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TREATMENT OF SDED. Significant advances in the understanding of the physiology and pathophysiology of male sexual function,as well as in the methods of its investigation and treatment,have been attained during the past decades. Since SD is common in male patients affected by neurological diseases,including stroke,neurologists should be aware of sexual problems and their treatment to improve patient quality of life.
Oral pharmacotherapy is currently the mainstay of treatment for ED. Although a number of oral prescription drugs might have the potential to be used to treat ED,most of these drugs act centrally,and they are not so effective in this regard and have a number of side effects.
Significant advances in the pharmacologic treatment of ED have occurred in recent years,most notably after the introduction of sildenafil,the first oral selective phosphodiesterase type 5 (PDE5) inhibitor,in 1998. Sildenafil quickly gained acceptance by the medical community and public because of its broad efficacy for different types of ED and ease of use. Other PDE5 inhibitors,including vardenafil,tadalafil,and the more recent avanafil,have since joined sildenafil to compete in the ED market. Common adverse events with all the PDE5 inhibitors include headache,flushing,nasal congestion,myalgia/back pain,and dyspepsia. However,these adverse events are generally mild,self-limited after long-term use,and not associated with treatment discontinuation. Lastly,the possible relationship between nonarteritic anterior ischemic optic neuropathy (NAION) and PDE5 inhibitor use has raised important questions; nevertheless,to date,there is no epidemiological evidence that the incidence of NAION is higher in patients receiving PDE5 inhibitors. PDE5 inhibitors have proven effective in the treatment of several neurological disorders,including spinal cord injury and multiple sclerosis (MS),and the compounds could be taken into consideration in treating stroke-induced SD,especially in young or middle-aged patients with few comorbidities. Although in patients with diabetes or hypertension,a dose of sildenafil 50mg does not appear to produce detrimental effects on cerebral blood flow,individuals with a history of stroke might be at increased risk of hemodynamic impairment after the use of the drug. Thus,having an accurate medical history is fundamental for patients with stroke before prescribing PDE5 inhibitors,starting with low doses.
Injectable and intraurethral agents were relegated to second-line therapy after the appearance of the effective oral PDE5 inhibitor. However,the local delivery of medication (i.e.,prostaglandin E1 [PGE1] and papaverine) remains useful,as in about 25 to 30 percent of patients with ED,PDE5 inhibitors are ineffective. Therefore,these second-line therapies could be a valid alternative in patients with more severe stroke.
About 40 percent of patients with ED have evidence of abnormal arterial flow,only partially involving aortoiliac bifurcation,since most men with major vessel disease rarely present with impotence. Conversely,the majority of vascular patients with ED have pathological changes in the small vessels of the penis and,generally,revascularization for such small arteries is challenging. Penile prosthesis offers a valid therapeutic alternative for patients who fail vasoactive drugs and vacuum-constrictive devices and who are not candidates for vascular reconstruction procedures.
Ejaculatory disorders. Since premature ejaculation (PE) is mostly due to a psychogenic etiology,psychosexual treatment is considered the mainstay,with high rates of success. Dapoxetine,a short-acting selective serotonin reuptake inhibitor (SSRI),could treat some patients,whereas some trials have evaluated the use of sertraline,with inconclusive results.
Since the most common etiology of anorgasmia is the intake of psychotropic agents,regaining the orgasmic sensation might be achieved with discontinuation and/or substitution of the inciting drug. In cases of anejaculation,vibratory stimulation might be helpful,but intact dorsal penile nerves are necessary for the ejaculatory response.
Ejaculatory pain represents a component of SD that has received little attention in the literature so far. Postorgasmic pain is associated with prostatitis,chronic pelvic pain syndrome,benign prostatic hyperplasia,ejaculatory duct obstruction,prostate radiation,and radical prostatectomy. However,it could rarely be related to CNS lesions,including stroke. In that case,the treatment options vary from antidepressants,such as amitriptyline; antiepileptics,such as pregabalin and topiramate; muscle relaxants; and even surgical procedures,such as pudendal nerve decompression,in the most severe cases.47
Nonpharmacological treatment. Besides pharmacological treatment,one of the most important,although often underestimated,success factors of SD therapy is undoubtedly the involvement of the patient’s partner in expert counseling. Psychosexual and relational counseling could be of help,especially when psychogenic factors overcome the organic ones.
Specific pelvic floor muscle training or individualized sexual rehabilitation might also be used in some cases,but data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice.","department":"
