Impotence Treatment Center

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Let's be honest. Every man wants to improve their sexual performance. Married, single, young, old, the truth is that almost all of us could stand for a pick-me-up every now and then. And in today's fast-paced world, they need a solution that works fast and continues to work. Meet Orexis

Unlike other treatments that you have to take hours in advance, that wear off quickly, and do nothing for you in the long-term, Orexis delivers both immediate and long term results. Even though you will feel the effects from the very beginning, Orexis continues to work long after!

Have you ever wondered whether or not your partner is pleased? Have you ever worried about your wife losing interest?Have you ever wondered about losing out on that special person because of poor performance the first time around? Impressions matter, and that is what makes Orexis worth its weight in gold.

So go ahead and take a chance! It could be the best decision you've ever made for your love life!

We've found the alt.support.impotence newsgroup to be an invaluable resource of information. We strongly suggest you visit their community to learn more about impotence and to talk about this sensitive issue. Rather than reinvent the wheel, we're reposting their already very comprehensive FAQ. For more information, visit http://www.alt-support-impotence.org.

Impotence Information & Resources

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  1. What is Erectile Dysfunction (ED) and how do I know if I have it?
  2. What's a {insert part of male sexual anatomy} and where is it?
  3. Someone told me I might have Peyronie's Disease.  What is it, and does it cause ED?
  4. What causes ED?
  5. I don't have a problem now.  What can I do to prevent ED in the future?
  6. I've finally decided to see a doctor about my ED problem.  What should I tell him, and what questions should I ask?
  7. My ejaculation is weak, and just dribbles out.  What can I do about it?
  8. I've heard of Kegel exercises.  What are they and how can they help my sex life?
  9. What treatments are available for ED?
What is Erectile Dysfunction (ED) and how do I know if I have it?

The terms erectile dysfunction, or ED, and impotence used to be considered to be interchangeable. However  the more appropriate term is erectile dysfunction; defined as the persistent inability to attain and maintain erections of sufficient rigidity for penetrative sexual intercourse. Impotence has pejorative connotations and includes this meaning.  But it also involves reduced potency which could include loss of libido, being sub-fertile or not having an orgasm, and premature ejaculation (ejaculating before or soon after beginning intercourse). 

Premature Ejaculation (PE), in particular, is highly subjective.  If you can achieve penetration before ejaculating then you have PE from a personal standpoint if you don't last as long as you and your partner desire.

Approximately 20 million men in the U.S. have ED to some degree, ranging from complete inability to have an erection to occasional problems.

ED is not only, "can't get it up," but, "it won't stay up long enough." (Like when we were 18-years old) Many are able to get an erection but sometimes can't keep it up long enough to achieve an orgasm and/or satisfy their partner. Age is certainly a contributing factor, and the majority of men with ED are over 40. This is by no means always the case;  we have questions from teens upward in age.   

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What's a {insert part of male sexual anatomy} and where is it?

We get many questions about male sexual anatomy.  What's the Corpus Cavernosa/Epididymus/Cowper's Gland, etc. 
Click Here for an illustration of internal and external male sexual anatomy with the parts labeled.

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Someone told me I might have Peyronie's Disease.  What is it, and can it cause ED? Peyronie's disease, a condition of uncertain cause, is characterized by a plaque, or hard lump, that forms on the penis. The plaque develops on the upper or lower side of the penis in layers containing erectile tissue. It begins as a localized inflammation and can develop into a hardened scar.

Cases of Peyronie's disease range from mild to severe. Symptoms may develop slowly or appear overnight. In severe cases, the hardened plaque reduces flexibility, causing pain and forcing the penis to bend or arc during erection. In many cases, the pain decreases over time, but the bend in the penis may remain a problem, making sexual intercourse difficult. The sexual problems that result can disrupt a couple's physical and emotional relationship and lead to lowered self-esteem in the man. In a small percentage of patients with the milder form of the disease, inflammation may resolve without causing significant pain or permanent bleeding.

The plaque itself is benign, or noncancerous. A plaque on the top of the shaft (most common) causes the penis to bend upward; a plaque on the underside causes it to bend downward. In some cases, the plaque develops on both top and bottom, leading to indentation and shortening of the penis. At times, pain, bending, and emotional distress prohibit sexual intercourse.

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  What causes ED?

The causes of ED are many and varied, and often unknown. ED can arise from psychological problems (psychogenic ED) or can be secondary (organic ED) to disease conditions such as diabetes or atherosclerosis, or a result of surgery; depression, anxiety, certain drugs, smoking, or alcohol .

Causes include:

  • Blood flow problems: Hardening of the arteries (atherosclerosis), high blood pressure, diabetes, or arterial damage (bicycle riding has been cited here)
  • Drug side effects: Sedatives, antihypertensives, diuretics, antidepressants, weight control drugs, peptic ulcer drugs, alcohol, nicotine, caffeine, opiates (marijuana, cocaine, etc) and many more. For a list of common drugs that may contribute to ED, see: http://www.impotenceworld.org/medication1.htm
  • Nerve impulse abnormalities: Conditions that reduce or block the nerve supply to the penis. Diabetes, stroke, spinal cord injuries, pelvic trauma.
  • Hormonal abnormalities: Diseases that disrupt the normal balance of hormones include kidney disease (and dialysis), liver disease and alcoholism, pituitary tumors, hypogonadism (lack of testosterone).
  • Surgery: Any surgery or medical procedure involving the pelvis, and especially the prostate or bladder
  • Prostatitus: Inflammation of the prostate
  • Prostate cancer: Treatments are usually the culprit whether surgery, radiation or seed implantation
  • Penile trauma or scarring: Peyronie's disease (scar tissue in the penis, or 'bent penis').
  • Psychological causes: Depression, stress, performance anxiety, guilt and misinformation about sexuality. Premature ejaculation, in particular,  is often a psychological problem and is most often observed in young men.

