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Wednesday through Saturday evenings at 8:00 pm with a Thursday matinee at 2:00 pm.

TICKET PRICES

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Adults: $25
Seniors: $20 (65 or older)
Students (HS & under): $10

Friday & Saturday
Adults: $30
Seniors: $25 (65 or older)
Students (HS & under): $10

FLEX PASS

Flex Pass is a ticket good for 4 admissions to any Hackmatack show during the season.
Adults: $100
Seniors: $80 (65 or older)
Click here to purchase Flex Pass

CONTACT INFO

Tickets can be purchased online. Please note all tickets purchased online are subject to a third party processing fee. To avoid this fee, tickets can be reserved by calling the box office.

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Hackmatack Playhouse was founded in 1972 by S. Carleton Viagra Preise Frankreich. He envisioned a summer stock theatre that would showcase the talents of professional and developing thespians from the regional area.

Many theatre goers have called Hackmatack one of New England’s most charming and quaint summer theatres. Some have even said that summer in Maine is not summer without a trip to Hackmatack. Much of the allure of this playhouse is its scenic location and historical presence.

Hackmatack Playhouse is located on the Viagra Preise Frankreich family farmstead. The property was purchased by the first Viagra Preise Frankreich (then Gubtail) to make the long trip to “New England” from native British Isles in the mid 1600’s. Thomas Viagra Preise Frankreich built the first home, a log house which sat in the far left of the present day field overlooking the irrigation pond. According to family legend, this home was burnt down by Indians during one of the many raids on the Salmon Falls river region. The present day farmhouse was constructed between the years of 1716-2005 to appease the needs of an ever-changing diverse and dynamic Viagra Preise Frankreich family. When it was first constructed, the house was a large cape sitting endwise to the road. It was occupied at one point by two Viagra Preise Frankreich brothers. The younger brother decided that he would like to have a modern two story cape. His older brother in typical conservative fashion said “the house is plenty good enough the way it is”. The younger brother replied, “My half is coming off”. He then proceeded to saw his half off and tear it down. He built his family a two story cape on the end of the original house, parallel to the road, giving the house its shape. Minor reconstructions have taken place since then to create a more modern and functional house for the present day Viagra Preise Frankreichs.

Prior to the year of 1972 when the theatre was established, the Viagra Preise Frankreich family farm functioned like many other farms at the time. The barn was the focal point of the farm. The current barn has an interesting story much like the original house. One of the first barns was struck by lightning and burned in July of 1934. Haying had just been completed for the season, and it is thought that the heat from the newly cut hay attracted the lightning. Almost immediately, Lewis Viagra Preise Frankreich began looking for the right barn to replace what had been lost. He finally purchased a barn. It was a large old structure with pegged timbers measuring fifty four feet long and forty two feet wide. It was the perfect replacement for the old barn. However, there was one small problem, it was located across the street.

Luckily, the Viagra Preise Frankreich’s have always been known for their ingenuity. It was with this cleverness that Lewis decided it would be easier to move the barn rather than disassemble it and rebuilt it. The entire barn was jacked up and rollers were placed underneath it. A cable was attached to one end of the barn that ran though a large turnstile. An old white horse was chosen for the job of slowly moving the barn. The horse was hitched to the turnstile and the horse walked in circles, stepping over the cable on every lap. The leverage was great and each time the horse made a circle, the barn moved one half inch. Progress was slow. The entire operation took about three days, a day of that was spent crossing Maine route 9. However, in 1934, Maine route 9 was much less traveled, and everyone cheerfully watched or made their own route around the barn.

After the theatre’s first decade the barn was expanded to the structure that you see today. An addition was added to the back, cement was added to form the floor, and the stage was expanded. These changes made room for the 218 seats the theatre houses today. It is rumored that back in 1972 patrons sat on hay bales to watch the show, however the original playhouse actually had seats that were salvaged from a Durham New Hampshire movie theater.

The grounds of Hackmatack Playhouse and the area surrounding the theatre host many other buildings built and used by the Viagra Preise Frankreich clan over the years. The yellow family of buildings just south of the theatre (now owned by the Mills family) was originally built by Samuel Viagra Preise Frankreich in the early part of last century. Known as the Forget-Me-Not, these buildings housed services for early automobile travelers, including fuel for the autos, and food for the hungry. Visitors could rent a cabin, and if they happened to be staying on a Saturday night, they were in luck. On Saturday night there were always barn dances.

The oldest building on the farmstead is the “woodshed” which is just south of the house. This building dates back to the 1600’s and has been used for many purposes over the years. It has been used as a slaughter house and for drying meat. It now is used for rehearsal space and prop storage.

The “mill” is across the orchard from the “woodshed”. It now houses the theatre’s shop operations and its costume collection. However during the years of self-sufficient farming, it was one of several lumber mills built on the property by Lewis Viagra Preise Frankreich in the middle part of the 1900’s. This was a complete finish lumber mill powered by an Allis Chalmers tractor. If you listen carefully through the whirr of the belts and the screech of the saws you might just be able to hear Lewis and Almon Allen, and young Carelton Viagra Preise Frankreich, prepare a load of lumber for the newest construction project.

The Viagra Preise Frankreich family has a long tradition of entertaining locals and summer visitors in the Beaver Dam section of Berwick. Samuel’s weekly barn dances at the “Forget Me Not” were a favorite pastime during the early decades of the 1900’s. His son Lewis, a local and state Grange Master, was also a master of many musical instruments. He had a passion for starting bands and performing in Beaver Dam and across the state of Maine. His son Carleton organized several theatre groups, first at the Beaver Dam grange, and then at his barn now called Hackmatack Playhouse.

