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Just as women have hot flashes when their estrogen levels fall during menopause, men whose androgen levels are falling to prepubertal levels also experience hot flashes. The history of headaches and the recent Hydrochlorothiazide and erections onset of visual problems are important clues--clues that too often are ignored in such cases. They suggest a space-occupying lesion of the hypothalamus or Hydrochlorothiazide and erections pituitary. Fatigue, weight gain, constipation, and dry skin are all nonspecific symptoms, but when added to the rest Hydrochlorothiazide and erections of the clinical picture, they Hydrochlorothiazide and erections suggest another pituitary deficiency: hypothyroidism caused by abnormal thyroid-stimulating hormone (TSH) secretion. Because thyroid dysfunction can cause erectile dysfunction, thyroid testing is indicated whenever there is a possibility Hydrochlorothiazide and erections of hypothyroidism, especially in an older patient. Although thyroid abnormalities are less common in men than in women, about 3% to 4% of men over age 60 have autoimmune thyroid disease. Although it is unlikely, psychological stress cannot yet be ruled out as a cause of erectile dysfunction is this patient. He is under stress at work, is having problems with his relationship, and is undoubtedly suffering performance anxiety because of his erectile dysfunction. Case 1 Workup The patient's vital signs were normal. Hydrochlorothiazide and erections Visual field testing to confrontation demonstrated bitemporal field cuts. The thyroid was normal to palpation. There was no gynecomastia, the pubic hair was Tanner V, and the testes were 20 mL in volume and soft. Reflex testing showed delayed relaxation. Laboratory test results were: luteinizing hormone (LH), 1 mIU/mL (normal, 5-15); follicle-stimulating hormone (FSH), 6 mIU/mL (normal, 5-15); testosterone, 80 ng/dL (normal, 300-1,000); prolactin, 20 mIU/mL (normal, <15); TSH, 4 mIU/mL (normal, 0.5-5); thyroxine (T4), 4 micrograms/dL (normal, 5-12); triiodothyronine resin uptake (T3RU), 22% (normal, 25%-35%); and random cortisol, 5 mIU/mL. Magnetic resonance imaging (MRI) showed a 1.8 cm Hydrochlorothiazide and erections intrasellar and suprasellar mass, with splay of the optic system. On corticotropin stimulation testing, the cortisol level rose from 4 to 9 mIU/mL (normal, >18). The findings on the physical examination make it Hydrochlorothiazide and erections clear Hydrochlorothiazide and erections that the patient has more than just stress-induced hypothalamic dysfunction. Bitemporal field cuts are an unusual finding that points to a pituitary problem. Even without this abnormality, however, the clinical picture is still consistent with a pituitary tumor. The delayed Hydrochlorothiazide and erections relaxation Hydrochlorothiazide and erections on reflex testing offers further evidence for hypothyroidism, and the softness of the testes is a sign of acquired hypogonadism. The lack of gynecomastia is to Hydrochlorothiazide and erections be expected, because the hypogonadism involves a loss of both estrogen and testosterone, rather than a Hydrochlorothiazide and erections lack of testosterone relative to estrogen. The pubic hair formation and testicular size are normal. The low levels of LH and FSH indicate pituitary dysfunction. The testosterone level is very low--a pubertal level--indicating that the defect is significant. The prolactin level is slightly elevated, which is usually a sign of pituitary stalk compression. The thyroid function test results are classic for secondary hypothyroidism. In primary hypothyroidism, the Hydrochlorothiazide and erections thyroid fails and the TSH level rises in response; here the pituitary tumor is compressing the thyrotrophs but has not completely destroyed them. Hence, the TSH level is Hydrochlorothiazide and erections within normal range, yet the low T4 level and low T3RU confirm hypothyroidism. The random cortisol assay is a screening test for the pituitary-adrenal axis. When the cortisol level is 5 mIU/mL or lower, as in this case, a corticotropin stimulation test is Hydrochlorothiazide and erections required. In this case, the test Hydrochlorothiazide and erections showed that adrenocorticotropic hormone (ACTH) function had been lost. Together with the other test results, this confirmed the diagnosis of hypogonadotropic hypogonadism. As expected, the MRI scan showed Hydrochlorothiazide and erections a pituitary macroadenoma. Surgery was indicated. Case 1 Treatment The patient was treated with cortisol and thyroid hormone, after which transsphenoidal pituitary surgery was performed and the tumor resected. Hydrochlorothiazide and erections Histopathologic analysis confirmed that the tumor was a glycoprotein-secreting adenoma. Several weeks after surgery, the patient Hydrochlorothiazide and erections reported that his libido and erections Hydrochlorothiazide and erections had returned. Six weeks postoperatively, hormonal therapy was withdrawn. Subsequent testing confirmed that pituitary function was normal. This patient had a glycoprotein-secreting pituitary tumor, also known as a nonfunctioning pituitary tumor. The tumor usually occurs in older men who present with erectile dysfunction and headaches. Once considered uncommon, glycoprotein-secreting pituitary tumors Hydrochlorothiazide and erections are now recognized as the second most common pituitary tumor. Prolactinomas are the most common, accounting for about 40% of cases. Growth hormone-secreting tumors, which cause acromegaly, account for about 10% of cases; ACTH-secreting tumors, which cause Cushing's syndrome, cause 10% or fewer of pituitary tumors. Pituitary tumors occur in about one in 10,000 persons. Until recently, many physicians did not look for these tumors, which escaped notice until they grew very large. Now that evaluation for hypogonadism in men with erectile dysfunction is being done more frequently, the tumors are being detected at an earlier stage. The urologic literature used to recommend against performing a hormonal evaluation in men with erectile dysfunction, because a hormonal cause was found in less than 10% of cases. Hydrochlorothiazide and erections However, that figure reflected the experience in urologic practices, which assess large numbers of younger men with stress-induced erectile dysfunction. In a retrospective study of 100 men with erectile dysfunction Hydrochlorothiazide and erections seen