Most ED has a physical cause, but there is almost always a psychological component. Even a single failure to maintain an erection can cause worrying, stress and apprehension. Worrying about it makes it worse, to the extent that the ED may persist even after the physical cause disappears.

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Is ED between the legs or in the brain?  

Although the end result of ED is certainly seen at the level of the penis, it can occur from changes in many different parts of the body, including the brain and spinal cord. Irrespective of origin, the end result is generally observed as changes in blood supply within the cavernosal tissue of the penis.

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How do I know if my ED is physical or in my head?  

There are ways to try and ferret out whether a particular case of ED is "psychogenic" or organic (physical).

Men normally have several involuntary erections each night during sleep (not to be confused with 'wet dreams') in addition to the erection most men have upon waking (the morning erection or 'piss' hardon).  If these erections are weak or missing there's at least a preliminary indication that something's wrong physically. 

The test for this is called Nocturnal Penile Tumescence testing (NPT) which can be done either in a sleep lab or at home. The most popular device for this test is called the RigiScan, which measures the frequency, longevity, and strength of erections that occur during sleep. Measuring these sleep erections is important because  nocturnal erections can be weak, short-lived or infrequent, indicating a physical cause despite the patient subjectively "remembering" he has nocturnal or morning erections. 

Tests to determine blood flow and venous competence of the erectile system are also available. These include penile doppler ultrasound, cavernosometry/cavernosography (pressure tests/x-rays of the penis during erection), penile arteriography, and various other tests. These tests are often of limited usefulness in the majority of ED cases, they  may be useful for men who have never experienced erections, or for men with known trauma such as a pelvic crush injury or similar perenial trauma. Limited usefulness means that the results of the tests will do little to change the recommended treatment and serve only informational purposes for the patient.  

To summarize, there are a variety of tests which can be performed to help determine the exact cause of a particular case of ED, but in the overwhelming majority of cases, once serious or life-threatening disease is ruled out they are unnecessary from a medical standpoint. 

In the future, as effective remedial treatments for such things as venous leakage and arterial damage/insufficiency are perfected and become generally available, these tests may become more valuable.  In the present state of the art, however,  there is little that can be done to correct these situations, and the treatment consists of simply alleviating the symptoms

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  Is ED like atherosclerosis? 

It has been claimed by some that ED could be considered to be atherosclerosis of the penis. Atherosclerosis  is  the "furring up" of arteries and small blood vessels, resulting in reduced blood flow. Doppler flow studies show that this can occur in the penis and in the blood vessels that supply it.

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Can stress cause ED?

One of most common psychological causes of impotence is stress or performance anxiety. During stress, sympathetic nerve impulses constrict smooth muscles within the penis and prevent blood from flowing in to cause an erection. Stress also causes a decrease in nitric oxide (NO), the substance which triggers muscle relaxation. Viagra enhances the action of NO so that smooth muscles can relax more easily. Studies have shown that once men overcome their anxiety simply by performing successfully, they often do not even need any more help from medication. Men who take Viagra may want to use it a few times and then try to have intercourse without it. In many cases, they find that they can wean themselves off the drug. 

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I have ED and drink alcohol heavily. Could this be the cause?  

This could certainly contribute to your ED. The simple solution is to either stop drinking entirely or reduce your alcohol intake drastically.

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Can bicycling cause ED?

At least one urologist, Irwin Goldstein, believes that bicycle seats, by exerting pressure on the nerve supply to the penis, can, in fact, cause reversible or irreversible damage and ED. This problem occurs most often in men who spend a lot of time riding.   Dr. Goldstein, however, probably represents a minority view in this. Several manufacturers have designed bicycle seats to reduce or eliminate the pressure. 

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The doctor said my ED is caused by venous leakage.  What is it?

An erection is a complex process.  To simplify as much as possible, here's what happens:  First, the deep arteries carrying blood into the penis expand, increasing blood flow.  This causes the spongy tissues that make up most of the shaft to expand and fill with blood.  When these tissues expand they press against and close off the veins (near the surface) draining blood from the penis, increasing blood pressure within the penis and sustaining the erection.  

Sometimes either the tissues don't expand enough or the veins are not flexible enough to be completely squeezed shut. When this happens the blood is allowed to drain out of the penis at the same rate as it enters, resulting in loss of erection.  This leakage of blood through the surface veins is called venous leakage.  It has nothing to do with the veins actually leaking blood into surrounding tissues; only that they're not completely shut off and "leak", like a leaky faucet.  A cock ring can help here by shutting off the veins externally with a tourniquet effect.

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I don't have a problem now.  What can I do to prevent ED in the future?

ED is associated with certain risk factors, including being overweight, being diabetic, having abnormal blood platelets, smoking too much or excessive alcohol intake. You can compensate for these by adjusting your lifestyle and so reduce the likelihood of ED occurring. You should also discuss with your primary care physician whether any of the drugs you may be taking could have an adverse effect on sexual function.

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I've finally decided to see a doctor about my problem.  What should I tell him, and what questions should I ask?

First off, it's a good idea to write down everything you want to discuss before you see the doctor.  Include a complete narrative of your particular problem; when it began, what your symptoms are, etc.  Be thorough and completely (even painfully, as one contributor put it) honest with yourself. If you think it's relevant, start at puberty or even before.  Your doctor depends on you for a lot of the information he needs to make a proper diagnosis.  Take two copies with you.. one for the doctor and one for you.  This approach has several added advantages.

  • You have plenty of time to think it through and include everything you want to say.  In the embarrassment of the moment, you will probably leave out something important if you rely on just talking it over with him.
  • Your doctor is a lot more likely to take you seriously if you've taken the trouble to write it all down.
  • You can go over the points with the doctor one by one, and you're both on the same "page" at all times.