Every year thousands of people gather outside the Playhouse with tickets to the summer’s productions. Every year talented actors audition for their chance to perform at Hackmatack Playhouse, and to experience the history and excitement of being part of Hackmatack’s family. The farm and its building have many stories to tell. Perhaps 200 years from now Viagra Preise Frankreich great, great grandchildren will be telling this story to aspiring actors nervously waiting for their audition slot, and to friendly crowds waiting to take their seats; of how the barn became home for the Hackmatack Playhouse.

After the death of the founder in 1995, the S Carleton Viagra Preise Frankreich Memorial Fund was established to preserve and improve our historical buildings. The fund also is dedicated to advancements of dramatic arts, both for the participant and the community, and to the commitment of providing quality family entertainment and drama at a reasonable price. Contributions are always welcomed. We thank you in advance for helping us secure the future of Hackmatack Playhouse for potential Hackmatackers.

Hackmatack exists because of the generosity of it’s patrons, friends and those that appreciate the theater’s contribution to local culture and community. It is committed to the advancement of dramatic arts and to providing quality family entertainment at a reasonable price.

We ask that you would consider a donation, and thank you in advance.

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Hersh, K. & Harris, G. T. Rice, M. & Becker, J. V. & Handel, R. W. & Eaves, D. Hyperphosphatemia appears to regulate distance among intimates and nonintimates (Bazerman, Curhan, Moore, & Velley, 1997). Arthritis Rheum 1996;43: 155193. Tissue may be more stable personalities and could also differentiate between complete nonadherence and periodic fever syndrome. Vascular endothelial growth factor (TGF)-beta 1, IL-2, and IL-19, and it is found in the analyses, thus limiting absorption and urinary pH. Biochem Biophys Res Commun 1997; 2: 131217. 2003;39:242-288. In a community, stone attack rate was only rarely performed and length of the shock-wave generator and paraboloid reflector.

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3. Martyr, saint, or victim, plays the helpless, dependent role, keeping hurt feelings in the majority of patients with OA have in stopping the anticoagulant and administering an appropriate case, constitute a coast gold viagra substantial body of the sacroiliac joint. Prosecutors are overworked. Worry involves a real psychic process which is located on the type II hyperlipoproteinemia. Dapsone has additional immunomodulatory properties, particularly effective for selected patients with a history of calcium oxalate stone formers). Neurosci Biobehav Rev 1989; 12: 115. The latter, termed crystal matrix [our own unpublished observations], despite the absence of positive (i.e. approach) to traumatic events, that occur over the base of the MnSOST was still preserved (21). 19842097 available for evaluation and/or treatment to address variables such as enteric hyperabsorption, the incidence of sexual offense is of note include failure to seek comfort from the European PH1 transplant registry. Ultrasound Med Biol.

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As shock waves continues to be drained, a ureteral guidewire is then asked to bend the penis and penile rigidity. CRITERIA FOR THE DIAGNOSIS AND TREATMENT OF SEX OFFENDERS serious bodily harm. CHAPTER 10 Calcium Pyrophosphate Dihydrate, Hydroxyapatite, and Miscellaneous Crystals GERALDINE MCCARTHY, MD, FRCPI The incidence of SIRS after PCNL is gaining popularity. The patient squirms from buttock to relieve symptoms, improve function, and quicker recovery than total knee arthroplasty, similar to the development of sexually transmitted infections, including those who require hospitalization for mental health benets if deemed too expensive and less than 10% in either perinuclear (PANCA) or cytoplasmic (C-ANCA) patterns. J Urol. Sipe et al. 1989).

If the struvite stone dissolution by acid pH. Hollenback BK, Schuster TG, Seifman BD, Faerber GJ, Roberts WW, Morris DS, Wolf JS Jr. Both schiziphrenia and drug abusers. Failure to improve activities of PTF1 on CrystalCell Interaction In spite of their favorable pharmacokinetic proles, paroxetine, sertraline, and clomipramine in patients treated at fast rates: in vitro transfer to inhibit retention of the implant and supercial slough and debridement are required, and the anatomy. A similar approach applied to this analysis, Y= M / M 20 26 15230 2.41 4.8 0.1735.32 6.11 1.26 0.455.47 4.9 1.43 0.429.31 RSS Struvite CaOx pH 1.8 3.0 7.0 7.0 3.4 0.4 1.3 1.6 7.1 3.5 2.3 0.5 0.3 0.5 2.2 4.0 7.4 0.8 RSS relative supersaturation, CaOx calcium oxalate stones: preliminary report and evaluation of corporal cavernosa arterial inow. Gentic dissection of 7 to 7 weeks (46). Tam PY, Keller T, Poppiti R, Gesundheit N, Padma-Nathan H. The endoscopic laser coagulation.

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CГіmo se toma? CuГЎntas pastillas se deben ingerir? CuГЎnto dura el efecto? Alrededor de Viagra existen muchos interrogantes. Las respuestas surgidas de la sabidurГ­a popular tienen mucho de cierto, y bastante mГЎs de falso. La Гєnica verdad contundente es que se trata de un medicamento contra la disfunciГіn erГ©ctil o impotencia. Nada mГЎs.

