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DESCRIPTION

If a man does not have the ability to achieve or maintain an erection adequate for normal sexual intercourse, he is said to be impotent. It is also referred to as erectile dysfunction and male sexual dysfunction. Impotence may be chronic or recurring, or it may occur as a single isolated incident. This condition is not considered normal at any age and is different from other problems that interfere with sexual intercourse such as lack of sexual desire and problems with ejaculation and orgasm.

These variations make defining ED and estimating its incidence difficult. Estimates range from 15 million to 30 million, depending on the definition used. According to the National Ambulatory Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7 physician office visits were made for ED in 1985. By 1999, that rate had nearly tripled to 22.3. It is estimated that as many as 30 million men in the United States suffer from at least occasional impotence. Most of these men are age 40 or over (one in three men over 60 is affected), but those under forty may also have the problem. An estimated 18 million men have recurring problems with impotence and it is estimate that about 1 in 10 adult males suffer from erectile dysfunction.

A much more common problem that affects the majority of men at some point in their life is the occasional failure to achieve an erection, which can occur for a variety of reasons, such as from drinking too much alcohol or from being extremely tired.

Failure to achieve an erection less than 20% of the time is not unusual and treatment is rarely needed. Failure to achieve an erection more than 50% of the time, however, generally indicates there is a problem requiring treatment.

ANATOMIC & PHYSIOLOGIC DESCRIPTION (How Does An Erection Occur?)



The penis is a complex organ. It is made of tissue, muscle, arteries, veins, and nerves. It begins inside your body near your prostate gland. Your penis serves many important purposes and has a variety of parts.

For an erection, the most important part is the corpora cavernosa. These are two cavities that run the length of your penis and actually fill with blood to create an erection. Basically, the penis is a "hydraulic" machine.

A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.

Erection begins with sensory or mental stimulation, or both (sexual stimulation). Your nervous system sends chemical messages (impulses) from the brain to your pelvic area and these local nerves cause the muscles inside your penis (of the corpora cavernosa) to relax. The arteries widen, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The corpora cavernosa, acting like a sponge, fills with blood. In fact, the corpora absorbs up to eight times more blood than when your penis is flaccid. As your penis swells and lengthens, the filled corpora cavernosa presses against the veins. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. The pressure reduces the blood flow from your penis. This keeps your erection firm enough for intercourse. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed. When everything works the way it should, you will keep your erection for as long as you are sexually aroused.

Arteries (top) and veins (bottom) penetrate the long, filled cavities running the length of the penis--the corpora cavernosa and the corpous sponglosum. Erection occurs when relaxed muscles allow the corpora cavernosa to fill with excess blood fed by the arteries, while drainage of blood through the veins is blocked.

To get a firm erection, you need a healthy brain, pliable blood vessels, fully functional nerves, and certain hormones. If you cannot get or maintain an erection, it is because something is interfering with the nerve messages or the blood flow to your penis. Doctors call this erectile dysfunction (ED), or impotence. Erectile dysfunction can have a psychological cause, but most often the cause is physical.

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CAUSES

Erections result from a complex combination of brain stimuli, blood vessel and nerve function, and hormonal actions. In order to achieve an erection three conditions must occur: The nerves to the penis must be functioning properly; the blood circulation to the penis must be adequate; there must be a stimulus from the brain. If there is something interfering with any or all of these conditions, a full erection will be prevented and impotence occurs.

Some of the factors that can lead to impotence include peripheral vascular disease; the use of certain medications, alcohol, or cigarettes; a history of sexually transmitted disease; and chronic illness such as diabetes or high blood pressure. Hormonal disturbances such as diminished levels of testosterone or elevated prolactin production, or over-or under production of thyroid hormone, may also cause impotence. Diabetes, which often leads to atherosclerosis and impaired circulation, is probably the most common physical cause of impotence.

Common causes of impotence (erectile dysfunction) include diseases that affect blood flow, such as atherosclerosis (hardening of the arteries); nerve diseases, psychological factors, such as stress, depression, and performance anxiety; and injury to the penis. Chronic illness, certain medications and a condition called Peyronie's disease (scar tissue in the penis) can also cause impotence.

In the past, it was assumed that impotence was primarily a psychological problem, but many therapists and health care providers today believe that as many as 85 percent of all cases of impotence have some physical basis. The Association for Male Sexual Dysfunction recognizes over 200 drugs that may cause impotence. Some of the most common are alcohol, antidepressants, antihistamines, antihypertensives, diuretics, narcotics, nicotine, sedatives, stomach acid inhibitors, and ulcer medications. Atherosclerosis, or hardening of the arteries, poses a risk to the condition of the heart and the penis. Most people today know smoking and eating fatty foods lead to the production of plaques that clog arteries and block the flow of blood to the heart. These plaques also can block the arteries leading to the genitals, interfering with the ability to attain an erection.

PSYCHOLOGICAL FACTORS

Psychological factors are responsible for 10%-20% of all cases of impotence. It is often a secondary reaction to an underlying physical cause. In some cases, the psychological effects of impotence may stem from childhood abuse or sexual trauma. However, the most common psychological causes of impotence include:

• Stress: Stress can be job-related, money-related, or the result of marital problems, among other factors.
• Anxiety: Once a man experiences impotence, he may become overly worried that the problem will happen again. This can lead to "performance anxiety," or a fear of sexual failure, and consistently cause impotence.
• Guilt: A man may feel guilty that he is not satisfying his partner.
• Depression: A common cause of impotence, depression affects a person physically and psychologically. Depression can cause impotence even when a man is completely comfortable in sexual situations. Drugs used to treat depression may also cause impotence.
• Low self-esteem: This can be due to prior episodes of impotence (thus a feeling of inadequacy) or can be the result of other issues unrelated to sexual performance.
• Indifference: This may come as a result of age and a subsequent loss of interest in sex, be the result of medications or stem from problems in a couple's relationship.

All men at one time or another will experience impotence. Only if the problem becomes persistent -- occurs more than 50% of the time -- should you be concerned and consider seeking medical advice and treatment. For men whose erectile dysfunction is caused by psychological problems, therapy may be needed.

PHYSICAL FACTORS

The process of achieving an erection is complex and problems may occur for a variety of reasons. These problems can be psychological, physical, or a combination of the two.

Physical causes of erectile dysfunction are related to a breakdown or damage to the sequence of events that lead to an erection. This sequence involves nerve impulses in the brain, spine, and penis as well as the subsequent response in the muscles, fibrous tissues, veins and arteries in and near the corpora cavernosa.

Often times the breakdown or damage in the sequence affects the arteries, muscles, and surrounding tissues of the penis, and this breakdown is most commonly the result of a disease. Diseases that commonly cause impotence include:

• Diabetes: Diabetes can cause nerve and artery damage that can make achieving an erection difficult. Between 35% and 50% of men with diabetes experience impotence.
• Kidney disease: Kidney disease can cause chemical changes to occur in your body that affect hormones, circulation, nerve function, and energy level. Often times these changes will lower a person's libido (sex drive) or sexual ability. Drugs used to treat kidney disease may also cause impotence.
• Neurological (nerve and brain) diseases: The nervous system (the body's system of nerves) plays a vital part in achieving and maintaining an erection and it is common for men with diseases such as stroke, multiple sclerosis (MS), Alzheimer's disease, Parkinson's disease and spinal cord injuries to experience impotence. This is due to an interruption in the transmission of nerve impulses between the brain and the penis.
• Vascular disease: Vascular diseases are those that affect the blood vessels. These diseases include atherosclerosis (hardening of the arteries), hypertension, and high cholesterol. These diseases, which account for 70% of physical-related causes of impotence, all restrict blood flow to the heart, the brain and, in the case of impotence, the penis. Atherosclerosis alone accounts for 50%-60% of impotence cases in men over age 60.
• Prostate cancer: Prostate cancer doesn't cause ED on its own, but surgery to remove the cancer can lead to erectile problems.

The physical causes of impotence are not only disease-related. There are many other potential causes, including:

• Surgery: Surgery performed to treat diseases such as prostate cancer and bladder cancer often require the removal of nerves and tissues around the affected area which can lead to impotence. Some of these surgeries result in only temporary problems (lasting 6-18 months) while others result in permanent damage to the nerves and tissue around the penis and require treatment in order for an erection to be achieved.
• Injury: Injuries to the pelvis, bladder, spinal cord, and penis that require surgery also commonly cause impotence.
• Hormonal imbalances: Hormonal causes of impotence account for only 5% of all people diagnosed with impotence. Imbalances of hormones, such as thyroid, prolactin and testosterone, can affect a man's response to sexual stimulation. These imbalances can be the result of a tumor on the pituitary gland, kidney disease, or liver disease.
• Venous leak: If the veins in the penis cannot prevent blood from leaving the penis during an erection, an erection cannot be maintained. This is known as a venous leak, and can be a result of injury or disease.
• Tobacco, alcohol or drug use: All three of these substance can damage a person's blood vessels and/or restrict blood flow to the penis, causing ED. Smoking in particular plays a large role in causing ED in people with arteriosclerosis.
• Prescription drugs: There are over 200 types of prescription drugs that may cause impotence.

MEDICATIONS / DRUGS

If you are having problems achieving or maintaining an erection you may want to take a look at your medicine cabinet. There are a number of prescription and over-the-counter drugs that may cause impotence. While these medications may treat a disease or condition, in doing so they can affect a man's hormones, nerves, or blood circulation, resulting in impotence or increase the risk of erectile dysfunction.

Medicines that may cause impotence (erectile dysfunction) are listed below.