at my endocrine impotence clinic, Hydrochlorothiazide and erections which serves an older group of patients with multiple systemic diseases, Hydrochlorothiazide and erections 48% of cases had a hormonal component. It Hydrochlorothiazide and erections was not necessarily the only cause--they also may have had vascular or neurogenic problems--but it was important enough not to miss, because treatment will not succeed if only part of the problem is addressed. Evaluation for hormonal deficiency is also important because there are many other risks associated with longstanding hypogonadism, such as osteoporosis and premature exacerbation of cardiovascular disease (probably due to estrogen deficiency, which occurs with loss of androgens). It was previously Hydrochlorothiazide and erections thought that if a patient had a defect in pituitary hormone production before surgery, it meant that the pituitary had been irrevocably damaged, and that the patient would require life-long replacement therapy after the surgery. We now know that when the operation is Hydrochlorothiazide and erections performed by a skilled neurosurgeon who is able to remove the tumor while preserving the pituitary, normal pituitary Hydrochlorothiazide and erections function can return. About six weeks after surgery, hormone replacement therapy is stopped and patients are retested. If the surgery was successful, the prognosis is very good. Periodic follow-up with MRI scans is indicated to detect recurrences, but they are rare. Should hypogonadotropic hypogonadism persist after tumor removal, the patient will need androgen replacement for androgenization or, to restore fertility, treatment with either human chorionic gonadotropin or pulsatile gonadotropin- releasing hormone (GnRH). At present, I use testosterone patches for androgen replacement. The patches are more expensive than intramuscular testosterone injections but allow closer mimicking of the normal diurnal variation in testosterone levels. The results are noticeable within a week of starting treatment. Case Hydrochlorothiazide and erections 2 Hydrochlorothiazide and erections Presentation A 65-year-old man presented with erectile dysfunction--he had noted gradual onset of difficulty in achieving and maintaining an Hydrochlorothiazide and erections erection during the past four years. He had had hypertension for 10 years and recently had been told that his blood cholesterol level was high. His family history was positive Hydrochlorothiazide and erections for coronary artery disease, hypertension, and hypercholesterolemia. The patient's medications included atenolol, 50 mg bid; hydrochlorothiazide, 50 mg a day; and aspirin, 325 mg a day. He had smoked a pack of cigarettes a day for 30 years, but quit two years earlier. He drank three beers each night. Physical examination showed a blood pressure of 160/90 mm Hg, the presence of arcus corneae, and an S4 heart sound. The liver and testicular examinations were normal, as were reflexes. The pedal pulses were diminished. Laboratory test results were: testosterone, 450 ng/dL Hydrochlorothiazide and erections (normal, 300-1,000); liver enzymes, normal; total cholesterol, 350 mg/dL, triglycerides, 300 mg/dL; and HDL, 25 mg/dL. From the Hydrochlorothiazide and erections history alone, one would expect that this patient's erectile dysfunction has a vascular cause and Hydrochlorothiazide and erections perhaps iatrogenic exacerbation. Coronary artery disease is a risk factor for erectile dysfunction, and recent studies have suggested that merely Hydrochlorothiazide and erections having a history of hypercholesterolemia points to an underlying vascular etiology. His long-standing hypertension also Hydrochlorothiazide and erections suggests vascular disease. This patient is taking two medications that have been associated with erectile dysfunction. Among the classes of currently used antihypertensive agents, beta-blockers and diuretics are most often at fault. Of the diuretics, hydrochlorothiazide is more of a problem than furosemide. Smoking increases the risk of vascular disease, of course. Excessive alcohol intake is directly toxic to the testicles and can result in decreased testosterone production. Alcohol is also directly toxic Hydrochlorothiazide and erections to the liver, and Hydrochlorothiazide and erections the resulting liver dysfunction can cause imbalance in testosterone and estradiol metabolism, which is often associated with gynecomastia. The patient's blood pressure reading indicates that his hypertension is inadequately controlled, and the S4 heart sound indicates that the hypertension is longstanding and has affected his heart. The presence of arcus corneae signifies Hydrochlorothiazide and erections prolonged hypercholesterolemia. Diminished pedal pulses offer further evidence for vascular disease. Hypogonadism cannot be reliably detected by clinical assessment alone, hence measurement of the testosterone level was indicated. Liver function testing was performed in light of the history of significant alcohol intake. The lipid panel confirmed hypercholesterolemia. There have been many studies on how to distinguish between psychogenic and vascular erectile dysfunction--for example, Hydrochlorothiazide and erections by monitoring for nocturnal erections. No controlled study has shown that the methods change the management strategy, however, so I limit the workup to the history, physical examination, and some laboratory testing to exclude other treatable causes of erectile dysfunction. Case 2 Treatment Atenolol and hydrochlorothiazide were replaced with enalapril. The patient was counseled on Hydrochlorothiazide and erections dietary changes that would help Hydrochlorothiazide and erections to lower his cholesterol level. A vacuum pump device was prescribed for the erectile dysfunction. Two months later, Hydrochlorothiazide and erections the patient's blood pressure was normal. He reported successful resumption of sexual intercourse using the vacuum pump. Evaluation of Hydrochlorothiazide and erections this patient's erectile Hydrochlorothiazide and erections dysfunction provided the opportunity Hydrochlorothiazide and erections to address the underlying hypertension Hydrochlorothiazide and erections and hypercholesterolemia. Otherwise he might not have presented until Hydrochlorothiazide and erections a stroke or heart attack occurred. Changing antihypertensive medication is especially important if the initiation of treatment and onset