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Viagra and testosterone therapy can work together. On its own, Viagra works miracles in men with erectile dysfunction as an isolated andropause symtpom, but it doesnt do much for those who suffer from mood swings, lowered libido, irritability and other symptoms of low testosterone. Specifically, it isn’t an aphrodisiac, so it doesn’t do much for the men who lose sexual desire.

Testosterone treatment, by itself, “can restore full potency in about two thirds of men suffering from andropause symptoms, and restore the libido in over 90 percent, this leaves a third whose minds are, as one patient put it, making appointments their bodies couldn’t keep.” 1 What happens when men combine testosterone therapy with Viagra?

Viagra combined with testosterone therapy

In one study of 100 men, aged 36-81, who had failed to fully regain their erections on testosterone alone, Viagra restored full potency in over 95 percent and it restored libido in another 95 percent. Viagra doesn’t do much for libido but the added confidence of being able to perform sexually after taking it may boost enthusiasm for sex. 2

Furthermore, the dose of Viagra required for optimal results was less than in men who were not using testosterone treatments and the effects seemed to last longer. The only unusual negative effect experienced by the men taking both testosterone treatment and Viagra was a higher than expected rate of “flushing” that may have been due to testosterone’s effect of causing blood vessels to dilate slightly.

The results of this and other studies suggest that men with symptoms of andropause and low testosterone who are experiencing erectile dysfunction might want to try testosterone treatment first for a three month period. Only if this is not successful in restoring sexual performance should they add Viagra at the lowest dose. Chances are great that the combination of testosterone treatment with Viagra will resolve impotence (ED) in a very short time.

1 Caruthers, Malcolm, MD. The Testosterone Revolution. London: Thorsons; 2001, p.144.
2 Caruthers, Malcolm, MD. The Testosterone Revolution. London: Thorsons; 2001, p.145.

Erectile Dysfunction Health Center

This content has not been reviewed within the past year and may not represent WebMD’s most up-to-date information.

To find the most current information, please enter your topic of interest into our search box.

“>WebMD News Archive

For men with low testosterone. taking testosterone along with Viagra may not help their erections more than if they only took Viagra, a new study shows.

“There were lots of reasons to think that it would work,” Boston University researcher Matthew Spitzer, MD, says of the common practice of combining the two treatments. “It was surprising to me that it didn’t.”

The study, published in the Annals of Internal Medicine. was a good one and the largest of its kind, “but will it change practice? In my opinion, no,” says urologist Jason Hedges, MD, PhD, of Oregon Health and Science University in Portland. He was not involved in the study.

“While low testosterone and [erectile dysfunction ] ED can be related, they are separate issues, and I treat them as such,” says Michael Eisenberg, MD, who also was not involved in the study. “I don’t expect that treating low testosterone will improve ED, but it will likely improve libido and interest in sex ,” says Eisenberg, an assistant professor of urology at Stanford University School of Medicine.

“There is no benefit to adding testosterone to [Viagra],” Spitzer says. He notes, though, that every case is different. “Treatment is a highly individual situation, and this study does not represent all men. If you benefit from both, you should be comfortable continuing this combined therapy.”

Testosterone and Viagra

Spitzer’s team studied 140 men with low testosterone for 14 weeks. All of the men took Viagra. Some also received testosterone gel, while others got a placebo .

During the study, the men reported how often they had sex and rated their sexual satisfaction, sexual desire and orgasms, and their ability to achieve and maintain an erection.

In every category, both groups had similar scores. On average, the men’s erectile function improved, with or without testosterone.

Treatment for the men in the study was “not a complete cure, but the improvements were substantial,” Spitzer says.

The study, Spitzer says, also reminds us that we don’t yet know all the ways in which drugs like Viagra work. One surprising discovery, he says, is that Viagra (sildenafil) appears to increase testosterone levels somewhat.

Testosterone or Viagra?

A recent study came out that essentially sent the message that Viagra was just as powerful as HRT (testosterone therapy) in several key areas. I covered this study and some more by the same researcher in my page on Does Testosterone Therapy Even Work?? Essentially what this researcher has been trying to show is that you can give a man Viagra and see him improve in erectile function and mood and then, when you add HRT on top of it, you get no additional improvement. The conclusion that the comes to is that HRT is, therefore, not really necessary and is an unneeded solution for most men.

However, let me give you 10 Reasons That Testosterone Therapy Will Usually Beat Out Viagra 24/7 365 (for men with low testosterone of course):

Need to boost your Nitric Oxide naturally through food, drink and supplements? Check out Lee Myer’s book here: The Peak Erectile Strength Diet

Or do you need the most comprehensive testosterone book in Amazon? Here it is: Natural Versus Testosterone Therapy

1. Venous Leakage. Penis tissues need testosterone and, when your testosterone gets low enough, the insides of your penis will literally start to wither. Connective tissue and nerves begin to atrophy. This can make it hard to close off an erection which means that as much blood leaks out of the penis as is getting pumped in, a condition I discuss in my link called Venous Leakage 101. Usually, HRT can partially or totally reverse this condition and, of course, the reason is that a fresh supply of testosterone literally brings the penis back to life and restores normal function. Now Viagra (and Cialis / Levitra) can help with this indirectly: they work by creating extra penile pressure, thus helping somewhat with the sealing off process. But clearly, this is a workaround solution and not getting at the root cause.

2. Insulin Sensitivity. A big percentage of males in the West have insulin resistance (prediabetes) and the suite of symptoms that usually accompany it called Metabolic Syndrome. Low testosterone actually accelerates Metabolic Syndrome and prediabetes by raising insulin levels and increasing insulin resistance. Furthermore, giving a low T guy testosterone will always lower his insulin levels. This effect is so powerful that at the HRT clinic I am going to they have been able to get virtually every Type II diabetic completely off of insulin. You can read about this more in my page on Testosterone and Diabetes. Taking Viagra or Cialis will have little impact in this area.

3. Decreased Hardening of the Arteries. Men who go on anti-androgens (for prostate cancer) have many nasty cardiovascular changes and one of them is an increase in arterial stiffness. [2] Furthermore, a study on dialysis patients showed a strong correlation between arterial stiffness and testosterone levels. [1] And, finally, giving men testosterone has been shown to actually reverse this arterial stiffness in large part or even totally in some cases. [3] There have been a couple of studies – and this is all quite controversial and discussed quite a bit on the Peak Testosterone Forum – that have shown that HRT increases cardiovascular risk. This makes no sense considering that testosterone has such a positive effect on arterial stiffness. How can you make arteries more stiff and improve CVD outcomes? However, for more information, see my page on The New Testosterone (HRT) Class Action Lawsuits .

NOTE: Testosterone therapy and Viagra / Cialis can work synergistically. Anything that gets a man to have more sexual intercourse will lead to increase baseline testosterone. And raising testosterone activates the enzyme (eNOS) that controls nitric oxide. So PDE5 Inhibitors can help testosterone and vice versa.

4. Decreases Arterial Inflammation. We need more study work on this, but there is research showing that testosterone seems to affect all the major players in this category, including IL-6, TNF-alpha, adiponectin and CRP. I cover this in my page on Testosterone and Inflammation. Again, it makes it very difficult to argue that low testosterone is healthy when it creates a pro-inflammatory environment.

5. Brain Health. One of the reasons that testosterone is so successful in my opinion is that it is so good for the male brain. Testosterone (and the ensuing rise in estradiol) increases dopamine and other critical neurotransmitters, something I document in my link on Testosterone and the Brain. On a practical level, this is extremely important. Low testosterone has been shown to disturb sleep and it is very often associated with anxiety, depression and fatigue .

Now the researcher mentioned above tried to challenge the use of HRT by noting that Viagra can improve mood just as much as HRT. Now, while it is true that Viagra can improve mood and various psychological parameters – nitric oxide improves blood flow to the brain and is a neurotransmitter in its own right: there simply is no substitute for testosterone. Working memory can be negatively impacted in a low testosterone man. Researchers also found that exercise has such a profoundly positive effect on the brain through it's increase of cerebral testosterone and that it can actually spawn neurogenesis. So it is very naive thinking to assume that by just popping a PDE5 inhibitor that you can solve a man's low T brain-related issues.

6. Natural. Many men and physicians feel that HRT is "unnatural." To them it seems on par with taking steroids and feels like "cheating." Some even think that it is just an excuse to try to jack up one's waning sex life and/or muscle mass. The same crowd would tend to feel that Viagra is a much less invasive and non-aggressive solution to a male's problems. However, I would argue the opposite: testosterone is actually one of the most natural male substances and is bsolutely critical for a man's health.

Would you replace your thyroid hormones if you were hypothyroid? Sure. Would you replace your CoQ10 levels if they were low? Sure. What if you were deficient in Vitamin D? Same thing. So why not replace testosterone in the same way to more youthful levels?

And remember: many forms of HRT actually administrer bioidentical testosterone. Although injectibles such as testosterone cypionate and enanthate require a simple ester chain to be broken off, this a very simple process for your body to do and one is left, again with bioidentical testosterone afterwards. So, essentially, all the major forms of testosterone are delivering bioidentical or extremely close-to-identical bioidentical and natural testosterone into your system. Speaking as a guy who was just miserable with low testosterone for decades and whose life was completely turned around from HRT, I can assure you that HRT has no comparison with taking steroids and I had no motivations to put on muscle or anything similar. I just wanted to feel human again.

7. Osteropenia and Osteoporosis. A man's estradiol comes from the conversion of some of his testosterone via the aromatase enzyme. Surprisingly, many men have such low testosterone that they simply cannot build up enough estradiol to maintain their bone mass. If your estradiol is below 15-20 pg/ml, then this is probably something to discuss with your doctor. See my page on Testosterone and Bone Mass for details.

CONCLUSION: This list could actually go on and on, but I believe I have painted an adquate picture here. Testosterone is simply too critical to just ignore and pop a PDE5 inhibitor. Basically, the above researcher is attacking testosterone therapy by going after the easy stuff. He knows that Viagra cannot help with osteoporosis. He knows that Viagra cannot reverse someone's diabetes. And he knows that Viagra cannot heal venous leakage or hardening of the arteries. So, in my opinion, he likely picked the one or two areas where Viagra excels and then used it to build an anti-HRT storyline.

I can only say that those who suggest this have clearly never had to suffer with low testosterone or experiencedits nasty side effects. I was just miserable during my low testosterone days and will only go back kicking and screaming – let me tell you. You can read about it in My Personal Health Story.

Furthermore, ignoring low T can actually be a very dangerous philophophy and could get some men hurt. Why? Because low testosterone increases your risk factors for so many diseases! This is the subject of my book Low Testosterone By The Numbers. which discusses how a man whose testosterone is between 250 and 400 ng/dl is at increased risk for all the conditions above.

Again, Viagra and Cialis have their place for some men, especially in the short term in low dosages. But to suggest that they can be a replacement for the very low hormone levels seen in the typical hypogonadal male is very risky in my opinion.

Other Articles You May Be Interested In:

1) Baylor College of Medicine, “Men with low testosterone, erectile dysfunction may improve sexual function with testosterone gels”

2) Clinical Science, 2003, 104:(195–201), "Testosterone suppression in men with prostate cancer leads to an increase in arterial stiffness and hyperinsulinaemia"

3) Eur J Endocrinol, May 1 2009, 160:839-846, "Effect of testosterone replacement therapy on arterial stiffness in older hypogonadal men"

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CГіmo funciona el nuevo Viagra para encuentros inesperados

La pastilla azul contra la disfunciГіn erГ©ctil se vuelve mГЎs discreta. El Viagra de la compaГ±Г­a Pfizer, lanzada en 1998 y que este mes cumple 15 aГ±os en EspaГ±a, presenta un nuevo formato dirigido a pacientes con encuentros sexuales esporГЎdicos. La nueva pГ­ldora es soluble en boca sin agua, algo que facilita su toma en cualquier situaciГіn.

“Va dirigido a pacientes que no tengan un encuentro sexual previsto, sino algo ocasional, semiprogramado y que no vaya a repetirse”, explica Natalio Cruz Navarro, coordinador de Andrología de la Asociación Española de Urología (AEU). La pastilla, con el mismo formato de rombo azul que la original, se coloca en la boca, donde se disuelve en menos de medio minuto como un caramelo. La compañía señala la “rapidez de disolución”, “comodidad” y “flexibilidad” como ventajas de este formato. En España, alrededor de dos millones de hombres padecen disfunción eréctil, pero solo un 25% están tratados, según esta asociación médica.

En 20 a 30 minutos se pueden notar los primeros efectos, que alcanzan la máxima eficacia a partir de una hora y con una duración de cuatro a seis horas. La nueva píldora “en principio no acelera el proceso porque la absorción en sangre es similar”, explica este experto, “pero quizá haya un efecto psicológico en el paciente respecto a una absorción más rápida”.

