Erythrocytosis has been noted in men on TRT, and should be monitored every 6–12 months depending upon the patients’ response to changes in haematocrit levels. For mild elevations, the dosage of testosterone can be decreased or the interval of using the medication can be increased. With the haematocrit greater than 50%, decisions to temporarily discontinue the medication or periodic phlebotomy may be indicated.38
Size matters, so get slim and stay slim. A trim waistline is one good defense — a man with a 42-inch waist is 50% more likely to have ED than one with a 32-inch waist. Losing weight can help fight erectile dysfunction, so getting to a healthy weight and staying there is another good strategy for avoiding or fixing ED. Obesity raises risks for vascular disease and diabetes, two major causes of ED. And excess fat interferes with several hormones that may be part of the problem as well.
Several studies have shown that erectile dysfunction is somehow linked to problems with cardiovascular health — which one comes first has been the question. It makes sense; the penis becomes erect through a complex system of blood vessels and spongy tissue called the corpora cavernosa — this is where the blood gets trapped, causing the erection. When problems arise through this system, whether they’re caused in the brain or through problems with the blood vessels, the penis can’t get erect.
The Medline (Pubmed) electronic database was searched (from June 1972 to November 2010) for systematic reviews that evaluated the effects of therapeutic exercise on ED. The key words and search terms used to develop the search strategy for each of these databases included: exercise therapy, aerobic exercise, therapeutic exercise, rehabilitation exercise, impotence and erectile dysfunction. In addition, the electronic searches were supplemented by checking the reference lists of any relevant identified articles.
The patient should be given every opportunity to choose among options, and to determine which fits best to his special needs and expectations. The clinician should also provide a supportive environment for shared decision-making. This management strategy must be supplemented by a careful follow-up in order to identify changes in patients’ expectations, possible side effects that may need treatment optimization.

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A 2011 study of 160 men with moderate or severe erectile dysfunction divided the group in two—80 men were given niacin supplements, and 80 a placebo. The group given niacin reported improved ability to “maintain an erection versus the control group.” It’s not exhaustive research, but still promising. The best part about niacin is that it’s naturally found in foods like turkey, avocado, and peanuts (yum). If you’re not a turkey sandwich fan, you can supplement with a vitamin B complex.
Erectile problems can happen to men of any age.  There are many factors that contribute to ED including poor health, untreated medical problems, medications and pornography use.  Many men struggle with understanding when they are experiencing situational sexual dysfunction verses when is your erectile issue an ongoing problem that requires medical help.
Your doctor may also choose to lower your dose of certain medications. Or your provider may switch the type of drug you’re taking if it’s interfering with your sex life. Some medicines used for managing blood pressure, insomnia, anxiety, depression, seizures and prostate problems increase the risk for erectile dysfunction. Beta-blockers (for high blood pressure), SSRIs (often used to treat depression) and the class of drugs called benzodiazepines (like Ativan, Xanax, Librium and Valium) are commonly tied to ED. You may want to speak to your doctor about this.

The first data on efficacy of sildenafil were published by Goldstein and colleagues (1998) Sexual intercourse was successful in 69% of all attempts for the men receiving sildenafil, as compared with 22% for those receiving placebo (p<0.001). The mean numbers of successful attempts per month were 5.9 for men receiving sildenafil and 1.5 for those receiving placebo (p<0.001). Efficacy parameters for sildenafil in 11 double-blind, placebo controlled, pre-marketing studies included the International Index of Erectile Function (IIEF) erectile function domain score and especially the questions 3 and 4 (ability to attain and ability to maintain an erection sufficient for intercourse respectively) as well as the general efficacy question (GEQ). In 6 of the 11 trials, patients maintained an event log of sexual activity. Patients were stratified in subgroups in terms of age, race, body mass index (BMI), duration of ED, ED etiology, smoking status, and concomitant conditions/medications (Figure ​(Figure2).2). All subgroups were well balanced between placebo and sildenafil. After 12 weeks of treatment, 46.5% to 87% of patients in the subgroups receiving sildenafil indicated that treatment had improved their erections compared with 11.3% to 41.3% of patients in subgroups receiving placebo. In the 6 trials in which sexual event log data were collected, significantly greater percentages of successful attempts at intercourse were reported by patient subgroups receiving sildenafil (52.6% to 80.1%) compared with patient subgroups receiving placebo (14.0% to 34.5%). All differences were statistically significant (Carson et al 2002).