Before you see the doctor, get as much information as you can about ED; what causes it, what YOU think the cause might be in your particular case, and the treatments that are available.  This way, you can not only discuss it intelligently with the doctor, but you can get an idea pretty quickly if this particular doctor is well versed in the subject or not.  If you know more about the subject  than the doctor does, you should find another doctor -- IMMEDIATELY!! Remember that ED has only recently "come out of the closet" and some doctors, GP's in particular but many urologists and endocrinologists as well, are not well educated on the subject.  If your doctor doesn't seem willing to discuss it, or dismisses it quickly, then find one who takes you seriously!  Remember, it's YOUR sex life you're interested in, and your doctor has no business dismissing it as unimportant.  It doesn't matter if you're eighteen or eighty, heterosexual, homosexual, or bisexual.. you've got a right to enjoy a satisfying sex life and your doctor is paid to help you do it!

 Read the information on this web site, and join the Alt.support.impotence on the Web discussion group.  Don't be afraid to ask questions.   There are a lot of people there who know a lot about all aspects of ED and they're there to offer advice.  There are no stupid questions as long as you're sincere. If you don't want your e-mail address or your identity known, read the FAQ about anonymous posting.  If you're still hesitant to sign up, you can  e-mail Jerry, Jim, or Fred directly. They'll answer you directly if you prefer. Your anonymity will be respected and preserved.

There are a couple documents you might want to print out and take with you when you visit the doctor.  These are the American Association of Clinical Endocrinologists (AACE) Clinical Guidelines for the treatment of  Male Sexual Dysfunction and Hypogonadism.  Hypogonadism is another term for hormonal problems (usually too little testosterone or too much estrogen, but there are other problems as well). You'll want this one if you feel your libido is low or you suspect you might be suffering from low testosterone. You'll do well to read these documents carefully and take one or both with you to the doctor.  They aren't perfect, but they're a great starting point for your discussion, and your doc may never have seen them.  You can either go to the AACE website at http://www.aace.com/clin/guides/sexualdysfunction.html and http://www.aace.com/clin/guides/hypogonadism.html, or you can download the Adobe Acrobat (PDF) versions from the ASI FTP site at ftp://alt-support-impotence.org/pub (Just click on the links).   If you get the Adobe version, it's already formatted for printing but you'll need the Adobe Acrobat Reader 4.0 if you don't already have it (you can download it free from the ASI FTP site as well, .file name ar405enq.exe. It's about 6MB, so be prepared to wait if you're using a modem).

Seeing a doctor about a sexual problem for the first time is painful and embarrassing for many men.  But consider the alternatives.  Chances are pretty good that your problem won't go away by itself.  It'll only get worse. As men,  we're reluctant to discuss our sex lives, and even more so when we feel there's a problem. Sexual potency in men is supposedly a given, and if a man can lay claim to being a man he's supposed to be able to perform every time at the drop of a hat. That's what you've heard in the locker room since you were a teenager, but  you and I (and all men) know privately that that's crap, and your doctor does, too.    The doctor is there to help you, so take advantage of it and get your sex life back on track!  No man older than a teenager can expect to get an erection and perform sexually every time he'd like.. there are just too many things that can interfere.  But we can expect to have a normal and satisfactory sex life regardless of age, and there are enough alternatives out there to ensure that it can happen.  A visit to the doctor and laying it all on the line is the first, and the most important, step in achieving it.  Don't delay!

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My ejaculation is weak, and just dribbles out.  What can I do about it?

Often, this is caused simply by getting older and losing some of the muscle tone in the pelvis.  It can also be caused byrestriction (scar tissue or some such) in the urethra, or an enlarged prostate. 

Also, especially if you've had prostate surgery, either a TURP or prostatectomy, it can be caused by a condition called "Retrograde Ejaculation"  There are two sphincters which close off the urethra; one where it exits the bladder and one where it exits the prostate and enters the penis.  During ejaculation, the sphincter at the exit from the bladder normally closes and the one at the exit of the prostate opens, directing the semen out of the penis through the urethra.  If this doesn't happen correctly, for instance if the sphincter at the exit from the bladder doesn't close completely or is damaged, then the ejaculate can go backwards into the bladder rather than out through the penis. Prostate surgery often damages one or both of these sphincters, especially the one at the bladder neck, which is why many men have incontinence problems following surgery of this type. Retrograde ejaculation isn't a serious problem unless you want to father a child.  It won't cause an infection or any other physical problem, except for personal dissatisfaction in not being able to ejaculate normally.  I you do want to father a child, sperm can actually be recovered from the urine and used for artificial insemination.

Lack of pelvic muscle tone can sometimes be improved by doing Kegel exercises.  This involves exercising the pubococcygeus , or PC, muscle, which stretches from the prostate to the anus.  It's used on a daily basis to shut off the flow of urine and feces until you're ready to relieve yourself, but it's also used in ejaculation.  The same muscle in women can be used to tighten the vagina during sex as well as in control of urine and feces.  This is the muscle that causes your penis to "jump" when it's erect and touched. If you've had prostate surgery, exercising this muscle can help to minimize incontinence problems, and may help to strengthen and control ejaculation as well.  Here's a link to a reasonable description of the exercises.

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I've heard of Kegel exercises.  What are they and how can they help my sex life?

Kegel exercises were first devised by a California Gynecologist, Dr. Kegel, to help women with stress incontinence, or urine leakage.  A welcome and unexpected side effect was strengthening of the vaginal muscles and increased sexual satisfaction for both the woman and her partner.  Recently, research has shown that males can gain significant improvement in erectile function as well through use of Kegel exercises.  There's an appendix on Kegels in The Testosterone Syndrome, by Dr. Eugene Shippen.  Click here for a link to a website with a good description of the exercises and how to do them.:

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Can prostate cancer cause ED?

Prostate cancer in itself does not normally cause ED, but the treatments for it certainly can.

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What is nerve-sparing radical prostatectomy?  