Lo que sí facilita es tomar la pastilla en cualquier momento, sin agua, como un caramelo, aunque siempre con receta médica. “Es mucho más discreta. En el caso de una pareja nueva, es más sencillo tomarla y no tener que dar explicaciones. Eso genera confianza”, asegura el doctor Cruz. “Hay muchos pacientes a los que el tener que ocultarse para tomar una pastilla les frena mucho a la hora de planear una relación sexual, sobre todo los jóvenes sin pareja estable, con relaciones esporádicas. La discreción que aporta esta presentación, sin duda alguna, representa una barrera menos en una enfermedad que ya de por sí tiene una elevada carga emocional”, coincide Rafael Prieto, presidente de la Asociación Española de Andrología, Medicina Sexual y Reproductiva, en el comunicado realizado por el laboratorio de EE UU.

El fГЎrmaco mГЎs vendido para disfunciГіn erГ©ctil es el Cialis de laboratorios Lilly

En octubre de 1998 Viagra (sildenafilo) llegó a España alrededor de una campaña mediática que la hizo inmensamente popular, algo que ocurrió en todo el mundo. Ha reportado ingresos mil millonarios anualmente al laboratorio con sede en Nueva York, pero desde este año ha perdido la patente y ya se comercializan los genéricos. Esta nueva formulación puede permitir “recuperar en algo el mercado”, cree el doctor Cruz, ante la pérdida de muchos pacientes que acuden a la versión sin marca, ya que estos fármacos en ningún caso están financiados por la sanidad pública.

Para el doctor Cruz, esta presentaciГіn se dirige a un nuevo tipo de pacientes, mГЎs joven y sin pareja estable, que busca la comodidad a la hora de enfrentarse a la disfunciГіn erГ©ctil pero sin tener que tomar a diario un fГЎrmaco. En EspaГ±a, el fГЎrmaco mГЎs vendido para esta patologГ­a, es el Cialis de laboratorios Lilly, que con solo cinco miligramos (frente a los 50 o 100 miligramos de Viagra) permanece en sangre 24 horas. frente a las cuatro o cuatro o cinco de la pastilla azul. Los mГ©dicos recomiendan tomar Cialis a quien tenga pareja habitual, ya que una dosis diaria permite no tener que estar pendiente de la pastilla ante un encuentro sexual dentro de las 24 horas. Este medicamento generГі 50,1 millones de euros en 2012 para Lilly, segГєn datos de IMS Health, por delante de Levitra, de Bayer, y Viagra.

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19. Juni 2015 . Wird Viagra noch gekauft. Im Sommer 2013 war es soweit: Das Schutzpatent für. Dazu zählen das Levitra Patent und das Cialis Patent. Wann laufen die Potenzmittel Patente ab. Im 2013 in Deutschland läuft der Patentschutz der Potenzpillen ab. Potenzmitteln der Marken "V. 21. Juni 2013 . Colourbox.de Das Patent für Viagra läuft am 22.Juni in mehreren Ländern ab. Damit. Mitte 2013 läuft in mehreren europäischen Ländern das Viagra Patent ab. Hier finden Sie eine Übersi. Viagra schweden rezeptfrei! Wann läuft das patent für cialis ab ; Sildenafil generikum preisvergleic. 30. Mai 2014 . Das Potenzmittel Cialis vom Hersteller Eli Lilly könnte demnächst. Die Patente. 29. Febr. 2016 . Das Cialis Patent läuft 2017 aus. des Original Cialis sich ab 2017 nicht nur. .

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Nach 15 Jahren lГ¤uft der Patentschutz von Pfizer fГјr Viagra aus. Das Potenzmittel kГ¶nnte nun billiger werden – Vorsicht ist allerdings geboten.

Als erste Potenzpille der Welt brachte Viagra wieder Schwung in viele Schlafzimmer und holte zugleich das Thema Erektionsstörungen ein Stück weit aus der Tabuzone. 15 Jahre nach der Markteinführung in Deutschland läuft am Samstag der Patentschutz des Herstellers Pfizer aus.

Als Viagra im Oktober 1998 erstmals in deutschen Apotheken verkauft wurde, war der Wirbel groß. zum ersten Mal gab es eine Pille zur Behandlung der sogenannten erektilen Dysfunktion, der Potenzstörung beim Mann.

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Die Konkurrenz sitzt schon in den Startlöchern: Mit dem Ende des Patentschutzes werden zahlreiche sogenannte Generika, also günstige Nachahmerpräparate, auf den Markt schwemmen. Einen Boom bei den Verschreibungen erwarten Ärzte aber nicht.

Die Erfolgsquote des Medikaments liegt immerhin bei 70 Prozent. Vor allem aber lässt sich mit Viagra gutes Geld verdienen.

Die Kunden mussten für ihren Traum von mehr Männlichkeit bislang allerdings tief in die eigene Tasche greifen. Da Viagra als sogenanntes Lifestyle-Präparat gilt, übernehmen die Krankenkassen nicht die Kosten. Mit dem Ablauf des Patentschutzes werden die Preise purzeln, denn die Nachahmerpräparate sind günstiger. Nach Angaben des Bundesinstituts für Arzneimittel und Medizinprodukte (BfArM) wurden dafür bereits 28 Zulassungen erteilt.

Pfizer gibt den Viagra-Markt nicht auf

Nach Angaben des Pharmaherstellers Pfizer wurden seit der MarkteinfГјhrung weltweit mehr als 1,8 Milliarden der blauen Tabletten an mehr als 37 Millionen MГ¤nner ausgegeben – davon an Гјber eine Million MГ¤nner in Deutschland. Zwar haben inzwischen auch andere Hersteller mit eigenen Potenzpillen nachgezogen, aber Viagra bleibt das Original.

Auch Pfizer will auf dem Generikamarkt mitmischen. Bereits seit dem 1. Juni verkauft der Konzern in Deutschland ein Nachahmerpräparat, das auf dem Viagra-Wirkstoff Sildenafil basiert. Kostet eine Viagra mit einer Dosis von 50 Milligramm 10,30 Euro, so bietet Pfizer das günstigere Präparat nun für 2,50 Euro pro Tablette an. Anders als das Original, das es auch weiterhin geben wird, sind die rautenförmigen Tabletten zudem weiß statt blau.

Schätzungen zufolge sind in Deutschland mindestens sieben Millionen Männer von Erektionsstörungen betroffen. Doch der Preis allein wird die Nachfrage nicht ankurbeln. «Die Schamgrenze bleibt», sagt Wolfgang Bühmann, Sprecher des Berufsverbandes Deutscher Urologen (BDU). Wie Viagra sind auch die Nachahmerprodukte verschreibungspflichtig. Nach wie vor aber gibt es bei vielen Männern mit Potenzstörungen eine hohe Hemmschwelle für den Gang in die Praxis. «Im Schnitt braucht ein Mann drei Jahre, bis er sich einem Arzt offenbart», weiß Bühmann.

Die kuriosen Ideen der Schmuggler

Warnung vor Billig-Viagra

Viele werden die Pillen deshalb wohl weiter illegal im Internet bestellen. Viagra ist nicht nur ein В«BlockbusterВ», sondern auch das mit Abstand am hГ¤ufigsten gefГ¤lschte Medikament. Die Plagiate stammen vor allem aus dem asiatischen Raum, aus Indien oder China. Laut Bundesvereinigung Deutscher ApothekerverbГ¤nde (ABDA) bringt gefГ¤lschtes Viagra auf dem Schwarzmarkt pro Kilogramm rund 90.000 Euro – und damit mehr als Kokain.

Allerdings sind die falschen Arzneien oft nicht richtig dosiert oder – im besten Fall – wirkungslos. Die BehГ¶rden warnen deshalb immer wieder eindringlich davor, Arzneien Гјber unsichere Internetquellen zu kaufen.

Ruth Haliti vom Zollkriminalamt in Bonn glaubt nicht, dass das Ende des Patentschutzes für Viagra in Deutschland und anderen europäischen Ländern den illegalen Markt einschneidend verändern wird. «Solange die Verschreibungspflicht bleibt, wird es einen illegalen Handel geben», sagt Haliti. Ohnehin läuft der Patentschutz für Viagra in den USA erst 2020 aus. (AZ/afp)

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Tratamiento de la disfunción eréctil con sildenafil en hombres con falla renal crónica

Aníbal Bustamante, César Augusto Restrepo · Manizales

Dr. AnГ­bal Bustamante Estrada: PsicГіlogo de la Universidad de Manizales y del Servicio de Terapia Renal de Caldas; Dr. CГ©sar Augusto Restrepo Valencia: NefrГіlogo, Universidad de Caldas y de la Universidad de Antioquia. Director CientГ­fico del Servicio de Terapia Renal de Caldas, Profesor Auxiliar Universidad de Caldas. Manizales.

Objetivos: evaluar la incidencia de disfunción eréctil en nuestra población de pacientes con falla renal crónica en tratamiento hemodialítico, y valorar en la población afectada la respuesta al medicamento sildenafil.

Métodos: todos los hombres que asistían al programa de hemodiálisis (42) de nuestra unidad renal se interrogaron respecto a su interés de participar en este trabajo, 30 estuvieron de acuerdo, ocho se descartaron por presentar enfermedad asociada que contraindicaba el uso del sildenafil, a los 22 restantes se les aplicó el índice internacional de función eréctil versión abreviada (IIEF-5), de los cuales 16 (72%) presentaron disfunción eréctil y a ellos se les administró el medicamento sildenafil por 12 semanas (previa autorización por escrito) a una dosis máxima de 50 mgs/día y no más de tres veces por semana ni menos de una.

Resultados: dos pacientes no completaron el tiempo estipulado ni la dosis sugerida y por lo tanto se excluyeron del informe final, la edad promedio de los pacientes fue de 53 años, tiempo promedio en hemodiálisis

17.9 meses y kt/v 1.32, la etiología de la falla renal crónica fue desconocida en 7.1%, nefropatía obstructiva 7.1%, por ácido úrico 7.1%, diabética 21.4%, glomerulopatía primaria 14% y nefropatía hipertensiva en 42.9% de los pacientes. El IIFE-5 demostró disfunción eréctil leve a moderada en 28.5% de los pacientes en hemodiálisis, moderada en 44% y severa en 28.5%; posterior al uso del sildenafil la disfunción eréctil fue leve en 35% de los pacientes y ausente en 65% restante. Los únicos efectos colaterales informados fueron calor facial, dispepsia y priapismo.

Conclusiones: 72% de los pacientes con falla renal crónica presentaron en nuestra unidad renal disfunción eréctil de algún grado, en ellos el medicamento sildenafil ofreció excelentes resultados y fue muy bien tolerado, la ausencia de un grupo control y el número bajo de pacientes obligan a mirar con cautela los resultados expuestos. (Acta Med Colomb 2002; 27: 198-203).

Palabras clave: trastornos sexuales, disfunción eréctil, falla renal crónica, sildenafil.

Introducción

La disfunciГіn erГ©ctil se definiГі por la Conferencia de Desarrollo y Consenso de los Institutos Nacionales de la Salud (NIH) como la incapacidad para lograr o mantener una erecciГіn suficiente para un desempeГ±o sexual satisfactorio (1). El estudio de envejecimiento masculino de Massachussets indica que 52% de los hombres con edad entre 40-70 aГ±os padece de algГєn grado de disfunciГіn erГ©ctil, siendo severa en 15% de los encuestados (2). Para valorar la funciГіn erГ©ctil se ha utilizado el Indice Internacional de FunciГіn ErГ©ctil (IIEF) (3), instrumento de encuesta autoadministrado que consta de 15 preguntas en las que se identifican cinco factores o dominios (funciГіn erГ©ctil, funciГіn orgГЎsmica, deseo sexual, satisfacciГіn coital y satisfacciГіn general), siendo considerado como un instrumento altamente sensible y específico para el diagnóstico de la disfunción eréctil y también para detectar cambios en relación con el tratamiento de la misma. Más recientemente surgió el IIEF-5 (4), una versión abreviada del IIEF y que es conocido comúnmente como el Inventario de Salud Sexual Masculino (SHMI), siendo un cuestionario de cinco preguntas el cual se enfoca en el diagnóstico de la función eréctil del paciente, esta versión abreviada facilita la utilización del IIEF en la práctica de la consulta médica cotidiana. Se ha demostrado que el SHMI evalúa en forma adecuada la capacidad del paciente para mantener una erección conveniente y tener un desempeño sexual satisfactorio así como el grado de satisfacción y confianza con el tratamiento; los componentes del SHMI son las preguntas 2,4, 5, 7 y 15 del IIEF que están incluidas en el dominio de función eréctil y en el de satisfacción del acto sexual, ellas son: ¿cómo califica usted su confianza de lograr y mantener una erección. cuando tuvo erecciones con estimulación sexual ¿qué tan frecuente fueron lo suficientemente firmes para la penetración. durante la relación sexual ¿qué tan frecuente tuvo usted la capacidad de mantener su erección después de la penetración. durante la relación sexual ¿qué tan difícil fue mantener su erección para terminarla? y finalmente cuando intentó tener relación sexual ¿qué tan frecuente fue satisfactoria para usted? Básicamente el paciente responde al anterior cuestionario de cinco preguntas cada una con cinco variables con su puntaje representativo, luego se suma y se logra un puntaje total, hombres con más de 21 puntos se clasifican como sin disfunción eréctil, con menos de 21 indica disfunción eréctil de diverso grado: leve (17-21), le ve-moderado (12-16), moderado (8-11) y severo (5-7).

