Erectile dysfunction and impotence. All about erectile dysfunction treatment

A new quality of treatment for erectile dysfunction.

On the At the Congress "Man and Medicine" stands and symposiums were devoted to the treatment of erectile dysfunction (ED) in men. But until quite recently, this problem was practically not discussed. Firstly, this pathology is not life-threatening, and doctors did not attach much importance to it. Secondly, not every patient admits that he is not all right in intimate terms. And third, there were no effective and easy-to-use treatments for ED. In the last five years, after the advent of type 5 phosphodiesterase inhibitors, a qualitative change has occurred. We asked one of the leading Russian urologists, head of the Department of Urology of the Russian Medical Academy of Postgraduate Education, Professor Oleg LORAN, to talk about modern approaches to the treatment of ED.

- Oleg Borisovich, let's start with the definition of ED.
- This concept appeared rather recently. Previously, erectile dysfunction was called impotence, and this word, which became a household word, jarred on patients, turned them into inferior people. Therefore, the international conciliation committee decided to introduce the concept of "erectile dysfunction", defining it as a permanent or temporary (at least 3 months) inability to achieve and maintain an erection sufficient for sexual intercourse.
Today, unfortunately, ED is quite common throughout the world. According to WHO, by 2025, about 322 million men will suffer from it. In Russia, approximately 6.5 million men over 35 years of age have erectile dysfunction (this is approximately 21% of the male population).

- Is there an age limit after which ED is considered normal rather than a pathology?
- We, urologists, believe that an erection should last a lifetime, although, of course, its quality depends on age. Let me remind you of the WHO definition, according to which health is physical, mental and social well-being. Social well-being provides for a fairly high quality of life, which directly depends on the reproductive function of a man.
With age, erectile dysfunction increases, they become more severe. In some men, benign prostatic hyperplasia joins.

Very often, the development of impotence is promoted by inflammatory diseases of the genitourinary system (urethritis, cystitis, pyelonephritis). Urethritis is an inflammatory process in the urethra, which is most often caused by sexually transmitted infections. Timely treatment of diseases of the genitourinary system serves as a prevention of the development of sexual dysfunctions.

- What causes ED besides age and prostate disease?
- This is diabetes mellitus (especially type 1), injuries of the genital organs, the problem of which becomes relevant in connection with local conflicts and wars. And finally, it should especially worry us, physicians, that in 25% of men with ED, its occurrence is associated with the intake of a number of medications for the treatment of hypertension, coronary heart disease. First of all, this applies to beta-blockers. The easiest to treat erectile dysfunction - psychogenic, which are characteristic mainly of young men. Organic ED associated with vascular diseases, the consequences of penile injuries, requires more serious and long-term treatment. However, today there are no incurable erectile dysfunctions.

- But do all patients know about it?
- I am afraid no. No more than 10% of men suffering from them turn to doctors about erectile dysfunction. Many patients are embarrassed to admit that they have erection problems. Someone hopes that it can improve spontaneously, while someone, on the contrary, puts an end to himself and believes that nothing will help him.

- And why do doctors very rarely initiate a conversation about erectile function with patients with the same diabetes mellitus or those who have had an acute myocardial infarction, for example?
- This is due, firstly, to the fact that general practitioners do not know enough about this problem. And secondly, the treatment of ED requires a lot of time, attention, conversations with the patient, monitoring the effectiveness of therapy. Not all doctors are ready to shoulder such a burden, believing that since erectile dysfunction is not life-threatening, then it is not necessary to deal with this problem. I cannot agree with this point of view.
One of the causes of ED is stress, which is aggravated by the inability of a man to have a sexual life, which leads to neurasthenia. It turns out a vicious circle, insoluble problems arise in the family. We should not forget about the interests of a woman who also suffers in this case. After all, the harmony of family life is also sexual harmony, it must be learned, it must be maintained throughout life.

- What can modern medicine offer for the treatment of ED?
- Today there are three main lines of treatment for ED.
gold standard - this is the use of modern drugs from the group of phosphodiesterase type 5 inhibitors. The principle of their action is the inhibition of the enzyme phosphodiesterase-5, which is responsible for the termination of erection. During sexual arousal, these drugs actively enhance the relaxing effect of nitric oxide on the smooth muscles of the cavernous body and increase blood flow in the penis.
Of the phosphodiesterase inhibitors, the most familiar to doctors and patients is Viagra, which has been present on our market for 5 years. This year, a new drug from this group appeared - Cialis, which is distinguished by a longer period of action (36 hours), during which a man can achieve an erection in response to sexual arousal and have sexual intercourse when it is convenient for him. Judging by international studies that have been conducted in a huge contingent of men with ED, the drug has proven itself very well. In addition to high efficiency and safety, Cialis is easy to use: it restores the ability to achieve an erection for a long time, while it can be taken after meals, in combination with alcohol, and does not require titration. Regarding alcohol, I will make a reservation that I mean a reasonable amount, and not the abuse of strong drinks.
Second line - various intracavernous injections using prostaglandins E. Their serious drawback is obvious from the name itself - injections into the penis, which often cause cavernous fibrosis, lead to compaction of the cavernous bodies, deformation of the penis. Too many patients refuse this method of treatment for obvious reasons.
And finally the third line It's a penile prosthesis. Today there are a lot of modern high-tech two- and three-component prostheses that are implanted in cavernous bodies. These prostheses do not change the appearance of the genitals and are activated only when necessary. They are quite reliable, but, unfortunately, very expensive.

- What drug is ideal for the treatment of ED?
- The one that is taken orally is effective, has a minimum of adverse reactions and allows a man to have a natural sex life.
Phosphodiesterase type 5 inhibitors are currently the best drugs for the treatment of ED if the patient does not have severe organic disorders. Both doctors and patients have already realized that there is a real opportunity to be treated. Phosphodiesterase-5 inhibitors on the market allow you to choose the best treatment option for the patient, depending on the sexual constitution, age, and sexual activity. The more such drugs appear, the better for our patients.

- Who should prescribe erection-enhancing drugs?
- I have always been a supporter of patients taking these drugs after consulting a doctor who should identify the form, assess the causes of ED and its severity. The patient, of course, must be assessed as a whole, taking into account his age, concomitant diseases, sexual constitution, and the rhythm of sexual life. It is necessary to find out if the patient is taking drugs that contribute to the development of ED.
It can be added that, as clinical studies have shown, phosphodiesterase-5 inhibitors do not have a negative effect on the cardiovascular system. Comparison of mortality in the group of men taking these drugs, with the placebo group did not reveal any difference. There are even works that prove that these drugs improve cardiovascular activity. A categorical contraindication to the use of phosphodiesterase-5 inhibitors is only the intake of nitrates used in the treatment of cardiovascular diseases.

When deciding on the appointment of drugs that help in the treatment of erectile dysfunction, the doctor must also understand that it is always not only about solving a problem for a man, but also about relationships in a couple. If we help the husband, and for the wife the sexual life is unimportant and uninteresting, then the effectiveness of such treatment will be much lower.
Sexual life is the destiny of healthy people with a normal attitude to life and intellect, who, when problems arise, try to solve them in a civilized way. I am glad that today doctors can offer them extremely effective means for this.

