ORAL AGENTS

Trazodone
The antidepressant trazodone was noted to occasionally induce priapism and therefore interest developed in its possible role in treatment of erectile dysfunction. There are reports of good erectogenic activity with trazodone, although no significant benefit was found in a placebo-controlled trial. There are also troublesome side-effects, including drowsiness, orthostatic hypotension, nausea and vomiting.

Sildenafil (Viagra®)
Sildenafil is a novel oral therapy currently under active investigation. It is a specific inhibitor of type 5 cGMP phosphodiesterase, which is the predominate isoenzyme in the cavernosal tissue of the penis. Its inhibition leads to increased local levels of the secondary messenger cGMP, leading to relaxation of smooth muscle in the cavernosal tissue. This in turn increases blood flow into the corpora cavernosa, an essential stage in the erectile process. In a double-blind cross-over study of 12 patients with erectile dysfunction of no established organic cause, an objective dose-dependent increase in erectile activity as determined by plethysmography (RigiScan, Dacomed Corporation, MN, USA) was demonstrated. Ten of 12 patients reported improved erectile activity in the sildenafil group compared with two of 12 taking placebo. In another double-blind placebo-controlled study of 351 men with erectile dysfunction, outcome by patient and partner questionnaire confirmed a significant dose-dependent improvement on erectile activity. Side-effects such as facial flushing, headaches and dyspepsia were rare and mild. Sildenafil seems to be efficacious and safe and will undoubtedly play a major role in the treatment of erectile dysfunction in the future. Buy Viagra Professional

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For patients with erectile dysfunction who cannot tolerate or do not respond to intracavernosal injections, there is a choice between a penile prosthesis or a vacuum device. A vacuum device works by creating penile congestion and enough rigidity to allow penetration (figure l). There are no comparative controlled studies and most of the questionnaire reviews are carried out by the manufacturers themselves. However, a satisfaction rate of 70% was reported by Price in diabetics, who also emphasized the importance of a stable relationship for success. One major disadvantage to the patient is that these devices are not available on the National Health Service and cost £200 or more. Of the 60% who were able to get an adequate erection, only one third purchased a device, claiming price as the limiting factor. There are few side-effects; some complained of pain and bruising at the site of the constricting rubber ring at the base of the penis and in a minority the partner found it an unacceptable method. cheap antibiotics pharmacy

Although not universally popular, for some patients who cannot tolerate intracavernosal injections or are too elderly or unfit to be offered a penile prosthesis, a vacuum device may be a very effective treatment and it does not carry the risk of priapism. buy antibiotic pills

Testosterone can be given orally, by injection or implant, and now by a transdermal route (patch). Oral administration of testosterone is an unreliable route for increasing testosterone levels and injections or implants, both invasive techniques, are needed to sustain increased levels. The testosterone patch is a convenient and noninvasive method of obtaining controlled and sustained increases in testosterone levels. However, the use of the testosterone patch has been limited to date, probably because of problems with skin irritation.

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Vasoactive intestinal polypeptide and phentolamine
Vasoactive intestinal polypeptide (VIP) is a postganglionic neurotransmitter which seems to have a role in the erectile process. VIP is described as a ‘facilitator’ of erections because intracavernosal injection leads to tumescence only. A combination of VIP and phentolamine can be very effective. In a study of 52 men with erectile dysfunction of mixed aetiology but full response to papaverine, intracorporeal injection of 30 ug of VIP and 0.5-2 mg of phentolamine led to a functionally rigiderection in 100% of cases. At 6 months follow-up no patient had complained of pain or suffered a complication such as corporeal fibrosis or priapism. VIP and phentolamine would seem to be a very promising, safe and efficacious treatment for erectile dysfunction and maybe an especially important alternative for patients who suffer PGEl-induced pain. At present this combina tion is currently only available on a named-patient basis in hospitals.

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