassed about my problem

13. I worry about being humiliated because of my problem

14. I try to avoid having sex

15. I feel different from other men because of my erection problem

16. I get less enjoyment out of life because of my erection problem

17. I feel guilty about my erection problem

18. I am afraid to ‘make the first move’ towards sex

19. I worry that my partner blames herself for my erection problem

20. I worry about letting her down because of my erection problem

21. I worry that I’m not satisfying her because of my erection problem

22. I worry that we are growing apart because of my erection problem

23. I worry that she is looking for someone else because of my erection problem

24. I feel that she blames me for my erection problem

25. I worry that she thinks I don’t want her because of my erection problem

26. I have trouble talking to her about my erection problem

27. My erection problem interferes with my daily activities

Reproduced with permission from Wagner et al., 1996
A careful drug history is particularly important as a considerable number of pharmacological agents are associated with the development of erectile dysfunction. Most potent in this respect are the agents used in the treatment of prostate cancer, such as LHRH analogues, which cause loss of libido and erectile dysfunction. Many other agents have less profound, but none the less significant, effects. Some of the more commonly encountered compounds implicated are listed in Table 6. 


Antihypertensive agents, such as β-blockers and thiazide diuretics, are the most commonly implicated agents. Antidepressants, especially monoamine oxidase inhibitors and tricyclic compounds, are also common causes of erectile dysfunction. Serotonin reuptake inhibitors may not only cause erectile dysfunction, but also retard ejaculation.
The question of smoking and alcohol intake needs to be addressed. William Shakespeare himself noted that alcohol increases the desire, but diminishes sexual performance. Smoking should be strongly discouraged and, in some cases, the use of skin patches containing nicotine suggested.
Specific enquiry should be made concerning concomitant conditions, particularly those affecting the vascular or neurological systems such as angina, hypertension, diabetes mellitus, thyroid disease, renal failure or peripheral vascular disease. The presence of previous pelvic surgery should be ascertained and accurately documented.








Table 6 

Major tranquilizers

phenothiazines, e.g. fluphenazine

chlorpromazine, promazine, mesoridazine

butyrophenones, e.g. haloperidol

thioxanthenes, e.g. thiothixene
Antidepressants

tricyclics, e.g. nortriptyline, amitriptyline,

calcium antagonists

desipramine, doxepin
monoamine oxidase (MAO) inhibitors, e.g.

isocarboxazide, phenelzine, tranylcypromine,

pargylene, procarbazine

lithium
Anxiolytics

benzodiazepines, e.g. chlordiazepoxide,

diazepam, chlorazepate
Anticholinergics

atropine

propantheline

benztropine

dimenhydrinate

diphenhydramine

estrogens
Cardiac

digoxin

lipid-lowering agents

Antikypertensives

diuretics, e.g. thiazides, spironolactone

vasodilators, e.g. hydralazine

central sympatholytics, e.g. methyldopa,

clonidine, reserpine

ganglion blockers, e.g. guanethidine, bethanidine

β-blockers, e.g. propranolol, metoprolol, atenolol
ACE inhibitors

Recreational drugs

alcohol

marijuana

amphetamines

barbiturates

nicotine

opiates
Antiandrogenics

cyproterone acetate

flutamide

bicalutamide

LHRH analogues
5α-reductase inhibitors

Miscellaneous

cimetidine

clofibrate

metoclopramide

baclofen

indomethacin

and many others

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This commercial reminds me of when my friends and I got together and jammed about our anti-diarrheal medication.

Seriously, what the hell is going on here?

Some buddies convene at a rustic bar in the middle of nowhere -- all hopped-up on viagra -- and break into song, while waiting for their erectile dysfunction medication to kick in.

After performing a rousing (arousing?) little ditty about how badly they want to bump uglies with their wives, they start to chub up; so they do some manly back-slapping, and high-fiving, before tearing out of the parking lot to go rape their women.



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Gaming tops tablet activity, says Google study















A Google AdMob study of tablet usage has found that playing games is more popular than any other activity.
A new survey by Google AdMob has found that tablet owners primarily use their touchscreen devices for playing games, the Guardian reports. Other popular uses include emailing, social networking and consuming media like videos, music and e-books.
Out of the 1,430 tablet owners interviewed, 84 percent used the device for playing games. “Searching for information” came in as the second most-popular activity at 78 percent, followed by emailing (74 percent), reading the news (61 percent) and using social networks (56 percent). Only 51 percent use their order cialis for watching videos or reading music, the study found. And Reading e-books was only popular among 46 percent of those interviewed.
The study also shows that cialis, while not yet more popular than PCs, are certainly making headway against their bulky competition with 28 percent identifying their tablet as their primary computer, and 43 percent admitting that they spend more time using their tablet than their PC.
Despite obvious benefit of being able to easily take a tablet anywhere, most people (82 percent) say they mostly use their device at home. A mere 11 percent said they use their tablet as a mobile device. A total of 68 percent of owners use their tablet at least one hour per day, with 34 percent admitting that they use the device for two or more hours daily.
While some of the information wasn’t much of a surprise (59 percent use their tablets more than they read books), the study did find that 1 in 3 tablet owners use their tablet more than they watch TV. (Which would probably explain why Time Warner and Cable vision are so anxious to offer their programming on the iPad.)
Google never explicitly mentions what type of tablet those they interviewed own, but considering that the study was conducted last month, it’s safe to assume that a large percentage of those polled owned an Apple iPad.