See -

In cases where a comprehensive examination did not reveal the cause of the disease, treatment of ED according to certain standards, taking into account the effectiveness of the method, safety, invasiveness, material costs, and patient satisfaction.

Before starting treatment, the patient should be convinced of the need to exclude all factors that negatively affect erection, as well as normalize lifestyle and sexual activity.

A stable cure should be expected in psychogenic ED (through rational psychotherapy), post-traumatic arterial ED in young men, in hormonal disorders, and androgen deficiency (by restoring the physiological concentrations of androgens in the blood serum by prescribing the latest generation testosterone drug).

In the treatment of ED, the stages of therapeutic measures are shown. Hospitalization is indicated only for complex diagnostic measures and / or surgical interventions.

There are several treatment methods:

1. Medicines for oral use: phosphodiesterase type 5 inhibitors. (the so-called first-line therapy) - three drugs of this group are currently widely used: Sildenafil(great application experience); Verdenafil(rapid onset of action and less dependence on fatty foods and alcohol) and Tadalafil(duration of action, up to 36 hours)
2. Vacuum constrictor method - The essence of the method is to create a negative pressure in the cavernous bodies of the penis using a vacuum device. An increase in blood flow causes an erection, to maintain which a compressive ring is placed on the base of the penis, limiting the venous outflow. This method has a lot of side effects, such as pain, subcutaneous hemorrhage, difficulty in ejaculation and decreased sensitivity. That is why a third of patients refuse this method.
3. Psychosexual Therapy - Whatever the genesis of ED, psychosexual therapy should be a mandatory component of treatment. In all cases, the physician should use his influence to improve interpersonal relationships between sexual partners. It is highly desirable that the partner be involved in the treatment process, ideally as a co-therapist.
4. Intracavernous administration of vasoactive drugs. This method is used in the absence of the effect of the previous two methods. For administration, alprostadil, phentolamine, papaverine is used as monotherapy or combination. The initial dose of alprostadil is 10 mgc after dissolution in 1 ml of sodium chloride. If necessary, the dose can be doubled. Erection occurs after 5-15 minutes after injection, and lasts an average of 90 minutes. Having chosen the optimal dose and having taught the patient how to manipulate, you can switch to the autoinjection method (injections are performed by the patient on their own at home) no more than twice a week. But this method has a number of contraindications and complications, which the patient must be aware of. With a long-term erection that lasts more than 4 hours, it is necessary to see a doctor who will perform a puncture of the cavernous bodies with aspiration of blood, and, if necessary, introduce minimal doses of adrenomimetic drugs.

Surgical treatment is the last resort

An in-depth knowledge of the anatomy and physiology of the penis has made it possible to develop fundamentally new methods for correcting disturbed eerctile function through interventions on the penis, in particular on its vessels. Implantable prostheses with separable components are gradually being replaced by one-piece prostheses. However, the number of supporters of prosthetics is decreasing due to the improvement of alternative methods of treatment, for example by injection vasodilators and revascularization.

Currently, two types of prosthesis are used for implantation: semi-rigid and inflatable. The best one-piece semi-rigid penile prostheses are Dynaflex, Dura II, AMS 600, Mentor Malleble, Accuform, OmniFhase, or DuraPhase. Most often, the last of these models are used. Before the operation, prostheses of several sizes and a calibration ruler are selected and sealed in sterile bags or immersed in a solution of erythromycin (500 mg per 500 ml of saline).

Access. Despite the fact that most urologists prefer other accesses - subcoronal, penoscrotal(or subpubic) access to the cavernous bodies, some still prefer suprapubic, perineal, dorsal (or ventral), middle access. Unfortunately, the last of the listed accesses have significant disadvantages: implantation perineal access requires more time and is more often fraught with complications of wound infection due to the proximity of the anus to the area of ​​operation; transection of lymphatic vessels rear incision can lead to swelling of the penis. At distal access sometimes develops a partial loss of sensitivity of the head, even if it is possible not to damage the median dorsal nerve. It should also be noted that circumcision is not mandatory, and even undesirable, as it increases the risk of infection.

Preoperative preparation patient begins the day before surgery. On the eve of the evening and in the morning on the day of the operation, the patient should treat the external genital organs with a solution of povidone-iodine for 10 minutes and inject a cream containing an antibiotic into the nostrils every 4 hours (it should be noted that parenteral administration of antibiotics begins the day before and 3 more days after the operation. ). More information about preoperative preparation can be found here. “The operating field of the genitals is subject to careful shaving and a 10-minute treatment with povidone-iodine. At the mouth of the urethra, 3 ml of a solution of bacitracin with neomycin is injected, after which the head of the penis is clamped with a special clamp. An antibiotic is administered intravenously before the operation.

Interested parties can find a more detailed description of the methods of conducting operations here.

VENTAL ACCESS –anesthesia. The operation is performed under local anesthesia (produce a blockade of the nerves of the penis). Incision runs along the median suture of the penis distal to the penoscrotal junction, 4–5 cm long (although a transverse incision is also possible).

PERINAL ACCESS –anesthesia . The operation is performed under general anesthesia. The operating field is delimited from the anus with a sterile plastic material, which must be securely glued and sutured to the skin. The incision is longitudinal or inverted U-shaped.

SUBCORONAL ACCESS - access is very convenient for implantation of AMS 600, Mentor Malleable and Accuform prostheses, as well as Dura II. Unfortunately, in some cases, the use of this access leads to a partial loss of sensation in the area of ​​the glans penis. Anesthesia- local, carried out by introducing 10 ml of 0.25% lidocaine under the fleshy fascia around the base of the penis and 5 ml under the skin proximal to the crown. Incision transverse, 1 cm proximal to the coronal sulcus along the dorsum of the penis.

REAR ACCESS – a single incision on the dorsum of the penis, closer to the base. Anesthesia is local.

VENTAL ACCESS (Mulkegy access) – local anesthesia - the nerves of the penis are blocked with a 1% lidocaine solution, a tourniquet is applied to the base of the penis and another 20-25 ml of lidocaine solution is injected through a butterfly needle into one of the cavernous bodies, after which the tourniquet is removed. Incision carried out along the ventral surface, closer to the base of the penis, 4-5 cm long.

PUBLIC ACCESS - transverse incision just below the inferior border of the pubic symphysis.

POSTOPERATIVE COMPLICATIONS

SEXUAL ACTS IS POSSIBLE ONLY AFTER 4 WEEKS AFTER THE SURGERY!!! Please pay special attention to this, as this will allow you to reduce the risk of such postoperative complications as erosion of the cavernous body, which can also occur with excessive expansion of the prosthesis channel. Prolonged pain or Curvature of the penis may occur when implanting an overly long prosthesis. The most serious complication resulting in implant removal is Infection. Often there is a complication such as urinary retention, requiring catheterization of the bladder and the use of β-blockers. With a short foreskin that does not completely cover the head, there is paraphimosis, in which they resort to a longitudinal dissection of the foreskin from the back. Sometimes there are complaints of pain during intercourse and outside of it. Only in rare cases, this may lead to the removal of the prosthesis. In such patients, the head of the penis "freezes" in cold weather.