Los trastornos en la función sexual son quejas comunes de los pacientes con FRC, ellos incluyen disfunción eréctil, disminución de la libido y disminución en la frecuencia de las relaciones sexuales, su naturaleza es orgánica y por lo tanto el medio urémico es el principal desencadenante (5).

En pacientes en hemodiálisis la prevalencia de disfunción eréctil es globalmente de 82% en un reciente estudio (6), siendo severa en 45% de los pacientes, con una prevalencia de 63% en menores de 50 años y de 90% en mayores de 50 años, relacionándose directamente con factores como el aumento de la edad y la presencia de diabetes mellitus e inversamente con el uso de Iecas. En pacientes en diálisis peritoneal también recientemente en una encuesta previa al uso del sildenafil se detectó disfunción eréctil en 46% de los pacientes (7).

Con base en lo anterior nosotros decidimos estudiar en nuestra unidad renal la incidencia de disfunción eréctil en los pacientes con falla renal crónica sometidos a tratamiento hemodialítico, y en aquéllos afectados (sin contraindicaciones) proponerles el uso del sildenafil observándose su respuesta al medicamento y posible aparición de efectos colaterales.

Material y métodos

El estudio se realizó en la Unidad Renal del Servicio de Terapia Renal de Caldas (Hospital Santa Sofía), en el cual para la fecha que se llevó a cabo (septiembrenoviembre del 2000) atendía 63 pacientes en hemodiálisis y 60 en diálisis peritoneal. Para llevarlo a cabo se interrogó a los hombres del total de pacientes en hemodiálisis respecto a su interés de participar en este estudio; los que estuvieron de acuerdo fueron sometidos a revisión de su historia clínica en forma exhaustiva y se les practicó un examen físico muy completo, descartándose aquéllos que presentaban alguna contraindicación para el uso del sildenafil, los pacientes a los que no se les detectó contraindicaciones se sometieron al cuestionario del IIEF-5 o SHMI en sus cinco preguntas claves, solicitándoles que respondieran el cuestionario indicándose su grado de disfunción eréctil antes del diagnóstico de la insuficiencia renal crónica y después del mismo. En aquellos pacientes en los cuales se detectó disfunción eréctil se les propuso la autoadministración 60 minutos previos a la relación sexual de 25 mg de sildenafil permitiéndose aumentar la dosis posteriormente en 25 mg si la dosis inicial fracasaba, aprobándose como dosis máxima 50 mg no más de tres veces por semana y no menos de una vez por semana; para evitar posibles efectos colaterales se les recomendó a los pacientes no utilizar el medicamento hasta después de cuatro horas de finalizada la terapia hemodialítica, el estudio se llevó a cabo en el grupo de pacientes que aceptaron tomar el medicamento, para lo cual se obtuvo consentimiento escrito por cada uno de ellos, y se practicó durante 12 semanas tiempo posterior al cual se los sometió de nuevo a los pacientes al cuestionario del IIEF-5 para poder obtener factores comparativos adecuados. Se excluyeron del uso del medicamento aquellos pacientes con riesgo clínico significativo de acuerdo con el documento de consenso de expertos del ACC/AHA (8) y se monitorizaron los efectos colaterales de acuerdo con el siguiente cuestionario: efectos colaterales cardiovasculares: calor facial, cefalea, dolor torácico, palpitaciones, vértigo ortostático; gastrointestinales: dispepsia, diarrea; visuales: aumento de la percepción de la luz, visión borrosa, confusión del color azul con el verde; musculoesqueléticos: mialgias; urológicos: priapismo; cutáneos: rash y otros incluido retinitis.

El sildenafil fue proporcionado muy generosamente por Laboratorios Pfizer asegurándose de esta manera un adecuado suministro del medicamento.

Resultados

Del total de 63 pacientes en hemodiálisis 42 (66%) eran varones, de ellos 30 estuvieron de acuerdo en participar en el estudio, ocho se descartaron por tener problemas que contraindicaban el uso del sildenafil, por lo tanto 22 fueron sometidos al cuestionario del IIEF-5, de ellos se detectó disfunción eréctil en 16 pacientes (72.7%) iniciándose con ellos la autoadministración del sildenafil según el protocolo y el consentimiento previo por escrito. Dos pacientes no completaron el tiempo estipulado ni las dosis recomendadas y por lo tanto no se consideraron en el reporte final. El origen de la falla renal crónica fue en 7.1% desconocida, en 7.1% obstructiva (hipertrofia prostática), en 7.1% por ácido úrico, en 21.4% diabética, en 14.2% glomerulopatía primaria y en 42.9% por nefropatía hipertensiva (Tabla 1). Todos los pacientes presentaban hipertensión arterial primaria o secundaria, la edad promedio fue de 53 años, el tiempo promedio en hemodiálisis era de 17.9 meses, la función renal residual de 2.3 ml/minuto y el KT/V 1.32 (Tabla 2). El IIEF-5 demostró que antes del diagnóstico de la insuficiencia renal crónica sólo 14.28% de los pacientes sufrían de leve disfunción eréctil y el 85.71% de ninguna disfunción; después del diagnóstico de la insuficiencia renal crónica la disfunción eréctil se distribuyó en levemoderada 28.57%, moderada 42.88% y severa 28.57%; después de la administración del sildenafil y completado el tiempo recomendado de 12 semanas sólo 35.71% de los pacientes se encontraban en disfunción eréctil leve y el 64.28% sin ninguna disfunción eréctil (Figuras 1 A, IB, IC y 2), la dosis promedio utilizada fue de 50 mg y ningún paciente fue retirado por efectos colaterales atribuidos al sildenafil, los únicos efectos colaterales relatados fueron dispepsia, calor facial y priapismo cada uno en un paciente respectivamente. En promedio el efecto del medicamento se extendió hasta por 11.1 horas (Tabla 3), fue interesante encontrar que el uso de medicamentos antihipertensivos fue muy variado, de tal manera que el 64.28% de los pacientes utilizaban bloqueadores alfa 1, 78.57% bloqueantes de los canales del calcio, 42.85% ,ecas y el 7.14% antagonistas del receptor de angiotensina II (Tabla 4); en cuanto al número de medicamentos antihipertensivos tomados 28.57% de los pacientes tomaban uno, 57.14% dos, 7.14% tres y 7.14% cuatro (Tabla 5). En cuanto a fármacos que se metabolizan por o que inhiben la citocromo P4503A4 7.14% de los pacientes tomaban atorvastatina, 7.14% lovastatina, 42.8% diltiazem y 35.7% isradipino. Otros medicamentos administrados porque las enfermedades asociadas lo exigían fueron ácido acetilsalicílico, furosemida, ácido fólico, complejo B, carbonato de calcio, sulfato ferroso, hierro dextran IV, eritropoyetina, ranitidina, digoxina, diclofenaco, colchicina, allopurinol, hidroxicina, gemfibrozil, amitriptilina, midazolam y sulfonato de poliestirene sódico.

Tabla 1. Origen de la falla renal crГіnica.

Tabla 2. CaracterГ­sticas de os pacientes.

Figura 1. A* DisfunciГіn erГ©ctil antes de la insuficiencia renal crГіnica. B: DisfunciГіn erГ©ctil durante de la insuficiencia renal crГіnica. C: DisfunciГіn erГ©ctil durante la terapia con sildenafil.

Figura 2. Cambios en la disfunciГіn erГ©ctil segГєn IIFE-5.

Tabla 3. Respuesta al medicamento.

Tabla 4. DistribuciГіn de uso de antihipertensivos.

Tabla 5. Antihipertensivos diarios.

Discusión

Los trastornos en la función sexual son quejas comunes de los pacientes con falla renal crónica, ellos incluyen la disfunción eréctil (la manifestación más frecuente), disminución de la libido y disminución de la frecuencia de las relaciones sexuales (9). Se entiende por disfunción eréctil en el hombre la incapacidad para lograr o mantener una erección del pene lo suficiente para un desempeño sexual satisfactorio (1); en pacientes con falla renal crónica su naturaleza es orgánica y por lo tanto el medio urémico es el principal desencadenante, como lo demuestra la tendencia a mejorar cuando se establece una terapia dialítica satisfactoria o cuando el paciente es sometido a un trasplante renal, terapia con la cual se ha logrado la mayor restauración en la función sexual (10). La uremia se asocia a disminución de la espermatogénesis, daño testicular con infertilidad y disminución de la androgénesis gonadal (función endocrina gonadal), esta última manifestada por poca capacidad de secretar testosterona por la células de Leydig en respuesta a la administración de gonadotrofina coriónica humana, compuesto con acción semejante a la hormona luteinizante, a ello podría contribuir un probable bloqueo de factores urémicos sobre el receptor de la hormona luteinizante (LH). Los niveles de testosterona total y libres séricos se encuentran bajos en la uremia, además la reserva de gonadotrofinas está conservada con producción normal de LH ante el estímulo con hormona liberadora de gonadotrofina (GnRH), de echo los niveles de LH se encuentran altos en la uremia y son el resultado de disminución en la liberación testicular de testosterona asociado a una disminución en la depuración renal de la LH; la secreción de la hormona folículoestimulante (FSH) se ha encontrado elevada en hombres con falla renal crónica, ello podría ser el resultado de disminución en la producción de inhibina por las células de Sertoli, de tal manera que a mayor daño de los túbulos seminíferos más alta será la FSH constituyéndose ella en un marcador de poca recuperación testicular postrasplante renal cuando sus cifras son muy altas (11). Altos niveles de prolactina se describen en la FRC por disminución de su excreción renal o por aumento en su producción la cual en parte está asociada a hiperparatiroidismo secundario, su significado no es claro ya que su disminución por el uso de bromocriptina no corrige la disfunción sexual. El análisis del semen de pacientes con FRC demuestra disminución del volumen eyaculado con oligo o completa azoospermia y bajo porcentaje de espermatozoides motiles. La histología de biopsias testiculares demuestra daño de los túbulos seminíferos, atrofia de células de Sertoli, fibrosis intersticial y calcificaciones; es importante aclarar que a la fecha los factores responsables del daño testicular en el medio urémico no son claros, y se esperan investigaciones al respecto que permitan establecer el motivo de la causalidad (12).

En pacientes con FRC es importante además descartar otros factores que contribuyan a la disfunción eréctil, de ellos se ha visto que el estrés es importante ya que pacientes en diálisis peritoneal que no tienen relaciones sexuales son más deprimidos y ansiosos, y siempre que no se encuentre un origen claro es importante considerar factores psicológicos como depresión. Otros factores orgánicos no urémicos pueden contribuir a la disfunción eréctil en pacientes con falla renal crónica, se incluyen algunos relacionados con la enfermedad de base tipo: neuropatía periférica, disfunción autónoma, enfermedad vascular periférica, hipogonadismo y medicamentos entre los cuales se destacan principalmente los diuréticos, los ß-bloqueadores, los agonistas alfa 2 central y los antidepresivos.

Antes de la aparición del sildenafil se recomendaba practicar a los pacientes con FRC y disfunción eréctil una serie de estudios que permitiera descartar otras causas o factores orgánicos no urémicos que la explicaran, recientemente la utilización del sildenafil es el método recomendado como ideal para diferenciar entre etiología psicógena versus orgánica, aunque en situaciones no claras se debe recurrir a los esquemas clásicos que incluyen LH, FSH, testosterona (en relación con hipogonadismo), prolactina y test de tumescencia penil nocturno. A pacientes con disfunción eréctil sin erección matutina y test de tumescencia nocturna negativo se les suministra sildenafil y se les clasifica en dos grupos según su respuesta: aquéllos en los cuales hay erección se deben de valorar para una causa psicosocial, y en aquéllos en los que no se genera erección se debe de considerar una etiología vascular o neurogénica o endocrina. En pacientes con disfunción eréctil pero con erección matutina y test de tumescencia positivo se debe de considerar disminución de la libido y deben descartarse factores endocrinos, de ellos se les solicita niveles de prolactina, si sus valores son altos se procede con una prueba de bromocriptina, si sus valores son bajos se les solicita la medición de testosterona la cual si se informa baja obliga a una prueba terapéutica con esta hormona (13).

El tratamiento de la disfunción eréctil en pacientes urémicos ha pasado a través de diversos procedimientos, ellos incluyen descontinuar la probable medicación culpable, maximizar la dosis de diálisis hasta obtener un KT/V satisfactorio para el programa dialítico, corregir la anemia si está presente, controlar el hiperparatiroidismo secundario, suplementar zinc por vía oral, psicoterapia y medicación psicoactiva; el uso de agonistas de dopamina y de testosterona dependerá de los niveles de prolactina y testosterona respectivamente. Otras alternativas terapéuticas son alprostadil intrauretral y dispositivos de vacío sobre el pene (14).