Hydrochlorothiazide and erections of erectile dysfunction coincide. In this case, a medication change was further justified because of inadequate blood pressure control. Angiotensin-converting enzyme (ACE) inhibitors do not appear to cause erectile dysfunction and calcium channel blockers rarely do, so these are the drugs that I usually prescribe if I think medication is interfering with sexual functioning. Unfortunately, a change in antihypertensive medication alone is unlikely to restore erectile function. Correction of this patient's blood lipid levels is long overdue. If dietary changes do not sufficiently improve his lipid profile within a few months, he will be a candidate for therapy with an HMG-CoA reductase inhibitor. I usually prescribe the vacuum pump device to treat erectile function in a case like this. (Sildenafil is not only on Hydrochlorothiazide and erections the formulary at my clinic; it would be Hydrochlorothiazide and erections alternative treatment in this patient.) The vacuum pump device consists of a lucite tube and pump; the suction pulls blood into the penis. Once an erection Hydrochlorothiazide and erections has been produced, a rubber ring is placed at the base of the penis to maintain the erection. The vacuum pump has no major side effects, it can Hydrochlorothiazide and erections be used as often as the patient wishes, it can be used in all types of erectile dysfunction, and it has the highest success rate--it is effective in 90% to 95% of cases. Obviously, it is not meant for a man who is not in a stable relationship, largely because of poor patient acceptance. There has been some speculation that vacuum pump devices might be contraindicated in patients taking warfarin because of the potential for ecchymosis from the ring, but studies have eliminated that concern. Case 3 Presentation A 52-year-old diabetic man presented with erectile dysfunction. His pubertal development had been normal. The Hydrochlorothiazide and erections diabetes had been diagnosed 15 years Hydrochlorothiazide and erections earlier. At the time of diagnosis, he had had problems with impotence that resolved as the hyperglycemia was brought under control. Erectile dysfunction had returned gradually Hydrochlorothiazide and erections during the past two years. He rarely had morning erections. The dysfunction had created stress in his relationship with his wife. The Hydrochlorothiazide and erections patient had taken an oral hypoglycemic agent for five years after diagnosis of diabetes and had been on insulin for the past 10 years. He had diabetic complications, including mild retinopathy, proteinuria, and mild peripheral neuropathy. Symptoms of gastroparesis had developed during Hydrochlorothiazide and erections the past six months. His current insulin regimen consisted of 30 Hydrochlorothiazide and erections units Hydrochlorothiazide and erections of NPH (neutral protamine Hagedorn) Hydrochlorothiazide and erections and 15 units of regular insulin in the morning, and 10 units of NPH and 8 units of regular in the evening. Other medications included lisinopril (15 mg a day) and simvastatin (10 mg a day). He did not smoke or Hydrochlorothiazide and erections drink excessive amounts of alcohol. Noteworthy findings on the physical examination included a blood pressure Hydrochlorothiazide and erections reading of 120/80 mm Hg without significant orthostasis, retinopathy, absence of an S4 heart sound, and slightly soft Hydrochlorothiazide and erections testes. Sensation to pinprick on the calf was decreased. Laboratory test results were: serum testosterone, 200 ng/dL; total cholesterol, 150 mg/dL; triglycerides, 250 mg/dL; and HDL, 35 mg/dL. Glycosylated hemoglobin was 10% (normal, <6.5%). Diabetes is one of the most common causes of erectile dysfunction. A combination of Hydrochlorothiazide and erections vascular and neurologic disease is usually at fault, although hormone deficiency, medications, and psychogenic aspects also may be involved. All five components Hydrochlorothiazide and erections may be present in a single patient. Men with non-insulin-dependent diabetes mellitus (NIDDM) often have acute erectile dysfunction at the onset of the disease, simply as a result of severe hyperglycemia. The mechanism of erectile dysfunction may include hypogonadotropic hypogonadism as well as metabolic and neurologic dysfunction (caused by glucose toxicity) in the testes. Vascular factors also may be involved, since the hyperglycemia is usually associated with severe hyperlipidemia. The erectile dysfunction associated with new-onset diabetes may improve when hyperglycemia is brought under control. In a patient with longstanding diabetes, the presence of other end-organ complications makes it more likely that erectile dysfunction is due to diabetes. In this patient, clinical assessment suggests a strong neurogenic component; the diminished sensation denotes peripheral neuropathy and the gastroparesis indicates autonomic neuropathy (although the lack of orthostasis suggests that the neuropathy is not Hydrochlorothiazide and erections severe). The proteinuria suggests a vascular component and, even though the absence of an S4 argues against that, it should be remembered that an S4 is not always Hydrochlorothiazide and erections present in diabetic patients with coronary artery disease. Drug-induced erectile dysfunction does not appear to be an issue in this patient, since neither the ACE inhibitor nor the HMG-CoA reductase inhibitor that he is taking affects erectile function. The softness in the testes suggests a minor hormonal component, and indeed the testosterone level is slightly decreased. A low-normal or slightly low testosterone level is a typical finding in diabetic patients with erectile dysfunction. Although the reading confirms that hormone deficiency is one of his problems, a testosterone level of 200 ng/dL would not by itself cause significant hypogonadism and symptoms. Parenthetically, I would note that this patient's blood Hydrochlorothiazide and erections pressure needs to be watched, and if Hydrochlorothiazide and erections it increases, he will need an additional hypertensive medication because he is already taking a maximal dose of lisinopril. Increasing Hydrochlorothiazide and erections data suggest that tight control of Hydrochlorothiazide and erections blood pressure with ACE inhibitors helps to prevent both the renal and the vascular complications of diabetes. Consequently, I have become much more aggressive with