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The mean age of the study group was 59.6 11.2 y.13 54 24 Mike Tyson Sais He Was Taking These Pills For Ed had arteriogenic ED, 16 54 30 had mixed vasculogenic ED, 9 54 17 had cavernosal veno occlusive dysfunction, 11 54 20 had post radical retropubic prostatectomy ED 88 Pill and 5 54 9 had psychogenic ED.13 54 24.1 responded to sildenafil at a median maximal dose of 200 Mike Tyson Sais He Was Taking These Pills For Ed mg, 4 13 required 150 mg and 9 13 required 200 mg.41 Aloe Vara Male Enhancement 54 76 failed to Non Pharmacological Erectile Dysfunction respond to sildenafil.Mean IIEF question 3 and 4 scores were 1.5 and 1.4 at baseline, 2.2 and Aloe Vara Male Enhancement 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, respectively.After 4 weeks, treatment was regarded as having improved their erections by 37 , 46.3 and 68 of patients with sildenafil 100 mg, 150 mg and 200 mg, respectively.34 54 63 reported Aloe Vara Male Enhancement adverse effects with maximal dose sildenafil comprising headache 19 , facial flushing 32 Non Pharmacological Erectile Dysfunction , dyspepsia 14 , nasal congestion 11 , dizziness 5 and visual disturbances 5.4 Aloe Vara Male Enhancement 13 31 responders refused to continue treatment due to adverse effects.In conclusion, sildenafil at doses of up to 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 Non Pharmacological Erectile Dysfunction and a 31 treatment discontinuation rate.IntroductionErectile dysfunction ED is the inability to achieve and maintain an erection of sufficient rigidity for satisfactory sexual intercourse.1 Community based epidemiological studies suggest that sexual dysfunction, particularly ED, is a common disorder Aloe Vara Male Enhancement in patients and is associated with reduced Non Pharmacological Erectile Dysfunction quality of life.2,3,4,5Sildenafil citrate ViagraTM, 88 Pill Pfizer, UK , a potent, competitive phosphodiesterase Non Pharmacological Erectile Dysfunction type 5 iso enzyme PDE 5 inhibitor, is the first oral medication 88 Pill 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 Non Pharmacological Erectile Dysfunction range of patients, including those with hypertension, diabetes, spinal cord injury, other Mike Tyson Sais He Was Taking These Pills For Ed concomitant medical conditions, and in those patients taking a wide Mike Tyson Sais He Was Taking These Pills For Ed variety of concomitant medications.Its efficacy appears related to the extent and severity of 88 Pill 88 Pill ED, with significantly reduced efficacy demonstrated in patients with severe vasculogenic ED, Non Pharmacological Erectile Dysfunction diabetic ED and post radical prostatectomy ED.6,8,9,11Jarow et Mike Tyson Sais He Was Taking These Pills For Ed al reported a sildenafil response rate of 65 , significant improvement in quality of life and a 35 incidence of adverse effects.9 Virag reported similar results with a 60 response rate and a 26.75 incidence of adverse effects.10 McMahon et al reported a similar response rate of 88 Pill 67.5 but a Big Mans Penis Pump higher incidence of adverse effects of 53.6.11 These authors report a similar efficacy rate but a higher 88 Pill 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 Aloe Vara Male Enhancement group of patients with chronic ED, unresponsive Non Pharmacological Erectile Dysfunction to sildenafil 100 mg, who were treated in a home setting with doses of sildenafil in excess of the recommended maximum dose 150 mg Big Mans Penis Pump and 200 mg.Treatment efficacy, safety and tolerance was evaluated using serial physician interviews and 88 Pill the Big Mans Penis Pump patient self administered IIEF questionnaire.Materials and methodsFifty four fully evaluated patients with chronic ED who had previously failed to respond to a home trial of sildenafil 100 mg with erections suitable 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 colour duplex Doppler ultrasonography CDU before and after intracavernous vasoactive drug challenge 20 mg alprostadil.Rigiscan nocturnal penile tumescence 88 Pill testing, dynamic infusion cavernosometry and cavernosography DICC and 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 Non Pharmacological Erectile Dysfunction 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 hour before planned sexual activity until either maximal response or intolerable adverse effects occurred.The primary efficacy end point was the response to the questions 3 and 4 of the erectile function domain of the International Index of Erectile Function IIEF after 88 Pill a trial Non Pharmacological Erectile Dysfunction of each dose Aloe Vara Male Enhancement of sildenafil.The secondary efficacy end point was the response to the global assessment