When writing this article, materials were used from articles posted on the Internet, in particular, materials from Wikipedia, from an article posted in the journal Pharmacist "Choosing the optimal drug for the treatment of hypertension in men", from an article in the journal Health of Ukraine "Men's reproductive health: diseases that easy to prevent and difficult to cure", posted on the website www.health-ua.org, from an article by I.I. Gorpinchenko "Male hypogonadism: clinic and treatment", from an article by R.E. Barabanova "Prevention of impotence", from the article "Treatment of erectile dysfunction" on the website "I am healthy. ru", from the reference book of medicines "Vidal", from the book of Professor Pak Jae Wu "To Myself Su Jok Doctor" and other sites posted in Internet, as well as on the basis of my experience as a reflexologist.

Erectile dysfunction (ED). Impotence- violation of the erection of the penis, sexual impotence, which manifests itself in the inability of a man to have sexual intercourse. According to statistics, every tenth man suffers from erectile dysfunction. Most often, ED develops in men after 45 years of age, but it also occurs in younger men.

Erectile dysfunction often leads to deep psychological depression, creates disharmony in sexual relations, and destroys family relationships.

1. Psychological problems, make up 20% of the total number

2. Sedentary lifestyle. In the absence of physical activity, the blood supply to organs and tissues, including the genital organs, decreases. The oxygen-rich arterial blood does not enter the blood vessels of the penis. This breaks the erection. The sexual activity of a man is reduced.

In the vessels and tissues of the small pelvis, stagnation of lymph and blood occurs, oxygen starvation (ischemia) of the male genital organs develops, local immunity decreases, inflammatory and tumor processes develop in the genitourinary system.

In acute inflammatory processes in the urogenital area, most men turn to doctors - venereologists, urologists and receive adequate treatment.

However, sluggish chronic inflammation of the genitourinary system of men is practically not disturbed. But chronic inflammation destroys the cavernous bodies of the penis and the prostate gland.

Cavernous bodies lose their firmness, elasticity and ability to fill with blood normally. The erection weakens, disappears, there is a fear of inability to have sexual intercourse.

Prostate gland (prostate)- an organ that produces prostatic juice for spermatozoa, which forms the basis of sperm. The prostate is located under the bladder, covers the exit from the bladder with a ring.

In the prostate, chronic inflammation progresses without symptoms or they are minimally expressed and do not bother the man. There are mild pains, cramps, a feeling of heaviness, discomfort in the lower abdomen, above the pubis and in the perineum. But these symptoms may or may not be present.

Prostatitis can create a prerequisite for the development of benign prostatic hyperplasia (BPH). BPH usually develops in men after 40 years of age. Prostatitis in this case is a factor in the start and development of the disease.

Benign prostatic hyperplasia is a benign tumor which over time increases in size, compresses the bladder, urethra.

At the same time, there is difficulty urinating, a weak pressure of the jet during urination, a feeling of incomplete emptying of the bladder, frequent urge to urinate at night, which force the man to visit the toilet several times at night and potency decreases sharply. BPH can degenerate into a serious oncological disease - prostate cancer.

Learn more about chronic infections. In recent years, the term Sexually Transmitted Infections (STIs) has emerged. This is a group of diseases that are predominantly sexually transmitted.

Infection with these infections can occur during genital, oral, anal types of sex. The causative agents of infections can be in the genital tract, in the mouth, in the anus, in the eyes. Diseases proceed for a long time and often imperceptibly. This can be the cause of infection of your sexual partner.

HIV is an infection that causes AIDS, and syphilis is transmitted not only through sexual contact, but also through the blood.

With untimely access to a doctor, the diseases become chronic, cause various inflammatory diseases, infertility in men and women.

Symptoms of STIs in men:
- discharge from the urethra, which may be white, mucous, green, frothy, with or without an odor;
- itching, pain and burning in the urethra;
- increased urge to urinate;
- pain above the pubis, in the perineum, inguinal region, in the testicles, in the anus;
- there may be an increase in body temperature.

Complications of STIs in men:

Chronic urethritis - inflammation of the urethra;

Chronic prostatitis - inflammation of the prostate gland;

Chronic colliculitis - inflammation of the seminal tubercle;

Chronic vesiculitis - inflammation of the seminal vesicles;

Chronic orchitis - inflammation of the testicle;

Chronic epididymitis is inflammation of the epididymis.

All of these diseases can lead to infertility and impotence.
With STIs, there can be no self-healing. You can’t self-medicate and assume that it’s “from a cold” or from hypothermia or from the fact that “dirt got in”. Only a timely visit to a doctor - a venereologist or a urologist will help restore health.

Prevention and protection measures against STIs:

Mutual fidelity, moral purity, avoidance of too early sexual life outside of marriage;

Avoid casual sex;

Using a condom is a classic way to prevent STIs, but you should be aware that it does not protect 100% from sexually transmitted diseases;

Observe the rules of personal hygiene in intimate life and demand the same from a partner;

Make your sexual behavior safe, limit the number of sexual partners to a minimum. This advice applies to people of any sexual orientation, as STIs are transmitted through any type of sex.

You should also remember about infectious diseases such as mumps (mumps) and chicken pox. These infections are more common in children. These infections can be complicated by testicular inflammation (orchitis) with subsequent development of infertility and possible ED.

4. Smoking- causes spasm and damage to blood vessels, including

In addition, poor development of secondary sexual characteristics: lack of hair growth on the face and body, female-type pubic hair growth, underdevelopment of the external genital organs - a small penis, depigmentation of an underdeveloped scrotum, small testicles, an underdeveloped prostate gland, high voice.

If hypogonadism develops due to androgen deficiency after puberty, then the signs are as follows: muscle atrophy, female-type obesity, osteoporosis, anemia (decrease in hemoglobin and red blood cells), low sperm volume, decreased libido (sex drive), prostate atrophy , the dimensions of the penis are preserved, the shape and pigmentation of the scrotum are preserved.

A benign tumor of the pituitary gland - adenoma contributes to increased production of the hormone prolactin - hyperprolactinemia. It also disrupts the production of testosterone and leads to persistent impotence.

In secondary hypogonadism, in addition to signs of testosterone deficiency, obesity and signs of insufficiency of other endocrine glands - the thyroid, the adrenal cortex - are often observed due to the loss of hormone-producing functions of the pituitary gland. In these cases, sexual desire and potency are absent, infertility develops, vegetative-vascular disorders.

The hypogonadism of aging men is also highlighted. They develop partial androgen deficiency - lack of testosterone and pathological menopause. At the same time, the pituitary gland does not produce enough luteinizing and follicle-stimulating hormones, which cause the testicles to produce testosterone and sperm in sufficient quantities. The level of female sex hormones produced by the liver in men also increases.

With hypogonadism in aging men, the following syndromes appear.

A. Psycho-emotional. The ability for productive thinking decreases, memory and attention weaken, irritability and fatigue increase, general well-being worsens, and working capacity decreases.

B. Vegetovascular. There is a feeling of heat (hot flashes), fluctuations in blood pressure, dizziness, sudden redness of the face and upper body.

B. Sexy. Change in libido (decrease, absence, perversion), decreased erection, increased duration of sexual intercourse up to the absence of ejaculation, weakening of orgasm.

G. Somatic. Osteoporosis, weight gain due to internal obesity, gynecomastia, decreased muscle mass and physical strength, thinning and atrophy of the skin.