antihypertensive therapy; I treat patients with Hydrochlorothiazide and erections insulin-dependent diabetes mellitus (IDDM) and proteinuria, even if their blood pressure is normal, and I treat patients with NIDDM as soon as the blood pressure rises above 120/80 mm Hg. This patient's lipid profile also leaves something to be desired. The LDL level is low, Hydrochlorothiazide and erections but the triglyceride level is not Hydrochlorothiazide and erections optimal. If changes in his diet do not reduce the triglyceride level, he will be a candidate for treatment with atorvastatin. Case 3 Treatment The patient was managed with intracavernosal injection of alprostadil and androgen replacement via a low-dose testosterone patch. He reported improved erectile function and increased energy and a sense of Hydrochlorothiazide and erections well being. In addition, the patient received dietary counseling and the insulin regimen was adjusted. The glycosylated hemoglobin decreased to 8%. My usual recommendation for diabetic patients with erectile Hydrochlorothiazide and erections dysfunction is injection of alprostadil into the corpora cavernosa of the penis. The treatment is particularly suited to diabetic patients because they often have neurologic complications, making the injections less painful than in other patients. In addition, those who are taking insulin are already familiar with needles and syringes and are Hydrochlorothiazide and erections less likely to be squeamish about injecting the penis. Intracavernosal injection is effective in about 65% of cases. The vacuum pump is held in reserve as second-line treatment. Implantable penile prostheses were commonly Hydrochlorothiazide and erections used to treat erectile dysfunction in the 1970s and 1980s. They are used much less frequently today, because they are expensive and may have many complications. Hydrochlorothiazide and erections Infection and poor wound healing Hydrochlorothiazide and erections are particular problems Hydrochlorothiazide and erections in diabetic patients, often necessitating removal of the implant--at which point the option for injection therapy has been eliminated. However, some of the newer implants Hydrochlorothiazide and erections may be appropriate for young men Hydrochlorothiazide and erections with severe Hydrochlorothiazide and erections erectile dysfunction that does not respond to other therapy. Intraurethral placement of vasoactive medication was recently introduced as an alternative to intracavernosal injections. However, several studies have shown it to be less effective, with Hydrochlorothiazide and erections a success rate as low as 30% in diabetic Hydrochlorothiazide and erections patients. Side effects of intracavernosal injection include priapism and penile fibrosis. Patients with neurogenic or psychogenic erectile dysfunction should use a low dose of alprostadil. If the dose is too high, the risk of priapism is significant. I often titrate the dose to determine the amount needed. When priapism occurs, the patient has to go to an emergency room where he will be Hydrochlorothiazide and erections treated with intravenous epinephrine or with an 18-gauge needle that is inserted into the corpora cavernosa to withdraw blood. There have been only rare reports of more severe consequences, such as loss Hydrochlorothiazide and erections of the penis due to infarction. The rate of priapism as a complication varies according to the agent used. Alprostadil has a much lower risk of priapism and fibrosis than do papaverine and phentolamine. However, alprostadil is more likely to cause a burning sensation. For that reason, it used to be mixed with papaverine, but papaverine has been withdrawn as a treatment for outpatients. Because of neuropathy, diabetic patients may not experience a burning sensation with alprostadil. It is not clear whether Hydrochlorothiazide and erections better control of this patient's diabetes during the previous 10 years would have prevented erectile dysfunction. It seems logical that tight control of blood glucose levels Hydrochlorothiazide and erections will forestall erectile dysfunction, just as it can prevent retinopathy, renal failure, and macrovascular disease. Nevertheless, there are no prospective double-blind, placebo-controlled studies to confirm that long-term tight control reduces the incidence of erectile dysfunction. Case 4 Presentation A 48-year-old man had experienced acute onset of erectile dysfunction six months earlier. He had no other medical problems. Pubertal development had been normal. He was the father of three children. On further questioning, the patient said that he had lost his job four months ago. He was having problems with his Hydrochlorothiazide and erections relationship with his wife, and had increased his Hydrochlorothiazide and erections alcohol consumption from two beers a week to four beers a day. The physical examination was normal. The serum testosterone level was 450 ng/dL. The patient was advised that his drinking was probably contributing to his erectile dysfunction and that he should reduce his intake. Referral for Hydrochlorothiazide and erections psychological counseling was offered but he refused because of the cost. Instead, the physician discussed the patient's circumstances with him. A six-week trial of Hydrochlorothiazide and erections yohimbine, 5.4 mg tid, was prescribed. The patient returned eight weeks later and reported some improvement in erectile function. He felt that yohimbine had been helpful; however, he had also found a job, was experiencing less psychological stress, and had reduced his alcohol consumption. Although the history in this case indicated that psychological stress was the major trigger for the erectile dysfunction, it was important to consider the possibility of other components. As noted, erectile dysfunction rarely Hydrochlorothiazide and erections results from an isolated cause. In this case, further questioning was needed to reveal that alcohol was almost certainly a major contributor. Obtaining an accurate history of alcohol intake is notoriously difficult. Instead of asking the patient, "Do you Hydrochlorothiazide and erections drink?" ask, "When you drink, do you drink beer, whiskey, or wine?" After identifying the drink of choice, pick a large amount and let patients come down from there; with Hydrochlorothiazide and erections beer, for example, ask if they drink a six-pack at a time. Determining the true amount of alcohol intake often