TYPE OF DRUG

GENERIC AND BRAND NAMES

Diuretics and Antihypertensives

Hydrochlorothiazide (Esidrix, HydroDIURIL, Hydropres, Inderide, Moduretic, Oretic, Lotensin) Chlorthalidone (Hygroton) Triamterene (Maxide, Dyazide) Furosemide (Lasix) Bumetanide (Bumex) Guanfacine (Tenex) Methyldopa (Aldomet) Clonidine (Catapres) Varapamil (Calan, Isoptin, Verelan) Nifedipine (Adalat, Procardia) Hydralazine (Apresoline) Captopril (Capoten) Enalapril (Vasotec) Metoprolol (Lopressor) Propranolol (Inderal) Labetalol (Normodyne) Atenolol (Tenormin) Carteolol (Cartol) Phenoxybenzamine (Dibenzyline) Spironolactone (Aldactone)

Antihistamines

Fluoxetine (Prozac) Tranylcypromine (Parnate) Sertraline (Zoloft) Isocarboxazid (Marplan) Anitriptyline (Elavil) Amoxipine (Asendin) Clomipramine (Anafranil) Desipramine (Norpramine, Pertofrane) Nortriptyline (Pamelor) Phenelzine (Nardil) Buspirone (Buspar) Chlordiazepoxide (Librium) Clorazepate (Tranxene) Diazepam (Valium) Doxepin (Sinequan) Imipramine (Tofranil) Lorazepam (Ativan) Meprobanate (Equanil) Oxazepam (Serax) Phenytoin (Dilantin)

Antihistamines

Dimehydrinate (Dramamine) Diphenhydramine (Benadryl) Hydroxyzine (Vistaril) Meclizine (Antivert) Promethazine (Phenergan)

Non-steroidal anti-inflammatory drugs

Naproxen (Anaprox, Naprelan, Naprosyn) Indomethacin (Indocin)

Parkinson's disease medications

Biperiden (Akineton) Benztropine (Cogentin) Trihexyphenidyl (Artane) Procyclidine (Kemadrin) Bromocriptine (Parlodel) Levodopa (Sinemet)

Antiarrythmics

Disopyramide (Norpace) Glycopyrrolate (Robinul)

Histamine H2- receptor antagonists

Cimetidine (Tagamet) Nizatidine (Axid) Ranitidine (Zantac)

Muscle relaxants

Cyclobensaprine (Flexeril) Orphenadrine (Norflex)

Tranquilizers

Chlorpromazine (Thorazine) Fentanyl (Innovar) Fluphenazine (Prolixin) Haloperidol (Haldol) Mesoridazine (Serentil) Prochlorperazine (Compazine) Promazine (Sparine) Thioridazine (Mellaril) Thiothixene (Navane) Trifluoperazine (Stelazine)

Prostate cancer medications

Flutamide (Eulexin) Estrogen (Stilphostrol) Leuprolide (Lupron)

Chemotherapy medications

Busulfan (Myleran) Cyclophosphamide (Cytoxan)

Anti-seizure medications

Phenytoin (Dilantin)

If you experience impotence and think that it may be a result of medication you are taking, do not stop taking the medication without first consulting your health care provider. If the problem persists, your health care provider may be able to prescribe a different medication.

Other substances or drugs that can cause or lead to impotence include recreational and frequently abused drugs, such as:

• Alcohol
• Amphetamines
• Barbiturates
• Cocaine
• Marijuana
• Methadone
• Nicotine
• Opiates

Aside from the well-known complications that the use and abuse of these drugs can cause, impotence is not often mentioned. However, use of these drugs can cause impotence. These drugs not only affect and often times suppress the central nervous system, but can also cause serious damage to the blood vessels, resulting in permanent impotence.

DIABETES

It is estimated that about 50% of men with diabetes will experience impotence. Men with diabetes tend to develop impotence 10 to 15 years earlier than men without diabetes. As men with diabetes age, impotence becomes even more common. Above the age of 55, the likelihood of having difficulties with an erection occurs in approximately 70% of men with diabetes. Above age 70, there is about a 95% likelihood of having some difficulty with erectile function.

The causes of erectile dysfunction in diabetic men are complex and involve impairments in nerve, blood vessel, and muscle function.

Men with diabetes having trouble with achieving and/or maintaining an erection can take oral medicine like Viagra. Viagra is generally a successful therapy for erectile dysfunction, with about 50% of people achieving positive results using the drug with a minimum of side effects. Additional treatments men with diabetes might want to consider include intracavernous injection therapy, vacuum constriction devices, intraurethral therapy, and sex therapy.

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SIGNS & SYMPTOMS

Basic symptoms include the following:

• Inability to achieve a penile erection adequate for normal sexual intercourse.
• Inability to maintain a penile erection adequate for normal sexual intercourse (erection may be too weak, too brief, or too painful).

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PREVENTION

For people who are at risk of developing impotence due to personal behavior, such as drinking too much alcohol, steps may be taken to prevent its occurrence. However, other causes of impotence may not be preventable.

For people who are at risk of developing impotence, taking active steps to prevent its occurrence will not only help you maintain erectile function, but also help you lead a healthier life overall. Some steps you can take to prevent ED include:

• Stop smoking to decrease your risk of developing atherosclerosis (narrowing of the arteries).
• Exercise regularly.
• Maintain a healthy weight.
• Take prescribed medications as directed.
• Avoid excessive use of alcohol (more than three drinks a day).
• Avoid the use of illegal drugs.

If you have a chronic illness such as diabetes or kidney disease, follow your doctor's guidelines to keep these conditions in control.



TREATMENT

Because there are a variety of causes for impotence, there are several different tests your health care provider may use to diagnose the condition and determine its cause. Only after the cause of impotence is determined can it be effectively treated.

IMPOTENCE SELF TEST

The appropriate treatment for impotence depends upon whether the cause is physical or psychological. A man whose impotence is psychologically based generally still has erections during sleep, whereas an individual whose impotence is physical in origin usually does not. One easy inexpensive way to test for nocturnal erections is with postage stamps. Glue a strip of stamps around the shaft of the penis before going to bed. If the ring of stamps is broken in the morning, the cause of the impotence is likely psychological. If the strip is unbroken, the impotence is likely physiological. You can also purchase a kit called Snap Gauge. This test is designed to detect and measure the rigidity of erections experienced during sleep.

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Before ordering any tests, your health care provider will review your medical history and perform a thorough physical examination. The health care provider will also "interview" you about your personal and sexual history. Some of these questions will be very personal and may feel intrusive. However, it is important that you answer these questions honestly. The questions asked may include:

• What medications or drugs are you currently using? This includes prescription drugs, over-the-counter drugs, herbal supplements, dietary supplements, and illegal drugs.
• Have you had any psychological problems such as stress, anxiety, and depression?
• When did you first notice symptoms of erectile dysfunction/impotence?
• What are the frequency, quality, and duration of any erections you have had?
• What are the specifics of the circumstances under which impotence first occurred?
• Do/did you experience erections at night or during the morning?
• What sexual techniques do you use?
• Are there problems in your current relationship?

The health care provider may also wish to interview your sexual partner since your partner may be able to offer in sight about the underlying causes.

After your physical examination and interview, your health care provider may then order any one of the following tests:

• Complete blood count (CBC): This is a set of blood tests that, among other things, can detect the presence of anemia. Anemia is caused by a low red blood cell count and can cause fatigue, which in turn can cause ED.
• Liver and kidney function tests: These blood tests may indicate whether impotence may be due to your kidneys or liver functioning improperly.
• Lipid profile: This blood test measures the level of lipids (fats), like cholesterol. High levels may indicate atherosclerosis (hardening of the arteries), which can affect blood circulation in the penis.
• Thyroid function test: One of the thyroid hormones' functions is to regulate the production of sex hormones, and a deficiency in these hormones may contribute to or cause ED.
• Urinalysis: Analysis of urine can provide a wealth of information, including information on protein, sugar, and testosterone levels. Abnormal measurements of these substances can indicate diabetes, kidney disease, or a testosterone deficiency, all of which can cause erectile dysfunction.
• Duplex ultrasound: This is perhaps the best test for evaluating impotence. An ultrasound uses high-frequency sound waves to take "pictures" of the body's tissues. For people with erectile dysfunction, an ultrasound may be used to evaluate blood flow and check for signs of a venous leak, atherosclerosis or tissue scarring. This test is performed both while the penis is erect (usually induced by an injection of a drug that stimulates erection) and also while it is soft.
• Bulbocavernosus reflex: This test evaluates nerve sensation in the penis. During the test, your health care provider will squeeze the head of your penis, which should immediately cause your anus to contract. If nerve function is abnormal, there will be a delay in response time.
• Nocturnal penile tumescence (NPT): This test measures a man's erectile function while he is sleeping. Normally, a man will have five or six erections while asleep. These erections occur about every 90 minutes and last for about 30 minutes. A lack of these erections may indicate there is a problem with nerve function or circulation to the penis. The test uses two methods, the snap gauge method and the strain gauge method. The snap gauge method is performed by wrapping three plastic bands of varying strength around the penis. Erectile function is then measured based on which of the three bands breaks. The strain gauge method works by placing elastic bands around the tip and base of the penis. If the penis becomes erect during the night, the bands stretch, measuring the changes in penile circumference.
• Penile biothesiometry: This test involves the use of electromagnetic vibration to determine sensitivity and nerve function. A decreased sensitivity to these vibrations may indicate nerve damage.
• Vasoactive injection: During this test, an erection is produced by injecting special solutions that cause the blood vessels to dilate (enlarge) allowing blood to enter the penis.
• Dynamic infusion cavernosometry: This test is used for men with erectile dysfunction who have a venous leak. During this test, fluid is pumped into the penis at a predetermined rate. By measuring the rate at which fluid must be pumped to attain a rigid erection, health care providers can determine the severity of the venous leak.
• Cavernosography: Used in conjunction with the dynamic infusion cavernosometry, this test involves injecting a dye into the penis. The penis is then X-rayed so that the venous leak can be seen.
• Arteriography: This test is given to people who are candidates for vascular reconstructive surgery. A dye is injected into the artery believed to be damaged and X-rays are taken.