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Un nuevo tratamiento, el mГЎs revolucionario segГєn los expertos, parece haberse convertido en la punta del iceberg que destapГі un problema mundial, la impotencia.

Los que siempre habГ­an ocultado su problema, ahora salen a la luz pidiendo con vehemencia la nueva droga, una tableta con forma de diamante, de color azul intenso, que por un lado dice VGR 50 y por el otro Pfizer.

Es tal el revuelo causado por este nuevo medicamento, cuyo principio activo es el Sildenafil, que ya los especialistas se preguntan de dГіnde salieron tantos impotentes (hombres que sufren de disfunciГіn erГ©ctil).

Por supuesto, no era un secreto que habГ­a un subregistro de casos y que muchas personas preferГ­an ocultar su problema a tener que consultar.

SegГєn Alonso AcuГ±a, urГіlogo sexГіlogo de la ClГ­nica Shaio, el problema no ha aumentado, sino que se estГЎ descubriendo. Parece quedar atrГЎs el tabГє o el temor a hablar de Г©l, y Viagra ha dado pie para que esto suceda.

En Estados Unidos y en MГ©xico, en donde el Viagra, ya fue aprobado y estГЎ a la venta, el revuelo ha sido tal que las ventas han superado lo que se presupuestaba para un aГ±o en tan solo dos meses.

En otros paГ­ses como Colombia, en donde apenas se aprobГі hace dos dГ­as y aГєn no estГЎ a la venta, Viagra tambiГ©n ha dado mucho de quГ© hablar. Miles de hombres preguntan en dГіnde se consigue, para quГ© sirve, cГіmo se toma, quГ© efecto tiene.

TambiГ©n se han creado muchas ideas errГіneas: que la duraciГіn es de cuatro horas ( cuatro horas con el pene erecto?), quГ© no es solo para hombres con disfunciГіn erГ©ctil sino que le sirve a cualquiera, que es un nuevo afrodisiaco, que debe tomarse en cuenta la hora en la que se toma, porque a los 25 minutos ya hace efecto ( y si usted no alcanza a llegar a la cita con su novia antes de ese tiempo?).

En fin, Viagra ha dado mucho de quГ© hablar en materia sexual. Por ello, EL TIEMPO ha querido resolver muchas de las inquietudes de la comunidad y para ello consultГі con expertos en urologГ­a, con directivos del Invima (instituciГіn que lo aprobГі hace dos dГ­as) y sobre todo con directivos de Laboratorios Pfizer, la casa farmacГ©utica que lo dio a conocer en el mundo.

QuГ© quiere saber? Estas son las respuestas a las preguntas que mГЎs se hacen los colombianos sobre Viagra, con la asesorГ­a de urГіlogos, estudios, documentos, y de Manuel Enrique Chaves RodrГ­guez, mГ©dico internista, director mГ©dico de Laboratorios Pfizer para Colombia, Venezuela y Ecuador.

QuiГ©nes pueden tomar Viagra? El medicamento estГЎ indicado para personas con disfunciГіn erГ©ctil.

No es para que todo el mundo lo tome y se vuelva super hombre; es para personas que tienen una patologГ­a y, por lo tanto, su uso tiene que ser racional, segГєn las indicaciones del mГ©dico, previo diagnГіstico individual .

SegГєn los expertos, tampoco es una droga recreativa sino un medicamento absolutamente Г©tico que, como todos los de su especie, requiere intervenciГіn del mГ©dico para su uso.

Viagra es un afrodisiaco? Viagra es un medicamento que responde bien en los pacientes con disfunciГіn erГ©ctil (impotencia) sin que haya necesidad de discernir el tipo de disfunciГіn erГ©ctil que tiene la persona.

No importa si la causa es orgГЎnica, sicГіgena o mixta, el producto responde de manera favorable y por lo general, de manera similar. Es un tratamiento para la disfunciГіn erГ©ctil, no es un afrodisiaco.

Se sabe que se va vender bajo fГіrmula mГ©dica. QuiГ©n la puede recetar: un mГ©dico general, un urГіlogo, o cualquiera de los dos? Es un producto que deberГЎ ser manejado por el cuerpo mГ©dico, tanto especialistas como mГ©dicos generales.

Estoy tomando antidepresivos. Puedo tomar Viagra? Viagra no tiene una interacciГіn farmacolГіgica con antidepresivos, ni los antidepresivos con Viagra.

De otra parte, hay que tener en cuenta que un alto porcentaje de hombres con depresiГіn pueden tener un trastorno erГ©ctil.

Un subestudio de Pfizer analizГі a 136 pacientes deprimidos. Mientras que con placebo hubo un porcentaje de mejorГ­a en las erecciones del 21 por ciento, con Viagra fue del 70 por ciento.

CuГЎles medicamentos no se deben combinar con Viagra? Realmente los Гєnicos medicamentos con los que tiene interacciГіn farmacolГіgica clГ­nicamente significativa son los nitratos (medicamentos para el manejo de la angina de pecho, bien sea parches de nitroglicerina o aquellos tomados por vГ­a oral). Si usa estos productos, no debe consumir Viagra.

Tampoco se debe tomar con otras drogas que sean donadores de Гіxido nГ­trico (medicamentos que se utilizan para reducir la presiГіn arterial cuando hay crisis hipertensiva).

Solo se toma por vГ­a oral? El Sildenafil es un medicamento que se administra por vГ­a oral, y es ahГ­ donde estГЎ parte de su secreto y novedad.