requires several discussions. Also ask patients when they drink, since they may Hydrochlorothiazide and erections not understand that intermittent drinking can have persistent effects. I have seen patients who drank heavily on the weekend and nothing at Hydrochlorothiazide and erections all during the week and who presented with erectile dysfunction and painful right-sided gynecomastia (which was worse on Mondays). Their liver enzymes were not severely elevated, but the drinking had nevertheless caused a Hydrochlorothiazide and erections symptomatic imbalance of testosterone and estradiol. In patients with a history of chronic alcohol Hydrochlorothiazide and erections abuse, I order liver function tests. Their erectile function may not return even if they reduce their alcohol intake. Since this patient's increase in alcohol intake was fairly acute, his erectile function Hydrochlorothiazide and erections improved as soon as he began Hydrochlorothiazide and erections to drink less. Psychotherapy? Despite Hydrochlorothiazide and erections the ubiquity of the psychological component in erectile dysfunction, there have been no controlled studies to show whether psychotherapy or counseling actually helps. Even assuming that such intervention would be helpful, there are no data Hydrochlorothiazide and erections on the best approach. Should patients receive behavioral therapy? Counseling? Is simply talking with the primary care physician sufficient? The primary care physician should at least acknowledge Hydrochlorothiazide and erections psychological stress as a Hydrochlorothiazide and erections component of erectile dysfunction. Sometimes acknowledging the problem is enough: The patient just needs to talk about it. Sometimes further intervention is required. Whether this is provided by the primary care physician depends on Hydrochlorothiazide and erections his or her level of comfort with that aspect of treatment. As in this case, insurance coverage is often an important factor as well. Pharmacologic Therapy Yohimbine. With a patient such as this, whose erectile dysfunction appears largely psychogenic, we occasionally offer a trial of yohimbine, an alpha-2-adrenergic antagonist that may increase intracavernosal blood flow. The drug often is not efficacious; however, it is inexpensive and has virtually no side effects, aside from minimally Hydrochlorothiazide and erections lowering blood pressure Hydrochlorothiazide and erections in some cases. One older study showed that yohimbine was effective Hydrochlorothiazide and erections in 50% of men with psychogenic impotence; placebo was effective in 30% of cases. According to recent studies, the Hydrochlorothiazide and erections effectiveness of yohimbine may be improved by combining it with Hydrochlorothiazide and erections the serotonin agonist trazodone. Sildenafil. The options for treatment of erectile dysfunction have radically changed with the introduction of sildenafil, the first truly effective oral Hydrochlorothiazide and erections medication for this condition. Recent advances in our knowledge of the physiology of erection have facilitated understanding of the pharmacodynamics of sildenafil. Erection is initiated by dilation of the arterial bed, which increases blood flow and pressure; it is maintained by restriction Hydrochlorothiazide and erections of venous outflow. Previously it was believed that the parasympathetic system was critical in maintaining erection. Now we know that the major player is the nonadrenergic, noncholinergic (NA-NC) system, which was identified 50 years ago but never studied in detail until recently. The NA-NC system uses nitric oxide as a neurotransmitter. Through its second messenger, cyclic guanine monophosphate (cGMP), nitric oxide triggers relaxation of penile endothelium and smooth muscle, allowing expansion of the lacunar spaces within the corpora and the trapping of blood by compression of peripheral draining venules. Sildenafil, a type Hydrochlorothiazide and erections 5 phosphodiesterase inhibitor, prevents the breakdown of cGMP, thus prolonging erection. It has no effect Hydrochlorothiazide and erections on libido Hydrochlorothiazide and erections and it does not cause erection, but it maintains an Hydrochlorothiazide and erections erection once it has been achieved. Although the NA-NC system is particularly prominent in the penis, Hydrochlorothiazide and erections it Hydrochlorothiazide and erections is also found in the heart, the Hydrochlorothiazide and erections brain, and other organs. Its presence in the eye explains the blue visual hue that some patients experience after taking sildenafil. The most common side effects of sildenafil are headache, flushing, and dyspepsia. It Hydrochlorothiazide and erections can also decrease blood pressure. Because the decrease may be synergistic with the hypotensive action Hydrochlorothiazide and erections of nitrates, sildenafil Hydrochlorothiazide and erections is contraindicated in patients taking a medication that contains nitrates, such as nitroglycerin. In addition, sildenafil alters the half-life of many other medications, Hydrochlorothiazide and erections and many medications change the half-life of sildenafil. The list of agents that can interact with sildenafil includes such common medications as nonselective beta-blockers, erythromycin, itraconazole, Hydrochlorothiazide and erections potassium-sparing diuretics, and cimetidine. It is not known whether those interactions affect the side effects of sildenafil--especially the incidence or severity of hypotension. In initial clinical trials, hypotension was reported in about 3% of patients, but those Hydrochlorothiazide and erections trials included a large percentage of young men with psychogenic impotence. Hydrochlorothiazide and erections Obviously, patients with vascular disease or diabetes have more problems with blood pressure regulation and theoretically with Hydrochlorothiazide and erections orthostatic hypotension. A number of deaths have occurred among patients taking sildenafil since it became available. The U. S. Food and Drug Administration (FDA) is currently investigating those deaths. Evaluating sildenafil has been difficult because it is one of several drugs that have been approved during the past two years through a new FDA process. Previously, a drug was not approved until studies had been published. Now the FDA allows pharmaceutical companies to submit unpublished studies. With this streamlined process, a drug can be