Before you are given any of these tests, your health care provider will explain what is involved. If you have any questions, do not hesitate to ask your health care provider.

LIFESTYLE CHANGES

One way to improve erectile dysfunction is to make some simple lifestyle changes. For some men, adopting a healthier lifestyle, such as quitting smoking, exercising regularly, and reducing stress, may be all that is needed to find relief. For those who require more intensive treatment, adopting these lifestyle changes in addition to other treatments can further help.

Quit Smoking: Quitting smoking can be very difficult and there is no single best way to quit that works for all people. Some approaches to try that might help you kick the habit include:

• Pick a quitting date one to three weeks in the future. Prepare for the date by cutting down on smoking, staying away from your favorite places to smoke, and making a plan for how you will deal with stressful events without smoking.
• On your quitting date, get rid of all cigarettes, keep busy, and stay in smoke-free places.
• Talk to your health care provider to see if you should try nicotine replacement therapy. The nicotine patch, nicotine gum, or other medication can be helpful but they will not take away your cravings to smoke.
• Make a clean break. Do not allow yourself to smoke "now and then." An addiction to nicotine can be reactivated anytime, even years after quitting.
• Take it one moment, one hour, one day at time. Cravings to smoke are usually short-lived and will go away whether or not you have a cigarette.
• Get help with quitting if you need it. Choose a comprehensive smoking cessation program that does not rely on a single technique (such as hypnosis). Your doctor can point you in the right direction.

Exercise Regularly: Regular exercise can improve your health in many ways. Along with improving erectile function, exercise can:

• Strengthen the heart.
  
• Improve the flow of oxygen in the blood.
  
• Build energy levels.
  
• Lower blood pressure.
  
• Improve muscle tone and strength.
  
• Strengthen and build bones.
  
• Help reduce body fat.
  
• Help reduce stress, tension, anxiety, and depression.
  
• Boost self-image and self-esteem.
  
• Improve sleep.
  
• Make you feel more relaxed and rested.
  
• Make you look fit and healthy.

To get the most benefit, you should exercise at least 20 to 30 minutes, three times a week. Current studies suggest that four or five times a week is best. If you are a beginner, exercise for 20 minutes and build up to 30 minutes. Before beginning any exercise program, you should consult with your health care provider. This is especially important if you have had a sedentary lifestyle for quite some time.

When starting out, you should plan a routine that is easy to follow and stick with. As the program becomes more routine, you can vary your exercise times and activities. Here are some tips to get you started.

• Choose an activity you enjoy. Exercising should be fun not a chore.
• Schedule regular exercise into your daily routine. Add a variety of exercises so that you do not get bored. Look into scheduled exercise classes at your local community center.
• Exercise does not have to put a strain on your wallet. Avoid buying expensive equipment or health club memberships unless you are certain you will use them regularly.
• Stick with it. If you exercise regularly, it will soon become part of your lifestyle.

If you feel you need supervision or medical advice to begin an exercise program, ask your health care provider to refer you to physical therapy. A physical therapist can evaluate your needs and start you on a safe and effective exercise program.

Reduce Stress: Stress is common to everyone. Our bodies are designed to feel stress and react to it. It keeps us alert and ready to avoid danger. But it is not always possible to avoid or change events that may cause stress and it is easy to feel trapped and unable to cope. When stress persists, the body begins to break down and illnesses can occur. The key to coping with stress is to identify stressors in your life and learn ways to direct and reduce stress.

Learning an effective means of relaxation and using it regularly is a good first step. Allow yourself some "quiet time," even if it's just a few minutes. Examine and modify your thinking, particularly unrealistic expectations. Talking problems out with a friend or family member can help put things in proper perspective. Seeking professional assistance can help you gain a new perspective on how to manage some of the more difficult forms of stress. Other approaches to reducing stress include:

• Keep a positive attitude. Believe in yourself.
• Accept that there are events you cannot control.
• Be assertive instead of aggressive. "Assert" your feelings, opinions or beliefs instead of becoming angry, combative or passive.
• Learn to relax.
• Exercise regularly. Your body can fight stress better when it is fit.
• Eat well-balanced meals.
• Stop smoking.
• Consume moderate amounts of alcohol and caffeine.
• Set realistic goals and expectations.
• Get enough rest and sleep. Your body needs time to recover from stressful events.
• Don't rely on alcohol or drugs to reduce stress.
• Learn to use stress management techniques and coping mechanisms, such as deep breathing or guided imagery.

Sex therapy is a short-term form of counseling, generally involving 5 to 20 sessions with a sex therapist. A typical session may be one hour every week or every other week.

During the session, the counselor will give the patient "assignments" to do at home, such as:

• Reading books about sexuality.
• Touching exercises that are designed to take away the pressure to perform during sex.
• Practicing better sexual communication skills.

Sex therapy may be useful for treating erectile dysfunction if a man is able to have a normal erection during sleep, the results of his physical examination and blood tests are normal and he is generally in good health. Sex therapy may also be helpful when erectile dysfunction is caused by stress, such as: work worries, financial worries, relationship conflicts, and poor sexual communication. In these cases, sex therapy may be the best treatment option.

Sex therapy is most effective when a man's sexual partner is willing to be part of the treatment. Studies have shown that for men with stress-related impotence, having the partner involved in the therapy resolves the problem 50%-70% of the time. When the man must go through counseling alone, the results are somewhat lower.

Sex therapy is unlikely to work if a man drops out of treatment after only one or two sessions.

Sometimes several sessions of sexual counseling can be helpful to a man who is going to receive medical or surgical treatment for erectile dysfunction. A counselor can help guide a couple in agreeing on a treatment or help them improve their sexual communication and lovemaking skills. A single man may benefit from counseling on how to talk to his partner about penile injections or a vacuum constriction device, both treatments for erectile dysfunction.

Some insurance plans cover sex therapy. Once you select a therapist, call her/him to ask about whether or not his or her services are covered by your insurance provider. If payment cannot be worked out through insurance, many therapists can adjust their fees. Sex therapy clinics tend to be less expensive than private therapists. The cost of sex therapy programs varies, but generally range between $600 and $2,300, depending on the nature of the problem and the response to treatment.

Call your local hospital or university medical center to see if they have a sex therapy clinic. Also, ask your health care provider if he or she can recommend a therapist.

ORAL MEDICATIONS

Currently there are only three oral drugs approved by the FDA to treat erectile dysfunction: Cialis, Levitra, and Viagra. All work by increasing the flow of blood into the penis, so that when a man is sexually stimulated, he can get an erection.

There is not much difference between drugs used for erectile dysfunction. Cialis, Levitra and Viagra work by a similar mechanism to cause erection. There are subtle differences in how long the drug works and how quickly it works. Levitra works a little longer than Viagra and takes effect a little faster than Viagra. They both take effect in about 30 minutes. With Levitra, the effects last for about 5 hours. The effects with Viagra last 4 hours.

According to some experts, Cialis takes a bit longer to work, but the effects last for much longer - two-to-three days.

Follow the directions on your prescription label carefully and ask your health care provider or pharmacist to explain any part that you do not understand. Take these drugs exactly as directed. Do not take more or less of it or take it more often than prescribed by your health care provider. Do not take these drugs more than once a day.

If one of these Drugs isn't Effective for erectile dysfunction, you should probably not try another. Because these drugs work the same way, it's unlikely that you'll have success with one if you've failed to achieve an adequate erection with the other.

There are certain situations in which these drugs may not be safe to take. Before taking them, tell your health care provider:

• If you are allergic to Viagra or any other drugs.
• About any prescription or non-prescription medications you are currently taking, including herbal and dietary supplements.
• If you are scheduled for surgery, including dental surgery.
• If you take nitroglycerin or a long-acting nitrate to treat chest pain. The combination of Levitra or Viagra with these drugs can cause dangerously low blood pressure.

These drugs should be kept in its original container and out of reach of children. Store them away from excess heat and moisture (not in the bathroom). Discard any medication that has expired or is no longer needed.

Side effects are not common but they can occur. Side effects can include:

• Headache
• Upset stomach
• Flushing (feeling warm)
• Nasal congestion
• Changes in vision (Viagra only)
• Back pain (with Cialis)

Call your health care provider if you experience severe forms of these symptoms or if they do not go away after 4-8 hours.

Warning: Call your health care provider immediately if you experience any of the following symptoms:

• Rash
• Painful erection
• Prolonged erection (longer than 4 hours)
• Fainting
• Chest pain
• Itching or burning during urination

VIAGRA LINKS

Men Devastated When Viagra Fails

Viagra Safe for Some Men With Heart Failure

Erectile Dysfunction

ALPROSTADIL

Alprostadil is a type of medicine that causes blood vessels to expand, increasing blood flow throughout the body. By increasing blood flow to the penis, alprostadil helps facilitate an erection. Alprostadil can be given either by injection or as a suppository. When given as a suppository, the medicine is placed into the opening at the tip of the penis. When injected, a needle and syringe is used to inject the medicine in the penis. If you receive the injection-form, alprostadil is sold under the brand names Caverject, Edex, and Prostin VR. Suppository-form of alprostadil is sold under the brand name MUSE. Alprostadil should only be used in men with erectile dysfunction. If this medicine is not used properly, permanent damage to the penis can occur.