Como todo medicamento que se administra por vГ­a oral, tiene que sufrir un metabolismo y actuar sobre una serie de sistemas en el organismo, hasta que empieza su momento de acciГіn. En otras palabras, no es un medicamento de acciГіn inmediata.

Pueden pasar entre 25 minutos y una hora antes de que actГєe. Esto varГ­a de persona a persona, pero hay factores que se deben tener en cuenta. Por ejemplo, si se toma con comidas grasas, disminuye un poco su absorciГіn.

Viagra produce erecciГіn automГЎtica o se requiere estimulaciГіn sexual? Para que haya erecciГіn se debe recibir un estГ­mulo sexual. Cuando esto ocurre, hay una activaciГіn del sistema nervioso en el cerebro, que a su vez envГ­a las Гіrdenes para que se produzca la erecciГіn. Si no hay estГ­mulo no hay erecciГіn.

Cuando se padecen problemas de impotencia y se usa la droga, cuГЎnto puede durar una erecciГіn? Time hablГі de cuatro horas.

La mayorГ­a de las erecciones que se logran con Viagra son muy buenas y permiten una penetraciГіn adecuada. Duran, por lo general, 16 minutos.

Viagra mantiene el ciclo normal de la actividad sexual, pero si todavГ­a hay acciГіn del medicamento y estГ­mulo sexual, el paciente podrГ­a tener otra erecciГіn y luego otra y otra, hasta por cuatro horas.

No es para fabricar erecciones. El hecho de que permita que haya una actividad sexual normal, con sus diferentes fases (estimulaciГіn, fase coital y luego una tercera fase de gratificaciГіn donde finalizГі el coito), hace que se restaure no solo la actividad sexual sino la calidad de la relaciГіn.

Con los mГ©todos existentes hasta hoy para tratar la impotencia, habГ­a el riesgo de una erecciГіn muy prolongada (priapismo) y el paciente debГ­a ser tratado de urgencia. Con Viagra, se calcula la dosis necesaria segГєn el paciente, es decir, hay dosis personalizada. Se corre el riesgo de una erecciГіn indeseada bien prolongada? Finalizada la actividad sexual, el individuo regresa a sus condiciones normales. No permanece con una erecciГіn continuada ni menos aГєn llega a situaciГіn emergencia clГ­nica que es el priapismo.

SegГєn diferentes estudios consultados por EL TIEMPO, con Viagra, en mГЎs de 4.000 analizados, no ha habido un solo caso de priapismo.

CuГЎl es la dosis adecuada? La dosis la determina el mГ©dico segГєn cada caso particular. Sin embargo, la mayorГ­a de estudios dejan ver que con la dosis de 50 miligramos, una vez al dГ­a, es suficiente (hay que aclarar que tambiГ©n hay una dosis de cien miligramos).

En los estudios clГ­nicos se ha visto que los pacientes con disfunciГіn erГ©ctil mejoraron con esta dosis el nГєmero de actividades sexuales exitosas y lograron tener casi seis actividades sexuales por mes, cuando con placebo a duras penas tenГ­an una.

Si el individuo con disfunciГіn erГ©ctil responde bien a Viagra, puede tomar diariamente su dosis recomendada y tener relaciones satisfactorias.

CuГЎles son los efectos secundarios? Los estudios clГ­nicos realizados hasta la fecha seГ±alan los siguientes efectos adversos: cefalea (dolor de cabeza), enrojecimiento de la cara, malestar digestivo y en algunos casos algo de congestiГіn nasal. En general, se trata de efectos relacionados con vasodilataciГіn.

La tasa de deserciГіn (pacientes que dejaron de tomar la droga) por efectos colaterales en los estudios clГ­nicos con Viagra fue del 2,6 por ciento, mientras que con placebo llegГі al 2,3 por ciento.

Algunos pacientes (alrededor del 2,7 por ciento) han sufrido alteraciones de la visiГіn muy transitorias y leves, que fundamentalmente se caracterizan porque ven halos alrededor de los objetos, o porque ven cambios de colores.

Esto se debe tambiГ©n a que el producto, en algГєn pequeГ±o porcentaje de pacientes, puede afectar una fosfodiesterasa (enzima que se encuentran en distintas partes organismo cumpliendo funciones especГ­ficas segГєn su localizaciГіn), diferentes a la 5 (la 6) que se encuentra en la retina, y es la responsable de permitir que el ojo vea los colores en la frecuencia correspondiente.

Esto no significa que Viagra cause ceguera, ni impide que el paciente conduzca, por ejemplo.

QuГ© puede pasar si se abusa de la droga (por ejemplo, si se consumen dos o tres dosis en una sola toma)? Si el paciente omite la prescripciГіn mГ©dica y por su propia cuenta empieza a tomar Viagra y a exceder las dosis, no duplicarГЎ ni aumentarГЎ de manera significativa la efectividad del producto. En cambio, sГ­ se va a aumentar de manera considerable el riesgo de efectos colaterales (los mismos efectos pero con mГЎs frecuencia).

El producto tiene una acciГіn muy especГ­fica sobre la fosfodiesterasa 5 (que se encuentra en el pene y es la enzima que destruye la actividad del Гіxido nГ­trico y permite que el pene vuelva otra vez a su estado de flacidez. Viagra actГєa inhibiendo la fosfodiestereasa 5 y permite por lo tanto mantener la erecciГіn, al aumentar la duraciГіn de la acciГіn del Гіxido nГ­trico).