La fisiopatología de la erección del pene involucra la liberación por parte de los nervios no adrenérgicos no colinérgicos (nitrérgicos) y las células endoteliales del cuerpo cavernoso del oxido nítrico en respuesta a la estimulación sexual; el óxido nítrico a su vez activa la enzima guanilato ciclasa, la cual aumenta a partir del GTP los niveles de GMPc generándose por acción de este último relajación de la musculatura lisa que rodea el cuerpo cavernoso, dilatación de las arterias helicianas del pene y constricción de la salida venosa, todo lo anterior lleva a acumulación de sangre y congestión que es lo que caracteriza a la erección. El GMPc es degradado por la fosfodiesterasa 5 a GMP su forma inactiva, el sildenafil es básicamente un inhibidor de la fosfodiesterasa 5, de tal manera que aumenta la vida media del GMPc lo cual genera una relajación acrecentada de la musculatura lisa del pene y una prolongación de la erección (15). Como consecuencia de su efecto vasodilatador en ocasiones el sildenafil puede precipitar hipotensión sistémica severa y compromiso de la perfusión orgánica, ello se describe principalmente en las siguientes situaciones: uso de nitratos, isquemia coronaria activa, insuficiencia cardíaca con baja presión arterial y bajo volumen efectivo, regímenes antihipertensivos que incluyen varios medicamentos y finalmente administración concomitante de diversos fármacos que pueden prolongar la vida media del sildenafil tipo inhibidores de la citocromo P450 3A4 (8).

La experiencia con el uso del sildenafil en pacientes con ERC es escasa a la fecha, sólo se han descrito tres trabajos: en el primero Rosas y colaboradores investigaron 15 pacientes en tratamiento hemodialítico a los cuales se les diagnosticó disfunción eréctil por aplicar el IIEF, en ellos la administración del sildenafil mejoró en 66.7% de los pacientes la función eréctil, aunque no el dominio del deseo sexual (16); en el segundo trabajo Juergensen y colaboradores encuestaron 22 pacientes con falla renal crónica en tratamiento de diálisis peritoneal continua respecto a su función eréctil, de ellos 17 presentaron disfunción y a 15 se les administró sildenafil, desafortunadamente sólo seis pacientes completaron el período de estudio de las 12 semanas y sólo en dos se obtuvo respuesta satisfactoria al sildenafil (7); en el último trabajo Arcoraci en Mendoza, Argentina utilizó sildenafil en tres pacientes con FRC en hemodiálisis y disfunción eréctil, en ellos el sildenafil logró efectividad terapéutica y no generó efectos hipotensivos importantes (17).

En nuestro trabajo los resultados de administrar sildenafil en pacientes con FRC demuestran muy buenos resultados, a lo anterior indudablemente contribuye la selección de pacientes que se llevó a cabo, las bajas dosis iniciales del sildenafil (ya que la falla renal crónica prolonga la vida media del fármaco) y el evitar su uso dentro de las cuatro horas posterior al procedimiento dialítico, todo con el propósito de prevenir la aparición de efectos colaterales que en algún momento pudieran atentar contra la vida y el bienestar del paciente. Es interesante anotar que el uso concomitante de medicamentos antihipertensivos de muy diversa clase no se asoció a efectos colaterales como tampoco la administración concomitante de inhibidores de la citocromo P450 3A4. Aunque la población estudiada fue pequeña es indudablemente importante aclarar que se hace necesario el estudio con un mayor número de pacientes que permita obtener resultados estadísticamente más significativos con el propósito de dar más claras recomendaciones respecto del uso del sildenafil en pacientes con FRC; también se debe anotar que la ausencia de un grupo control pudo haber ocasionado sesgo y sobre valoración de la efectividad real de la intervención medicamentosa, siendo estas dos últimas limitaciones del diseño factores claves a corregir en trabajos futuros.

Summary

Objectives: the erectile dysfunction is a frecuent entity in patients with chronic renal failure, its nature is organic and directly related with the uremic state. There should be always discarded other etiologies possible. The purpose of this work was to evaluate the incidence of erectile dysfunction in our population of patients with chronic renal failure under hemodialytic treatment, and to evaluate in the affected population the response to sildenafil.

Methods: all men attending the hemodialysis program (42) of our renal unit were interrogated regarding their interest of participating in this study, 30 agreed, 8 were discarded because they presented associated illness contraindicating the use of the sildenafil. The international index of erectile dysfunction (IIEF-5) was applied to the remaining 22 patients, among them 16 (72%) presented erectile dysfunction, sildenafil was administered to for 12 weeks to a maximum dose of 50 mg/day no more than three times per week no less that one.

Results: two patients did not complete the specified time or the suggested dose and therefore excluded. The age average of the patients was 53 years, time average in hemodialysis treatment was 17.9 months and the K/tv was 1.32. The etiology of chronic renal failure was unknown in 7.1 %, obstructive nephropathy 7.1%, uric acid nephropathy 7.1%, diabetes nephropathy 21.4%, primary glomerulopathy 14% and hypertensive nephropathy in 42% of the patients. The IIEF-5 showed light to moderate erectile dysfunction in 28.5% patients, moderate in 44% and severe in 28.5%, after the use of sildenafil the erectile dysfunction was light in 35% and absent in 65%. The only reported collateral effects were facial heat, dyspepsia and priapism.

Conclusions: 72% of the patients of our renal unit whit chronic renal failure presented erectile dysfunction of some degree, in them the medication sildenafil offered excellent results and it was very well tolerated, the absence of a control group and the low number of patients obligues to cautions interpretation of the results.

Key words:sexual dysfunctions, erectile dysfunction, chronic renal failure, sildenafil

Referencias

1. NIH Consensus Development Panel on Impotence: Impotence. JAMA 1993;270:83-90

2. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, Mckinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts male aging study. J Urol 1994;151:54-61.

3. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The International Index of Erectile Function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997;49:822-830.

4. Rosen RC, Cappelleri JC, Smith MD, Lisky J, Pena BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as diagnostic tool for erectile dysfunction. Int J ImpГґt Res 1999;11:319-326.

5. Toorians AF, Giltay EJ, Donker AJ, and Gooren LJ. Sexual functioning in chronic renal failure. Semin Dial 1997;10:176-181.

6. Rosas SE, Joffe M, Franklin О•, Strom BL, Kotzker W, Brensinger C, Grossman E, et al. Prevalence and determinants of erectile dysfunction in hemodiГЎlisis patients. Kidney Int 2001;59:2259-2266.

7. Juergensen PH, Botev R, Wuerth D, Finkelstein SH, Smith JD, Finkelstein FO. Erectile disfunction in chronic peritoneal dialysis patients: incidence and treatment with sildenafil. Perit Dial Int 2001; 21:355-359

8. Cheitlin MD, Hutter AM, Brindis RG, Ganz P, Kaul S, Rusell RO, et al. Use of sildenafil (viagra) in patients with cardiovascular disease- ACC/AHA expert consensus document. Circulation 1999;99:168-177.

9. Schmidt RJ, Holley J. Sexual function in patients with end stage renal disease. Semin Dial 1998;11:181-184.

10.Diemont WL, Vruggink PA, Meuleman EJH, Doesburg WH, Lemmens WAJG, Berden JHM. Sexual dysfunction after renal replacement therapy. Am J Kidney Dis 2000;35:845-851.

11. Palmer BF. Sexual dysfunction in uremia. J Am Soc Nephrol 1999;10:1381- 1388.

12. Toorians AW, Giltay E, Donker AM, Gooren LG. Sexual functioning in chronic renal failure. Semin Dial 1997;10:176-181.

13. Bellighieri G, Santoro D, Lo Forti B, Mallamance A, DeSanto RM, Savica V. Erectile dysfunction in uremic dialysis patients: diagnostic evaluation in the sildenafil era. Am J Kidney Dis 2001 ;38: S115-S117.

14. Lawrence IG, Price DE, Howlett TA, Harris KPG, Feehally J, Walls J. Correcting impotence in the male dialysis patient: experience with testosterone replacement and vacuum tumescence therapy. Am J Kidney Dis 1998;31:313-319.

15. Steers WD. Viagra-after one year. Urology 1999;54:12-17

16. Rosas SE, Wasserstein A, Kobrin S, Feldman HI. Preliminary observations of sildenafil treatment for erectile dysfunction in dialysis patients. Am J Kidney Dis 2001;37:134-137.

17.Arcoraci C, Orellano S, Discepolo M, Rios R. Tratamiento de la disfuncion sexual con sildenafil en pacientes en hemodiГЎlisis e interacciГіn con las drogas antihipertensivas. Rev Nefrol Dial y Transpl 2000;50:29-31.

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"The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause. "

- Fourth Amendment to the United States Constitution

The Electronic Communications Privacy Act (ECPA) was a forward-looking statute when enacted in 1986. It specified standards for law enforcement access to electronic communications and associated data, affording important privacy protections to subscribers of emerging wireless and Internet technologies. Technology has advanced dramatically since 1986, and ECPA has been outpaced. The statute has not undergone a significant revision since it was enacted in 1986 – eons ago in Internet time.

As a result, ECPA is a patchwork of confusing standards that have been interpreted inconsistently by the courts, creating uncertainty for both service providers and law enforcement agencies. ECPA can no longer be applied in a clear and consistent way, and, consequently, the vast amount of personal information generated by today’s digital communication services may no longer be adequately protected. At the same time, ECPA must be flexible enough to allow law enforcement agencies and services providers to work effectively together to combat increasingly sophisticated cyber-criminals or sexual predators.

The time for an update to ECPA is now. Privacy advocates, trade associations, think tanks, legal scholars, start-ups, and major Internet and communications companies have developed consensus around the notion of a core set of principles intended to simplify, clarify, and unify the ECPA standards; provide clearer privacy protections for subscribers taking into account changes in technology and usage patterns; and preserve the legal tools necessary for government agencies to enforce the laws and protect the public.

Changes in Technology Have Outpaced the Law

Justice Brandeis famously called privacy “the most comprehensive of rights, and the right most valued by a free people.” Of course, privacy must be balanced against other societal interests. Electronic communications and associated data can provide key evidence in the investigation of many crimes, and the assistance of service providers is often necessary to access such evidence. With respect to communications privacy and law enforcement investigations, the courts and Congress have sought to develop rules for government surveillance that balance three interests: the individual’s constitutional right to privacy, the government’s need for tools to conduct investigations, and the interest of service providers in clarity and customer trust.

Since enactment of ECPA, there have been fundamental changes in communications technology and the way people use it, including –

  • Email: Most Americans have embraced email in their professional and personal lives and use it daily for confidential communications of a personal or business nature. Because of the importance of email and unlimited storage capabilities available today, most people save their email indefinitely, just as they previously saved letters and other correspondence. The difference, of course, is that it is easier to save, search and retrieve digital communications. Many of us now have many years worth of stored email. Moreover, for many people, much of that email is stored on the computers of service providers.
  • Mobile location: Cell phones and mobile Internet devices constantly generate location data that supports both the underlying service and a growing range of location-based services of great convenience and value. This location data can be intercepted in realtime, and is often stored in easily accessible logs files. Location data can reveal a person’s movements, from which inferences can be drawn about activities and associations. Location data is augmented by very precise GPS data in many devices.
  • Cloud computing: Increasingly, businesses and individuals are storing data “in the cloud,” with potentially huge benefits in terms of cost, security, flexibility and the ability to share and collaborate.
  • Social networking: One of the most striking developments of the past few years has been the remarkable growth of social networking. Hundreds of millions of people now use social media services to share information with friends and as an alternative platform for private communications.

In the face of these developments, ECPA does not provide protection suited to the way technology is used today:

  • Conflicting standards and illogical distinctions: ECPA sets rules for governmental access to email and stored documents that are not consistent. A single email is subject to multiple different legal standards in its lifecycle, from the moment it is being typed to the moment it is opened by the recipient to the time it is stored with the email service provider. To take another example, a document stored on a desktop computer is protected by the warrant requirement of the Fourth Amendment, but ECPA says that the same document stored with a service provider may not be subject to the warrant requirement.
  • Unclear standards: ECPA does not clearly state the standard for governmental access to location information.
  • Judicial criticism: The courts have repeatedly criticized ECPA for being confusing and difficult to apply. The Ninth Circuit in 2002 said that Internet surveillance was “a confusing and uncertain area of the law.” In the past 5 years, no fewer than 30 federal opinions have been published on government access to cell phone location information, reaching a variety of conclusions.
  • Constitutional uncertainty: The courts have been slow to address the application of the Fourth Amendment to new services and information. So far, among the regular federal appellate courts, only the Sixth Circuit has held that the Constitution protects stored email (Warshak), while the Ninth Circuit has held that there is a Constitutional privacy right in stored text messages (Quon). The Supreme Court has ruled that prolonged tracking with a GPS device is a search under the Fourth Amendment, but it has not yet ruled on use of cell tower data for tracking over time.