approved before clinicians have the chance to read peer-reviewed data and decide whether their patients falls into the same category as patients in the initial studies. Instead, the Hydrochlorothiazide and erections physician has only the drug company brochure, which does not offer the detail of a peer-reviewed journal article. The first study Hydrochlorothiazide and erections of data on different patient populations taking sildenafil was published several months after the drug became available for clinical use. While the package insert indicated an overall efficacy of 82% (vs 24% for placebo), analysis showed Hydrochlorothiazide and erections that the efficacy was 68% in patients with hypertension, 57% in diabetes, 61% after trans-urethral prostatic resection, and 43% after radical prostatectomy. Moreover, those results were obtained in a selected patient population, not from general clinical use. Physicians need additional information from peer-reviewed studies so that they can assess the risk-benefit ratio of sildenafil Hydrochlorothiazide and erections and make rational treatment decisions in individual cases. Hydrochlorothiazide and erections Meanwhile, third-party payers are trying to decide whether they should reimburse the cost of the drug. Arguments against coverage include the fact that erectile dysfunction is not a life-threatening condition. Also, since many third-party payers do not pay for oral contraceptives for women, they feel that they should not reimburse for a drug that enhances sexual performance Hydrochlorothiazide and erections in men. In any case, newspaper reports indicate that sales of sildenafil have slowed in recent months. The decrease has been attributed to refusals for insurance coverage and increasing reports of side effects. A human element may also be involved. For example, in several studies of penile prostheses, patient interviews confirmed that the prostheses functioned well, but interviews with the patients' wives revealed that the patients were not using it. Similar findings have been reported in studies of other treatments for erectile dysfunction; the actual frequency of use is much less than that initially described by the patient. The ability Hydrochlorothiazide and erections to have sex is only one element in a complicated equation that determines whether or how often a patient has sexual relations. Future Possibilities. Other oral agents for erectile dysfunction are undergoing clinical trials and should soon be available. Apomorphine, an opiate antagonist, has shown up to 70% efficacy in patients with psychogenic impotence; it will probably be available for clinical use late this year. Also under FDA review is an oral preparation of phentolamine. This agent blocks norepinephrine, Hydrochlorothiazide and erections causing smooth-muscle relaxation and vasodilation. In preliminary studies, it was effective in 60% to 80% of patients and had fewer side effects than sildenafil. For patients using intracavernosal injection, a combination Hydrochlorothiazide and erections of vasoactive intestinal peptide (VIP) and phentolamine is under investigation. Both agents are smooth muscle relaxants, and vasoactive intestinal peptide appears to increase production of nitric oxide. Case Commentary CHRISTINE K. CASSEL Mount Sinai Medical Center, Hydrochlorothiazide and erections New York Although the frequency of erectile dysfunction increases with advancing age, societal attitudes have Hydrochlorothiazide and erections discouraged older men from seeking treatment. Interest in sex was considered appropriate for young men only; the "dirty old man" was an object of derision. While physicians now recognize sexuality Hydrochlorothiazide and erections as a legitimate concern for men regardless of their age, as a gerontologist, I often encounter men in their 70s or 80s who are embarrassed to bring up the subject. (Those who are in a longstanding marriage may be more willing to mention it than those who are trying to start a new relationship.) Yet, as Wierman's case histories illustrate, when patients do come forward, the physician often can provide effective treatment not only for the erectile dysfunction itself, but also for underlying disorders. The disorders I see most often in my practice are endocrine, particularly thyroid disease. Both hyperthyroidism and hypothyroidism can cause erectile dysfunction as well as subtle problems such as confusion, depression, sleep disruption, and weight loss or gain. All of these symptoms could be written off as "just old age"--but as with many other complaints in the elderly, that is not an acceptable answer. The patient whose physician says "It's just your age" should seek a second Hydrochlorothiazide and erections opinion. I have had several patients who presented with impotence as their chief complaint--sometimes their only complaint--who proved to have hypothyroidism. Moreover, there is a syndrome among the elderly called apathetic hyperthyroidism, which stands in strong contrast to the hyperactivity, insomnia, and jitteriness seen in the typical young patient with hyperthyroidism. Indeed, because thyroid disorders occur so commonly with age--affecting perhaps 10% of the elderly population--I order a thyroid panel almost routinely whenever I see a new patient. Thyroid function Hydrochlorothiazide and erections often is abnormal, and correcting it Hydrochlorothiazide and erections makes the patient feel and function better in many dimensions, including sexuality. I would also underscore Wierman's point that drug side effects are an important cause of erectile dysfunction. Antihypertensive agents, as in the second case, are a frequent offender, but many other drugs--and many drug interactions--can cause impotence or loss of libido. In geriatric medicine, it is standard practice to review every single one of a patient's medications and its potential side effects to make sure that the complaint is not drug-related. That practice also applies in erectile dysfunction, especially since the Hydrochlorothiazide and erections advent of sildenafil. Indeed, I worry that some patients may be receiving sildenafil as a treatment for erectile dysfunction that is in fact the result of another medication that the patient is taking. In general, it is a bad idea to prescribe a new medication in order to counteract the side effect of a current medication. Instead, the physician should try to carefully withdraw the offending medication and then substitute a different class