D. Urogenital. Signs of obstruction of the lower urinary tract - the development of benign prostatic hyperplasia (adenoma), atony of the scrotum, hypoplasia (reduction in size) of the testicles, atony of the prostate gland.

In the diagnosis of hypogonadism, the determination of testosterone, luteinizing, follicle-stimulating hormones, prolactin is important. Laboratory diagnosis of hypogonadism includes the study of ejaculate.

Hypogonadism is characterized by a decrease in the volume of the ejaculate and the concentration of spermatozoa, an increase in the number of pathologically altered forms and immobile spermatozoa. To diagnose hypogonadism, the level of fructose, citric acid and zinc in the ejaculate is determined, and the amount of lecithin grains is also determined.

Men suffering from hypogonadism should seek medical help and be treated by an endocrinologist and andrologist.
Treatment of male hypogonadism includes the initial correction of hormonal disorders by non-hormonal means: diet, vitamin therapy, biological stimulants, tissue preparations. Hormone replacement therapy with testosterone and its analogues is prescribed only by the attending physician after examining the patient.

8. Severe general somatic non-communicable diseases: diseases of the cardiovascular system, kidneys, liver, brain and spinal cord, tumors, diabetes mellitus significantly reduce sexual function and lead to ED. General exhaustion of the body, hormonal imbalance, circulatory and metabolic disorders often impair potency and lead to infertility.

ED is primarily associated with cardiovascular diseases: arterial hypertension, atherosclerosis and diabetes mellitus.

Erectile dysfunction often causes high blood pressure. Even in the absence of atherosclerosis, with prolonged uncontrolled arterial hypertension, the walls of the arteries lose their elasticity, and the vessels are unable to supply the penis with the necessary amount of blood. There is also an increase in the processes of free-radical oxidation in the tissues of the penis.

With atherosclerosis, the level of cholesterol in the blood rises, atherosclerotic plaques form in the vessels, including in the thin vessels that supply the penis. There is insufficient blood flow to the organ, ED develops, which accounts for 40% of ED cases in men.

In diabetes, blood glucose levels rise. Blood thickens, and its delivery to the vessels of the genital organs is difficult, blood microcirculation is disturbed throughout the body, including in the genital organs, ED occurs.

9. Childhood and congenital diseases can cause up to 70% of male infertility and cause ED. These are diseases such as cryptorchidism, varicocele, inguinal hernia, testicular dropsy, orchitis - inflammation of the testicles as a result of mumps or chicken pox, testicular torsion.

Boys should be annually examined by a pediatric surgeon, urologist or andrologist in order to possibly identify these diseases.

10. Medications can also cause ED. These include corticosteroids, anticonvulsants, alpha and beta-blockers, cytostatics (anticancer drugs), antipsychotics, antidepressants, tranquilizers, drugs that lower blood pressure.

These drugs:

Reduce libido by suppressing the central nervous system, reducing testosterone levels, developing dysphoria - low mood;

Erection is disturbed, for example, with a decrease in systemic arterial pressure;

Ejaculation and orgasm are disturbed;

They create drug priapism with subsequent persistent ED, due to the intake of certain drugs, for example, prazosin. Priapism is a painful pathological erection that lasts more than 6 hours without sexual desire and does not stop after intercourse. In this case, the outflow of blood from the caverns - the cavernous bodies of the penis is disturbed.

Most often in 12 - 15% of ED develops in the treatment of arterial hypertension. So sympatholytics - reserpine, raunatin, octadin reduce libido, impair erection and disrupt ejaculation. And if they are used in combination with diuretics, then ED is from 35 to 48% of the total number of those treated for arterial hypertension.

Men suffering from arterial hypertension should select drugs taking into account the preservation of their sexual function. So, in case of arterial hypertension, calcium antagonists that do not reduce sexual function, for example, verapamil, and angiotensin-converting enzyme inhibitors, for example, lisinopril, diroton, can be prescribed.

Digoxin, diuretics from the thiazide group, adrenergic blockers, clonidine, methyldopa, cholesterol-lowering drugs weaken erections, reduce libido and cause ED. Long-term use of the diuretic spironolactone for more than three months leads to the development of impotence and gynecomastia.

Long-term use of diphenhydramine and other antihistamines leads to general fatigue, drowsiness, weakening of libido and ED.

Antipsychotics reduce libido, except for haloperidol, which increases libido.

Antidepressants, tranquilizers, barbiturates (hypnotics), bromine drugs reduce libido and potency.

Drugs for the treatment of Parkinsonism inhibit sexual function and cause ED.

Violations of sexual function are observed in the treatment of anti-tuberculosis and antitumor drugs.

Treatment with female sex hormones can negatively affect sexuality. The introduction of female sex hormones (estrogens) or even their topical application leads to a decrease in testosterone levels, weakening of libido, erection and weakening of orgasm.

11. Occupational hazards. Male infertility and ED often occur in men who work in conditions of elevated temperatures, ionizing radiation, toxic substances, and regular heavy lifting. The production of sperm is inhibited by the constant wearing of mobile phones on the belt and in the genital area.

12. Physical injury. Bruises, tears, cuts and other mechanical injuries of the genital organs (penis, testicles, prostate gland, vas deferens) lead to impaired potency and infertility due to tissue destruction, circulatory disorders, development of inflammatory changes and the formation of adhesions.

13. Exposure to high temperatures. Frequent and long stays in the steam room, work in hot shops, a long feverish period in infectious diseases (tonsillitis, pneumonia, influenza) and similar extreme situations associated with staying in areas with high temperatures reduce the formation of spermatozoa and reduce their quality, can lead to infertility . So after a sauna or a prolonged fever, spermogram indicators return to normal after 5 weeks.

Prevention and possible treatment of impotence.

Most men with impotence can be helped. This is done by urologists, andrologists, sexologists. Only a doctor can determine the cause of ED and recommend appropriate treatment. Modern medicine offers different methods of solving these delicate problems.

Diet for ED has a powerful preventive healing effect. Nutrition must be balanced, products must have restorative properties. Men's food should contain proteins, fats, carbohydrates as the basis of nutrition. Lean meat and fats should be included in the diet, as a source of cholesterol, from which testosterone is synthesized.

It is desirable to use the following products: whey, sour goat's milk (cow's milk is possible, but the effect will be weaker), honey, millet, vegetable oil, tomatoes, brewer's yeast, carrots, rose hips, celery, garlic, onion, dried dates, almonds, pistachios, walnuts.

The body must receive zinc in sufficient quantities, which is needed for the synthesis of testosterone. Zinc is found in lamb, seafood (squid, mussels, shrimp), fish (salmon, trout, saury), oysters, nuts (walnuts, peanuts, pistachios, almonds), pumpkin and sunflower seeds. You can also take medicinal zinc - containing complexes sold in pharmacies.

Other minerals involved in the synthesis of testosterone: selenium, magnesium, calcium.

Selenium is found in very small amounts in any plant, but its optimal amount is found in brewer's yeast and garlic.

Magnesium is found in various nuts, greens, oatmeal, green peas, chocolate, cocoa, corn.

Calcium is found in apples, green peas, whole wheat grains, fresh cucumbers, all types of cabbage, celery, lettuce, radishes, cottage cheese, white cheeses.

To keep testosterone levels normal, men need moderate exercise.- classes in the gym with weights, work at their summer cottage. These are preventive measures.