This murky legal landscape does not serve the government, customers or service providers well. Customers are, at best, confused about the security of their data in response to an access request from law enforcement. Companies are uncertain of their responsibilities and unable to assure their customers that subscriber data will be uniformly protected. The current state of the law does not well serve law enforcement interests either, as resources are wasted on litigation over applicable standards, and prosecutions are in jeopardy should the courts ultimately rule on the Constitutional questions.

The solution is a clear set of rules for law enforcement access that will safeguard end-user privacy, provide clarity for service providers, and enable law enforcement officials to conduct effective and efficient investigations.

Guiding Principles for ECPA Reform

The overarching goal of our ECPA reform principles is to balance the law enforcement interests of the government, the privacy interests of users, and the interests of communications service providers in certainty, efficiency and public confidence.

We are guided by the following concepts:

  • Technology and Platform Neutrality: A particular kind of information (for example, the content of private communications) should receive the same level of protection regardless of the technology, platform or business model used to create, communicate or store it.
  • Assurance of Law Enforcement Access: The reform principles would preserve all of the building blocks of criminal investigations – subpoenas, court orders, pen register orders, trap and trace orders, and warrants – as well as the sliding scale that allows the government to escalate its investigative efforts.
  • Equality Between Transit and Storage: Generally, a particular category of information should be afforded the same level of protection whether it is in transit or in storage.
  • Consistency: The content of communications should be protected by a court order based on probable cause, regardless of how old the communication is and whether it has been “opened” or not.
  • Simplicity and Clarity: All stakeholders – service providers, users and government investigators – deserve clear and simple rules.
  • Recognition of All Existing Exceptions: Over the years, a variety of exceptions have been written into the ECPA, such as provisions allowing disclosures to the government without court orders in emergency cases. These principles should leave all those exceptions in place.

Rather than attempt a full rewrite of ECPA, which might have unintended consequences, our recommendations focus on just a handful of the most important issues – those that are arising daily under the current law: access to email and other private communications stored in the cloud, access to location information, and the use of subpoenas to obtain transactional data.

Our principles do not seek to answer all questions or concerns about ECPA. Though members of the coalition may differ on the specifics, and some individual members would support additional changes, we all agree that these principles provide a framework for opening a public dialogue on the issue.

Specific Background on ECPA Reform Principles

1. The government should obtain a search warrant based on probable cause before it can compel a service provider to disclose a user’s private communications or documents stored online.

  • This principle applies the safeguards that the law has traditionally provided for the privacy of our phone calls or the physical files we store in our homes to private communications, documents and other private user content stored in or transmitted through the Internet "cloud"– private emails, instant messages, text messages, word processing documents and spreadsheets, photos, Internet search queries and private posts made over social networks.
  • This change was first proposed in bi-partisan legislation introduced in 1998 by Senators John Ashcroft and Patrick Leahy. It is consistent with appeals court decisions holding that emails and SMS text messages stored by communications providers are protected by the Fourth Amendment, and is also consistent with the leading legal scholarship on the issue.

2. The government should obtain a search warrant based on probable cause before it can track, prospectively or retrospectively, the location of a cell phone or other mobile communications device.

  • This principle addresses the treatment of the growing quantity and quality of data based on the location of cell phones, laptops and other mobile devices, which is currently the subject of conflicting court decisions; it proposes the conclusion reached by a majority of the courts that a search warrant is required for real-time cell phone tracking, and would apply the same standard to access to stored location data.
  • A warrant for mobile location information was first proposed in 1998 as part of the bipartisan Ashcroft-Leahy bill. It was approved 20 to 1 by the House Judiciary Committee in 2000.

3. Before obtaining transactional data in real time about when and with whom an individual communicates using email, instant messaging, text messaging, the telephone or any other communications technology, the government should demonstrate to a court that such data is relevant to an authorized criminal investigation.

  • In 2001, the law governing “pen registers and trap & trace devices”—technologies used to obtain transactional data in real time about when and with whom individuals communicate over the phone—was expanded to also allow monitoring of communications made over the Internet. In particular, the data at issue includes information on who individuals email with, who individuals IM with, who individuals send text messages to, and the Internet Protocol addresses of the Internet sites individuals visit.
  • This principle would update the law to reflect modern technology by establishing judicial review of surveillance requests for this data based on a factual showing of reasonable grounds to believe that the information sought is relevant to a crime being investigated.

4. Before obtaining transactional data about multiple unidentified users of communications or other online services when trying to track down a suspect, the government should first demonstrate to a court that the data is needed for its criminal investigation.

  • This principle addresses the circumstance when the government uses subpoenas to get information in bulk about broad categories of telephone or Internet users, rather than seeking the records of specific individuals that are relevant to an investigation. For example, there have been reported cases of bulk requests for information about everyone that visited a particular web site on a particular day, or everyone that used the Internet to sell products in a particular jurisdiction.
  • Because such bulk requests for information on classes of unidentified individuals implicate unique privacy interests, this principle applies a standard requiring a showing to the court that the bulk data is relevant to an investigation.

To simplify, clarify, and unify the ECPA standards, providing stronger privacy protections for communications and associated data in response to changes in technology and new services and usage patterns, while preserving the legal tools necessary for government agencies to enforce the laws, respond to emergency circumstances and protect the public.

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En cas d’allergies de l’Г©lГ©ment de base comme Sildenafil Citrate, le patient doit rester loin de Viagra et d’autres formes rГ©alisГ©es avec cet ingrГ©dient potentiel. Haut sera le remplacement permanent de Viagra artificielle accessible, compte tenu de vos dГ©placements pour ces mГ©dicaments dГ©bilitantes. HereРІР‚ в„ў examen de sa dans les aliments qui favorisent la plus forte concentration de nutriments stimulant sexuellement. Prenez soin de prendre de l’aspirine et d’autres tueurs over-the-counter douleur, car ils peuvent provoquer des acouphГЁnes. Votre Г©tat de santГ© est l’une des chose la plus prГ©cieuse dans votre vie. Avez-vous mis sur un intestin, mГЄme si vous n’avez pas l’air d’ГЄtre de manger plus. La vitamine C et E sont des nutriments essentiels qui peuvent ГЄtre utiles non seulement dans la dysfonction Г©rectile, mais dans d’autres fonctions de l’organisme en mГЄme temps. Les rГ©sultats de la recherche ont Г©galement montrГ© que le sildГ©nafil peut ГЄtre en mesure d’amГ©liorer la condition cardiaque crГ©ation de nouvelles possibilitГ©s pour le traitement des maladies cardio-vasculaires. Un grand nombre d’hommes qui consomment des drogues pharmacologiques ont accusГ© plusieurs effets secondaires de toutes sortes. Generic Viagra peut ГЄtre le mГ©dicament de lutte contre l’impuissance classique utilisГ© pour obtenir sur ces maladies sexuelles. Cependant, ces mГ©dicaments ED populaires ont leurs propres problГЁmes et des effets indГ©sirables. SantГ© – Le chroniqueur sur Twitter (et je promets de commencer Г  poster souvent). Il dispose d’un inhibiteur de l’enzyme qui assure une bonne phosphodiester le flux de sang dans le pГ©nis organe. Le centre engouement en ligne a aidГ© plusieurs hommes Г  rГ©soudre leurs problГЁmes de problГЁmes d’impuissance. Si le niveau dans les PDE5 chimiques augmente avec votre corps, la circulation sanguine vers le pГ©nis est fixГ©, rГ©sultant en ED.

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Par consГ©quent, avant de prendre du Viagra (citrate de sildГ©nafil), vous devriez trouver la raison de la maladie, et cela peut ГЄtre fait par un mГ©decin. L’article poursuit en faisant entendre que le Viagra sans ordonnance irait Г  l’encontre des ventes de copies non autorisГ©es potentiellement dangereuses ou de contrefaГ§on de Viagra que les gens achГЁtent sur Internet sans ordonnance d’un mГ©decin; 688 mots; dГ©pose le rapport des mГ©dias. Viagra est commercialisГ© aux hommes vieillissants dont les femmes sont homologues passant par leur propre crise sexuelle – la mГ©nopause. Quand un homme est stimulГ© sexuellement ses artГЁres pГ©niennes passer par un processus pour se dГ©tendre et l’agrandir. Un examen des sous-groupes dГ©mographiques ont dГ©montrГ© l’efficacitГ© quelle que soit la sГ©vГ©ritГ© initiale, l’Г©tiologie, la race et l’Гўge. Comme Viagra Plus est une version avancГ©e des pilules de Viagra toujours populaires amГ©lioration de sexe masculin, il peut ГЄtre utilisГ© non seulement pour traiter la dysfonction Г©rectile, mais aussi l’Г©jaculation prГ©maturГ©e. Ne pas prendre du Viagra, tout en prenant Revatio, sauf si votre mГ©decin vous le dise. Que dire Г  votre mГ©decin avant de commencer ViagraOnly votre mГ©decin peut dГ©cider si le Viagra est bon pour vous. Viagra (citrate de sildГ©nafil) peut ГЄtre prescrit comme pour faire court, si pour le traitement Г  long terme des troubles de l’Г©rection et l’utilisation continue du mГ©dicament ne provoque pas de consГ©quences graves. Lorsque viagra est apparu sur le marchГ©, les amateurs espГ©raient que les pilules permettrait de revitaliser la vie sexuelle et ont Г©tГ© déçus de dГ©couvrir qu’ils ne sont pas une solution Г  une relation qui avait perdu son Г©clat. Il n’ya pas de diffГ©rences dans la construction que vous obtiendrez avec ou sans viagra – seulement la capacitГ© Г  obtenir une Г©rection est affectГ©e. Viagra, Г©galement connu comme le sildГ©nafil, est fabriquГ© par Pfizer Inc. La prise de Viagra Plus vous aidera Г  faire Г©jaculer deux ou mГЄme trois fois en une nuit.

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DISTRIBUTOR VIAGRA

OBAT KUAT VIAGRA

Tujuh puluh dua persen, 80%, dan 85% dari pasien pada pengguna yg mengkonsumsi 25 mg, 50 mg, and 100 mg VIAGRA, masing-masing tercapai ereksi cukup keras pada saat berhubungan seks dibandingkan dengan selain Viagra. Pada pria yang mengkonsumsi VIAGRA menunjukkan perbaikan dalam kemampuan mereka untuk mendapatkan juga dapat mempertahankan ereksi jauh lebih dashyat dibandingkan dengan mereka yang di konsumsi selain obat kuat Viagra. (Hasil individu dapat bervariasi, minumlah dgn teratur untuk mendapatkan hasil jauh lebih baik), Temuakan semua pengalaman yang menakjubkan dengan Viagra sebagai suplement Anda.

OBAT KUAT PRIA

Kita hidup di dunia baru yang muudah mendapatkan informasi apapun tentang seksual atau alat bantu sexual yg dapat langsung diakses melalui internet, bagi anda dan siapapun yg membutuhkan Obat kuat sex. Ketersediaan obat yang meningkatkan kinerja seksual dan budaya yang berbeda di mana perempuan sekarang mempunyai hak untuk meng explor seksualitas mereka sendiri. pertanyaannya adalah (Bagaimana sebagian pria mengimbangi kebiasaan sex dari aspek paling penting untuk mendapatkan seksualitas yg hebat, tahan lama menjadikan kualitas sex lebih baik dalam mengimbangi hal tersebut. ) Viagra jawabannya untuk Obat kuat pria .

OBAT KUAT SEX

Banyak yg mengatakan untuk para pria muda dan lebih lanjut, Viagra selalu menjadi pilihan bahkan ketika orang itu tidak memiliki disfungsi ereksi. Kami sudah mendengar dari banyak contoh Viagra digunakan oleh pria dan wanita untuk meningkatkan ketahanan ereksi lebih baik juga sebagai obat kuat sex pria pasangan nya. Viagra menambah gairah seksual lebih optimal juga mengimbangi sex pasangan bagi pasangan pengantin baru, petualang sex juga bagi penikmat sex.
Temukan keajaiban obat kuat sex di Viagra

OBAT KUAT ALAMI

Obat kuat atau Suplemen Pria alami, paling dicari di dunia. Viagra suplemen obat kuat pria yg menginginkan daya magic sex paling dasyat maka akan anda temukan di Viagra. Baca aturan pakai untuk menjaga stabilitas Sex, hasil maksimal juga kenyaman Dengan mengkonsumsi Viagra secara teratur maka dalam waktu 7-1bln Sebagai Suplemen Pria maka daya keinginan sex akan menjadi pengalaman seksual paling menakjubkan banyak wanita membeli Viagra sebagai Obat kuat sex untuk pacar-pacar mereka karena ingin meningkatkan hasrat juga kualita seksual lebih baik

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Data negative tentang Viagra mewarnai pasar obat kuat sex pria, tidak heran karena pasar viagra begitu sangat dasyat permintaan pasar untuk memenuhi kebutuhan suplement fenomenal pills biru / Viagra. Maka hembusan negative terus datang bahwa ada sebagian mengatakan Viagra adalah Doping, Ilegal, Berbahaya dll. Di produksi USA yg sangat ketat standar untuk kesehatan masyarakat luas dan dinyatakan sangat baik untuk di konsumsi sesuai aturan pemakaian sesuai petunjuk dokter. Apapun Obat, Suplemen yang di produksi bila di konsumsi tidak sesuai anjuran pemakaian atau petunjuk dokter maka akan sangat berbahay bagui kesehatan, begitupun juga Viagra jg suplement lainnya. So dari itu kenapa kami sebut Viagra obat Herbal. Yes. Viagra adalah herbal yng sangat baik untuk meningkatkan daya tahan tubuh dan membangkitkan sex bila di minum sesuai anjuran produsen, Kami Distributor Viagra memberikan garansi khasiat yang ada pada Viagra untuk para pelanggan jg para pembeli bila di minum secara teratur sesuai anjuran produsen.