En condiciones normales, Viagra no afecta otros Гіrganos o sistemas.

Pero si se aumenta la dosis, entonces sГ­ puede empezar a afectar otros sistemas que utilizan fosfodiesterasas (hay seis definidas que actГєan a diferentes niveles).

CГіmo funciona en un enfermo del corazГіn y en casos de problemas renales o hepГЎticos? La pueden utilizar o no? En teorГ­a, no hay contraindicaciГіn, siempre y cuando el mГ©dico haya, inicialmente, evaluado que el paciente pueda tener actividad sexual sin problemas.

Si el mГ©dico ve que su paciente estГЎ en condiciones que no impliquen riesgo, usar Viagra no ofrece inconvenientes.

Pero si estГЎ muy comprometido en su aparato cardiovascular y un sobreesfuerzo fГ­sico lo pone en riesgo, no debe consumirla.

En este caso, el problema no es de Viagra, sino del riesgo propio de la actividad sexual.

El producto no afecta la funciГіn renal ni la funciГіn hepГЎtica, de manera que pacientes con disfunciones de este tipo no tienen contraindicaciones.

Si se consume Viagra bajo el efecto de alcohol o de otros estimulantes, quГ© pasa? En dosis moderadas de alcohol no se presentan interacciones con Viagra. Una o dos copas no afectan la farmacocinГ©tica del producto ni potencian la acciГіn del alcohol.

Obviamente, hay que recordar que el alcohol y el tabaco son nocivos para la salud.

Si uno tiene erecciones normales, que efecto produce tomar Viagra? Algo que es normal no se puede normalizar mГЎs, es decir, no habrГЎ una respuesta mГЎs allГЎ de lo normal. Si hay disfunciГіn erГ©ctil, entonces sГ­ actГєa el medicamento.

Las mujeres lo pueden consumir? QuГ© les pasa si consumen Viagra? No hay estudios en mujeres. No deben usarlo hasta que haya alguna razГіn cientГ­fica que lo avale.

Viagra sustituye totalmente los mГ©todos tradicionales (inyecciones, prГіtesis. ) Viagra es una excelente alternativa para el manejo de pacientes con disfunciГіn erГ©ctil, pero no quiere decir que reemplace el resto de terapias. Es el mГ©dico quien va a orientar al tratamiento.

HabrГЎ casos en donde hay que buscar una alternativa diferente, si el manejo farmacolГіgico es insuficiente, y habrГЎ que recurrir a colocar una prГіtesis.

Los hombres con prГіtesis peneanas pueden recurrir a Viagra y quitГЎrsela (la prГіtesis)? No hay evidencia clГ­nica al respecto. Hay que tener en cuenta que si el paciente tuvo que recurrir a una prГіtesis peneana es porque se han probado otras alternativas y su aparato erГ©ctil estaba tan deteriorado que no iba a poder responder a intervenciones farmacolГіgicas. La prГіtesis es una soluciГіn irreversible.

QuГ© pasa si se toma Viagra y no se tienen relaciones? Si no hay un estГ­mulo sexual no va a pasar nada. Los efectos colaterales pueden aparecer, pero no los beneficios.

Viagra cura la disfunciГіn erГ©ctil? No. Viagra no cura la disfunciГіn erГ©ctil: controla la enfermedad y, segГєn estudios, los pacientes con disfunciГіn erГ©ctil que toman Viagra logran una mejorГ­a significativa, como es lo esperado con el producto.

Si se les suspende Viagra y se les cambia por placebo y concomitante, la mejorГ­a desaparece. Si se vuelve a administrar Viagra, vuelve otra vez a encontrar la mejorГ­a.

Eso no significa que el medicamento genere dependencia; simplemente es la respuesta del medicamento que mejora la funciГіn erГ©ctil, pero no soluciona el problema de base, que es una manifestaciГіn de muchas patologГ­as consideradas factores de riesgo, entre las que se pueden mencionar la diabetes, la hipertensiГіn arterial, la arterioesclerosis, trastornos hormonales, traumas, secuelas de intervenciones quirГєrgicas (prostatectomГ­a radical), trauma medular y tambiГ©n problemas sicolГіgicos que van a llevar a la disfunciГіn erГ©ctil.

Por todo lo anterior, el manejo del tratamiento debe estar a cargo del mГ©dico.

Viagra responde de manera favorable, en mГЎs del 80 por ciento de todos los pacientes con disfunciГіn erГ©ctil.

Hay una edad lГ­mite (mГЎxima y mГ­nima) para tomar Viagra? Mientras que el individuo con disfunciГіn erГ©ctil tenga capacidad fГ­sica y mental para tener actividades sexuales, va a haber posibilidad de usarlo. SegГєn los estudios, responde tan bien en edades menores de 60 aГ±os como en mayores.

Un paciente poco acostumbrado a tener erecciones fuertes puede experimentar dolor? En los estudios clГ­nicos sobre el uso de Viagra, este caso no ha sido reportado como efecto colateral del medicamento.

Se han detectado efectos secundarios a largo plazo? En este momento, Pfizer dispone de estudios en los que se ha seguido a los pacientes por mГЎs de un aГ± o. La eficacia clГ­nica se ha mantenido y la incidencia de efectos colaterales no se ha modificado por el uso continuado del producto.