Sex hormones are synthesized during deep sleep. Constant lack of sleep reduces the level of testosterone in the blood, so men need at least 7 to 8 hours of sleep in complete silence and darkness. Sufficient good sleep is the prevention of impotence.

Medical treatment for ED.

Treatment of ED with androgens is prescribed by the attending physician urologist, andrologist, sexologist.
The discovery of drugs such as sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra) restored the sex life of many men and solved their problems. These drugs increase blood flow and help fill the cavernous bodies of the penis with blood, give an effective erection.

Patients who have cardiovascular disease should use these drugs with caution and start at low doses. Men taking nitrates should not use these drugs.

Prostate massage may be used to treat ED caused by chronic inflammation of the prostate. Her massage is carried out with a finger through the anus.

This massage is used to stimulate the prostate gland, stimulate blood flow to the prostate gland, reduce prostate inflammation, help relieve pain and discomfort in the genital area, help manage ED, and reduce the risk of prostate cancer. Such a massage can only be carried out by a health worker who knows the technique of performing massage or a urologist, andrologist, sexologist.

Used to eliminate ED hormonal injections directly into the penis. But you need to learn how to do them from your doctor.

In cases not subject to conservative treatment, surgical correction of ED is performed. Pump-like devices are inserted into the penis, allowing the wearer to literally turn the erection on and off at will.

Many men are embarrassed to see a doctor about impotence, but this is wrong. After talking about this with the doctor, they have every chance of improving and restoring their sex life.

I will give examples of the treatment of impotence with folk remedies.

Treatment of impotence with honey balm. To prepare it, take 250 grams of crushed aloe leaves, honey and Cahors. Mix everything thoroughly and let it brew for 5-6 days, preferably in the refrigerator. After the infusion, strain. Take this remedy 3 times a day before meals for 1 month. Start taking with a teaspoon 3 times a day, gradually increase the dose to 1 tablespoon. After a week break, the course of treatment can be repeated.

Treatment of impotence mumiyo. Mumiyo helps with impotence, as a general tonic. Take 2 grams of mumiyo and dissolve in 150 ml of water. Take the remedy every morning before meals, 1 tablespoon for 10 days. After a five-day break, a ten-day course of treatment can be repeated.
For a second course of treatment, in addition to mumiyo, you need to add more honey. You need to make 2 solutions: dissolve 2 grams of mumiyo in 150 ml of water and 150 ml of honey. Mumiyo must also be taken in the morning, and honey solution - before bedtime, 1 tablespoon. Then there is a break of 10 days. Then you need to spend the third ten days of treatment. After a ten-day break, the dose of mumiyo should be doubled, that is, take 4 grams of mumiyo for water and honey.

Treatment of impotence with herbs. For the treatment of impotence, herbal collection is used, which increases potency. Take 5 teaspoons of clover, mint, nettle and St. John's wort, pour into a thermos, pour boiling water and let it brew for 20 minutes. It should be taken 1 glass of infusion 3-4 times a day.

Treatment of impotence with ironwort (white-colored gourd). Helps very well. Take 4 tablespoons of iron and half a liter of natural grape wine. Boil the herb in wine for 5 minutes, and after half an hour you can take the composition of 50 ml before bedtime.

Increased potency in men. To do this, every day you need to use a glass of walnuts, washing them down with goat's milk. Increased potency and sexual desire. Nuts should be eaten in 2 to 3 doses, for example, half a glass in the morning and half a glass in the evening. The course of increasing potency in men is 4 weeks.

Exercises to increase potency.

Do exercises daily to increase potency.

1. Sit down, take a big breath, while exhaling, tighten the muscles of the anus. Then relax. You need to start with 20 - 30 seconds, then bring the constant voltage to three to five minutes. The more you develop these muscles, the stronger your potency, erection and orgasm will be. The development of the muscles of the anus is one of the methods of folk treatment of impotence.

2. "Lotus position" (swastikasana). This is a comfortable posture

Hold your breath until you feel a strong tension. At the end of this exercise, the legs should be slowly lowered. Start the exercise with two minutes and gradually increase the time to 30 minutes.

This exercise is considered a cure for all diseases, significantly improves the general condition of the body, increases vitality and intelligence, has a therapeutic effect on diseases of the liver and intestines, the spine becomes flexible, blood circulation in the spinal cord improves, the nervous system is toned, and working capacity improves.
Reflexology at home can help with impotence, if it is a consequence of stress, neurosis, physical and mental stress. Su Jok therapy techniques are especially effective in these cases.

In case of impotence, it is necessary to influence the energy points of the feet, the points of correspondence to the pituitary gland, adrenal glands, genitals, kidneys, navel, lower back.


Regardless of the causes of impotence, therapeutic the impact must begin with heating the energy points on the yin - the surfaces of the feet. It is best to do this with a wormwood cigar, which must be set on fire and the points of correspondence should be warmed up using the “up-down” pecking method.

After warming up the points, you should put the seeds of dill, parsley, onion, celery, juniper berries on them and fix them with a band-aid. Any parts of these plants can be placed on the correspondence points, as they generally enhance sexual activity.

Slices of garlic cloves or onions can be placed on the correspondence points under the patch, as they enhance potency. Change seeds daily after warming up the points, put fresh ones. Try to always have seeds on the feet at the points of correspondence with the genitals, kidneys, and lower back.

To stimulate the work of the sex glands that produce male sex hormones, massage the correspondence points of the pituitary gland, adrenal glands and testicles.

Men, maintain and maintain your sexual function at the proper level, live in joy, give this joy and your love to women! Be real men!

I think that this article will interest and help you. Post your reviews and recipes for the preservation and treatment of male solvency in the comments.

Dosta N.I., Valvachev A.A.

Advances in scientific and clinical research erectile dysfunction (ED) obtained over the past 15 years have led to the emergence of new directions in the treatment of ED, including new pharmacological agents for intracavernous, intraurethral, ​​and, later, oral use (1). Previously widely used various reconstructive vascular operations have recently been associated with poor results in the long-term follow-up period. As a result, the treatment strategy for ED has now changed significantly (4). Recent data on the efficacy and safety of oral drugs for the treatment of ED, and due to the huge media interest in this area, has led to an increasing number of men seeking help for treatment. ED. Many physicians without basic knowledge and clinical experience in diagnosing and treating ED are occupied with only one goal - making a decision regarding the treatment of these men. Therefore, many patients with ED may receive little, and some of them no, examination before any treatment is prescribed. In some cases, men without ED may seek treatment to increase their seemingly faltering sexual activity. Under such circumstances, the underlying disease causing the symptoms (i.e. ED and others) may go unnoticed and untreated.
The primary goal of a treatment strategy in patients with ED is to treat its symptoms. Because ED can often be associated with mutated or reversible risk factors, including lifestyle or medication-related factors that need to be changed before or with specific treatment, ED in these cases can be treated fairly successfully with available drugs, but they may be absolutely ineffective in the presence of unresolved hidden problems (risk factors). ED can be treated quite successfully using the available recognized methods of treatment, however, it must be emphasized that it cannot always be completely cured. The exceptions are psychogenic ED, post-traumatic vascular erectile dysfunction in young men, and ED with hormonal disorders (hypogonadism, hyperprolactinemia) (4). This suggests that the treatment strategy for ED should be structured and include requirements such as efficacy, safety, invasiveness and cost, as well as patient preference.