Alprostadil delivered via the injection method causes an erection firm enough for sexual intercourse in approximately 80% of men with erectile dysfunction, regardless of their age or the cause of their problem. Alprostadil delivered via a suppository is not as effective as when it is delivered by penile injection; it produces an erection in approximately 30% of men with erectile dysfunction.

Alprostadil usually begins to work in about 5 to 10 minutes. Intercourse should be attempted within 10 to 30 minutes after using the medication. An erection may continue after ejaculation.

This medicine is not right for everyone. Before taking alprostadil, tell your health care provider:

• If you have ever had an allergic reaction to alprostadil.
• If you are allergic to any other substances such as medicine, foods, preservatives, or dyes.
• If you are taking any prescription or over-the-counter medicine including herbal and dietary supplements.
• If you have a penile implant.
• If you have a history of priapism.

Also, tell your health care provider if you have any medical problems, especially:

• Abnormalities to your penis such as curvature or birth defects.
• Bleeding problems.
• Penile infection.
• Red or itchy penis.
• Conditions that cause thickened or slower blood flow such as leukemia (cancer of the blood), sickle cell disease or thrombocythemia (large number of platelets).

If alprostadil is not safe for you to take, your health care provider can recommend other treatment options that are appropriate based on your health and medical history.

The suppository-form, called MUSE, is a small pellet of alprostadil that is placed inside the urethra (the small opening on the end of the penis) to dissolve inside the penis causing blood vessels to expand so that more blood can flow into the penis allowing for an erection to occur. Before using the suppository-form of alprostadil, be sure that you fully understand how to administer it. Do not insert more than two doses of alprostadil within a 24-hour period and do not use any more than the health care provider-recommended dose during a single usage. This could result in permanent damage to the penis. Also, when using the suppository-form of alprostadil, use a condom if having sexual intercourse with a pregnant woman. The effects of this medicine on early pregnancy are unknown.

Inserting the Suppository:

• Before inserting the pellet of medicine, urinate; the small amount of urine left in the urethra will help dissolve the suppository after it has been inserted.
• Push the medicine through the urethra.
• To help dissolve the suppository once inside, roll your penis between your hands for 10 seconds. If you feel any stinging, continue this motion to help the stinging stop.
• Sitting, standing or walking for 10 minutes while an erection is developing helps increase the blood flow to your penis to gain a proper erection.

If you have any questions, be sure to ask your health care provider or pharmacist.

When using the injection-form of alprostadil, the medicine is inserted through the wall of the penis using a needle and syringe. The needle goes into the spongy tissue on the side of the penis. Once inside, the medicine works the same way as the suppository form works - blood vessels dilate (enlarge) allowing for blood flow to the penis to increase and an erection to occur.

How to inject alprostadil: There are several alprostadil products that can be injected. The injection method for these products is the same, however the methods for preparing the mixtures are different. Be sure you know which product you are using and that you fully understand the proper way to mix the medicine. As with the suppository-form of medicine, the injection-form of alporstadil should not be used more often than prescribed or in larger amounts as this could result in permanent damage to the penis.

Before drawing the medicine into the syringe, be certain that you have washed your hands with soap and water and set the bottles on a clean surface. It is also important to wipe the tops of the injection bottles with an alcohol swab. Do not wipe the needle with the same alcohol swab. After a single-use injection is mixed, alprostadil must be used immediately. Throw away any unused mixture in the syringe. It cannot be stored for later injection. Do not reuse your needles.

If you have any questions about how to use this medication, ask your health care provider or pharmacist.

Making choices about Method of Delivery: It's a personal choice that should be made with the help of your health care provider and your partner. There are pros and cons of each mode of delivery. For example, the injection may be more painful, but it tends to be more effective than the suppository-form.

Condom Use: When using alprostadil, either by suppository or injection, use a condom if having intercourse with a pregnant woman. The effects of alprostadil on the fetus are still unknown.

Storing Your Medicine: Alprostadil should be kept in its original container and out of the reach of children. The suppository-form of alprostadil can be stored at room temperature, away from excess heat or moisture (such as the bathroom) for up to 14 days. Otherwise store it in the refrigerator, but be sure to keep it from freezing. While in powder form, alprostadil can be stored at room temperature, away from excess heat or moisture (such as the bathroom) for up to three months. Do not keep outdated medicine or medicine that you no longer need.

Side effects with alprostadil are not common, but they do occur. Contact your health care provider if you notice severe and prolonged:

• Bleeding or spotting from the urethra (mild bleeding can be expected).
• Stinging of the urethra.
• Penile pain.

Side effects associated with injection include:

• Bleeding at the site of injection.
• Pain at the site of injection (common).
• Painful erection.
• Bruising or clotted blood in the area of the injection. This is usually caused by an incorrect injection.

If any of the above listed side effects are severe and prolonged, call your health care provider.

Contact your doctor immediately if the following side effects occur:

• Curving of the penis with pain during an erection.
• Erection continues for four to six hours with severe and continuing pain in the penis.
• Swelling in or pain of the testes.
• Dizziness.
• Faintness.
• Pelvic pain.
• Flu-like symptoms.

TESTOSTERONE DEFICIENCY

Testosterone is a hormone produced by the testicles and is responsible for the proper development of male sexual characteristics. Testosterone also regulates the expansion of arteries, promotes the circulation of blood, and is responsible for the maintenance of muscle bulk. Without adequate production of testosterone, erectile dysfunction, among other problems, can develop. Testosterone replacement therapy may improve erectile dysfunction and other consequences of low testosterone production.

As a man ages, the amount of testosterone in his body gradually declines. This natural decline starts after age 30 and continues throughout life. Other causes of lowered testosterone levels include:

• Injury or infection to the testicles.
• Chemotherapy or radiation treatment for cancer.
• Hemochromatosis (too much iron in the blood).
• Dysfunction of the pituitary gland (a gland in the brain that produces many important hormones).
• Inflammatory diseases such as sarcoidosis (a condition that causes inflammation of the lungs).
• Medications, especially those used to treat depression or mental illness and heartburn.
• Chronic illness.
• Stress.
• Alcoholism.

Symptoms of Testosterone Deficiency: Without adequate testosterone a man may lose his sex drive, have weakened brain and intellectual activity, and may often feel moody. Low levels of testosterone may also result in an increase in stomach and upper body fat, a decline in the amount of muscle in the body, as well as a decline in strength. Bone thinning osteoporosis may also result from low testosterone levels. Other symptoms of lowered testosterone levels include:

• Erectile dysfunction.
• High cholesterol levels.
• Depressed mood.
• Anxiety.
• Problems with concentration and memory.

The only accurate way to detect the condition is to have your health care provider measure the amount of testosterone in your blood. If you have low testosterone, your health care provider can prescribe testosterone replacement therapy (TRT). Testosterone is available in pill form, patches, injections, or it can be implanted under the skin.

Absorbing testosterone through the skin via a patch or gel, or receiving an intramuscular injection is the best method of delivering TRT. Testosterone in an oral form is not absorbed very well by the body and may increase the risk of high cholesterol and heart and liver problems.

Testosterone injections are generally administered every two weeks and can be given either by your health care provider or you can learn to give them yourself or teach a family member to give them. Aside from needing to receive a shot every two weeks, the other drawback to injections is that relief from symptoms of low testosterone may be irregular in between shots.

Skin patches effectively deliver testosterone consistently into the body. Depending on the product, these patches can be applied to the scrotum, the buttocks, the arms, or the back. Many men experience mild skin irritation in response to these patches, however the irritation is only rarely severe.

Talk to your health care provider to determine if TRT is right for you and which mode of delivery would be best.

TRT Contraindications & Side Effects

Testosterone replacement therapy can increase cholesterol levels. It can also increase the size of the prostate and if early prostate cancer is present, it can stimulate the cancer's growth. Thus, TRT may not be right for men who have high cholesterol or other heart disease risk factors or prostate cancer or are at risk for prostate cancer. It is important for all men considering TRT to undergo a thorough prostate cancer screening prior to starting this therapy.

As long as the amount of testosterone given elevates the blood levels to within the normal range, side effects are rare. The following symptoms may indicate that you are receiving too much testosterone and should be brought to your health care provider's attention:

• Nausea and vomiting.
• Priapism.
• Acne.
• Swelling of the ankles.
• Headaches.
• Noticeably increased appetite.
• Breast enlargement.

Like any other medication, directions for administering testosterone should be followed exactly as your health care provider has ordered. If you are unsure or have any questions about TRT, ask your health care provider.

VACUUM CONSTRUCTION DEVICE (VCD)

A vacuum constriction device (VCD) is an external pump with a band on it that a man with erectile dysfunction can use to get and maintain an erection. The pump helps the penis become erect while the band maintains the erection.

To use the device:

• Place the pump, which can be pumped by hand or run on batteries, over the penis.
• Pump the air out of the cylinder so that a vacuum is created. The vacuum draws blood into the shaft of the penis and causes it to swell and become erect.
• Once the penis is erect, with the help of lubricant slide the retaining band down onto the lower end of the penis.
• Remove the pump.
• The band can be left on safely for up to 30 minutes to allow for successful intercourse.

Studies suggest that about 50%-80% of men are satisfied with a VCD. Some men report that VCD works best after a partial erection is achieved through foreplay.