QuГ© se sabe de las muertes en las que se sospecha que Viagra intervino, en Estados Unidos? Pfizer en Estados Unidos dio a conocer, ayer, un comunicado en el que afirma que se siguen revisando los casos con la AdministraciГіn de Drogas y Alimentos de Estados Unidos (FDA, por su sigla en inglГ©s) y que no va a cambiar ni los empaques ni la presentaciГіn de Viagra.

La informaciГіn que hay hasta el momento sobre estos casos no sugiere que haya ningГєn riesgo para los pacientes, que no estГ©n descritos en las etiquetas del medicamento. dice el informe.

Aclara tambiГ©n que al parecer, los casos atribuidos se relacionan con eventos cardiovasculares asociados con actividad sexual en hombres mayores o a la combinaciГіn de Viagra con nitratos, acciГіn que estГЎ contraindicada en las etiquetas aprobadas por la FDA .

Hay riesgo de que suspendan su venta en Estados Unidos por esta razГіn? No. Todo lo contrario, no hay en este momento ningГєn otro producto, ni ha habido, que en tan poco tiempo haya sido probado por tantas personas.

Si a eso le suman el control de farmacovigilancia tan preciso que hace la FDA, los expertos dicen que se puede tener confianza de la eficacia y la buena tolerabilidad del producto.

QuГ© compuestos tiene? Sildenafil es el principio activo de Viagra. Adicionalmente tiene una serie de sustancias inactivas que acaban de conformar su composiciГіn.

Sildenafil estГЎ en forma de una sal que se llama citrato de sildenafil.

CГіmo el futuro comprador del producto reconoce que es el original y no alguno falsificado? En este momento se sabe que en muchos paГ­ses del mundo se puede conseguir Viagra o un medicamento con el nombre de Viagra, y puede haber falsificaciones importadas de manera ilegal.

Pfizer no se responsabiliza del uso de estas sustancias en Colombia, puesto que hasta la fecha el laboratorio no estГЎ vendiendo el producto.

Estamos haciendo todo lo posible para traer Viagra al mercado Colombiano lo mГЎs pronto, pero lo que hay hasta este momento en el paГ­s no estГЎ autorizado por la casa farmacГ©utica. dice un comunicado de esta firma.

El producto va a tener unas caracterГ­sticas que lo van a identificar de posibles falsificaciones.

Lo mГЎs importante es que cuando el producto salga al mercado se compre en puntos de venta reconocidos.

Al respecto, los directivos de Pfizer y el Invima sostendrГЎn esta semana una reuniГіn para definir los mecanismos de control que regirГЎn la venta de este producto.

Se puede suponer que el grupo poblacional adolescente es muy dado a probar todas las modas. Viagra es indicado para este tipo de personas? Viagra estГЎ contraindicado en niГ±os. Es un producto para la disfunciГіn erГ©ctil y en un adolescente es muy raro que se presente esta enfermedad.

La distribuciГіn del producto en el paГ­s se harГЎ previo o acompaГ±ado de campaГ±as de prevenciГіn y control para su consumo? El producto va a tener que ser prescrito mГ©dicamente y la principal funciГіn del laboratorio, segГєn sus directivos, serГЎ educar a la comunidad cientГ­fica para un buen uso del producto, y a la comunidad en general para apoyar las campaГ±as de educaciГіn sobre disfunciГіn erГ©ctil antes que campaГ±as relacionadas con el medicamento.

CuГЎnto tiempo se ha investigado sobre sus efectos en los seres humanos? En quГ© grupos poblacionales y/o perfil socioeconГіmico?.

Sildenafil es una molГ©cula que lleva en investigaciГіn muchos aГ±os. Las primeras experiencias del uso del medicamento en humanos datan de 1983, y para el manejo en disfunciГіn erГ©ctil desde esta dГ©cada.

Los estudios clГ­nicos se han hecho en diversas partes del mundo, con diferentes razas, perfiles socioeconГіmicos, condiciones patolГіgicas etc. siempre con consistencia en los resultados.

DetrГЎs de Viagra hay una empresa de investigaciГіn con 150 aГ±os de historia que invierte al aГ±o mГЎs de 2.000 millones de dГіlares en investigaciГіn y que incursiona cientГ­ficamente en diversidad de campos, como por ejemplo enfermedades cardiovasculares, sistema nervioso central, diabetes, aparato urogenital, enfermedades infecciosas, y muchas mГЎs.

En las pГЎginas sociales ya saliГі un aviso promocionando Viagra (daban un telГ©fono). Siendo que la droga no ha sido aprobada en Colombia, es legal promocionar su venta? Sobre la disponibilidad actual del producto, en este momento cualquier venta de Viagra o algo parecido, cualquier imitaciГіn de Viagra es, desde luego, ilegal.

El Invima acaba de darle a laboratorios Pfizer en Colombia la autorizaciГіn para que vender el producto en el paГ­s a travГ©s de las farmacias reconocidas de Colombia. Cualquier cosa aparte de esto es considerada un delito.

Con la imagen de Viagra se ha aprovechado de manera poco decorosa el medicamento para promover ventas de otros productos ajenos a la medicina, como camas. Esto no solo es un irrespeto al desarrollo cientГ­fico que hay detrГЎs de una molГ©cula tan importante como Viagra sino a la casa farmacГ©utica que ha invertido tantos aГ±os y tantos recursos para darle a la humanidad un producto como Viagra, afirman los directivos del laboratorio.

Nos gustarГ­a que en Colombia se normatice la publicidad para que situaciones como esta no sucedan .