Hormonal causes and treatment tactics
Testosterone deficiency may result from primary testicular failure or secondary to pituitary or hypothalamic disease, including a functionally active pituitary tumor leading to hyperprolactinemia.
Replacement therapy with testosterone(intramuscular, or transdermal) is effective, but can only be used after all other possible endocrinological treatments have failed. Testosterone replacement therapy is contraindicated in men with a history of prostate cancer. Before testosterone replacement therapy, it is necessary to conduct a prostate examination, including PSA, as well as liver function.
In men with impaired coronary circulation, testosterone replacement therapy is not contraindicated, but it is necessary to monitor the level of hematocrit, which in patients with heart failure may increase, in which case therapy should be stopped (2).

Post-traumatic ED with vascular disease in young patients
In young patients with pelvic or perineal trauma, vascular surgery is successful in 60-70% of cases. Vascular involvement should be diagnosed by duplex sonography and confirmation by pharmaco-arteriography is required. Vascular surgery for the treatment of veno-occlusive dysfunction is no longer recommended due to unsatisfactory results in the late postoperative period (14).

Psychosexual advice and therapy
Patients with psychiatric problems should be treated with psychotherapy, either alone or in combination with other therapies, but combination therapy has been shown to be more successful (3). In the recommendations of the European Association of Urology (4), the treatment of erectile dysfunction is divided into three lines. The first line includes medical treatment, the second line involves the use of drugs for intracavernous and intraurethral administration and the third line therapy means the use of surgical treatment: intracavernous prosthesis and vascular surgery.

First line therapy

Medical treatment

There are currently three potent selective PDE inhibitors, sildenafil, tadalafil, vardenafil and udenafil, approved by the European Medicines Agency and the American Pharmaceutical Commission with proven efficacy and safety for the treatment of ED.
Sildenafil - the first PDE-5 inhibitor. More than 20 million men were treated during the 6 years of its trial. Efficacy has been proven (an erection with rigidity sufficient for vaginal penetration) 30-60 minutes after taking the drug. Its effectiveness decreases after taking fatty foods due to the prolongation of the absorption time of the drug in the gastrointestinal tract. Doses of 25, 50 and 100 mg are used. The recommended starting dose is 50 mg and should be adjusted according to patient response as well as side effects. Sildenafil works for 12 hours.
In studies conducted over 24 weeks of treatment, adequate erections were reported by 56%, 77% and 84% of men receiving the drug at doses of 25, 50 and 100 mg, respectively, compared with 25% of men receiving placebo (1), then yes Sildenafil statistically improved sexual function in the majority of patients and improved with increasing doses.
Treatment with Sildenafil almost every subgroup of patients with ED was successful. 66.6% of diabetic patients reported improved erections and 63% had successful intercourse, compared with 28.6% and 33% of men receiving placebo (6). 76% of patients after radical prostatectomy responded to Sildenafil with normal erections (7).
Tadalafil shows its effectiveness in 30 minutes after taking it inside, but its peak effect is expected after about 2 hours. The effectiveness of the drug is maintained for 36 hours (8), and does not depend on food intake. It is used in doses of 10 and 20 mg. The recommended starting dose of 10 mg should be adapted according to the patient's response and side effects.
In 12-week dose-response studies, 67% and 81% of men treated with the 10 mg and 20 mg dose reported improved erections compared to 35% of men treated with placebo (13). These results have been confirmed in post-marketing studies (8). Tadalafil also improved sexual function in some patients with comorbidities. Thus, 64% of patients with diabetes mellitus reported adequate erections, compared with 25% of patients in the control group (9). In patients after radical prostatectomy, the average percentage of effective use of the drug was 54%.
Vardenafil It shows its effectiveness 30 minutes after taking it inside. Its effect is not reduced after taking heavy fatty foods and alcohol. The drug is used in doses of 5.10 and 20 mg. The recommended starting dose of 10 mg should be adapted to the patient's response and side effects. In vitro, Vardenafil is 10 times more potent than Sildenafil (10). Side effects of vardenophil are mild and transient (11).
In 12-week dose-response studies, 66%, 76%, and 80% of men receiving Vardenafil 5 mg, 10 mg, and 20 mg, respectively, reported improvement in erection compared with 30% of men receiving placebo (12).
The drug has also been shown to be effective in patients with severe comorbidities. Thus, 72% of diabetic men treated with vardenafil reported adequate erections, compared with 13% of control patients (48). In patients after radical prostatectomy, the average percentage of effective use of Vardanafil 20 mg was 74% (13).
In patients with cardiovascular disease, the use of PDE-5 inhibitors with stable angina did not cause myocardial ischemia (50-52). But if the patient is taking nitrates, treatment with PDE-5 inhibitors is contraindicated, as this can lead to a drop in blood pressure. Even if the patient begins an attack of angina pectoris, and shortly before that he took one of the PDE-5 inhibitors, taking nitrates is contraindicated, moreover, it is necessary to refrain from using them within 24 hours after taking Sildenafil and Vardenafil, and 48 hours after taking Tadalafil, given half-life of drugs.
Co-administration of PDE-5 inhibitors with antihypertensive drugs (ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, diuretics) can lead to a slight increase in blood pressure, which is insignificant for the patient. In general, for patients receiving antihypertensive therapy, there are no contraindications for the appointment of PDE-5 inhibitors, even if combined treatment of arterial hypertension is carried out.
It should be borne in mind that the use of PDE-5 inhibitors with alpha-blockers can sometimes lead to a decrease in blood pressure. It is recommended to take Sildenafil at a dose of 50 or 100 mg only after 4 hours after taking an alpha blocker. In the US, concomitant use of PDE-5 inhibitors and alpha-blockers is prohibited. However, co-administration of Vardenafil with Tamsulosin does not cause significant hypotension (14). In general, the interaction of PDE-5 inhibitors and alpha-blockers seems to be a very significant issue, since alpha-blockers occupy a leading place in the treatment of benign prostatic hyperplasia and in general symptoms of the lower urinary tract, in which most men have erectile dysfunction.
Apomorphine is a centrally acting drug (dopamine agonist) that improves erectile function (15,16). Apomorphine is used under the tongue in doses of 2 or 3 mg. Apomorphine is approved for the treatment of ED in several countries.
The effectiveness of apomorphine use varies from 28.5% to 55% (17–19). Due to the rapid absorption of the drug, in 71% of patients, an erection is achieved within 20 minutes. Of the adverse reactions to the drug - nausea (7%), headache (6.8%) and dizziness (4.4%) (18), are moderate. heavy side effects are extremely rare (<0.2 %) (20). Прием апоморфина не противопоказан мужчинам, получающим нитраты, гипотензивные средства всех классов(21). Препарат не усиливает либидо, а улучшает качество оргазма (22).
Comparative studies clearly show that apomorphine is much less effective than sildenafil, tadalafil and vardenafil. (22). The biggest benefit of using apomorphine is its safety associated with its lowest side effect profile (23), so it can be used to treat ED in men who are contraindicated with PDE-5 inhibitors.