Vacuum constriction devices are most commonly used to treat medical causes of erectile dysfunction. These causes include:

• Poor blood flow into the penis.
• Excess blood flow out of the penis during erection.
• Damage to nerves that control the erection reflex.

Because VCDs are safe to use and have few long-term side effects, they are also sometimes recommended as a treatment for anxiety-based erectile dysfunction.

Side Effects: The erection obtained by the VCD is not the same as an erection obtained naturally. The penis tends to be purplish in color and can be cold. To warm the penis so that it is not so cold, you can try putting a warm compress on it before having sex. Other side effects can include:

• Numbness.
• Decrease in the force of the ejaculation.
• Bruising and swelling of the penis.
• Difficulty achieving orgasm.

VCDs vary in cost from $300 to $500, depending on the brand and type. The battery-powered versions tend to be more expensive, but also tend to work a little more quickly. Battery-powered VCDs are especially helpful for men who do not have good hand strength and coordination. Most insurance policies, including Medicare, cover at least part of the costs of VCDs, especially if a medical causes for erectile dysfunction has been documented. Medicaid, however, does not cover VCDs.

PENILE IMPLANTS (PENILE PROSTHESIS)

Fortunately, there is one impotence treatment that enables sexual and romantic spontaneity. You can have that firm erection you want almost instantaneously... anytime, anyplace. This impotence treatment is a penile implant (penile prosthesis). Penile implants (often called "internal penile pumps") are one of several erectile dysfunction treatment options. Health care providers began doing penile implants in the early 1970s. Since then, nearly 300,000 men have received penile implants. About 20,000 men choose penile implants each year to treat impotence with positive results. According to research, both men and their partners have 90% satisfaction with penile implants. In most cases, a penile implant not only treats erectile dysfunction, but it resolves erectile dysfunction.

A penile implant generally requires a hospital stay of only a day or two. In many cases, an implant can be done as an outpatient procedure in a "23-hour stay." Many men report that the "return on investment" in the procedure can be gratifying.

There are three types of penile implants. All are totally concealed within the body and provide an almost immediate erection to enhance romantic spontaneity.

• 3-piece inflatable implants (about 75% of penile implants.)
• 2-piece inflatable implants (about 15% of penile implants.)
• Semi-rigid malleable (positionable) rods (about 10% of penile implants.)

Long-term clinical data shows penile implants to be highly effective and reliable. Studies also find a very high degree of satisfaction by both users and their partners.

Penile implants often follow a failure or poor treatment experience with Viagra or another therapy. As with all surgical procedures, there is a slight risk of infection. And although penile implants are highly reliable, malfunctions can occur over time. Reliability and inflation control, however, have significantly improved over the past few years.

Penile implants require a simple surgical procedure to place and totally conceal the prosthesis. An inflatable penile implant is a small, self-contained medical device that is implanted entirely within the body. It is not visible. Two cylinders are inserted side-by-side into the corpora cavernosa in the shaft of the penis (see Anatomy of the Penis.) During a natural erection, the corpora fill with blood. After a penile implant, when a man desires an erection, he uses the device to transfer fluid to the cylinders. The cylinders expand, enlarging or "erecting" the penis.

For malleable or "positionable" penile implants, the urologist places bendable rods into the penis. The man then gently bends his penis to achieve an erection.

Among other advantages, penile implants are the one option for treating physical erectile dysfunction that best preserves romantic spontaneity.

Health care providers normally recommend starting men with a less-intrusive treatment such as Viagra. If this fails, then penile implants may be the logical next step.

The cost of penile implants (including device, medical procedure, and after-care) usually ranges from $15,000 - $35,000. Most insurance plans, including Medicare, cover penile implants and procedures. There may be some level of co-pay for the patient. However, most men who choose a penile implant have failed previous erectile dysfunction treatment. Most gladly pay a small portion of the cost of the procedure to regain their ability to achieve an erection.

TYPES OF PENILE IMPLANTS

Three-piece inflatable penile implants: Three-piece penile implants are the most technologically advanced device. They are totally concealed within the body. Urologists consider the 3-piece inflatable implant to be the "gold standard" of penile implants.

Placement. During placement of the device, the patient usually is under general anesthesia. A skilled urologist trained in prosthetic urology performs the simple procedure. The procedure generally is on an outpatient basis, commonly called a "23-hour stay."

Using a small incision, the urologist positions inflatable cylinders in the corpora cavernosa. A small pump is positioned in the scrotum and a reservoir is placed deep in the abdomen. The reservoir is filled with saline solution. The device is completely hidden and unobtrusive.

Recovery time. It commonly takes about four to six weeks to regain sexual function. Patients can resume sexual activity after physician consultation.

How it works. Gently squeeze the concealed pump in your scrotum several times. This moves the saline solution from the reservoir into the cylinders. As the cylinders fill, the penis becomes erect and firm.

To end the erection, simply press a "deflation site" on the pump. Deflating the cylinders transfers the fluid back to the reservoir and the penis becomes flaccid.

Advantages of three-piece penile implants:

• Most closely resembles the process and "feel" of a natural erection.
• Simple, fast inflation preserves sexual spontaneity.
• Erection feels full.
• When deflated, the penis feels soft and flaccid and appears full and youthful.
• Totally concealed.

Disadvantages and risks of three-piece penile implants:

• Requires some manual dexterity to inflate.
• More mechanical parts than other penile implants.
• Complications can occur, including infection and device malfunction.

Two-piece inflatable penile implants: Two-piece inflatable penile implants are fluid-filled internal penile pumps. The two-piece system includes cylinders and a small pump. This makes it a slightly more complex device compared to malleable or "positionable" penile implants.

Placement. During the procedure, the patient usually is under either local or general anesthesia. The procedure generally is on an outpatient basis, commonly called a "23-hour stay."

A skilled urologist trained in prosthetic urology performs the procedure which usually takes 45 minutes or less. Using a small incision, the urologist positions inflatable cylinders in the corpora cavernosa. A small pump is positioned in the scrotum. The device is completely concealed and unobtrusive.

The pump inflates the cylinders by transferring fluid within the system. A simple deflation technique then transfers fluid to return the penis to a flaccid state.

Recovery time. It takes about four to six weeks to regain sexual function. Patients can resume sexual activity after physician consultation.

How it works. Gently squeeze and release the concealed pump in your scrotum several times. This transfers the fluid in each cylinder to the cylinder shaft. Your penis will then become erect.

To end the erection, gently bend your penis down for 6-12 seconds (as illustrated here.) This transfers fluid back into the reservoir.

Advantages of two-piece penile implants:

• Small inflation pump provides comfort and ease.
• Simple, fast inflation preserves sexual spontaneity.
• Fast and easy one-step deflation.
• Easier to conceal than a malleable implant.

Disadvantages and risks of two-piece penile implants:

• Requires some manual dexterity to inflate.
• More mechanical parts than malleable penile implants.
• Complications can occur, including infection and device malfunction.

Malleable (positionable) penile implants: This is the simplest of the penile implants.

Placement. Most skilled urologists will do the procedure on an outpatient basis, also called a "23-hour stay."

The surgeon gently places two bendable, "positionable" rods into the penis. The rods have an outer coating of silicone and inner stainless steel core or interlocking plastic joints. These enable the man to place the penis in either the erect or flaccid position.

Recovery time. It takes about four to six weeks to regain sexual function. Patients can resume sexual activity after physician consultation.

How it works. For intercourse, the man places his penis in the erect position. As he does so, the rods inside his penis bend. To conceal the penile implant, the man bends his penis down. He can bend the device in more than one place to create the desired erection.

Advantages of malleable penile implants:

• Easy to use.
• Generally the simplest surgical procedure for erectile dysfunction.
• Few mechanical parts mean less chance of malfunction.
• Least expensive penile implant.

Disadvantages and risks of malleable penile implants:

• The penis always has some degree of rigidity and may be difficult to conceal under tighter-fitting clothes.
• Complications can occur, including infection and device malfunction.

VASCULAR RECONSTRUCTIVE SURGERY

Vascular reconstructive surgery is sometimes used to treat erectile dysfunction. The goal of surgery is to improve the blood supply of the penis in attempts to improve a man's ability to get and maintain an erection. However, the procedure, which is technically difficult, costly, and not always effective, can result in nerve damage and scar tissue development.

Only a small percentage of men may be candidates for this surgery, in particular young men suffering from erectile dysfunction as a result of trauma to the penis and surrounding areas. If you fall into this category, talk to your health care provider to see if vascular reconstructive surgery is right for you.

Unfortunately, the long-term results from this type of surgery have been disappointing with even the best of results showing only 1 out of 20 men improved. However, for younger men with a single damaged blood vessel that occurred as a result of a pelvic or genital injury, the success rate for this treatment is higher (50%-75%).

Vascular reconstructive surgery of the penis generally involves bypassing blocked arteries by transferring an artery from an abdominal muscle to a penile artery so that it creates a path to the penis that bypasses the area of blockage that is inhibiting blood flow to the penis.

