View erectile dysfunction (ED) as a potential early warning sign of cardiovascular disease, prompting a comprehensive cardiovascular health assessment, as risk factors for both conditions are nearly identical.
Implement lifestyle modifications, including diet, exercise, adequate sleep, and stress reduction, as these have a significant positive impact on erectile function and overall quality of life.
Refrain from using finasteride or dutasteride due to concerns about ‘post-finasteride syndrome,’ which can cause irreversible sexual and neurological symptoms, and an increased risk of suicidal ideation.
When considering testosterone replacement therapy (TRT), prioritize addressing symptoms like low energy, libido, ED, increased fat, decreased muscle, depression, or poor sleep, rather than focusing solely on blood test numbers.
Do not start testosterone replacement therapy (TRT) if you are asymptomatic, as it can suppress your body’s natural production and may lead to lifelong dependence without current need.
Consider taking 5mg daily Cialis as a preventative measure or when mild ED symptoms appear, as it can promote hypertrophy of cavernosal smooth muscle, keep penile tissue healthy, and improve endothelial function.
Do not suffer in silence; seek care for sexual dysfunction due to its significant impact on quality of life. Patients should feel empowered to discuss sexual health, and clinicians should proactively ask about it.
If an erection lasts longer than four hours (priapism), seek immediate medical attention at the emergency room to prevent potential permanent damage to penile tissue.
If you experience a ‘sudden pop’ and significant swelling in the penile shaft during sexual activity, seek immediate medical attention for a potential penile fracture.
When a patient presents with both erectile dysfunction (ED) and premature ejaculation (PE), prioritize treating the ED first, as improving erection maintenance can often resolve or improve PE.
For testosterone replacement, consider subcutaneous injections (e.g., 50mg cypionate twice a week) as a preferred method due to its effectiveness, lower cost, and more physiological levels compared to other forms.
If taking exogenous testosterone, consider co-administering 500 units of HCG every other day to help protect endogenous testicular function and spermatogenesis.
For men on testosterone therapy who wish to preserve or restore fertility, consider HCG (1500-3000 units three times a week) or Clomid; for recovery from long-term suppression, HCG with recombinant FSH may be used.
For benign prostatic hyperplasia (BPH), consider alpha blockers (e.g., alfuzosin for lower retrograde ejaculation risk) or daily Cialis as medical treatment options, avoiding 5-alpha reductase inhibitors.
For Peyronie’s disease, use penile traction devices (e.g., Restorex) for 30 minutes, twice daily for three months, to potentially increase length, girth, and straighten curvature (also off-label for general enlargement).
Engage in regular sexual activity and ensure nocturnal erections to maintain penile muscle health and oxygenation, preventing atrophy and supporting erectile function.
If you experience ED but can achieve erections with masturbation or morning erections, it suggests psychogenic ED, which is treated with sex therapy and/or daily Cialis, rather than solely organic treatments.
Consider intranasal testosterone (Natesto, 11mg three times daily) as an option that may not significantly suppress spermatogenesis, offering a potential advantage for fertility-conscious men.
Oral testosterone undecanoate (e.g., Jotenzo, Talando, Keisotrex) is an option that avoids hepatotoxicity, but requires twice-daily dosing with meals (preferably fatty meals for older formulations) for proper absorption.
If considering testosterone pellets, be aware of the sharp decline in levels after 3-4 months, potentially requiring shorter intervals, and plan for 72 hours of no exercise post-insertion.
Avoid topical testosterone gels for men due to variable absorption, difficulty achieving desired levels, the burden of daily application, and the risk of transference to others.
For men with BPH, daily Cialis (5mg) is an FDA-approved treatment that can also improve erections, offering an alternative to Flomax which can cause retrograde ejaculation.
Daily Cialis (5mg) may improve systemic endothelial dysfunction, with benefits potentially persisting even after cessation, suggesting a broader cardiovascular health benefit.
During the active phase of Peyronie’s disease (first 12 months), focus on anti-inflammatories and potentially traction devices to prevent progression, as surgical options are typically reserved for the quiescent (stable) phase.
If using penile injections for ED, vary the injection site (e.g., opposite sides every other day) to mitigate trauma and reduce the risk of Peyronie’s disease.
Low-intensity shockwave therapy (LIST) for mild to moderate ED shows promise by promoting neo-angiogenesis and stem cell recruitment, but use with caution as it’s still considered investigational and many commercial devices may be ineffective.
Stem cell and PRP therapies for ED are largely investigational, with limited or no placebo-controlled trial data and no FDA approval, so approach with caution and awareness of the lack of proven efficacy.
For premature ejaculation (PE), first-line treatments include lidocaine spray (applied 10 minutes prior, wiped off), on-demand SSRIs (taken 6-8 hours prior), and sex therapy techniques like start-stop or squeeze.
Second-line therapies for premature ejaculation (PE) include tramadol (use with caution due to addiction risk) and alpha blockers like Flomax.
If experiencing anorgasmia or delayed ejaculation while on SSRIs, discuss with your doctor reducing the SSRI dose, as ejaculatory latency can be sensitive to dosage.
If starting testosterone therapy after radiation for prostate cancer, expect an initial rise in PSA until testosterone levels reach saturation (around 250 ng/dL), and discuss this with your oncologist and patient to manage expectations.
If seeking specialized care for male sexual health, find a provider through the Sexual Medicine Society of North America website, which lists qualified professionals.
Use the simple SEP2 and SEP3 questions (ability to get and maintain an erection for penetration/orgasm) to self-diagnose or discuss with a doctor if you have erectile dysfunction (ED).
Self-diagnose premature ejaculation (PE) if you experience a decreased ejaculatory time (e.g., <2 minutes for lifelong PE, or 50% reduction for acquired PE), a sense of loss of control, and are bothered by the condition.
If experiencing venous leak, a penile band (or manual pressure at the base) can be used to compress veins and prevent blood outflow, improving erection rigidity.
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