Radical prostatectomy is usually performed in the treatment of prostate cancer. There is a danger that during the procedure the nerve supply to the penis may be damaged, either reversibly or irreversibly, leading to ED. To limit the degree of damage, the standard procedure has been modified to maintain as much of the nerve supply as possible. Hence the term, "nerve-sparing radical prostatectomy". 

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I am 6 months post-radical prostatectomy. I get no erections and nothing helps. Will I recover?  

Recovery  is certainly possible, although not definite, that you may recover. What has been found is that the nerve damage associated with the prostatectomy can heal with time. Nerves have been shown to regenerate over a period of 1–2 years. Many patients with ED following radical prostatectomy respond to therapy and are able to regain full or partial erections.

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What treatments are available for ED?

There are a variety of treatments available, and many more are being developed. The choice of treatment should result from discussions between you, your sexual partner and your doctor.  Generally, the least invasive treatment which produces the desired results and is a satisfactory solution to both the man and his partner is the best.  The various options are listed below, in order of least to most invasive.

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Cock rings (restriction bands): What are they and how do they work?  

You can order them online, or get them from a drug store or a sex shop. Some of the best are either adjustable or come in assorted sizes for best fit.  There should be an easy method of removal -  either snaps or a ratchet arrangement (in the case of adjustable) or rubber ears in the case of elastic rings. Solid metal rings are dangerous since there's no easy method of removal.  Rubber "O" rings from the hardware store will work and are very cheap but are difficult to remove without cutting them off since there's no way to grasp them for removal. Removal is easier if you apply lubricant to your penis and the cock ring.

Since you are, in effect, applying a tourniquet to your penis the ring should not be left in place for more than about a half hour. This means you need to remove it as soon as you finish.  

The drawbacks are that you have to take a break from sex to put it on. It's sometimes uncomfortable, and it tends to pull your pubic hair, particularly when removing. One way around the hair pulling is to either trim or shave your pubic hair.   

No prescription is needed, the rings are quite safe and effective as long as you observe the half-hour rule.  They can be used to prolong or enhance a normal erection as well as keep you from losing your erection prematurely.

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Pumps (Vacuum Erection Devices): What are they and how do they work?

The pump basically consists of a clear acrylic cylinder, a vacuum pump and a cock ring.  The pump can either be integral with the cylinder or separate and attached with a plastic tube. It works by creating a vacuum around the penis, thus drawing blood into it and causing an erection. You start by stretching the cock ring over the open end of the cylinder.  Insert your lubricated penis, forming a seal against your body and operate the pump.  Once the erection is obtained you slip the cock ring off the cylinder onto the base of your penis, release the vacuum and remove the cylinder..  This maintains the erection for up to half an hour.  Cost ranges from about $200 to $450 and is often covered by insurance.  You can find them in adult stores, but these are always of inferior quality. Don't waste your money. Quality manufacturers include Osbon, Rejoyn and Pos-T-Vac.  Order through your urologist or a drug store that handles durable medical goods. The pump is probably the most reliable of all for getting and maintaining an erection.

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Viagra  

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Does everyone respond to Viagra?  

Viagra has revolutionized the treatment of ED.  While it's not for everybody it does the job for most ED sufferers.

The overall response rate is somewhere in the region of 60–70%, with roughly three-quarters of responders having a full erection. This response rate will depend on the patient population; the response rate in diabetics is marginally less and in post-radical prostatectomy -  only 50% of men are likely to respond.

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How does Viagra work? 

Viagra works by inhibiting an enzyme called phosphodiesterase (PDE), in particular, one member of this class of enzymes called PDE5. This enzyme is found within the penis and this accounts for the relatively selective action of Viagra on ED. By inhibiting PDE5, Viagra increases the level of cyclic guanosine monophosphate (cGMP). Elevated cGMP levels result in relaxation of the cavernosal smooth muscle, which in turn results in engorgement of the tissue and erection. In patients with ED, cGMP levels may be low and would therefore be raised by Viagra. 

Another explanation: Sildenafil is a phosphodiesterase inhibitor (PDE). Basically this means it stops the breakdown of cyclic-GMP (a neurochemical in the penis). The subtype of PDE in the penis is PDE5. The drug cross-reacts with PDE6 (which occurs in the retina) and can cause some visual disturbances (the "Blue Haze"). The drug is 10 times more effective on PDE5 (penis) than PDE6 (eye) so these visual disturbances are not all that common, though they can occur and we know the reason. No long term retinal problems were identified in the initial study--only some temporary visual changes.

For more information, call the American foundation for Urologic disease at 800-473-0616. Also check the web at www.iiem.org.

Here is a good report on what Viagra does: 

It is not an aphrodisiac. Your sex drive will not be affected. According to Pfizer, you will not get a spontaneous erection after you take the pill; stimulus will still be needed. (Note that some men report that they do get a spontaneous erection in spite of what Pfizer says.) That stimulus may be mental, visual or physical, in your case, perhaps your partner's touch. It all depends on the individual. Results vary but the effects of the drug typically last four hours or more. It takes anywhere from 15 minutes to an hour for the drug to become effective after you take it. 

You will have to keep taking Viagra. It is not a one-time treatment. The normal dose is 50 mg. You may find that 25 or even 12.5 mg works for you. However, you may need a 100mg dose. 

The drug is most effective if taken on an empty stomach. It should not be taken with any nitrate-containing drugs such as nitroglycerine. 

Side effects vary according to the individual and dose. Most common are headaches, nasal congestion, facial flushing, visual disturbances (bluish tint) and a sense of having a hangover the next day. Not everyone gets side effects and very few men have reported having to stop using the drug because of them. Most of the time, the dosage can be adjusted to minimize the side effects, or a drug such as aspirin or an antihistamine can be taken to relieve the discomfort. 

Pills are expensive...about $10 US. Some men have gotten the pills mail order. Most insurers in the US are not covering the drug or are limiting coverage to about one pill a week. If you have to pay for it yourself, and do not need the highest dose, it would behoove you to get 100 mg tabs and split them as the price is relatively independent of the dose size.