Other drugs for treating ED

Several other drugs have shown some efficacy in the treatment of ED (23).
Yohimbine is a centrally and peripherally active alpha2 adrenergic antagonist that has been used as an aphrodisiac for nearly a century.
Delekvamin is a more selective alpha2 antagonist than Yohimbine.
Trazodone- an inhibitor of serotonin reuptake (antidepressant), the use of which can lead to priapism, since the drug is not a selective adrenergic antagonist in smooth muscle cells. L-arginine is a nitric oxide donor and opioid receptor antagonist.
Korean Red Ginseng - Mechanism of action is currently unknown (although it may act as a nitric oxide donor).
Oral phentolamine (non-selective adrenergic antagonist) is in phase clinical trials (24).
In randomized trials, Yohimbine and Trazodone were found to be equivalent to placebo in patients with organic causes of ED (24). Studies on the effects of phentolamine have shown an efficacy of approximately 50% (24). Efficacy data on Korean Red Ginseng has shown that this agent can be used to treat ED (25).
Local decompression(LD) therapy, through pneumomassage of the penis, can also be successfully used to treat ED with a high success rate of up to 90%, although satisfaction with LD therapy varies from 27% to 94% (28). However, after 2 years of regular LD therapy, the effect decreases to 50–64% (29).
Side effects from ongoing LD therapy include pain, inability to ejaculate, petechiae, and penile numbness, which occurs in 30% of patients (30). Serious consequences, such as skin necrosis, can be avoided if patients remove the compression ring within 30 minutes of the onset of an erection. LD is contraindicated in patients with bleeding disorders, as well as during treatment with anticoagulants.
LD is generally not used in the treatment of young patients, however, it may be suitable for the treatment of patients with infrequent sexual intercourse and the presence of severe comorbidities, when other methods of treatment, including medication, are contraindicated.

Second line therapy

Patients who have not responded well to ED treatment with oral medications can be offered intracavernous treatment with an 85% success rate (31).
Intracavernous administration of vasoactive drugs was the first treatment for ED more than 20 years ago (32).
Alprostadil (Caverject, Edex/Viridal) is the first and only drug approved for intracavernous administration (33). The erection appears after 5-15 minutes and lasts according to the administered dose. If this technique is preferred, an explanation of the technique for administering the drug is required for the patient. It is also possible to use an automatic special pen, which facilitates the introduction of the drug.
The effectiveness of intracavernous administration of alprostadil is more than 70% in patients without concomitant diseases, and with existing ones (for example, diabetes or cardiovascular insufficiency). According to some studies, satisfaction with the use of this drug reaches 94% in patients, and 86-90.3% in sexual partners (34,35).
Complications of intracavernous administration of alprostadil include penile pain (50%), prolonged erections (5%), priapism (1%), and penile fibrosis (2%) (33,36). Pain usually resolves on its own with long-term treatment or can be managed with sodium bicarbonate or a topical pain reliever. Fibrosis requires a temporary cessation of injections for several months. Hypotension may also occur when using large doses of the drug. Patients should always be warned about the possibility of developing such side effects when using this method of treatment, since in some of them the resulting fibrosis may be irreversible.
Alprostadil is contraindicated in men who have an allergy to the drug, a tendency to priapism, a bleeding disorder.
Despite these favorable data, some patients 40.7-68% (37,38) refuse this treatment. The reasons for discontinuing treatment with intracavernous alprostadil are: inconvenience associated with the administration of the drug (29%), lack of a suitable sexual partner (26%), weak erection (23%), fear associated with the introduction of the drug with a needle (23%), fear of complications (22%) (38,39).
Today, intracavernous drug treatment for ED is considered a second-line therapy. In patients not responding to oral medications, intracavernous injections can be offered with a high success rate of 85% (31,40). Despite the apparent effectiveness of treatment with intracavernous injections, some patients still switch to oral drugs (90,91), however, almost one-third of them subsequently prefer combination treatment with PDE-5 inhibitors (41,42).

Combination Therapy

The purpose of combination therapy is to use drugs from different groups at lower doses of each of them. In this regard, the frequency of side effects decreases, and the effect of the treatment remains at the proper level.
Papaverine (20-80 mg) was the first drug used for intracavernous injections. However, this method is currently not recommended for the treatment of ED as a monotherapy, since its effectiveness is low.
In the literature, there is evidence of the use of drugs such as vasoactive intestinal peptide, nitric oxide (NO) (forskolin, moxisilite or calcitonin), gene-related peptide (CGRP), mainly in combinations with main drugs. Most combinations are not standardized, and the suitability for use of some drugs has been restricted worldwide.
Combinations of papaverine (7.5-45 mg) with phentolamine (0.25-1.5 mg), and papaverine (8-16 mg), phentolamine (0.2-0.4 mg) with alprostadil (10-20 mg ), have been widely used with good efficacy, although these regimens have never received formal investigator approval for the treatment of ED (43,44), especially the triple regimen, despite its high efficacy of up to 92% (44,45). It may be that, along with high efficiency, there is fibrosis of the penile tissue (5-10%), as well as a hepatotoxic effect from papaverine (46).
The introduction of alprostadil intraurethral
Intraurethral administration of alprostadil, in contrast to intracavernous administration, is a less effective treatment for ED. The efficiency of the method according to different sources does not exceed 65.9% (47,48,49,52). Moreover, maximum doses of 500 and 1000 mg are required in most cases to achieve an adequate erection (50). The use of a pressure ring at the root of the penis (ACTIS™) may improve the efficacy of intraurethral administration of alprostadil (51).
Of the side effects from intraurethral administration of alprostadil, there are local pain (29-41%), dizziness (1.9-14%), urethral bleeding (5%), urinary tract infections (0.2%), however, fibrosis of the penile tissue and priapism are very rare. (<1 %)(32).
Intraurethral drug treatment with alprostadil, a second-line therapy, is an alternative to intracavernous injections for patients who prefer less invasive treatment.