Viagra, Obat Disfungsi Ereksi

Pil viagra mengobati disfungsi ereksi

Viagra adalah obat anti disfungsi ereksi yang dapat membuat penis ereksi dengan keras ketika berhubungan intim. Disfungsi ereksi atau impotensi tidak lagi menjadi penyakit yang dikhawatirkan banyak pria sejak ditemukannya pil anti disfungsi ereksi Viagra.

Disfungsi ereksi adalah ketidakmampuan seorang pria mendapatkan ereksi yang keras dan mempertahankannya tetap keras saat berhubungan. Fungsi viagra adalah bekerja untuk menghilangkan hambatan dan ketidakmampuan tersebut.

Saat ini teknologi medis dan farmasi kita berada dalam tahap yang sangat maju, berbagai macam hal rumit seperti implantasi protesa, dan injeksi bisa dilakukan, bahkan sampai menciptakan pil praktis untuk menyembuhkan disfungsi ereksi seperti Viagra.

Fungsi viagra selain mengobati disfungsi ereksi. juga ternyata menimbulkan dampak sosial. Beberapa pria yang akhirnya bisa bercinta lagi ketahuan berselingkuh karena ingin mencoba efek viagra terhadap wanita lain.

Sebutlah kisah kakek dan nenek yang satu ini, Frank Bernardo (70) dan Roberta Burke (63) yang akhirnya harus bercerai gara-gara viagra. Menurut Burke, suaminya sudah menderita disfungsi ereksi sejak tahun 1994.

Tapi karena sama-sama cinta, dan usia juga sudah tua ketidakmampuan Bernardo tidak menjadi masalah bagi rumah tangga mereka. Sampai akhirnya Bernardo berkenalan dengan si mungil viagra, pil ajaib berwarna biru yang dapat mengembalikan keperkasaan dalam waktu singkat.

Dan benar, ternyata setelah Bernardo mengkonsumsi satu butir viagra, penisnya bisa ereksi keras dan tetap keras dalam waktu yang lama. Akhirnya bisa ditebak, Bernardo seperti mendapat mainan baru dan dia hidup seperti seorang perjaka lagi.

Dasar tua-tua keladi, ujar Burke, istri Bernardo. Setelah mendapatkan kembali keperkasaanya pada tahun 1998, Bernardo berselingkuh dengan beberapa wanita dan melupakan istrinya tercinta. Merasa terhina, Burke menceraikan suaminya dan menuntut ganti sebesar US 2 juta di pengadilan Mineola, New York.

Cerita Bernardo dan Burke adalah salah satu dampak sosial yang muncul sejak ditemukannya viagra. Viagra ibarat dewa penolong bagi jutaan pria di seluruh dunia. Tak heran jika pil ini laku keras dan terjual ke seluruh dunia meski harganya mahal.

Sebuah penelitian menyebutkan sampai saat ini terdapat sekitar 140 juta pria yang menderita disfungsi ereksi dalam berbagai tingkatan. Fungsi viagra adalah bagi penderita disfungsi ereksi yang disebabkan penyakit diabetes. gangguan syaraf tulang belakang dan prostatectomy. Karena pil biru ini dapat memperpanjang durasi ereksi maka dia cocok juga digunakan oleh penderita ejakulasi dini.

Viagra diproduksi dan dipatenkan di bawah bendera perusahaan Farmasi Amerika Serikat, Pfizer. Mengantongi ijin dari Lembaga Pengawasan Obat dan Makanan (FDA) AS pada tanggal 27 Maret 1998. Tidak sampai dua bulan sejak dijual ke pasar, sekitar 1,5 juta resep yang ditulis dokter setiap hari bagi para pria pemburu viagra. Karena adanya efek samping yang mungkin muncul, viagra memang disyaratkan oleh FDA untuk dijual hanya dengan resep dokter.

Harga resmi viagra adalah $US 16 per butir tapi dipasaran harganya bisa menjadi berlipat-lipat, belum lagi yang dijual di pasar gelap dan tanpa resep dokter. Bahkan di negara Thailand, orang rela membayar $US 60 hanya untuk mendapatkan satu butir viagra. Di Jerman DM 30 dan di Indonesia sekitar Rp. 258.000 per butir. Betapa mahalnya kesehatan seksual tersebut.

Di Indonesia, harga viagra bisa mencapai Rp.200.000 tergantung dari jenisnya. Beberapa obat viagra yang dijual di internet kemungkinan palsu karena bisa dibeli tanpa resep dokter. Untuk mengurangi terjadinya pemalsuan produk mereka, pihak pzifer selaku pemilik paten viagra juga menjual melalui toko online mereka di viagra.com.

Viagra Adalah Obat Disfungsi Ereksi, Bukan obat kuat

Viagra obat disfungsi ereksi

Manfaat viagra masih sering disalah artikan oleh sebagian orang. Pil biru ini dianggap sebagai obat kuat dan karena itu sering dikonsumsi tanpa resep dari dokter.

Ditemukannya viagra bisa dikatakan tidak sengaja. Semula sekelompok peneliti di perusahaan Pfizer merancang sebuah obat untuk mengatasi gangguan tekanan darah tinggi dan angina.

Para peneliti tersebut mulai merasa aneh ketika para pria yang menjalani tes obat tersebut tidak mengembalikan pil sisa sampel. Setelah melakukan pemeriksaan akhirnya ketahuan bahwa pil tersebut memiliki fungsi lain yang sangat menarik.

Bagaimana viagra bekerja?

Seorang pria yang menerima stimulasi seksual dari panca indera ataupun dari khayalan akan menyebabkan sistem syaraf mengirimkan sinyal ke penis dan menyampaikan pesan bahwa aktifitas reproduksi akan segera dilakukan, dan rangkaian sistematis tubuh pun bekerja otomatis menyebabkan penis ereksi.

Sinyal syaraf ke penis menyebabkan tubuh memproduksi hormon kimia yang disebut siklik guanosin monofosfat (cGMP). Zat kimia ini bertanggung jawab membuat otot pada dinding arteri penis menjadi relaks dan melebar. Satu zat kimia lainnya berkerja berkebalikan dengan cGMP yang bertugas menguraikan cGMP dan mengendurkan ereksi.

Semakin tua seorang pria, produksi cGMP nya semakin sedikit, hal inilah yang menyebabkan pria berusia tua umumnya menderita disfungsi ereksi, karena meskipun dia bisa terangsang tubuhnya tidak dapat memproduksi cGMP yang cukup untuk membuat penisnya ereksi dengan keras. Pembuluh darah dalam penis tidak bisa relaks dan melebar menyebabkan aliran darah tidak cukup banyak memasuki rongga penis.

Viagra bekerja dengan cara mencegah terurainya cGMP sehingga meningkatkan aliran darah yang masuk ke penis, menyebabkan penis terisi darah dan mengalami ereksi. Semakin banyak aliran darah yang masuk maka ereksi bisa berlangsung lebih lama. Sehingga manfaat viagra yang paling utama adalah menyebabkan ereksi penis keras dan tahan lama.

Percobaan viagra melibatkan 3.700 pria dengan usia bervariasi antara 19 sampai 87 tahun, dimana 550 orang diantaranya mengikuti tes tersebut selama satu tahun. Dari hasil percobaan diketahui bahwa manfaat viagra cukup bagus yaitu sekitar 60-80%.

Viagra diminum sekitar satu jam sebelum berhubungan, efeknya akan bekerja selama empat jam. Viagra bukan obat kuat untuk menciptakan ereksi jadi agar pemakai dapat ereksi dia harus menerima rangsangan seksual terlebih dahulu.

“Cara kerja Viagra adalah membantu anda mendapatkan ereksi yang keras tapi viagra tidak akan meningkatkan hasrat atau libido seks anda. Artinya pil ini bukan obat kuat atau aprodisiak”, ucap Dr. Harin Padma-Nathan, salah seorang direktur dari Male Clinic, Santa Monika.

Penderita disfungsi ereksi biasanya juga mengalami masalah lemah syahwat atau gairah yang rendah. Selama ini, mereka menggunakan beberapa alternatif pengobatan yang tidak praktis seperti suntik, implantasi protesa, dan penggunaan obat oles. Sekarang, mereka cukup meminum satu butir pil viagra dan masalah ereksi mereka dapat terselesaikan.

Pihak Pzifer, perusahaan Farmasi pemilik paten Viagra menyebutkan bahwa pil biru ini memiliki efek samping seperti iritasi pada perut, kepala pusing, dan penglihatan menjadi kabur. Bahkan bagi pengguna yang mengkonsumsi terlalu banyak tidak akan mampu membedakan warna hijau dengan biru.

Viagra tidak menimbulkan ereksi tapi mempermudah orang ereksi, jadi pil ini diminum dan tidak boleh disuntik ke badan. Penggunaan suntikan viagra sangat berbahaya dan menyebabkan priapismus. yaitu ereksi terjadi terus menerus selama berjam-jam meskipun ejakulasi telah terjadi dan terasa sakit, dampak paling berbahayanya adalah menyebabkan jaringan penis rusak permanen.

“Ereksi bisa terjadi karena ada pelebaran pembuluh darah dalam penis membuat pasokan darah meningkat dan penis pun ereksi. Viagra bekerja melebarkan pembuluh darah di penis bagi yang mengalami masalah pembuluh darahnya tidak bisa melebar. Setelah mengkonsumsi pil ini, barangkali ada bagian tubuh lain yang mengalami pelebaran sehingga menyebabkan efek samping”, ucap Dr. Akmal Taher, peneliti viagra wilayah Asia.

Viagra tidak boleh dikonsumsi bersamaan dengan obat jenis lain yang mengandung nitrat seperti obat untuk penyakit jantung sebab bisa menyebabkan kematian. Obat nitrat dan viagra bekerja saling menguatkan sehingga pelebaran pembuluh darah menjadi sangat hebat dan mendadak.

Gangguan Jantung dan Diabetes

Fungsi Viagra adalah bagi penderita diabetes

Setelah dijual bebas dipasaran, FDA (Lembaga pengawas obat di USA) melaporkan 16 orang meninggal setelah mengkonsumsi pil biru viagra. Bahkan sebuah laporan dari Wall Street Journal pada 29 Juni 1998 menyebutkan korban meninggal bertambah menjadi 30 orang, dengan korban tertua berusia 80 tahun dan termuda 48 tahun.

Walaupun sulit mengidentifikasi penyebab kematiannya, dari pemeriksaan diketahui bahwa rata-rata korban meninggal sedang menjalani pengobatan penyakit diabetes, jantung dan beberapa komplikasi penyakit lainnya.

Sebanyak 6 orang menderita penyakit jantung, dua orang sedang menjalani terapi hytrin, yang satu mengidap hipertensi dan stroke. Sementara yang lain mengalami gangguan denyut jantung tidak teratur yang sangat kronis, salah seorang korban juga menderita pembesaran prostat. Sebelum meninggal, dua orang sempat pingsan saat sedang berhubungan seks.

Dua lainnya mengalami serangan nyeri di dada dan tidak bisa diselamatkan melalui terapi resusitasi dan oemberian obat nitroglyserin. Terdapat dua korban yang meminum obat peneurun hipertensi dan aspirin sebelum mengkonsumsi viagra, mereka mengalami sesak nafas, wajah pucat dan akhirnya meninggal padahal belum berhubungan seks.

Enam dari 30 korban tersebut diketahui sedang mengidap penyakit diabetes. Bahkan salah satu diantaranya juga mengalami masalah kelainan fungsi paru-paru, ke enamnya meninggal satu jam setelah mengkonsumsi pil biru sildenafil sitrate tersebut.

Salah seorang korban meninggal setelah melakukan hubungan intim menderita detak jantung yang tidak teratur dan aliran darah dari jantung tidak lancar atau tersumbat. Korban tersebut meninggal saat pagi hari.