Aerobic exercises and pelvic floor exercises are two of the best methods to start with. As a matter of fact, you can see improvements on your condition without having to witness the side effects of other male enhancement products. For one, there are certain male enhancement products which should not be taken if you are suffering from other types of medical condition. For instance, if the product contains substances that may react to the male enhancement ingredients of a product, you may suffer from certain consequences.
Hearing loss or vision loss. Some men have had sudden loss of hearing or loss of vision after taking one of these medications. However, it isn't clear whether vision or hearing loss was directly caused by taking the medication or by a pre-existing condition. If you're taking an oral erectile dysfunction medication and have sudden loss of hearing or vision, seek prompt medical attention.
Recently, the US Food and Drug Administration (FDA) has issued a safety announcement regarding TRT. In part it reads ‘The benefit and safety of these medications have not been established. We are also requiring these manufacturers to add information to the labeling about a possible increased risk of heart attacks and strokes in patients taking testosterone.’37
While eating magnesium-rich foods or taking a magnesium supplement at the proper dosage is safe for most men, the mineral can interfere or interact with some medications. Discuss the benefits and risks of altering your daily magnesium intake with your doctor, particularly if you take blood pressure medications, diuretics, diabetes medications or antibiotics. Men diagnosed with erectile dysfunction often require changes in other minerals and vitamins or even prescription medication. Ensuring a proper daily intake of magnesium may help maintain healthy erectile function, but magnesium alone is unlikely to cause a significant reduction in ED symptoms. Magnesium levels can also be affected by excess weight, chronic stress and excessive amounts of alcohol. These factors may also be partially responsible for erectile problems.
A drug called Alprostadil, either alone or sometimes in conjunction with others such as papaverine and/or phentolamine, can be injected directly into the penis to dilate the arteries, experts say. The drug produces an erection in about 10 minutes that can last up to an hour. But there are several disadvantages, says Teresa Beam, MD, a urologist with the Grey Clinic. Some patients are averse to using a needle, which is why many men abandon the therapy. Those who give it a try may experience pain at the injection site or priapism (a painful erection lasting too long).
Psychotherapist, sex counsellor, and author Ian Kerner takes into account some of the psychological issues that can cause erections to wilt and suggests that Viagra can help in these instances. "I do find a higher percentage of men are dealing with sexual anxiety and sexual problems related to erectile quality and so there are more men dealing with situational ED and taking Viagra," he says. "The effect often for these men is a firmer, more consistent and dependable erection."
Past research has suggested that living a healthier life full of exercise and a good diet can bring men back to sexual health. But according to researchers at Cedars-Sinai Medical Center in Los Angeles, most of these studies underrepresented African-American men. “This study is the first to link the benefits of exercise in relation to improved erectile and sexual function in a racially diverse group of patients,” said senior author of the study Dr. Adriana Vidal, of Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute and Department of Surgery, in a press release.
The research found that most of the men were overcoming erectile dysfunction naturally. The remission rate of those with erectile dysfunction was 29% which is high. This shows that many of these factors affecting men are actionable providing them an opportunity to do something about their condition. "Even when medication to help with erectile function is required it is likely to be considerably more effective if lifestyle factors are also addressed says Dr. Sean Martin lead author of the research paper. 
A drug called Alprostadil, either alone or sometimes in conjunction with others such as papaverine and/or phentolamine, can be injected directly into the penis to dilate the arteries, experts say. The drug produces an erection in about 10 minutes that can last up to an hour. But there are several disadvantages, says Teresa Beam, MD, a urologist with the Grey Clinic. Some patients are averse to using a needle, which is why many men abandon the therapy. Those who give it a try may experience pain at the injection site or priapism (a painful erection lasting too long).
It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.
The endothelium is vital to the maintenance of vascular health. It is a critical determinant of vascular tone and patency, reactivity, inflammation, vascular remodeling, and blood fluidity. (9, 10). Nitric oxide (NO) is the most potent vasodilator and is secreted by the endothelium. It is synthesized from Larginine by the endothelial enzyme NO synthase (eNOS). NO released in response to sexual stimulation relaxes penile vascular smooth muscle by increasing intracellular cyclic 3′, 5′-guanosine monophosphate (cGMP) concentration. Vasodilatation of erectile tissues allows the sinusoidal spaces to fill with blood resulting in the attainment and maintenance of an erection (5).
The availability of phosphodiesterase type 5 inhibitors (PDE5i) has resulted in increasing numbers of patients seeking medical help for erectile function problems, but has also altered dramatically the medical management of ED (Hatzichristou and Pescatori 2001; Lewis et al 2001; Steers et al 2001). More physicians are treating ED, especially in the primary care setting, including minimal patient work-up and prescription of PDE5i due to their proven efficacy and safety profile. The management of ED by non-specialists includes minimal patient work-up and prescription of exclusively first-line treatment options in most cases, mainly due to the lack of time and background knowledge (Hatzichristou 2002). Sildenafil was the first available PDE5i that revolutionized ED treatment (Goldstein et al 1998). More than 30 million of men are treated worldwide with sildenafil accompanied by vast experience and research with more than 2600 papers published in Medline as of July 2006. Furthermore, new data suggest that sildenafil has beneficial effects in several chronic conditions. It has been recently approved for the treatment of idiopathic pulmonary hypertension (Galie et al 2005), and numerous articles have suggested that PDE5i may improve endothelial function (Katz et al 2000; Desouza et al 2002; Halcox et al 2002; Vlachopoulos et al 2003; Vlachopoulos et al 2004; Gori et al 2005; Hirata et al 2005). PDE5i have been also suggested to be beneficial for patients with premature ejaculation (Abdel-Hamid 2004). However, clinical studies have shown controversial results so far (Salonia et al 2002; Chen et al 2003; Atan et al 2006) and it remains uncertain, whether PDE5i act on the physiologic process of ejaculation, or indirectly, improving erectile function and therefore, reducing performance anxiety in men with ED.

As an alternative, Alprostadil is available as a pellet-like suppository that is inserted into the tip of the penis and absorbed through the lining of the urethra. This can help produce erections lasting for 30 to 60 minutes, according to the Impotence World Association (IWA). Unfortunately, the suppositories are less effective than injections and may cause pain and irritation, according to both Aigen and Beam.
In fact, one common reason many younger men visit their doctor is to get erectile dysfunction medication. Often, men with erectile dysfunction suffer with diabetes or heart disease, or may be sedentary or obese, but they don’t realize the impact of these health conditions on sexual function. Along with erectile dysfunction treatment, the doctor may recommend managing the illness, being more physically active, or losing weight.
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