Third line therapy

Penile prosthesis

Surgical implantation of the prosthesis is indicated for patients who are fully examined, and for whom various types of drug therapy have not given the desired result. The percentage of success of this method, based on patient satisfaction, is 70-87%) (53.54). There are two types of complications associated with the implantation of the prosthesis - complications of a mechanical nature and infection. It was noted that three-component hydraulic prostheses take root better in the summer (54,55). Appropriate surgical technique with rational antibiotic prophylaxis against Gram-positive and Gram-negative bacteria can reduce the incidence of infectious complications to 2–3% (56). The incidence of infectious complications can be minimized (up to 1%) by implantation of an antibiotic-impregnated prosthesis (AMS Inhibizone) or a thin film-coated prosthesis (Titanium) (57,58). Diabetes mellitus is not a contraindication for penile prosthesis (56). Infections, as well as erosions, are significantly higher (9%) in patients with spinal cord injuries (9%) (59. In the case of an infectious complication, the removal of the prosthesis and reimplantation after 6–12 months is necessary. The success rate of repeated operations is 82% (60).
Summing up the discussion of various methods of treating ED, it must be said that the main place in the treatment is pharmacotherapy, which is the most acceptable from the point of view of patients. This is due to the ease of use of various drugs, as well as their fairly high efficiency. At the same time, with the advent of several drugs, both among doctors and among patients, a completely natural question arises, which remedy is the best, how long should the prescribed drug be taken. An important issue is the question of the benefits of a particular drug in various concomitant diseases (CHD, diabetes, lipidemia, CNS diseases, etc.). Only at first glance it may seem that all PDE-5 blockers are equivalent since they belong to the same group of drugs. However, these drugs differ in their pharmacodynamics and pharmacokinetics, although the mechanisms of clinical differences in the effectiveness of these drugs are not yet fully understood (61). There are differences in the individual tolerability of various drugs by patients. The answer to these and other important questions can only be obtained in the course of randomized, placebo-controlled trials. In the meantime, it is rather difficult for doctors to reasonably choose one or another drug from the group of PDE-5 inhibitors (61). In addition, at present, unified parameters have not yet been developed and unified, according to which such studies could be carried out. Mulhall and Montorsi (62) proposed to include the following requirements in the study protocol to minimize the influence of prejudices of physicians and patients on the evaluation of the efficacy and safety of treating ED with various drugs (sildenafil, vardanafil, tadalafil): randomization of patients: double-blind control; no prior isolation of non-responsive or only primary patients; randomization of drug selection sequence; use of equivalent doses; sufficient time intervals for negative results; a single scale for evaluating results at the beginning and at the end of the study; assessment of the benefits of treatment in each group over the same period; equivalence of the length of treatment periods; assessment of benefits, eliminating bias towards any drug; neutral form of motivated consent and additional analysis in a separate Internet group.
Using such a protocol, Eusebio Rubio-Aurioles et al. (63) conducted a self-assessed clinical study of the efficacy and safety of vardenafil and sildenafil in the treatment of ED in patients with clinical manifestations of ED associated with diabetes, hypertension, and/or hyperlipidemia. 1057 patients were included in the two-protocol study group. In the first protocol (530 patients), vardenafil 20 mg was administered; in the second protocol (527 patients), sildenafil was administered at a dose of 100 mg. Patients received both drugs for 4 weeks at bedtime. One study was conducted in the USA (567 patients), the second - in Europe and Mexico (490 patients). Both studies were carried out in accordance with the requirements of the GCP and the Declaration of Helsinki. Evaluation of the effectiveness and safety of treatment was carried out 7 days after the last dose of the drug. When asked if there were any advantages in the action of any drug, 683 (73.4) patients answered this question in the affirmative, moreover, 38.9% of men preferred vardenafil and 34.5% - sildenafil, 26.6% did not note advantages. More interesting data came from the analysis of patients' responses to specific questions regarding the efficacy and safety of vardenafil and sildenafil in the treatment of erectile dysfunction they had. The results of this analysis are presented in table 1.

Benefits analysis of ED treatment with vardenafil and sidenafil
according to patients' answers to questions
Table 1

Analyzing this table, I would like to emphasize once again that this study is one of the few of its kind, where all kinds of subjective factors on the part of patients, doctors and representatives of manufacturers of the corresponding medicines are absolutely excluded. Therefore, it would be appropriate to note that, according to the main qualitative characteristics, the patients preferred vardenafil as the most effective drug. As for side effects, they were noted not so often and were not serious, both to one and the other drug, although when taking vardenafil, they were noted by a slightly larger number of patients.
At present, the question of the possibility of using PDE-5 inhibitors in the form of chronic regimens in the treatment of ED is extremely important. We are talking about the possibilities of using these funds not only in cases of urgent need, but in the form of long-term, continuous schemes. Recent studies in this area have led to the conclusion that with chronic use of such compounds, there is not only a systemic improvement in vascular factors, but also their change for the better directly in the penis (64, 65). Acute and chronic administration of PDE-5 inhibitors can improve endothelial and vascular function, both with and without cardiovascular comorbidity, due to their ability to maintain high plasma levels of cGMP, which is responsible for vascular tone. This mechanism may be the main explanation for the fact that spontaneous erections have been restored in many patients after long-term use of PDE-5 inhibitors (66–69). This may be a key fact justifying the possibility and necessity of using such drugs for the prevention of ED in some categories of patients, for example, after radical prostatectomy for prostate cancer. In search of an answer to these extremely important and interesting questions, Montorsi F et al. conducted an analysis of all publications on this issue for the period from January 1993 to September 2005. in the Medline and Cancerlit databases, as well as in the journals: European Urology, Journal of Urology, International Journal of Impotence Research, and Journal of Sexual Medicine (73).
Recently, the term “endothelial dysfunction” has been increasingly encountered in the literature. Endothelial dysfunction is an abnormal response of the endothelium in which the level of NO decreases and, accordingly, vasodilation decreases. This plays a large role in the development of atherosclerosis and acute coronary insufficiency (70). Endothelial dysfunction is commonly associated with cardiovascular risk factors such as hypertension, dyslipidemia, diabetes mellitus, and smoking, which are often external manifestations of ED in these patients (71). It has also been shown that endothelial dysfunction also underlies the onset of atherosclerotic processes and the further development of coronary heart disease (72).
Literature reviewed by Montorsi F et al.(73) using sildenafil and tadalafil as examples show that long-term use of PDE-5 inhibitors improves coronary blood flow in patients with ED and CAD (64-66)
More recently, very interesting data have been obtained regarding vardenafil (74). In particular, it has been shown that long-term use of vardenafil in the blood increases the concentration of circulating stem cells. These cells play a critical role in organ revascularization and repair of damaged endothelium (75). Another study showed that when the level of circulation of such cells decreases, risk factors for the development of cardiovascular diseases develop, that is, endothelial dysfunction develops (76). Other benefits have been found with chronic or long-term vardenafil: restoration of spontaneous erections, stimulation of reinnervation, protection of the cavernous tissue endothelium, inhibition of the development of fibroplastic processes, angiogenesis, growth of smooth muscle of the cavernous bodies and their differentiation (77).
As mentioned above, with the advent of new PDE-5 inhibitors (tadalafil, vardenafil), the question of the rational choice of the drug for each particular patient becomes more and more urgent. In this regard, the latest reports that have appeared in the press are very valuable.
In particular, Porst H et al. (78), studying the half-life and efficacy of various doses of vardenafil (5, 10 and 20 mg) in a large clinical, placebo-controlled material (383 patients), showed a high efficacy of vardenafil within 8 hours after taking its respective doses. This period is almost 2 times longer than the drug indicated in the official instructions (4.7 hours). Therefore, Inigo Saenz de Tejada (79) rightly points out that physicians now need to be aware of these nuances, since the effectiveness of the drug depends largely on how correctly the doctor explains everything about a particular remedy.
According to Klotz et al.(80), the elimination half-life of vardenafil is 4.7 hours for sildenafil and 4 and 17.5 hours for tadalafil, respectively. There is evidence in the literature that vardenafil is highly effective 8–12 hours after administration (81). The question naturally arises as to why a drug with a half-life of 4.7 hours is effective for at least 10 hours (79). This phenomenon is associated with the high biochemical activity of the drug molecule. Blount et al. (82) in their studies showed that it is 40 - 20 times higher than that of sildenafil and tadalafil, respectively. This explains the results obtained in their studies by Porst et al. (78).
Thus, despite the fact that PDE-5 inhibitors began to be used relatively recently, due to their unique properties associated with pharmacokinetics, pharmacodynamics and extremely high biochemical activity, these drugs can now be considered favorites among drugs for the treatment of vascular ED.

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