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Is my insurance likely to cover Viagra? 

Some do, but most don't.  Most insurance companies that cover Viagra will only allow a certain number of pills per month.  If this is the case, there's no reason you can't get a prescription for as many as you need and just pay the difference. 

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What is sildenafil? Is it the same thing as Viagra? 

Pfizer only has one drug for the treatment of ED. Sildenafil is the generic name of the active ingredient in Viagra tablets. Viagra is a trade name that can be protected by Pfizer.

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Does Viagra affect libido?  

There is no evidence to date that Viagra affects libido.  However, having said that, a person with ED tends to avoid  and suppress his desire for sex.  Viagra may give him the confidence to allow natural urges to come to the fore and, in effect, give his libido a boost..

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Will Viagra affect ejaculation?

Viagra is not known to affect ejaculation per se. However, it may reduce the refractory period, which is the time it takes to get another erection after ejaculating. Some men have reported, however, that it takes longer to ejaculate when using Viagra, and a few cannot orgasm at all even though they don't lose the erection.

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Does Viagra or any other drug cause reversal of ED? 

There is no evidence that Viagra does in fact cause reversal of the underlying disease process in ED. However, a number of men are finding that after several doses of Viagra normal activity seems to be restored.  This may be because their confidence in getting an erection has been restored and the anxiety that was contributing to the problem is absent.  It may also be part of the "Use it or Lose it" syndrome. In other words, it's easier to get a good erection if you have them regularly.  This has to do with the next question.

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After several doses of Viagra my erections occur without it. Does this mean that I have recovered? 

There is no evidence that Viagra actually has a direct effect on the underlying disease associated with ED. However, what may be happening according to one urologist, Irwin Goldstein, is that as your erections begin to reappear, you get better tissue oxygenation within the penile tissue resulting in some level of collagen breakdown. This collagen breakdown then restores tissue elasticity within the penile musculature and enables the normal erectile process to reoccur. 

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Viagra was originally developed for angina. Does this mean my blood pressure will change?

Your blood pressure may change on Viagra, although the changes in blood pressure observed in clinical studies are considered not to be clinically important. If you are on anti-hypertensive medication you should discuss this with your primary care physician. Viagra should not be used in conjunction with any drugs that contain nitrates, such as nitroglycerine, glyceryl trinitrate, isosorbide or amyl nitrate (poppers).

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Does Viagra have any side effects, and if so what are they?  

No drug is without side-effects. However, Pfizer have worked out the effective dose range that can be used to minimize side-effects. If the drug is used within this dose range -  usually 25–100mg -  side effects are likely to be minimal. Incidentally, not every individual will, in fact, experience side-effects.

Most of the side effects you might experience are covered in the product information sheet, but a few additional ones have been reported from users.  They can include headache, heartburn, nasal congestion, backache, slight dizziness, diarrhea, a next-day "hung over" feeling and some slight visual disturbance (blue haze).  Some users have experienced delayed or no ejaculation, especially after long-term use. Viagra will cause a drop in blood pressure, which is why it shouldn't be used with any medication containing nitrates, such as nitroglycerine.  

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What can I take to help eliminate side effects?  

In general, just take whatever you would normally take to alleviate the symptom if it occurred on its own.  For instance, for headache, take Tylenol or Ibuprofen.  For stomach upset or heartburn take an antacid. For a stuffy nose take a decongestant.  If you regularly experience the same side effects, try taking the remedy at the same time as you take the Viagra.  For the "Viagra Hangover", maybe a Bloody Mary or two.  There's not much you can do for the 'blue haze' except wait until the drug wears off.

It may be worth noting that Tagamet, the antacid, has been reported to increase Viagra's levels in the bloodstream. Pfizer's studies, however, showed that this only happens at about four times the usual Tagamet dosage, and at this level Tagamet can not only contribute to ED, but also to hair loss.  It's doubtful you'll see any change in the effectiveness of Viagra with a normal dose of Tagamet. 

There is a general consensus that the side effects lessen with continued use.

The main thing to remember about side effects is this:  Increasing dosage beyond what is required to get a serviceable erection increases the side effects without improving your erection.  In other words, to minimize side effects (and save money) use the smallest dose that does the job. 

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What does half-life mean and what does it have to do with Viagra?

The half-life of a medication is the time at which the level in the bloodstream is half of the maximum level. For Viagra, the half life is supposedly about 2-4 hours. This means if you take a 100mg dose, after four hours its effectiveness has dropped to what it would have been if you'd taken 50mg.

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After taking Viagra, why do I have erections the next morning?  

Although the half-life, that is the time for the plasma level of the drug to drop by 50%, of Viagra is about 2-4 hours, erections are quite commonly experienced for some considerable periods after that. This is probably because Viagra may be taken up into tissues and slowly released for up to 24 hours after a single dose.

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I have been advised that for best results I should take Viagra on an empty stomach. What is an empty stomach?

An empty stomach essentially means that you have not eaten food up to 2-3 hours prior to taking Viagra. The longer you can wait after a meal before taking Viagra the better.  Additionally, experience has shown that foods high in fat diminish the effect.  Some people have had good results by taking the pill about half an hour before a meal.  This gives the medicine time to get into the bloodstream before it can be affected by the food.

The best time to take Viagra is in the morning before breakfast.  This way you can be sure your stomach is empty, plus you're relaxed and testosterone levels are highest in the morning.

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Why is Viagra so expensive? 

Viagra has taken Pfizer some 10–12 years to develop at a cost of approximately $250–300 million. For Pfizer to maintain a research and development investment, they must try to recover this cost. This has to be done over a limited time as the patent office only gives about 20 years patent protection, which represents 5–6 years after a drug has been marketed. These factors are reflected in the pricing of Viagra.

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My insurance won't pay for Viagra.  How can I minimize the cost?