of drug. Circumspection is especially important with a newly released drug such as sildenafil. Although relatively few side effects of this drug have been reported, a complete understanding of the side-effects of any new drug cannot be established until it has been used by a large number of patients for an extended period. Even if sildenafil turns out to Hydrochlorothiazide and erections have no as yet unknown side effects, those currently reported (e. g., decreased blood pressure) Hydrochlorothiazide and erections may cause adverse Hydrochlorothiazide and erections interactions with other medications. Wierman's caution about that possibility is well taken. The case of the diabetic patient provides an excellent example of what we hope to prevent with the new emphasis on tight control of blood glucose Hydrochlorothiazide and erections levels in patients with this disease. It had always been assumed that diabetes leads more or less inexorably to neuropathy and vasculopathy and their resulting dismal array of complications, including impotence. Recent studies have shown, however, that very tight blood glucose control can slow or even Hydrochlorothiazide and erections halt the progression of diabetic complications. While erectile Hydrochlorothiazide and erections function was not used as an outcome Hydrochlorothiazide and erections measure in Hydrochlorothiazide and erections those studies, pathophysiology and common sense argue that because tight blood glucose control prevents other neurologic and vascular complications, it will also prevent erectile dysfunction. I would not hesitate to use that argument as a motivational tool in a diabetic patient. Finally, I would reinforce Wierman's observation about the psychological component in all men with Hydrochlorothiazide and erections erectile dysfunction. Physicians need to be more willing to talk with patients about this issue, or--if they do not wish to talk about it themselves--to set up a clear and easy system of referral to a skilled counselor. If the psychologic component can be addressed, then even a slight improvement in the physiologic component may be all it takes to restore erectile function. Selected Reading Bosshardt Hydrochlorothiazide and erections RJ et al: Objective measurement of the effectiveness, therapeutic success, and dynamic mechanisms of the vacuum device. Br J Urol 75:786, Hydrochlorothiazide and erections 1995 Goldstein I et al: Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 338:1397, 1998 Linet OI, Ogring Hydrochlorothiazide and erections FG: Efficacy and safety of Hydrochlorothiazide and erections intracavernosal alprostadil in men with erectile dysfunction. N Engl J Med 334:873, 1996 NIH Consensus Conference: Impotence. JAMA 270:83, 1993 Porst H: Transurethral alprostadil with MUSE (medicated urethral system for erection) vs intracavernous alprostadil: A comparative study in 103 patients with erectile dysfunction. Int J Hydrochlorothiazide and erections Impot Res 9:187, 1997 Wagner G, Saenz de Tejada I: Update on male erectile dysfunction. BMJ 316:678, 1998 Welt CK, Hall JE: Gonadotropin deficiency: Differential diagnosis and treatment. In Diseases of the Pituitary: Diagnosis and Treatment, Wierman ME (Ed). Humana Press, Totowa, NJ, 1997, pp 221-246 HOME | CURRENT ISSUE | PAST ARTICLES | SEARCH | GENETICS SERIES CAPSULE & COMMENT | CME | ADVERTISER SERVICES | ABOUT US Copyright (C) 2001. The McGraw-Hill Companies. All Rights Reserved Privacy Policy. Privacy Notice. Yahoo! GeoCities Yahoo! Sorry, this site is temporarily Hydrochlorothiazide and erections unavailable! The web site Hydrochlorothiazide and erections you are trying to access has exceeded its allocated data transfer. Visit our help area for more information.Access to this site will be restored within an hour. Please try again later.http://www.geocities.com/Wellesley/1889/Impotence.html Need extra data transfer? 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To learn more about how we use your information, see our Yahoo Privacy Policy Prescription Drugs and Sex”Not Always Hydrochlorothiazide and erections a Good Mix - Swedish Medical Center, Seattle, WashingtonPDF Version | Search | Send-to-Friend | Health Hydrochlorothiazide and erections Library HomeSexuality & Health Prescription Drugs and Sex”Not Always a Good Mixby Elaine Hydrochlorothiazide and erections Gottleib Joe S., a 50 year-old accountant, takes a prescription medication for his high blood pressure. Jane L., a 35-year-old computer programmer, alleviates her depression with another medication. They Hydrochlorothiazide and erections both feel good all day, but certain problems arise at night. Joe can't maintain an erection and Jane takes Hydrochlorothiazide and erections a long time to have an orgasm. After a few months of these problems, Joe and Jane start to avoid their partners in bed. Sex becomes an ordeal instead of a pleasure.Joe and Jane's experiences are typical of the millions of Americans who take prescription drugs. "I rarely see couples with sexual dysfunctions where one or the other or both are not on some kind Hydrochlorothiazide and erections of long-term Hydrochlorothiazide and erections medication," says Judy Hydrochlorothiazide and erections Seifer, PhD, sex therapist and clinical professor at Wright State University in Dayton, Ohio.Sexual Side EffectsFor many people, sexual dysfunctions as side effects of medications come as an unpleasant surprise. "Unfortunately, some doctors just don't tell patients about the most common drug side effects. Other doctors believe that Hydrochlorothiazide and erections if you tell patients they'll have a sex problem, you may create it or have them looking for it," says Dr. Adam Keller Ashton, clinical assistant professor of Psychiatry at the State University of New York at Buffalo and a member of the Society of Sex Therapy and Research.Taking a drug that diminishes your sexual functioning doesn't mean the end of your sex life. There are many treatments that can alleviate sexual side effects. If you suspect that a drug you're taking is affecting Hydrochlorothiazide and erections your sexuality, the first step is to consult your health care provider and your pharmacist.Most people are greatly relieved when they discover that the drug is the problem and not themselves, reports Dr. Jay Dudley Hydrochlorothiazide and erections Chapman, a gynecologist in Cleveland, Ohio and Academic Dean of the Institute for Advanced Study of Human Sexuality in San Francisco. If your