FUTURE TREATMENT OPTIONS

Future treatments for erectile dysfunction focus on providing medications that are more effective, work rapidly, and have fewer, if any, side effects than currently available treatments. Currently there are three oral medications available to treat erectile dysfunction - Cialis, Levitra and Viagra . A number of pharmaceutical companies are researching new treatments for impotence, and many new options may be just around the corner. These include:

• Cialis (tadalafil): Cialis works like Viagra, but stays in the bloodstream longer, between 24-36 hours. As a result, a man is able to have sex again during that time without taking more medication.
• Uprima: Still undergoing clinical trials, Uprima comes in a tablet form that dissolves under the tongue. Uprima works by stimulating the brain chemical dopamine, which heightens sexual interest and sensations. A small number of people passed out after taking Uprima, so its release in the U.S. is on hold; however, it is currently available in Europe. Clinical trials are also currently being conducted on a nasal spray form of this drug.
• Topiglan: Still under investigation, if Topiglan were to be approved by the FDA, it would be the first topical medication applied to the penis to treat erectile dysfunction. Topliglan uses the same drug that is used in injection therapy and suppository therapy, alprostadil. If Topligan proves safe and effective, injection and suppository therapy would no longer be required. The man could get the same benefit by applying the medication topically. Initial clinical trial results yield few side effects.
• Alibra: Still under review by the FDA, Alibra is similar to alprostadil, but it lasts longer and has a built-in painkiller.

LONG-TERM EFFECTS OF ERECTILE DYSFUNCTION (IMPOTENCE)

Erectile dysfunction takes more than a physical toll; the emotional impact the condition can have on a man and his partner can be just as difficult. It is common for men with erectile dysfunction to feel anger, frustration, sadness, or lack confidence. However, the condition can be treated. The first step in addressing your concerns about erectile dysfunction is to be honest with yourself, your partner, and your health care provider. Once erectile dysfunction has been brought out into the open, coping with it as you go through treatment will be easier and less stressful. Communication is essential to a successful diagnosis and treatment, as well as, helping your partner understand your feelings.

While you are being treated for erectile dysfunction, it is important to be patient with your progress and keep in mind that everybody is different and that a treatment that might work for one person may not work or be appropriate for you. It is also important to know that the treatment you choose may not work the first time or may not work every time.

For some couples sex therapy may be necessary to help you and your partner cope. It may also help you to hear from some men who have erectile dysfunction and learn about their experiences. Contact your health care provider about local support groups in your area.

Everyone experiences stress. Our bodies are designed to feel stress and react to it. It keeps us alert and ready to avoid danger. But, when stress persists, the body begins to break down and problems, like erectile dysfunction, can occur. The key to coping with stress is identifying stressors in your life and learning ways to reduce them.

DEFINITION OF STRESS: Stress is your reaction to any change that requires you to adjust or respond. It's important to remember that you can control stress because stress comes from how you respond to stressful events.

STRESS CAUSES: Stress can be caused by anything that requires you to adjust to a change in your environment. Your body reacts to these changes with physical, mental, and emotional responses. We all have our own ways of coping with change, so the causes of stress can be different for each person.

Common causes of stress include:

• Death of a loved one.
• Confrontations.
• Marriage.
• Deadlines.
• Legal problems.
• Job loss.
• Divorce.
• New job.
• Retirement.
• Money problems.
• Illnesses.

When you are not sure of the exact cause of your stress, it may help to know the warning signs of stress. Once you can identify these signs, you can learn how your body responds to stress. Then you can take steps to reduce it.

WARNING SIGNS OF STRESS: Your body sends out physical, emotional, and behavioral warning signs of stress.

Emotional warning signs of stress include:

• Anger.
• Inability to concentrate,
• Unproductive worry.
• Sadness.
• Frequent mood swings.

Physical warning signs of stress include:

• Stooped posture.
• Sweaty palms.
• Chronic fatigue.
• Weight gain or loss.
• Erectile dysfunction.

Behavioral warning signs of stress include:

• Over-reacting,
• Acting on impulse.
• Using alcohol or drugs.
• Withdrawing from relationships.
• Changing jobs often.

COPING WITH STRESS:

• Lower your expectations; accept that there are events you cannot control.
• Ask others to help or assist you.
• Take responsibility for the situation.
• Engage in problem solving.
• Express distressing emotions. Be assertive instead of aggressive. "Assert" your feelings, opinions or beliefs instead of becoming angry, combative or passive.
• Maintain emotionally supportive relationships.
• Maintain emotional composure.
• Challenge previously held beliefs that are no longer adaptive.
• Directly attempt to change the source of stress.
• Distance yourself from the source of stress.
• Learn to relax.
• Eat and drink sensibly.
• Stop smoking or other bad habits.
• Exercise regularly.
• Maintain a healthy sense of self-esteem.

Experts agree that coping is a process rather than an event. Thus, an individual may alternate between several of the above coping strategies in order to cope with a stressful event.

SEEKING HELP WITH STRESS

You should seek help in dealing with your stress when you experience any of the following:

• Marked decline in work/school performance.
• Excess anxiety.
• Alcohol or drug abuse.
• Inability to cope with demands of daily life.
• Irrational fears.
• Obsessive preoccupation with food and fear of becoming obese with no relationship to actual body weight.
• Significant change in sleeping or eating habits.
• Persistent physical ailments and complaints.
• Suicidal thoughts or urge to hurt others.
• Self-mutilation, self-destructive or dangerous behavior
• Sustained withdrawn mood or behavior.

Your personal health care provider can assist you in seeking help with stress. He or she can determine if your stress is due to an anxiety disorder, a medical condition, or both and can refer you to a mental health professional, if necessary. If an emergency, call a crisis hotline, or go to the nearest emergency room.

For some men, being stressed may just make you irritable, but for others too much stress can cause sexual problems, such as erectile dysfunction. For these men, learning to relax and ease stress is all that may be needed to treat ED.

STRESS MANAGEMENT TECHNIQUES

In order to learn how to relax, you need to become familiar with your own breathing patterns and change them in ways that will help you relax. Your breathing pattern is often disrupted by changes in emotion. People who are anxious tend to hold their breath and speak in a high-pitched voice as they exhale. On the other hand, people who are depressed, tend to sigh and speak in a low-pitched voice as they exhale.

Below are a few relaxation exercises. But first, be sure that you have a quiet location that is free of distractions, a comfortable body position, and a good state of mind. Try to block out worries and distracting thoughts.

Rhythmic breathing: If your breathing is short and hurried, slow it down by taking long, slow breaths. Inhale slowly then exhale slowly. Count slowly to five as you inhale, and then count slowly to five as you exhale. As you exhale slowly, pay attention to how your body naturally relaxes. Recognizing this change will help you to relax even more.

Deep breathing: Imagine a spot just below your navel. Breathe into that spot, filling your abdomen with air. Let the air fill you from the abdomen up, then let it out, like deflating a balloon. With every long, slow exhalation, you should feel more relaxed.

Visualized breathing: Find a comfortable place where you can close your eyes and combine slowed breathing with your imagination. Picture relaxation entering your body and tension leaving your body. Breathe deeply, but in a natural rhythm. Visualize your breath coming into your nostrils, going into your lungs and expanding your chest and abdomen. Then, visualize your breath going out the same way. Continue breathing, but each time you inhale, imagine that you are breathing in more relaxation. Each time you exhale imagine that you are getting rid of a little more tension.

Progressive muscle relaxation: Switch your thoughts to yourself and your breathing. Take a few deep breaths, exhaling slowly. Mentally scan your body. Notice areas that feel tense or cramped. Quickly loosen up these areas. Let go of as much tension as you can. Rotate your head in a smooth, circular motion once or twice. (Stop any movements that cause pain!) Roll your shoulders forward and backward several times. Let all of your muscles completely relax. Recall a pleasant thought for a few seconds. Take another deep breath and exhale slowly. You should feel relaxed.

Relax to music: Combine relaxation exercises with your favorite music in the background. Select the type of music that lifts your mood or that you find soothing or calming. Some people find it easier to relax while listening to specially designed relaxation audio tapes, which provide music and relaxation instructions.

Mental imagery relaxation: Mental imagery relaxation, or guided imagery, is a proven form of focused relaxation that helps create harmony between the mind and body. Guided imagery coaches you in creating calm, peaceful images in your mind -- a "mental escape." Identify your self-talk, that is, what you are saying to yourself about any problems you have. It is important to identify negative self-talk and develop healthy, positive self-talk. By making affirmations, you can counteract negative thoughts and emotions. Here are some positive statements you can practice.

Let go of things I cannot control.
I am healthy, vital, and strong.
There is nothing in the world I cannot handle.
All my needs are met.
I am completely and utterly safe.

HELPFUL LINKS

Endocrinology & Impotence (Erectile Dysfunction)
Impotence.org
4-Men.org: Impotence
Male Impotence Treatment: Latest Info on Erectile Dysfunction
eMedicine: Impotence/Erectile Dysfunction Introduction
Sex Education Links: Impotence & Erectile Dysfunction

CONSIDERATIONS

A study done at the Boston University School of Medicine linked overall health to impotence. Researchers studied the medical histories of 1,300 men aged 40 to 70 years. They found some impotence in a total of 52 percent of those under study. Men who were being tested for heart disease, high blood pressure, or diabetes were one and a half to four times more likely to than the overall group to be completely impotent later in life. The situation was even worse for men who had heart disease or hypertension and who smoked.

Alcohol intake decreases the body's ability to produce testosterone. Research at Chicago Medical School revealed that drinking alcohol may cause the hormonal equivalent of menopause in men. Alcohol not only affects sexual function, but also helps set the stage for a heart attack and other dangerous conditions.

Arteriosclerosis, which restricts blood supply to the penis and to the nerves that govern sexual arousal, may result in a "failure to perform." If impotence is related to clogged blood vessels, a diet low in fats can actually help reverse the problem. See Arteriosclerosis/Atherosclerosis, Cardiovascular Disease, and/or Circulatory Problems for more information.