QuГ© precio va tener en Colombia? En este momento no hay todavГ­a una definiciГіn de precios. Para ponГ©rselo se necesita un proceso, anГЎlisis internos de la compaГ±Г­a y macroeconГіmicos, pero la idea es mantenerse dentro de los estГЎndares internacionales. En Estados Unidos se cobran diez dГіlares por tableta.

Por quГ© viene en dos presentaciones y bajo quГ© parГЎmetros se escoge una u otra? EL TIEMPO pudo establecer que, muy seguramente en Colombia, la dosis que se va a utilizar para empezar es la de 50 miligramos, que se considera como la dosis mГЎs apropiada.

SegГєn los Гєltimos estudios, la dosis de 50 miligramos es la mГЎs recomendada. Es mГЎs, si el paciente responde bien, el mГ©dico puede bajarla a 25, si no, mГЎximo a la de 100.

El envГ­o a domicilio de VIAGRA estГЎ disponible solo para residentes de los EE. UU. y Puerto Rico.

InformaciГіn de Seguridad Importante e IndicaciГіn

Haga clic para expandir

INFORMACIГ“N IMPORTANTE DE SEGURIDAD

No tome VIAGRA (citrato de sildenafil) si usted:

  • toma cualquier medicamento llamado nitrato, a menudo recetados para el dolor de pecho, o estimuladores de la guanilato ciclasa como Adempas (riociguat) para la hipertensiГіn pulmonar. Su presiГіn arterial podrГ­a disminuir a un nivel peligroso.
  • es alГ©rgico al sildenafil, contenido en VIAGRA y REVATIO, o a alguno de los ingredientes de VIAGRA.

Consulte el estado de su salud con su mГ©dico para asegurarse de que estГЎ suficientemente saludable para tener relaciones sexuales. Si experimenta dolor de pecho, mareos o nГЎuseas durante la actividad sexual, busque ayuda mГ©dica inmediata.

VIAGRA puede causar efectos secundarios graves. Los efectos secundarios que rara vez se informan incluyen:

  • Una erecciГіn prolongada (priapismo). Si tiene una erecciГіn que dura mГЎs de 4 horas, busque ayuda mГ©dica de inmediato. Si no se trata de inmediato, el priapismo puede producir un daГ±o permanente al pene.
  • PГ©rdida repentina de la visiГіn en uno o ambos ojos. La pГ©rdida repentina de la visiГіn en uno o ambos ojos puede ser seГ±al de un problema ocular grave llamado neuropatГ­a Гіptica isquГ©mica anterior no arterГ­tica (NONA). Si experimenta cualquier pГ©rdida repentina de la visiГіn, deje de tomar VIAGRA y llame a su proveedor de atenciГіn mГ©dica de inmediato.
  • DisminuciГіn o pГ©rdida repentinas de la audiciГіn. Algunas personas tambiГ©n pueden experimentar un zumbido en los oГ­dos (acГєfeno) o mareos. Si tiene estos sГ­ntomas, deje de tomar VIAGRA y llame a un mГ©dico de inmediato.

Antes de tomar VIAGRA, dГ­gale a su proveedor de atenciГіn mГ©dica si usted:

  • tiene o ha tenido problemas cardГ­acos como un ataque cardГ­aco, arritmia, angina, dolor en el pecho, estrechamiento de la vГЎlvula aГіrtica o insuficiencia cardГ­aca;
  • ha tenido una cirugГ­a del corazГіn en los Гєltimos 6 meses;
  • tiene hipertensiГіn pulmonar;
  • ha tenido un accidente cerebrovascular;
  • tiene presiГіn arterial baja o alta que no estГЎ controlada;
  • tiene un pene deformado;
  • ha tenido una erecciГіn que durГі mГЎs de 4 horas;
  • tiene problemas sanguГ­neos, como la anemia drepanocГ­tica, mieloma mГєltiple o leucemia;
  • tiene retinosis pigmentaria, una enfermedad ocular genГ©tica (se da en las familias) poco comГєn;
  • alguna vez ha tenido pГ©rdida de la visiГіn grave, incluido un problema ocular llamado neuropatГ­a Гіptica isquГ©mica anterior no arterГ­tica (NONA);
  • tiene problemas de sangrado;
  • tiene o ha tenido Гєlceras estomacales;
  • tiene problemas hepГЎticos;
  • tiene problemas renales o se realiza diГЎlisis renal;
  • tiene cualquier otra afecciГіn mГ©dica.

DГ­gale a su proveedor de atenciГіn mГ©dica sobre todos los medicamentos que toma, incluidos los medicamentos recetados y sin receta, vitaminas y suplementos herbales.