Obat Viagra Harus Dengan Resep Dokter

Meskipun penyebab kematian tersebut masih diperdebatkan, pihak FDA selaku penanggung jawab menyebut tidak ada bukti bahwa viagra adalah penyebab langsung kematian tersebut. Kemungkinan ada faktor lain seperti penyakit yang menjadi faktor dominan penyebab kematian.

Menurut seorang ahli, kemungkinan kematian disebabkan adanya komplikasi antara viagra dengan nitroglyserin (obat penyakit jantung). Sementara itu analisa dari Dr. Adolph Hutter, seorang ahli jantung klinis dari General Hospital, Massachusetts menyebutkan kematian kemungkinan akibat faktor emosi dan fisik yang tidak terkendali saat berhubungan, terlalu lama tidak bercinta menyebabkan mereka sangat bersemangat.

Dr Akmal Taher sependapat dan berujar, “ada 1 juta pria berusia di atas 50 tahun yang memiliki risiko meninggal yang sama meskipun tidak mengkonsumsi pil viagra, apalagi diantara mereka itu ada yang mengidap masalah jantung. Kemungkinan meninggalnya bukan karena viagra melainka karena terlalu bersemangat sehingga terjadi serangan jantung”.

Dan memang berdasarkan penelitian terhadap 4.000 orang di USA dan Eropa yang meminum pil Sildenafil tersebut, tidak satu pun yang meninggal, baik dalam jangka 3 bulan setelah percobaan maupun setelah 6 bulan.

Menyikapi kasus tersebut, negara selain Amerika saat ini masih wait and see. Sampai artikel ini ditulis, Badan Pemeriksa Obat dan Makanan Indonesia juga belum meloloskan obat ini ke tanah air. Di negara-negara Timur Tengah, viagra dinyatakan obat terlarang. Di Arab Saudi dilakukan tes terhadap 30 orang dengan tingkat keberhasilan 85%, tapi meski demikian pemerintah Arab Saudi belum meloloskan obat ini untuk dijual.

Negara pertama di luar Amerika Serikat yang menjual viagra adalah Thailand, tapi dengan persyaratan ketat, yakni harus dengan resep dokter. Pelolosan ini dijalankan dengan pengawasan ketat dari pemerintah yakni berupa pemantauan terhadap efek sampingnya selama 2 tahun ke depan. Setelah Thailand, menyusul Malaysia yang mengijinkan penjulan viagra.

Menyontek keberhasilan viagra dan antusiasme masyarakat mendorong perusahaan farmasi lain menciptakan produk sejenis yang konon katanya lebih aman, contohnya adalah cialis dan levitra. Adalah perusahaan farmasi Zonagen Inc yang berasal dari Texas memproduksi Vasomax sebagai obat disfungsi ereksi alternatif selain viagra.

Dengan semakin banyaknya obat sejenis viagra yang diklaim mampu menyembuhkan disfungsi ereksi maka perlu juga diperhatikan terjadinya perubahan perilaku dalam masyarakat terutama kaum pria. Beberapa laporan juga menyebut bahwa viagra menyebabkan tingginya penularan penyakit dan infeksi menular seksual .

Beberapa remaja yang sama sekali tidak menderita impoten tercatat menjadi konsumen setia pil biru tersebut. Jika kondisi ini terus terjadi maka si remaja tadi kemungkinan besar akan menderita impoten permanen saat usianya bertambah tua.

Kesimpulannya, viagra hanya bisa dikonsumsi oleh pria penderita disfungsi ereksi atau impotensi. Pil ini bukan obat kuat yang bisa dikonsumsi siapa saja, anda harus melalui pemeriksaan kesehatan yang ketat dari dokter sebelum meminum beberapa butir viagra.

***
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Detail Produk obat kuat viagra asli usa 100 mg

Obat kuat viagra asli usa 100 mg merupakan obat kuat untuk merangsang pria dewasa serta meningkatkan vitalitas untuk dapat berhubungan badan dengan istrinya untuk mencapai suatu hubungan yang maksimal seperti disaat malam pertama, obat kuat viagra dapat meningkatkan ereksi lebih keras, kencang dan tahan lama saat diranjang untuk melakukan hubungan seksual sampai puas dan klimaks, suatu hubungan akan tercipta mesra disaat kedua belah pihak pasangan saling memenuhi syarat seperti stamina badan dan alat kelamin yang selalu merangsang dan mempunyai nafsu tinggi untuk selalu menjadikan hubungan sex akan lebih menjadi romantis untuk menciptakan keluarga harmonis.

Banyak orang merasa menggunakan obat kuat viagra usa dapat meningkatkan performa seorang pria dengan instan sehingga dapat memuaskan pasangan, impian kepuasan dan keperkasaan inilah yang membuat viagra laris dipasaran, sayangnya banyak orang tidak dapat memilih viagra dengan tepat, belum lagi efek samping yang tidak diperhitungkan dengan baik juga sering kali membuat banyak orang kecewa atau bahkan harus menanggung akibat yang cukup beresiko. selain itu beberapa pria juga hanya asal membeli viagra tanpa tau persis sistim kerja, bahan pembuatannya dan bagaimana cara penggunaannya dengan tepat, contohnya. anda tidak mau jadi bagian dari orang – orang ini, oleh karena itu ada beberapa hal penting yang harus anda cermati sebelum memilih dan menggunakan viagra agar anda mendapat manfaat maksimal dan kepuasan diranjang.

Apa itu sebenarnya viagra? Secara singkat viagra adalah jenis obat kuat yang juga disebut sidenafil sitrat yang diperuntunkan khusus pria dewasa guna mengatasi disfungsi ereksi dan meningkatkan performa seksual pria, pria yang mengkonsumsi viagra akan ereksi dengan lebih kuat dan keras serta lebih panjang. fungsi inilah yang membuat banyak pria tergiur untuk mencoba viagra sayangnya tidak semua orang menyadari bahwa hubungan seksual memerlukan lebih dari sekedar performa seksual yang tinggi, untuk dapat menikmati dan mencapai kepuasan, selalu diperlukan rangsangan seksual dan pemanasan yang cukup. ada banyak khusus dimana seorang pria tepat tidak dapat melakukan hubungan seksual sesuai dengan harapannya karena mengabaikan faktor psikologisnya dan pasangan.

Selain itu cara dan dosis mengkonsumsinya juga sangat mempengaruhi hasilnya, viagra sebaiknya dikonsumsi setengah sampai satu jam sebelum memulai aktifitas seksual, obat ini akan mulai bereaksi pada waktu tersebut, selain itu dalam satu hari sebaiknya kita tidak mengkonsumsi lebih dari satu tablet viagra, pada umumnya satu tablet viagra memiliki dosis sekitar 100 mg, padahal dalam 1x 24 jam dosis maksimal menggunakan viagra yang disarankan dokter hanyalah 50 mg kecuali atas petunjuk dokter, sebaiknya kita hanya mengkonsumsi viagra dengan dosis dibawah 100 mg dalam 1x 24 jam. Menurut The American Journal Of Medical Association penggunaan viagra tidak selalu meningkatkan performa sexual dan dosis yang berlebihan justru tidak akan memperlemah performa seksual secara permanen.

Efek samping viagra yang harus dipertimbangkan

Meski aman jika dikonsumsi sesuai dosis yang disarankan tetap saja kita harus mempertimbangkan penggunaan viagra bukan untuk melanggar penggunaan viagra namun untuk mengetahui efek samping akan membuat kita lebih berhati – hati. Berikut beberapa efek samping yang umum dialami oleh pengguna viagra. sakit kepala, dingin, dan penglihatan agak kabur, jika anda mengalami salah satu dari efek samping tersebut anda tidak perlu khawatir karena gejala akan hilang dengan sendirinya setelah beberapa jam dari waktu penggunaan obat kuat viagra.

Namun ada beberapa efek samping yang sebaiknya diwaspadai seperti. nyeri dada, badan sakit dan pegal – pegal, ruam kulit, kurangnya sensitifitas tubuh, sulit tidur, mual, detak jantung tidak teratur atau palpilasi, dan sering berkeringat dingin. Jika anda mengalami efek samping yang seperti ini ada beberapa kemungkinan kondisi yang harus diwaspadai, misal dosis viagra yang terlalu tinggi atau pemakaian viagra yang terlalu sering. Selain itu bisa jadi tubuh anda tidak dapat mentoleransi bahan tertentu yang terkandung dalam tablet viagra tersebut atau anda memiliki kondisi tubuh tertentu yang tidak tahan terhadap viagra, jika efek samping tersebut berlangsung seharian sebaiknya anda memeriksakan diri kedokter dan mengecek kondisi tubuh anda, serta membawa viagra yang anda konsumsi untuk dikonsultasikan dengan dokter anda.

Jika anda mengalami efek samping yang perlu diwaspadai namun tidak segera mengatasinya efek samping lebih lanjut seperti pingsan, stroke, pendarahan hidung, serangan jantung, gangguan pendengaran, perubahan tekanan darah drastis dan penurunan kesadarahan bisa terjadi sewaktu – waktu. namun anda tidak perlu khawatir efek samping yang serius! ini hanya akan terjadi jika anda mengkonsumsi viagra secara berlebihan atau mengabaikan efek samping ringan yang anda alami.

Memang banyak tablet viagra dan obat kuat aman yang beredar dipasaran, untuk mendapatkan sebaiknya anda membeli dari sumber terpercaya seperti dokter, apotok, klinik, rumah sakit atau atau mitra – mitra toko obat yang mempunyai lisensi keamanan dari sumber yang terpercaya sepeti toko online obat yang kami jual, jangan lupa mengecek kandungan dan tanggal kadar luarsa dalam kemasan, pastikan kemasan juga dalam kondisi baik, untuk memastikan keaslian dan kualitasnya.

Bagi anda yang masih ragu untuk mengkonsumsi viagra yang didapat dipasaran, ada beberapa alternatif viagra alami yang patut dicoba dan aman :

(minyak zaitun) Tahukan anda salah satu penyebab lemahnya performa seksual adalah jumlah hormon testosteron yang rendah, ini dapat diatasi dengan minyak zaitun. Mulailah mengganti penggunaan minyak sayur pada tumisan dan salad dengan minyak zaitun selain lebih sehat bagi jantung minyak zaitun juga kaya akan nutrisi dan vitamin E yang mampu meningkatkan produksi hormon testosteron, produk hormon testosteron akan mempertinggi gairah dan performa seksual anda dengan efektif.

(buah berris) Kabar baik bagi pecinta buah berris seperti blueberry atau strowberry, kedua jenis buah ini dapat memacu performa seksual dengan efektif. buah berris termasuk juga raspberry mengandung vitamin C antioksidan, dan volatnya yang tinggi membuat anda semakin prima diranjang.

(daging merah) Konsumsi daging merah rendah lemak yang berprotein tinggi mampu memberi asupan protein sehat, kalsium, dan mineral yang dapat memperlancar peredaran darah. peredaran darah yang lancar dan asupan protein yang cukup juga akan mempengaruhi kemampuan ereksi penis, ingatlah penis menjadi tegang juga karena aliran darah didalam pembuluh darah pada penis dan sekitarnya. konsumsilah daging merah 2x dalam seminggu didalam menu makan anda, dijamin bukan hanya tubuh yang lebih sehat, ranjang anda juga akan lebih panas.

(almond dan kacang – kacangan) Mulai sekarang gantilah cemilan anda dengan lebih banyak almond dan kacang – kacangan, termasuk biji – bijian seperti biji bunga matahari. bahan alami ini mengandung vitamin B dan zinc, zat besi, protein nabati, dan selenium yang mampu meningkatkan performa seksual dengan efektif, konsumsi secara teratur dalam menu makan anda dapat menimbulkan efek seperti menggunakan viagra.

(semangka) Yang terakhir adalah semangka buah yang banyak mengandung air ini ternyata dapat berfungsi sebagai viagra alami yang ampuh, menurut penelitian di T&M texas university kandungan vitamin A dan C dalam semangka yang berpadu dengan kalium, selenium, licopen, dan mineral lain sangat berpengaruh pada produksi libido dalam tubuh baik pada laki – laki dan perempuan, libido inilah yang berpengaruh pada tingkat gairah seksual seseorang, selain itu kandungan mineral dan vitamin dalam semangka juga mampu memperlama ereksi penis, konsumsi semangka secara teratur sebagai buah harian akan membuat anda seperti menggunakan viagra obat kuat

Viagra usa juga mampu mengatasi impotensi dan ejakulasi dini serta cocok digunakan untuk pria frustasi seperti mempunyai penyakit diabetes atau kehilangan nafsu seksual sama sekali untuk melakukan hubungan sexual, oleh karena itu obat viagra ini bisa dikonsumsi untuk orang yang mempunyai gejala-gejala seperti itu untuk mengobati atau mengembalikan penyakit yang diderita orang tersebut, viagra juga sering dikenal dengan nama istilah lain seperti pil biru (blue tablet) banyak masyarakat kita mengenal viagra dengan istilah tersebut karena dari warna pilnya sendiri memliki warna biru yang cukup dikenal dengan sebutan pil biru. salah satu ciri dari keaslian obat viagra usa 100 mg memiliki cetakan disamping sisi luar tablet pada bagian sisi kanan dan kiri dengan bertuliskan pfizer dan VGR 100 yang bisa anda lihat pada tablet viagra asli ini.