Viagra comes in three strengths: 25, 50 and 100mg.  For some reason known only to Pfizer the three dosages all cost about the same; between $7 and $11 per pill depending on where you get it.

Find the lowest price

The most obvious cost saving device is to find the lowest price.  Shop around among your local pharmacies; you'll find the price varies a lot.  You can telephone and ask the price; there's no secret about it.  In general, you'll probably find the lowest price at discount pharmacies like Wal-Mart or Target.  There are some reputable online pharmacies who offer very attractive prices.  Drugstore.com , Planetrx and the AARP Pharmacy are among these.  Steer away from the online "Viagra without a prescription" sites.  They're bad news.

Split the pills

Regardless of the dosage you need, get a prescription for the 100mg pills.  You can use a sharp knife or an inexpensive pill splitter (available from the pharmacy) to split the pill into halves or quarters.  The medicine is evenly distributed throughout the pill, so there's no problem of getting more in one split part than another.  Also, exact dosage is no problem if the pill doesn't split evenly; approximate is fine.  If you're worried about this, just crush the pill into powder, divide the powder and put it in empty gelatin capsules you can get from GNC.

If you're worried about your doctor prescribing the 100mg pills when you only need 50's, don't.  The doctor understands economy as well as you do.  Just explain what you're going to do and he'll likely be happy to comply.

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Is there any way I can make Viagra work faster?

You can dissolve the pill in a little water (a bathroom paper cup is about right) and drink it. If you're using a whole pill, break or crush it first for faster dissolving.  Don't worry about the blue coating -  it doesn't contain any medicine. Experience has shown that this cuts the time for the Viagra to take effect down to about 15-30 minutes.  Some people find that using hot water works even faster.  The resulting drink is bitter but tolerable, and you can always follow it a with a little fresh water to wash away the taste.

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I took my first dose of Viagra and nothing happened.  What's wrong?

First off, you may be one of the  20-30% of men for whom Viagra just doesn't work.  If that's the case don't despair; there are other alternatives.

Keep in mind that Viagra doesn't give you an automatic erection.  It simply enables you to get a normal erection with a normal amount of sexual stimulation; visual, mental or manual. This means that if you take a pill and then the occasion for sex doesn't arise as expected, nothing will happen except you've just wasted a few bucks.

It's very important to take Viagra on an empty stomach.  This means waiting 2 hours at a minimum after eating before taking the pill.  Food high in fats have the worst effect, but alcohol in moderation seems to be OK.  Best time is in the morning before breakfast when  your stomach is empty, you're relaxed and your natural testosterone levels are the highest.  Some men have found that they can take the pill about half an hour before eating.  This gives the medicine time to get into your bloodstream before the food arrives. Since the Viagra will work for at least a couple hours this gives you time for a leisurely meal followed by some satisfying sex.

You may be taking too low a dose.  Most men find that 50mg is about right, but others get the required effect on more or less.  Try upping the dosage, but keep in mind that the maximum recommended dosage is 100mg in a 24 hour period.  Also keep in mind that increasing the dosage will increase any side effects you experience.  Using a higher dosage than you need will increase side effects without improving your erection.  To avoid disappointment with your partner it's probably better to experiment solo, with masturbation before going for a home run.

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What are some of the contributors experiences with Viagra? 

Here is a mixture of individual's reports: (Try this at home. Your experiences may vary.)

TIME DELAY:  I've had my best results after waiting a couple of days between pills. I don't know why but it seems to work better even though the literature says you can take it daily.

FACE FLUSHING:  I delay dick stimulation until I feel flush in my face which can take as long as 45 minutes after taking the pill.

PURPLE DICK:  About 5-10 minutes after the face flush, my dick takes on a red/purple hue. Not sure if it's blood or medicine but after this is when stimulation works best for me. I don't know why ... maybe prior stimulation pushes medicine out of the dick.

LITTLE IS BETTER: Again, I'm not sure why ... but for me ... slower and gentler stimulation proves best. Maybe time is needed for the old nerve cells to get reactivated, but soft squeezing of the head, body and finally the base now gets me close to a "woody".

EATING: The consensus is, don't eat for at least two hours before taking Viagra. It slows the effect of the pill. For you morning folks, the fat in milk slows it.

PILL ACTION: Instructions say take the pill an hour before sex. The effect should last about four hours. (Called a 'Four-hour half-life') Some have found that if they crush the pill, then take it the effect is quicker and more dramatic. Presumably because they get the effect all at once. The word is, Viagra's maker (Pfizer) is going to make a wafer, so it will act faster.

FASTER PILL ACTION: Some of us have found that if you chew the pill, or dissolve it in a small amount of water and take it (tastes very bitter), the results take effect in 15 to 30 minutes. 

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Can women take Viagra? 

Clinical trials on the effects of Viagra on female sexual dysfunction are underway, with promising but mixed results so far.  Especially for women of child bearing age, taking Viagra before it's got a clean bill of health through extensive testing could be a risky business.  There's no proof that the medicine won't affect a fetus and cause any number of birth defects.  Theoretically Viagra should enable more engorgement of the clitoris and labia and increased vaginal lubrication, resulting in more satisfying sex.  Better to be safe and wait until the verdict is in.

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I don't have ED.  Will Viagra or other drugs for ED enhance my sexual powers? 

There is no evidence that Viagra will affect normal sexual function. If you can get a hard erection and keep it until you ejaculate, it's very doubtful Viagra will do anything positive for you.  However, there have been a few reports of priapism with the recreational use of Viagra.  Priapism is a persistent and painful erection, and is something you definitely don't want to experience.  It can cause damage to your penis.

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Muse suppositories. What are they and how do they work?

Muse is a tiny suppository which is inserted about an inch deep into your urethra using a disposable applicator. The medication, Prostaglandin (the same medication as in Caverject), is absorbed through the urethra and into the corpa cavernosa, the erectile tissues of the penis causing smooth muscle relaxation and a resulting erection. It works in just a few minutes.  It's quite expensive, and may or may not be covered by insurance.