A study done at Boston University showed that men who smoke one pack of cigarettes a day for five years were 15 percent more likely to develop clogging in the arteries that serve the penis, a situation that can cause impotence. In addition, heavy smoking decreases sexual capability by damaging the tiny blood vessels in the penis. The use of marijuana and cocaine also result in impotence.

Duplex ultrasonography, a non-invasive method of measuring penile blood flow, is a reliable method of determining whether arterial occlusion plays a role in impotence. If your health care provider believes atherosclerosis to be the underlying problem, he or she may advise vascular surgery to improve blood flow to the penis.

According to figures from impotence organizations, only about 5 percent of the estimated 30 million men affected are aware of therapy options.

Urologists differ in the types of treatment they recommend for impotence, but many opt first for nonsurgical treatment.

Injections of the drugs papaverine (Pavabid) and phentolamine (Regitine) or prostaglandin E1 (PGE1) into the base of the penis before intercourse have been shown to be roughly 80 percent effective in producing "satisfactory erection" in impotent men who have tried it. The drug alprostadil also is available in an injection kit (Caverject). These drugs work by relaxing smooth muscle, causing the blood vessels in the penis to dilate, promoting an erection that can last an hour or more. An estimated 300,000 men in the United States use this technique each year. Possible side effects include priapism (prolonged, painful erections). Also, although the injections are done with a tiny needle, and are supposed to be painless when done properly (proper technique is crucial), this prospect is unappealing to many men. A less invasive technique, which involves instilling alprostadil into the urethra with a tiny plunger, is another option that may be available.

Yohimbine (sold under the brand name Dayto, Yocon, and Yohimex) is a prescription drug that has bee approved by the FDA for treatment of impotence. Its effectiveness is questionable, however. Many experts consider it to be, in essence, a placebo. Yohimbine has an effect on the body similar to that of adrenaline; it speeds up the heartbeat and elevates blood pressure. Beware of yohimbine if you have high blood pressure.

If impotence is linked to high levels of the hormone prolactin, bromocriptine (Parlodel) may be prescribed to correct the problem.

A number of vacuum devices are used to promote erection. With these devices, a cylinder is placed over the penis and a hand pump is used to create a vacuum in the cylinder. This in turn causes blood to flow into the penis, creating an erection. The user then puts a constriction band around the base of the penis, causing the erection to last up to 30 minutes. These devices are available by prescription only. Some 100,000 men in the United States choose this method of treatment each year. Problems abound with this technique, however.

Since the early 1970s, more than 250,000 American men have turned to inflatable penile implants to mechanically create erections. Penile implants are surgically installed devices that are made of silicone or polyurethane. One type is made of two semi rigid but bendable rods; another type consists of a pump, a fluid-filled reservoir, and two cylinders into which the fluid is pumped to create an erection. Penile implants are now coming under FDA scrutiny. Since 1984, the FDA's Center for Devices and Radiological Health has logged more than 6,500 reports of problems with inflatable devices - a large number for a medical device, according to the FDA. With the development of more effective agents, implants are now considered to be a last resort, to be tried only when all other methods have failed.

Dr. Robert Frankt of Budapest University in Hungary found a great increase in sexual vitality and energy in men using a combination of two herbs, green oats (Avena sativa) and stinging nettle. "Feeling one's oats" is an expression that originated centuries ago, and probably with good reason; a study by the Institute for Advanced Study of Human Sexuality found that men who suffered from reduced sexual desire and diminished performance were helped by green oats. Nettle is full of vital minerals and is good also for hypoglycemia, allergies, depression, prostate and urinary tract disorders, and a host of other problems.

See Hypothyroidism and Hyperthyroidism for more information.

Keep in mind that sexual function changes with age. As you age, you may require more stimulation and a longer period of time to achieve an erection.

Investigate the possibility of heavy metal intoxication. A hair analysis can reveal possible heavy metal poisoning. See Hair Analysis for more information.

If you suspect impotence may be related to a drug you are taking, discuss this with your health care provider. There may be satisfactory alternatives that will not cause this problem. certain blood pressure medications and tranquilizers often cause erectile dysfunction and erectile difficulties. The drugs cimetidine (Tagamet) and ranitidine (Zantac), which are used to treat ulcers and heartburn, also have significant side effects in some men. Caution: Do not stop taking a prescription drug or change the dosage without consulting with your health care provider.

Consider possible psychological factors that may be contributing to impotence, especially repressed anger or a fear of intimacy. Exploring psychological issues with a qualified therapist can help.

Consult a urologist for testing to determine whether impotence is caused by an underlying illness that requires treatment.

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DIETARY & HOLISTIC RECOMMENDATIONS

Eat a healthy, well-balanced diet. Include in the diet pumpkin seeds, bee pollen, or royal jelly. Caution: Bee pollen may cause an allergic reaction in some individuals. Start with a small amount, and discontinue use if a rash, wheezing, discomfort, or other symptoms occur. See Adult Regular Diet or MoonDragon's Diet Index for a specialized dietary plan if you have certain health issues, such as high cholesterol or diabetes.

Avoid alcohol, particularly before sexual encounters.

Do not consume animal fats, sugar, fried or junk foods.

Do not smoke. Avoid being around cigarette smoke.

Avoid stress.

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HERBS

Damiana is good for improving blood flow to the genital area.

Sarsaparilla contains a testosterone-like substance for men. Muscular men have higher testosterone levels.

Wild yam contains natural steroids that rejuvenate and give vigor to lovemaking. Steroids are what help exercise to melt off more weight. This hormone is found in the human body as dehydroepiandrosterone (DHEA). Take twice the amount recommended on the label for 2 weeks, then stop for 2 weeks. Continue this on-and-off cycle, taking the recommended amount.

Other herbs that may be beneficial include dong quai, gotu kola, hydrangea root, pygeum, saw palmetto, and/or Siberian ginseng.

There are a number of herbal products on the market that claim to help sexual potency:

• Prostata from Gero Vita International normalizes prostate function, increasing libido and erectile ability.
  
  
• Saw Palmetto Supreme from Gaia Herbs is an herbal tincture that helps to normalize prostate function.
  
  
• SensualiTea from UniTea Herbs contains damiana, sarsaparilla, and licorice root. It can be found in many health food stores that sell bulk herbs.
  
  
• Virility Two from KAL contains damiana, gotu kola, Jamaican ginger, oak grass powder, sarsaparilla, and yohimbe.

Be aware that the interaction of some herbals and prescription drugs can be harmful. For example, St. John's wort has been found to seriously reduce the effectiveness of certain drugs, such as cyclosporine -- a drug used to prevent organ rejection after transplant -- HIV drugs, and certain chemotherapy drugs. If you are taking a prescription drug, consult with a health care provider who is knowledgeable about herbs and drugs and their possible interactions or contraindications.

HERBAL & ALTERNATIVE THERAPY LINKS

Men Herbal: Infertility Herbal Therapy
Stayerect.com: Male Sexual Performance Formula
MotherNature.com: Herbs for Health & Healing: Impotence
HealthWorld Online: Herbal Medicine - Male Impotence
Peaceful Mind: Alternative Therapies for Impotence
Healthwell Natural Health: Erectile Dysfunction
Holistic Urology: Alternative Therapies for Sexual Dysfunction
Natural Therapies for Prostate Problems

BOOKS - RECOMMENDED READING

Sexual Nutrition: How to Nutritionally Improve, Enhance, and Stimulate Your Sexual Appetite

-- By Dr. Morton Walker

The Viagra Alternative: The Complete Guide to Overcoming Erectile Dysfunction Naturally

-- By Marc Bonnard M.D.

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DIETARY SUPPLEMENT RECOMMENDATIONS

Eat a well balanced diet and take vitamin and mineral supplements, if needed.

Helpful supplements may include:

• Vitamin C with Bioflavonoids and Zinc helps boost testosterone levels.
• Vitamin E increases blood circulation.
• Essential Fatty Acid Complex aids in sperm formation.
• Selenium is found in high concentration in the testicles.
• DMG increases oxygen supply in the blood to all tissues.
• Yohimbe Bark expands the blood vessels in the penis and increases blood flow. People with high blood pressure should not use yohimbe bark.
• Horny Goat Weed and Maca increase sexual desire and sexual stamina.
• Saw Palmetto benefits prostate health and normal prostate function.
• Man Bao is a Chinese formula that has been used for sexual stamina.

NUTRITIONAL SUPPLEMENTS

NUTRIENTS
Supplement	Suggested Dosage	Comments
Essential
Prostata from Gero Vita	As directed on label.	Enhances libido and erectile function.
Vitamin E	Start with 200 IU and up daily and slowly increase to 400-1,000 IU daily.	Increases circulation.
Zinc	80 mg daily. Do not exceed this amount.	Important in prostate gland function and reproductive organ growth. Use zinc gluconate lozenges or OptiZinc for best absorption.
Important
Dimethylglycine (DMG) ( Aangamik DMG from Food Science Labs)	As directed on label.	Increases oxygen supply in the blood to all tissues. Blood vessels must be dilated for an erection to occur. Use a sublingual form.
GH3 from Gero Vita	As directed on label.	Stimulates the activity of sex hormones. Caution: Do not use GH3 if you are allergic to sulfites.
Octacosanol	1,000-2,000 mcg 3 times weekly.	Natural source of vitamin E. Good for hormone production.
Helpful
L-Tyrosine	500 mg each daily, on an empty stomach. Take with water or juice. Do not take with milk. Take with 50 mg vitamin B6 and 100 mg vitamin C for better absorption.	Helps stabilize moods and alleviate stress. See Amino Acids for more information. Caution: Do not take tyrosine if you are taking an MAO inhibitor drug.
Raw orchic glandular	As directed on label.	Glandular extracts from the male reproductive organs that promote their function. See Glandular Therapy for more information.
Vitamin A Plus Natural beta-carotene Or Carotenoid complex (Betatene)	15,000 IU daily. 15,000 IU daily. As directed on label.	Antioxidants that enhance immunity.
Vitamin B complex	50 mg 3 times daily.	Needed for a healthy nervous system, and are important in all cell activity.
Plus extra Vitamin B6 (pyridoxine)	50 mg 3 times daily.	Required for the synthesis of RNA and DNA, which govern cellular reproduction.