Viagra usa 100 mg dominan beredar diberbagai belahan dunia seperti indonesia, malaysia dan belahan dunia lainnya, obat kuat asli ini berasal dari negara usa yang sudah terkenal akan pengobatannya khususnya untuk pria dewasa agar tetap perkasa karena dinegara tersebut sex merupakan persoalan utama yang perlu diperhatikan dalam kehidupan berumah tangga, obat viagra usa sangat aman 100% tanpa bahaya efek samping untuk digunakan bagi pria dewasa maupun yang sudah berumur 60 keatas karena obat ini selain memperbaiki ereksi juga dapat menambah vitalitas pria semakin kuat, pada dasarnya viagra 100 mg mengacu jantung untuk bekerja sempurna mengalirkan darah kepenis serta membangkitkan gairah pria dewasa atau yang sudah tua dan juga dapat mengobati penyakit seperti diabetes, kencing manis serta baik untuk suplemen harian untuk tetap menjaga kebugaran tubuh kita.

ATURAN MINUM OBAT KUAT VIAGRA

baik diminum sesudah makan 1/2 tablet atau setengah dari dosis 100 mg dengan air mineral dan tunggu selama 30 menit untuk berhubungan maka dengan sendirinya obat ini akan bekerja maksimal, untuk pengobatan disfungsi ereksi konsumsilah 25 mg atau 1/4 dari dosis 1 tablet setiap 3x sehari untuk mengembalikan kepercayaan anda sebagai lelaki perkasa saat diranjang.

PERHATIAN PELARANGAN VIAGRA ASLI

  • tidak boleh dikonsumsi untuk wanita dan anak-anak
  • masalah kesehatan jantung dan hati sebaiknya konsultasikan dulu dengan dokter anda
  • gunakanlah sesuai dosis aturan

NETTO. 30 TABLET

HARGA VIAGRA. Rp. 1.000.000 – USA

NB. minimal pengambilan 5 tablet harga Rp. 200.000

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Viagra Use Frequency

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Niagara Falls Frozen

Example:[Collected via e-mail, 2006]

Thought you might appreciate seeing this old photo. I’ve read of this but never saw the photo before. Makes you wonder just HOW COLD and HOW LONG it was that cold.

THIS PICTURE WAS TAKEN WHEN NIAGARA FALLS WAS COMPLETELY FROZEN IN THE YEAR 1911. A VERY RARE PHOTO.

Origins: Niagara Falls (actually the collective name for a set of three waterfalls along the Niagara River that forms the border between New York and Ontario: the American Falls, the Bridal Veil Falls, and the Canadian/Horseshoe Falls) is the

celebrated natural phenomenon that has awed generations of honeymooners. Although it may seem astounding to contemplate, the tremendous volume of rushing water (hundreds of thousands of gallons per second) that is Niagara Falls does “freeze” from time to time, although very rarely “completely” as suggested in the text accompanying the above-displayed image: despite the abundance of ice visible in the image, water can still be seen flowing over the falls in several distinct streams. As noted in the Washington Post. the sight of a “frozen” Niagara falls is not so unusual a phenomenon:

Niagara Falls gets cold every year. The average temperature in Niagara Falls in January is between 16 and 32 degrees. Naturally, it being that cold, ice floes and giant icicles form on the falls, and in the Niagara River above and below the falls, every year. The ice at the base of the falls, called the ice bridge, sometimes gets so thick that people used to build concession stands and walk to Canada on it. It’s nothing out of the ordinary. It is not, to put it bluntly, big polar vortex news.

During occasional periods of prolonged cold weather falling water and spray from Niagara Falls may freeze into ice formations, and ice mounds or floes may form in the Niagara River (sometimes creating ice bridges that stretch across the width of the river), but only once in recorded history has freezing weather actually stopped water from flowing over the falls. This instance occurred in March 1848 when a preponderance of ice above the falls reduced the flow of water over the falls to a trickle, as reported in the Buffalo Express newspaper:

The Falls of Niagara can be compared to nothing but a mere mill dam this morning. In the memory of the oldest inhabitants, never was there so little water running over Niagara’s awful precipice, as at this moment! Hundreds of people are now witnessing that which never has, and probably never may again be witnessed on the Niagara River.

Last night at 11 o’clock the factories fed from the waters of this majestic river were in full operation, and at 12 o’clock the water was shut off, the wheel suddenly ceased their revolutions, and everything was hushed into silence. Various are the conjectures as to the cause; the most reasonable of which is that Lake Erie must be making a grand delivery of ice, and this the mouth of the Niagara, although large, is not quite enough to take in the whole at once, and that the consequences are, back water.

The sepia-toned photograph shown above, which dates to about 1909. corresponds to a view of the American Falls:

Although the text that accompanies the sepia image in e-mail forwards and social media postings usually states that the photo dates from 1911, other sources assign a variety of different dates to it. Much of the Niagara River around the falls was frozen in 1912, an ocurrence that resulted in a tragic accident when an ice bridge across the river broke free from its shoring as several people were traversing it. Three people were unable to make it back to shore in time and were killed as the loosened ice plunged down the river.

In the wake of the January 2014 “polar vortex” that brought bitterly cold weather to much of the eastern half of the United States, a number of photographs were circulated via social media purporting to show Niagara falls in a currently frozen state:

All of these images antedated the January 2014 polar vortex, however, having originated in 2007. 2012. and 2011. respectively. (The falls did ice over twice during the winter of 2014, however.)

Later versions of the example e-mail that was originally forwarded in 2007 included additional (undated) photographs of the falls in winter, obviously from different years (from top left: 1906. 1902. and 1936 ):

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Some ‘Frozen Niagara Falls’ Photos Really Are Too Good To Be True

According to Yahoo! News this is not the first time people have raised questions about the veracity of Niagara Falls photos. Experts still question the authenticity of some famous winter photos taken in the the early- and mid-1900s and archived at Niagara Falls Public Library.

But while the 167-foot Niagra Falls may not have frozen completely solid during this recent cold snap, the landmark did partially freeze, resulting in some genuinely spectacular pics.

This photo of Niagara Falls partially frozen over was taken on January 9, 2014.

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Common use

The main component of Viagra is Sildenafil Citrate.
Sildenafil Citrate affects the response to sexual stimulation. It acts by enhancing smooth muscle relaxation using nitric oxide, a chemical that is normally released in response to sexual stimulation. This smooth muscle relaxation allows increased blood flow into certain areas of the penis, which leads to an erection.
Sildenafil Citrate is applied for the treatment of erectile dysfunction (impotence) in men and pulmonary arterial hypertension.
Sildenafil Citrate may also be used for other purposes not listed above.

Dosage and direction

Usually the recommended dose is 50 mg. It is taken approximately 0,5-1 hour before sexual activity. Do not take Viagra more then once a day.
A high fat meal may delay the time of the effect of this drug.
Try not to eat grapefruit or drink grapefruit juice while you are being treated with Sildenafil Citrate .

Precautions

Before you start taking Sildenafil Citrate. tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.
Aged people may be more sensitive to the side effects of the drug.

Viagra is contraindicated in patients who take another medicine to treat impotence or using a nitrate drug for chest pain or heart problems.
This medicine should not be taken by women and children as well as in patients with a known hypersensitivity to any component of the tablet.

Possible side effect

The most common side effects are headache, flushing, heartburn, stomach upset, nasal stuffiness, lightheadedness, dizziness or diarrhea.
A serious allergic reaction to this drug is very rare, but seek immediate medical help if it occurs.
Many people who use this medicine do not have serious side effects.
In case you notice any side effects not listed above, contact your doctor or pharmacist.

Drug interaction

This drug should not be used with nitrates and recreational drugs called “poppers” containing amyl or butyl nitrite; alpha-blocker medications; other medications for impotence; high blood pressure medicines, etc.
Consult your doctor or pharmacist for more details.

Missed dose

Viagra is used as needed, so you are unlikely to be on a dosing schedule.

Overdose

If you think you have used too much of this medicine seek emergency medical attention right away. The symptoms of overdose usually include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

Storage

Store your medicines at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store the drugs in the bathroom. Keep all drugs away from reach of children and pets.

Disclaimer

We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information at the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

Common use

The main component of Viagra is Sildenafil Citrate.
Sildenafil Citrate affects the response to sexual stimulation. It acts by enhancing smooth muscle relaxation using nitric oxide, a chemical that is normally released in response to sexual stimulation. This smooth muscle relaxation allows increased blood flow into certain areas of the penis, which leads to an erection.
Sildenafil Citrate is applied for the treatment of erectile dysfunction (impotence) in men and pulmonary arterial hypertension.
Sildenafil Citrate may also be used for other purposes not listed above.

Dosage and direction

Usually the recommended dose is 50 mg. It is taken approximately 0,5-1 hour before sexual activity. Do not take Viagra more then once a day.
A high fat meal may delay the time of the effect of this drug.
Try not to eat grapefruit or drink grapefruit juice while you are being treated with Sildenafil Citrate .

Precautions

Before you start taking Sildenafil Citrate. tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.
Aged people may be more sensitive to the side effects of the drug.

Viagra is contraindicated in patients who take another medicine to treat impotence or using a nitrate drug for chest pain or heart problems.
This medicine should not be taken by women and children as well as in patients with a known hypersensitivity to any component of the tablet.

Possible side effect

The most common side effects are headache, flushing, heartburn, stomach upset, nasal stuffiness, lightheadedness, dizziness or diarrhea.
A serious allergic reaction to this drug is very rare, but seek immediate medical help if it occurs.
Many people who use this medicine do not have serious side effects.
In case you notice any side effects not listed above, contact your doctor or pharmacist.

Drug interaction

This drug should not be used with nitrates and recreational drugs called “poppers” containing amyl or butyl nitrite; alpha-blocker medications; other medications for impotence; high blood pressure medicines, etc.
Consult your doctor or pharmacist for more details.

Missed dose

Viagra is used as needed, so you are unlikely to be on a dosing schedule.

Overdose

If you think you have used too much of this medicine seek emergency medical attention right away. The symptoms of overdose usually include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

Storage

Store your medicines at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store the drugs in the bathroom. Keep all drugs away from reach of children and pets.

Disclaimer

We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information at the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

Common use

The main component of Viagra is Sildenafil Citrate.
Sildenafil Citrate affects the response to sexual stimulation. It acts by enhancing smooth muscle relaxation using nitric oxide, a chemical that is normally released in response to sexual stimulation. This smooth muscle relaxation allows increased blood flow into certain areas of the penis, which leads to an erection.
Sildenafil Citrate is applied for the treatment of erectile dysfunction (impotence) in men and pulmonary arterial hypertension.
Sildenafil Citrate may also be used for other purposes not listed above.

Dosage and direction

Usually the recommended dose is 50 mg. It is taken approximately 0,5-1 hour before sexual activity. Do not take Viagra more then once a day.
A high fat meal may delay the time of the effect of this drug.
Try not to eat grapefruit or drink grapefruit juice while you are being treated with Sildenafil Citrate .

Precautions

Before you start taking Sildenafil Citrate. tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.
Aged people may be more sensitive to the side effects of the drug.

Viagra is contraindicated in patients who take another medicine to treat impotence or using a nitrate drug for chest pain or heart problems.
This medicine should not be taken by women and children as well as in patients with a known hypersensitivity to any component of the tablet.

Possible side effect

The most common side effects are headache, flushing, heartburn, stomach upset, nasal stuffiness, lightheadedness, dizziness or diarrhea.
A serious allergic reaction to this drug is very rare, but seek immediate medical help if it occurs.
Many people who use this medicine do not have serious side effects.
In case you notice any side effects not listed above, contact your doctor or pharmacist.

Drug interaction

This drug should not be used with nitrates and recreational drugs called “poppers” containing amyl or butyl nitrite; alpha-blocker medications; other medications for impotence; high blood pressure medicines, etc.
Consult your doctor or pharmacist for more details.

Missed dose

Viagra is used as needed, so you are unlikely to be on a dosing schedule.

Overdose

If you think you have used too much of this medicine seek emergency medical attention right away. The symptoms of overdose usually include chest pain, nausea, irregular heartbeat, and feeling light-headed or fainting.

Storage

Store your medicines at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store the drugs in the bathroom. Keep all drugs away from reach of children and pets.

Disclaimer

We provide only general information about medications which does not cover all directions, possible drug integrations, or precautions. Information at the site cannot be used for self-treatment and self-diagnosis. Any specific instructions for a particular patient should be agreed with your health care adviser or doctor in charge of the case. We disclaim reliability of this information and mistakes it could contain. We are not responsible for any direct, indirect, special or other indirect damage as a result of any use of the information on this site and also for consequences of self-treatment.

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