Although there was much interest and optimism in the response rate to MUSE when it was introduced in 1995, more recent data presented at the American Urological Association (AUA ) are less encouraging, with response rates only marginally better than with placebo. Pain was also apparent at the delivery site in approximately 30%  of patients.The consensus on the group is that it only helps about 3% of users and "hurts like hell", causing an ache in both penis and testicles.  The dropout rate in users is quite high, but until the advent of Viagra, Muse was the treatment of choice for men who did not want penile injections or any of the less invasive treatments.

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I've heard about penile injections for ED.  What's this all about?

There are several drugs which can be injected directly into the erectile tissues of the penis to cause an erection.

Before you run screaming at the idea of sticking a needle in your dick, be assured that the injections are made with a very fine needle (the type normally used for insulin) and are less painful than a flu shot.  The following questions discuss the various drugs and how they're used.

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What is Caverject?

Caverject is the trade name for an injectable solution of prostaglandin E1 (PGE1) or alprostadil, which is manufactured by Pharmacia-Upjohn. There are other variants of this including Edex, a similar product from Schwarz-Pharma.

Caverject makes the shot kit. (Do a Internet search for 'Caverject') It is portable and does not require refrigeration until you mix the ingredients.  It's expensive, compared to the PGE1 or PPP. A popular complaint is that the needle is very large. Many here will tell you to purchase the small needles that diabetics use for insulin injections. Mix your powder and liquid using the large needle supplied with the kit, then change to the small needle for the injection. The reason the company supplies large needles may be the worry you might break off the needle in your dick and sue them.

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 What are Bimix and Trimix injectables? 

Bimix and Trimix are injectables for intracavernosal administration. They refer to any combination of either two or three chemicals. Bimix is often a mixture of papaverine and phentolamine, while Trimix would add PGE1. Other cocktails are used, mainly in Europe.

These mixtures are not commercially available but must be mixed by a compounding pharmacy.  They are generally much cheaper than Caverject or Edex, and tend to minimize aching in the penis or testicles which is a problem in some men with Prostaglandin (PGE-1) alone.  A compounding pharmacy is one which will create custom medications on a doctor's prescription; it usually doesn't include the corner drugstore or large chain pharmacies.

If you need to find a compounding pharmacy close to where you live, you can go to the International Academy of Compounding Pharmacists at http://www.iacprx.org/ .  You can fill in a form on the site and they'll mail you a list of pharmacies in your area.

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My urologist says he's going to try me on injections my next visit.  What should I expect?

Either the doctor or a nurse will inject your penis with a test dose of the chosen medication and observe the reaction.  Since different men react in varying degrees to the same dose, this is to establish what's the correct dosage for you.  The doctor or nurse will also show you how to administer the shots yourself.  Depending on your penis's reaction to the test dosage the doctor will write you a prescription showing a higher, a lower or the same dosage for home use.  

When you inject at home you may get a different reaction than you did in the doctor's office.  That's because the environment is different;  you may be more or less relaxed or apprehensive.  You can adjust the dosage upwards or downwards in small increments until you find the right dosage for you.  The danger of too large a dose is that you may get an erection that refuses to go down.  This is called Priapism and if it goes on for more than three hours you should contact your doctor immediately.  Priapism can be serious.

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Do the shots hurt?  

Less than in your arm. The small needles, combined with the soft tissue, makes it go in easy. It's just a little unnerving the first time. And the first time is usually done by a Dr. in their office.

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How do I give myself an injection?  

A diagram usually comes with the medicine. One says to lay your dick to one side, against your body, and shoot into it. Another has you hold it out. The idea is to inject into the corpora cavernosa; the tubes on each side of your dick. Going into the side at about the 9 o'clock to 11 o'clock, or, 1 o'clock to 3 o'clock position. This way you miss the urethra. Anywhere from the base of your dick (next to your body) to about ¾ of the length. Don't shoot in the head (ouch!)

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What about the possibility of scarring?  

The understanding is that there's a possibility that Prostaglandin (PGE1) can cause scarring, (fibrosis) with long-term use. Several men in the group, however, have used injections for years with no adverse effects. There seems to be less risk with Trimix.  Penile fibrosis can lead to Peyronie's disease or "bent penis".

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Will the shots give me a 100% erection by themselves?

They can, but in practice the shot alone should give you about an 80% erection. Stimulation should bring it the rest of the way up. If the shot alone gives you a 100% erection, you may have an erection for a longer time than you want. Many have received a shot in the doctor's office and had little to nothing happen. Yet when they inject at home, in a situation where they began having sex, it worked. 

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I get erections but they don't last long enough. Will the shots help? 

They should. You will find that the erection can last longer than the sex. In other words, after climax, you may retain your erection.

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Does it matter which side I inject? 

No. The corpora are connected. 

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How long is too long a time for an erection?  

If your erection lasts for 3 hours or more, it's time to call the doctor.  An erection that won't go down is called Priapism, and can be extremely painful and harmful to penile tissues.  The doctor will prescribe an antihistamine and possibly caffeine.  In extreme cases they may have to drain the blood from your penis.

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What is the medicine in the shots?  

Most doctors start you out with PGE1 . This is Prostaglandin E1 (AKA Alprostadil) and is the ingredient in Caverject and Edex.  If this doesn't work the doctor may prescribe  Tri-mix, which is a mixture of Prostaglandin, Papaverine and Phentolamine.  A typical mix,  in one bottle, is: Prostaglandin, .05ml; phentolamine, .55ml; Papaverine, 2.5ml; Saline, 1.2ml.

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Can I use my injectables intravenously to get better effect?  

In a word, NO.  It would be inadvisable to do this and may be positively dangerous. Certainly with Trimix, side-effects are minimized by the fact that you are applying the drug intracavernously and are, in fact, localizing the effects of the drug to the corporal tissue. To give the drug intravenously would be likely to cause serious systemic side-effects.