health care provider isn't open to discussing the problem with you, Chapman advises finding one who will.High Blood Pressure Medications By reducing the force of blood flow, which helps Hydrochlorothiazide and erections men to get erections and women to become lubricated, high blood pressure medications can have a negative impact on sexual arousal. (Most high blood pressure medications Hydrochlorothiazide and erections are used by men).The following guide lists some common prescription high blood pressure medications and their documented sexual side effects.Chlorothiazide and Hydrochlorothiazide (Diuril, Hydrodiuril) These medications can Hydrochlorothiazide and erections cause men to have difficulty getting erections, but have little effect in women.Methyldopa (Aldomet) This medication decreases sexual desire, arousal, and orgasm. It is a strong drug that Hydrochlorothiazide and erections acts on the beta nerves which are involved in Hydrochlorothiazide and erections sexual arousal.Clonidine (Catapres) This drug blocks emissions during orgasm.Propranolol (Indera) This medication may make it Hydrochlorothiazide and erections difficult Hydrochlorothiazide and erections to ejaculate.Treatment OptionsThe first approach is usually to try switching to a different Hydrochlorothiazide and erections drug or lowering the dosage. Another possibility is to stop taking the drug for a specified period, like Hydrochlorothiazide and erections a weekend, when you plan to have sex (a "drug holiday"). (Note: this should never be tried without consulting your healthcare provider.)If none of these approaches help or aren't appropriate, impotence treatments are an option. There are Hydrochlorothiazide and erections pills, injections, or implants that are inserted into the penis to produce erections. Viagra is a medication that can help improve a man's ability to have and maintain an erection. It is still being tested for use in women.Dr. Ashton has also had favorable results treating patients with drug antidotes that counter the negative sexual effects of high blood pressure medications. These drugs include Buspar, Ritalin, Urecholine, Hydrochlorothiazide and erections and Serzone.Don't be embarrassed to speak with your pharmacist, as well. He or she has much knowledge about the side effects of medication, and can provide valuable information to you and your health care provider.AntidepressantsTricyclates - include older drugs such as Elavil and Imipramine that have little effect on sexual functioning; in fact, they may cause a slight increase in desireMAO Inhibitors - Hydrochlorothiazide and erections drugs like Parnate or Nardil may make orgasm more difficult for womenSelective seratonin reuptake inhibitors (SSRIs) - popular drugs like Prozac, Zoloft and Paxil may reduce desire and orgastic response in both men and women.Treatment OptionsFor some people, feeling better emotionally via pharmacologic means makes up for any sexual problems caused by antidepressants. However, others stop taking these medications because of the sexual effects.The treatment options are similar to those for high blood pressure medications. You can switch to a different antidepressant like Wellbutrin or Serzone which have few sexual side effects, reduce the dosage, or try drug holidays. Unfortunately a different medication may not alleviate the depression as well.Dr. Ashton conducted a Hydrochlorothiazide and erections major study of drug antidotes for antidepressants and found three”Yohimidine, Amantidine, and Cyproheptadine”were quite effective in Hydrochlorothiazide and erections countering sexual side effects. Another antidote for women is small doses of testosterone, which increases libido and arousal. Unlike antihypertensives, most people don't need to take antidepressants for their entire lives. Once they stop taking the drugs, their sexual functioning returns to normal.Other MedicationsTranquilizers like Valium and Librium can increase the sexual Hydrochlorothiazide and erections desires Hydrochlorothiazide and erections of inibited people, but, as with other sedatives such as drugs and alcohol, they can also delay arousal and orgasm. Judy Seifer finds that many of her patients who take a variety of prescription and over-the-counter medications at the same time experience changes in sexual functioning. She works with their healthcare providers to Hydrochlorothiazide and erections pinpoint the "problem" drugs.Psychological EffectsFor most people, a sudden change in sexual responsiveness has at least some emotional impact. Dr. Ashton has had patients whose prior sexual problems surface Hydrochlorothiazide and erections during discussions of sexual side effects. Some people on antidepressants become depressed again over their lack of sexual fulfillment. Myles Hydrochlorothiazide and erections finds that sexual difficulties are a blow to people's self-esteem. It can be a great loss for a man not to be able to have an erection or a woman to become aroused. As a result, sex with their partners can become so uncomfortable that the couples often end up withdrawing from the relationship.Myles uses a variety of sex therapy techniques to help couples communicate their feelings and reconnect with each other. These include nonsexual touching exercises like massage that help partners to experience physical pleasure together once again.Many people find new ways to enhance their sexual satisfaction. "You don't have to have a sexless life if you're taking drugs," says Myles.RESOURCES:American Association for Marriage and Family Therapyhttp://www.aamft.org/ Food and Drug Administrationhttp://www.fda.gov/Last reviewed May 2005 by Rosalyn Carson-DeWitt, MDAll EBSCO Publishing proprietary, consumer health and medical information found on this site is accredited by URAC. URAC's Health Web Site Accreditation Program requires compliance with 53 rigorous standards of quality and accountability, verified by independent audits.Please be aware that this information is Hydrochlorothiazide and erections provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Hydrochlorothiazide and erections Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any Hydrochlorothiazide and erections questions you may have regarding a medical condition.Editorial Policy | Privacy Policy | Terms and Conditions | Hydrochlorothiazide and erections SupportCopyright 2005 EBSCO Publishing Hydrochlorothiazide and erections All rights reserved. effects of drug lopressor side effects buy tenormin cost usa |