IMPOTENCE/ERECTILE DYSFUNCTION (ED) SUPPLEMENTAL PRODUCTS

Information, supplements and products for impotence, also known as erectile dysfunction (ED).

	Longings For Men - 60 Caps, Natural Penis Supplement Max Strength, (The Real Thing for Men, Not an Imitation) Increase YOUR penis length and width - Soft & Erect! Improve YOUR ability in bed & satisfy both of you. Increase YOUR sexual endurance and last longer. Develop the confidence that YOU should have.
	Ascend For Men, Natural Penis Enhancement - 60 Caps Ascend is an all natural herbal solution for erectile dysfunction, impotence and other male sexual disorders. It contain no drugs, no stimulants and has no side effects. It is safe and effective for men of all ages.
	Horny Goat Weed w/ Maca, 808mg - 60 Caps Standardized Formula for Men & Women Horny Goat Weed provides a serious boost to men or women who need it. Based on the latest scientific research into performance and well-being. Each safe, highly potent capsule contains a unique and powerful complex of herbs formulated to support libido and sexual activity. Horny Goat Weed is an all-natural phyto-aphrodisiac.
	Yohimbe Express Liquid Extract - 2 fl. oz. In the medical profession, some practitioners use the whole crude herb, some use only a tincture or extract of the herb, and some prefer to use only the mineral components of the substance.
	Maca (Lepidum meyenii) Tincture, 100% Organic - 2 fl. oz. Today Maca is used to increase energy and support the immune system. Maca can help a number of conditions from fatigue to frigidity.
	Kombucha Miracle Fungus - Kombucha Tea Benefit 's - By Harald Tietze - Paperback One time best seller, Kombucha Miracle Fungus is all about synergy and Kombucha Tea Benefit's it is an easy read for those interested in the synergy Kombucha offers or Kombucha benefit's.
	Advanced Yohimbe Plus, Sexual Enhancer - 120 Gelcaps Yohimbe is the only plant-derived sexual stimulant that has been adopted by mainstream medicine. Advanced Yohimbe-Plus is formulated with seven other performance-enhancing herbs that demonstrate an extraordinary effect when used together.
	Irwin Naturals Advanced Ginza Plus, Multi Adaptogen, - 75 Gelcaps Irwin Naturals Advanced Ginza-Plus is a balanced formula combining five powerful adaptogens, including one of the highest potency ginseng extracts on the market.
	Irwin Naturals Steel Libido for Men, Sexual Enhancer, - 75 Gelcaps The clinically supported ingredients in Irwin Naturals Steel Libido create a powerful one-two punch to your sexual performance and enjoyment.
	Pleasure Pill, Male and Female Sexual Enhancement - 30 Gelcaps Pleasure Pill ™ was created for Male and Female Sexual Enhancement.
	Eros Rx Ultra Sex Drive Enhancer - 60 Tabs Formulated to enhance nutritional support for the male and female sex drive. Eros Rx is the most complete sex drive formula on the market.
	Procaine Ultra GH9 (Ultimate 9), 100mg - 60 Caps Procaine Ultra GH9 is the MOST TRUSTED Anti-Aging THERAPY - of choice of the RICH & FAMOUS in over 70 countries.
	Horny Goat Weed Express Liquid Extract - 2 fl. oz. Horny Goat Weed was first described in ancient classical Chinese medicinal texts an aphrodisiac which was used to increase libido in men and women, and improve erectile function in men.
	Super Manhood, Male Libido Enhancement, TCM Formula, Wenyang yishen - 100% Natural, 500mg - 60 Caps This time-honored Male Libido Enhancement formula is made of extracts from prepared rehmannia root, fried common yam, wolfberry fruit, prepared Chinese dodder seed, eucommia bark in giner, freid antler glue, Asiatic cornus fruit, Chinese angelica root, cinnamon bark, prepared aconite, lindera root, alpinia fruit, mantis egg case and Chinese leek seed.
	Perfect Female Rx - 60 Caps Increase female sex drive with Perfect Female Rx, the doctor recommended female herbal supplement. Not only does it increase the female sex drive and libido, it also supports normal hormonal balance and sexual health.
	Yohimbe (Corynanthe yohimbe) Powder - 4 oz. Bulk Orally, yohimbe is used as an aphrodisiac, for impotence, exhaustion and even angina. Yohimbe is also used for general sexual dysfunction in men and women.
	Tongkat Ali (Eurycoma Longifolia Jack) / Pasak Bumi, Liquid Extract - 2 fl. oz. Tongkat Ali (Eurycoma longifolia) has an ancient reputation as an aphrodisiac in Malaysia and Indonesia, where its known as Pasak Bumi. Its name means "Ali's staff or walking stick" in reference to its effects on male sexuality.
	Tongkat Ali ( Eurycoma Longifolia Jack ) / Pasak Bumi Powder - 4 oz. Bulk Tongkat Ali (Eurycoma longifolia) has an ancient reputation as an aphrodisiac in Malaysia and Indonesia, where its known as Pasak Bumi. Its name means "Ali's staff or walking stick" in reference to its effects on male sexuality.
	Maca (Lepidum meyenii) Powder - 4 oz. Bulk Today Maca root is used to increase energy and support the immune system. Alternative Health & Herbs Remedies Maca Powder can help a number of conditions from fatigue to frigidity.
	Egyptian Blue Lotus Tincture Herbal Aphrodisiac, 100% Organic - 2 fl. oz. Egyptian Blue Lotus is an herbal aphrodisiac for a woman or man. It may also act as an a sedative and antispasmodic.
	Eros Rx Ultra Sex Drive Enhancer - 60 Tabs Formulated to enhance nutritional support for the male and female sex drive. Eros Rx is the most complete sex drive formula on the market.
	Sex Stimulant Formula Tincture, 100% Organic - 2 fl. oz. Use the Sex Stimulant Formula for impotence and as an all natural stimulant for sexual activity.
	Damiana Tincture, 100% Organic - 2 fl. oz. Damiana is used to treat asthma and other respiratory diseases, depression, digestive problems, menstrual disorders, and various forms of sexual dysfunction such as impotence in men, and inability to achieve orgasm in women.
	Spermarize Male Fertility Supplement Formula - 90 Tabs Spermarize Male Fertility Supplement has been developed and used in China to increase male sperm count and the mobility of human sperm.
	Male Energy Tea with Black Cumin Seed - 20 Tea Bags This tea is for the guys! Made with Ginseng, Ginkgo, Yohimbe, Saw Palmetto, Black Cumin Seed and other herbs — this energizing tea will get their motor running.
	Manhood Herbal Tea - 20 Tea Bags In Chinese Medicine these Herbs enhance energy, support the immune system, and are considered an elixir for sexual functions.
	Tribulus Terrestris Organic Standardized Extract, 1000mg - 30 Tabs Tribulus is Nature's master hormone regulator for men and women and has been used for centuries to treat a wide variety of health problems including loss of libido (sex drive), impotence, infertility, edema, liver, kidney and heart problems, PMS, menopause, and more. Tribulus is a safe, non-hormonal food supplement prepared from the herb, Tribulus terrestris.
	Yohimbe Express, 1000mg - 60 Caps Yohimbe has gained a reputation for its staying power. Yohimbe is designed to provide you and your mate with a memorable night of romance.
	Yohimbe Tincture, 100% Organic - 2 fl. oz. Yohimbe is often used for impotence and sexual dysfunction.
	Male Hormone Tincture (sex drive), 100% Organic - 2 fl. oz. The Male Hormone Tincture bring balance to the male hormones for impotence and for prostate problems.
	Vitamin E, d-alpha tocopherol 400 IU - 100 Softgels Vitamin E has potent antioxidant activity, supplies oxygen to the blood, aids in strengthening capillary walls, and plays a beneficial role in cancer and cardiovascular disease prevention, anti-aging benefits, circulation, wound-healing, immune function, nervous system function, PMS, hot flushes, diabetes, vascular disease, eye health, tissue repair, athletic performance, leg cramps, skin and hair health, and alleviating fatigue.
	Zinc Lozenges w/ Echinacea & Vitamin C, Nature's Way 23mg - 60 Lozenges Nature's Way Zinc lozenge boosts cold season defense with zinc, widely recognized as an important nutritional support during the cold season, and echinacea pupurea, clinically shown to support the immune system, and Vitamin C, a vitally important vitamin for general health maintenance.
	Vitamin C 1000 with Bioflavonoids, Nature's Way, 100% Natural, 1000mg - 250 Vcaps Nature's Way Vitamin C with Bioflavonoids provides antioxidant protection for many of the body's important enzyme systems.
	Prostate Formula Tincture, 100% Organic - 2 fl. oz. For prostate problems and to balance male hormones. Helps alleviate swelling and inflammation of the prostate.
	Men's Health & Stamina Men! Discover Virility, Stamina, Potency, and Strength. maintain a Healthy Heart, Prostate And More! Your Natural Health Solution Starts Here.

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