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What can cause the plunger on the syringe to sometimes push hard?

If you draw slightly more into the syringe than your normal dosage, then expel the excess back into the vial, you'll probably find the problem will go away. The flexible plunger is a tight fit in the syringe bore, and if its edge hangs on the surface when depressed, it will distort and bind. Drawing extra liquid in, then expelling it, lubricates the surface of the cylinder.

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Is there something to relieve the pain associated with Caverject?  

One person reports he used lidocaine (not marcaine, or lidocaine with epinephrine, which might defeat the purpose and would be dangerous) after Radical Prostatectomy when he was experiencing significant pain. Half the diluent in the Caverject kit syringe was replaced with 1% Lidocaine, resulting in a 0.5% solution. "The Lidocaine has no effect on the surface nerves and the solution was not noticeably different in action, other than less pain. This procedure was recommended on Upjohn's web site over two years ago."  Consult with your doctor before trying this!

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I have noticed that injection therapy gives me a harder erection and Viagra a more natural one. Is this a common finding?  

Viagra is essentially just restoring normal function and hence you get a natural erection. On the other hand, substances you inject, e.g. Caverject, are having a direct effect on the cavernosal smooth muscle. Also, as they are locally applied, you quite often appear to get a harder erection either subjectively, i.e. as you see it yourself, or objectively when you use a device like RigiScan to measure it.

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What about Priapism (an erection that won't go down)?  I've heard it can be a problem with injections.

This can be a problem, especially of you take too large a dose.  It's unlikely to happen if you follow the injection guidelines your doctor gave you and increase or decrease dosage in small steps until you find the right dosage for you.  Your doctor should definitely have given you specific instructions about what to do in case this happens. If not, then be sure to ask about it!  This will normally involve a prescription which you should have filled and on hand, and instructions about either calling the doctor or going to the emergency room if the prescription doesn't work.

In general, you should be concerned about any erection that lasts for more than about 3 hours (but follow your doctor's advice about this).  We're talking about a hard, steady erection here; not one that comes and goes.  The problem is that with a very hard erection, there is virtually no blood flow through the penis, since the veins that carry blood away are shut off tight.  Blood flows in but can't leave.  All the oxygen in the blood captured in the penis is used up and the blood stagnates and thickens, making it even harder for it to be removed by any veins that are still open. If this goes on too long it can cause permanent damage to the erectile tissues. 

In extreme cases you might have to go to a hospital or doctor's office for treatment.  The treatment may involve injection of antihistamines, caffeine or adrenaline directly into your penis, or "bleeding" your penis to remove stagnant blood.

There are a few things you can do before resorting to the emergency room if you think your erection is lasting too long.  Here's a copy of a message Jerry posted.  He's been through an extended bout of priapism caused by penile injections:

Your doctor should give you some pills that counteract the shots. It's usually three pills, to be taken after three hours of erections. Each pill taken a half-hour after the last. The pills are each equal to about 4-5 cups of coffee. In other words, coffee (caffeine) works against erections.

Another emergency method is to stand (not lie in bed) and squeeze, attempting to force blood out of the penis. Keep the pressure on for 15-20 minutes. Obviously your hands will tire. Squeeze 50 seconds, rest 10 seconds. The standing and squeezing also causes some adrenaline and this, too, counters erections. Adrenaline is the medicine they inject in your penis if the doctors have to get your erections down. Apparently exercising creates some adrenaline and will help get it down.

Here's another suggestion from a poster:

One way to check to make sure you have adequate
blood flow is to use ice cubes to cool it (your penis) way down. If it gets warm
again on its own, you know there is adequate blood flowing through it
to avoid damage. (This is what my doc told me.)

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  What are penile implants and how do they work?

Implants are prosthetic devices inserted in the penis to take the place of the erectile tissues of the penis.  They come in several different types and prices.  Most are made by American Medical Systems.  Implants should be considered as a last resort since inserting them destroys the erectile tissues of the penis.  There's no going back.  For a good description, go to:

http://www.drmobley.com/daveL44.htm

Here's a summary of what's available, 'borrowed' from http://www.msdinst.com/implant.htm:

Malleable Prosthesis

Prostheses come in several styles, malleable (bendable) and inflatable. Each malleable prosthesis consists of two cylindrical plastic rods from 6-10 inches long and up to 1 inch thick, with tapered ends. These rods fit the body because the penis is actually twice as long as it appears. At least half of it extends behind the skin where it cannot be seen, and is fixed to the bones of the pelvis. Malleable implants always remain the same length, width and degree of hardness, but they are cleverly made so that when the penis containing the prosthesis is bent upwards, it produces a hard, normal-looking erection. When bent downward so that it hangs comfortably in front of the scrotum, it looks like a normal flaccid organ.

Inflatable Prosthesis

2 (left, above) and 3 piece inflatables

All inflatable prostheses have three components: a cylinder, a reservoir and a pump. In some models the pump and the reservoir are combined into a resi-pump. Instead of two plastic malleable rods, the inflatable prosthesis has two hollow expandable, balloon-like cylinders, about 2 1/3 inches wide, that become longer, fatter and harder as fluid (sterile salt water) is pumped into them from the reservoir.

Inflatable prostheses range from 8 - 14 inches in length. The reservoir is a hollow plastic ball, capable of holding 2 1/2 - 3 1/2 ounces of liquid. The pump is a hollow ball the size of a large grape. When the ball is squeezed manually, fluid is forced from the reservoir into the cylinders, which become hard and distended, producing an erection. The erection will not go down until the deflate bar of the pump is gently pressed. The component parts of this device are connected by plastic tubing. The reservoir is placed inside and behind the lower abdominal muscles; the pump goes into the scrotum behind the testicles; and the cylinders go inside the spongy-tissue-containing tubes in the penis. Everything is concealed. Nothing shows.

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