Aloe Vara Male Enhancement 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 patients with chronic ED and a mean age of 59.6 11.2 y were enrolled in the study group.The etiology of ED was psychogenic in 5 patients 9 , arteriogenic in Non Pharmacological Erectile Dysfunction 13 patients Big Mans Penis Pump 24 , cavernosal veno occlusive dysfunction CVOD in 9 patients 17 , MVED in 16 patients 30 and post radical retropubic prostatectomy ED in 11 patients 20.The mean duration of ED was 16..6 months range 4 C32.Twenty four patients had diabetes mellitus, 27 had hypertension, 26 had dyslipidaemia and 20 Aloe Vara Male Enhancement Aloe Vara Male Enhancement 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 Aloe Vara Male Enhancement of EDFull size tableErections of sufficient rigidity and duration for satisfactory sexual intercourse occurred in 13 patients 24.1 at a median maximal dose of 200 mg.Four patients 7.4 required 150 mg and 88 Pill comprised 2 Aloe Vara Male Enhancement 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 Mike Tyson Sais He Was Taking These Pills For Ed occlusive dysfunction and 2 patients with post 88 Pill radical prostatectomy ED.Nine of the 13 patients 69 Aloe Vara Male Enhancement who responded chose to continue therapy with sildenafil.Overall, high dose sildenafil was effective in 4 out of 5 patients 80 with psychogenic ED and 9 out of 49 patients 18.4 with organic ED Table 2.Of the 11 Mike Tyson Sais He Was Taking These Pills For Ed patients with post radical Big Mans Penis Pump prostatectomy ED, 2 patients had Mike Tyson Sais He Was Taking These Pills For Ed undergone Mike Tyson Sais He Was Taking These Pills For Ed 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 man Mike Tyson Sais He Was Taking These Pills For Ed treated with a unilateral NSRRP.Table 2 Response rate for sildenafil 150 mg, sildenafil 200 mg and sildenafil overallFull size table.Mean responses to Aloe Vara Male Enhancement questions 3 Aloe Vara Male Enhancement and 4 of Aloe Vara Male Enhancement the IIEF erectile function domain, the primary Big Mans Penis Pump end point, were 1.5 and 1.4 at baseline, 2.2 and 1.9 Aloe Vara Male Enhancement 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 and Big Mans Penis Pump at all doses P 0.001.The overall mean score for Q3 and Q4 for 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 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 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 Non Pharmacological Erectile Dysfunction as a single tablet, 1 hour before sexual activity.Only 1 dose should be taken in any 24 hour period.The onset of the effect may be delayed if taken with food.Viagra is supplied in boxes of 4 tablets..THE PRICES LISTED ARE FOR MEDICATION DISPENSED ON A 88 Pill PRIVATE PRESCRIPTION.SOME PATIENTS,HOWEVER, MAY BE ELIGIBLE TO OBTAIN Big Mans Penis Pump THIS MEDICATION ON AN NHS PRESCRIPTION.YOUR DOCTOR Non Pharmacological Erectile Dysfunction WILL BE ABLE TO Non Pharmacological Erectile Dysfunction ADVISE YOU WHICH TYPE OF PRESCRIPTION YOU Non Pharmacological Erectile Dysfunction 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 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 Non Pharmacological Erectile Dysfunction in the corpus cavernosum Big Mans Penis Pump and allowing inflow of blood.Sildenafil has no direct relaxant effect on isolated human corpus cavernosum, but enhances the effect of NO by Aloe Vara Male Enhancement inhibiting PDE5, which is responsible Non Pharmacological Erectile Dysfunction for Mike Tyson Sais He Was Taking These Pills For Ed the biodegradation of cGMP in the corpus cavernosum.When sexual stimulation causes local release of NO, inhibition of PDE5 by sildenafil produces increased levels of cGMP in the corpus cavernosum, 88 Pill resulting in smooth muscle relaxation and increased inflow of blood to the corpus cavernosum.Sildenafil, at recommended doses, has no effect in the absence of sexual stimulation.Studies 88 Pill in vitro have shown that sildenafil has between 10 and 10,000 fold Non Pharmacological Erectile Dysfunction greater selectivity for PDE5 than for other phosphodiesterase isoforms Non Pharmacological Erectile Dysfunction namely PDEs 1, 2, 3, 4, and 6 and greater than 700 fold effect on PDE7 PDE11.In particular, sildenafil has greater than 4,000 fold selectivity for PDE5 over PDE3, the cAMP Mike Tyson Sais He Was Taking These Pills For Ed specific phosphodiesterase isoform involved 88 Pill in the control of cardiac contractility.Sildenafil is about 10 fold as potent for PDE5 compared to PDE6, an isoenzyme found in the retina this lower selectivity is thought to be the basis for colour vision abnormalities observed with higher doses or plasma levels of sildenafil see WARNINGS AND PRECAUTIONS, DETAILED PHARMACOLOGY.PDE5 is also found in lower concentrations in platelets, vascular and visceral smooth muscles, and skeletal muscle.The sildenafil induced inhibition of PDE5 in these Big Mans Penis Pump tissues appears to be the basis for the enhanced platelet antiaggregatory activity of nitric oxide observed in vitro, 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 Aloe Vara Male Enhancement of 8.3 Aloe Vara Male Enhancement 5.3 88 Pill mm Hg.The decrease in blood pressure was Big Mans Penis Pump most notable approximately 1 2 hours after dosing.The effects are not related to dose or plasma levels.Larger Mike Tyson Sais He Was Taking These Pills For Ed effects were recorded among patients receiving concomitant nitrates see CONTRAINDICATIONS.Effects of VIAGRA on Cardiac Parameters Single oral doses of VIAGRA up to 100 mg in healthy volunteers produced no clinically relevant effects on ECG.Effects of VIAGRA on Erectile Response VIAGRA Mike Tyson Sais He Was Taking These Pills For Ed was studied in clinical trials of various designs.In fixed dose clinical trials, Big Mans Penis Pump 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, 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 Mike Tyson Sais He Was Taking These Pills For Ed improved significantly on VIAGRA compared to placebo.These studies included patients 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 Big Mans Penis Pump 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 32 minutes for subjects receiving placebo, 25 mg and 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 Mike Tyson Sais He Was Taking These Pills For Ed minutes Big Mans Penis Pump 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 fat meal, the rate of absorption was significantly decreased, with a 29 88 Pill reduction in Cmax and a 60 minute delay Aloe Vara Male Enhancement in Tmax..The patient may find that it takes longer to work if taken with Big Mans Penis Pump a high fat meal.However, although it was Aloe Vara Male Enhancement statistically significant AUC decreased by 11 , the decrease in the extent of Big Mans Penis Pump absorption was not clinically relevant.The relative bioavailability fed fasted was 89 90 Aloe Vara Male Enhancement CI 84 94 see DRUG INTERACTIONS.Distribution The mean steady state volume of distribution Vss for Big Mans Penis Pump sildenafil is 105 Aloe Vara Male Enhancement litres, indicating Big Mans Penis Pump distribution into the tissues.Sildenafil and its major circulating N desmethyl metabolite are both approximately 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 88 Pill route and CYP2C9 minor route hepatic microsomal isoenzymes.The major circulating metabolite results from N Big Mans Penis Pump demethylation of sildenafil at Big Mans Penis Pump 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 of this metabolite Non Pharmacological Erectile Dysfunction are approximately 40 of those Mike Tyson Sais He Was Taking These Pills For Ed seen for sildenafil.The N desmethyl metabolite is further metabolised, with a terminal half life of 88 Pill approximately 4 hours.Excretion The total body clearance of sildenafil is 41 L h with a resultant Aloe Vara Male Enhancement terminal phase half life of 3 5 hours.After either oral Big Mans Penis Pump or intravenous administration, sildenafil is excreted as metabolites Mike Tyson Sais He Was Taking These Pills For Ed predominantly in the feces approximately 80 of administered dose and to a lesser extent in the urine approximately 13 of the administered dose.Special Populations and ConditionsGeriatrics Healthy elderly Non Pharmacological Erectile Dysfunction subjects 65 88 Pill 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 Non Pharmacological Erectile Dysfunction differences in plasma protein binding, the corresponding increase in free sildenafil plasma concentration was approximately 40.Hepatic Insufficiency In volunteers with hepatic cirrhosis Child Pugh A and B 88 Pill , sildenafil clearance was reduced, resulting in increases in AUC 85 and Cmax 47 compared to age matched volunteers with no hepatic impairment.The 88 Pill pharmacokinetics of sildenafil in patients with severe hepatic impairment Child Pugh class C have not been studied.Since Big Mans Penis Pump sildenafil Mike Tyson Sais He Was Taking These Pills For Ed clearance is reduced in geriatric patients 65 years or older , patients with renal impairment or patients with hepatic impairment, a starting dose of 25 mg should be considered.Based on efficacy and toleration, the dose may be increased Big Mans Penis Pump to 50 mg or 100 mg see WARNINGS Non Pharmacological Erectile Dysfunction AND PRECAUTIONS, DOSAGE AND ADMINISTRATION.Renal 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