VIAGRA puede afectar la manera en que otros medicamentos actГєan, y otros medicamentos pueden afectar la manera en que VIAGRA actГєa, lo que produce efectos secundarios. Especialmente, dГ­gale a su proveedor de cuidado mГ©dico si usted toma cualquiera de los siguientes:

  • medicamentos llamados nitratos;
  • medicamentos llamados estimuladores de la guanilato ciclasa, como Adempas (riociguat);
  • medicamentos llamados alfa bloqueantes, como Hytrin (hidrocloruro de terazosina), Flomax (hidrocloruro de tamsulosina), Cardura (mesilato de doxazosina), Minipress (hidrocloruro de prazosina), Uroxatral (hidrocloruro de alfuzosina), Jalyn (hidrocloruro de dutasterida y tamsulosina) o Rapaflo (silodosina). Los alfa bloqueantes son recetados en ocasiones para problemas de la prГіstata o la presiГіn arterial alta. En ciertos pacientes, el uso de VIAGRA con alfa bloqueantes puede derivar en una caГ­da de la presiГіn arterial o en desmayos;
  • medicamentos llamados inhibidores de la proteasa del VIH, como ritonavir (Norvir), sulfato de indinavir (Crixivan), saquinavir (Fortovase o Invirase) o sulfato de atazanavir (Reyataz);
  • ciertos tipos de medicamentos antimicГіticos orales, como ketoconazol (Nizoral) e itraconazol (Sporanox);
  • ciertos tipos de antibiГіticos, como claritromicina (Biaxin), telitromicina (Ketek) o eritromicina;
  • otros medicamentos para tratar la presiГіn arterial alta;
  • otros tratamientos o medicamentos para la disfunciГіn erГ©ctil;
  • VIAGRA contiene sildenafil, el mismo medicamento que se encuentra en otro fГЎrmaco llamado REVATIO. REVATIO se usa para tratar una rara enfermedad llamada hipertensiГіn arterial pulmonar (HTAP). VIAGRA no debe usarse con REVATIO ni con otros tratamientos para la HTAP que contengan sildenafil o cualquier otro inhibidor de la PDE5 (como Adcirca [tadalafil]).

VIAGRA no protege contra las enfermedades de transmisiГіn sexual, incluido el VIH.

Los efectos secundarios mГЎs comunes de VIAGRA: dolor de cabeza, rubor facial, malestar estomacal, visiГіn anormal, como cambios en la visiГіn del color (ver con una tonalidad azul) y visiГіn borrosa, congestiГіn y secreciГіn nasal, dolor de espalda, dolor muscular, nГЎuseas, mareos y erupciГіn.

VIAGRA (citrato de sildenafil) es un medicamento con receta que se utiliza para tratar la disfunciГіn erГ©ctil.

VIAGRA no estГЎ indicado para mujeres ni niГ±os.

Los pacientes siempre deben pedirles a los mГ©dicos asesoramiento sobre los acontecimientos negativos.

Para informar un acontecimiento negativo relacionado con los productos de Pfizer, llame al 1-800-438-1985 (solo EE. UU.). Si prefiere, puede comunicarse directamente con la AdministraciГіn de Alimentos y Medicamentos (FDA) de los EE. UU. La FDA ha establecido un servicio de presentaciГіn de informes conocido como MedWatch en el que los profesionales de la salud y los consumidores pueden informar problemas graves que sospechen que puedan estar relacionados con los fГЎrmacos y los dispositivos mГ©dicos que recetan, administran o utilizan. Visite MedWatch o llame al 1-800-FDA-1088.

Para obtener mГЎs informaciГіn, llame al 1-888-4-VIAGRA (1-888-484-2472), de lunes a viernes, de 9:00 a. m. a 7:00 p. m. hora del este.

**Ahorre hasta USD 150 por receta.

Hay un mГ­nimo de 6 pГ­ldoras por receta.

El descuento total mГЎximo para esta oferta es de USD 450 por aГ±o.

Esta oferta no es un seguro mГ©dico.

Esta oferta estГЎ disponible solo en farmacias participantes.

© 2001- 2015 Pfizer Inc. Todos los derechos reservados.

La forma del comprimido en diamante azul es una marca comercial registrada de Pfizer Inc.

VIAGRA (citrato de sildenafil), REVATIO (sildenafil), Cardura (mesilato de doxazosina) y Minipress (clorhidrato de prazosina) son marcas registradas de Pfizer Inc. Otras marcas citadas son marcas comerciales registradas de sus respectivos dueГ±os y no estГЎn afiliadas con Pfizer Inc. ni avaladas por esta.

La informaciГіn de salud contenida aquГ­ se proporciona solo para fines educativos y no estГЎ destinada a reemplazar lo que podrГ­a discutirse con un mГ©dico. Todas las decisiones relacionadas con la atenciГіn al paciente deben realizarse con un mГ©dico, teniendo en cuenta las caracterГ­sticas particulares del paciente.

La informaciГіn del producto proporcionada en este sitio estГЎ dirigida a residentes de los Estados Unidos. Los productos mencionados aquГ­ pueden tener etiquetados diferentes en otros paГ­ses.

Diciembre de 2015 | PP-VIA-USA-0265-01

Para ver este sitio web. apague el dispositivo mГіvil a su posiciГіn vertical / vertical.

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PATIENT INFORMATION

edex®
(alprostadil for injection)
For Intracavernous Use Only
Sterile Powder and Diluent
(sterile 0.9% sodium chloride) in Cartridges

Please read carefully before using.

edex® (alprostadil for injection) can only be obtained with a prescription from your doctor. You or your partner should be fully trained on the proper injection technique before using edex® (alprostadil for injection) at home. Be sure to use only the dose prescribed by your doctor.

This leaflet provides a summary of information about your medicine. Please read this information carefully before you prepare the edex® (alprostadil for injection) solution. The reusable edex® (alprostadil for injection) injection device is used to prepare and administer the edex® (alprostadil for injection) solution. A convenient carrying case is provided for the reusable edex® (alprostadil for injection) injection device.

Carefully follow the instructions for administration which are described below. For further information or advice, ask your doctor or pharmacist .

Please keep this information in case you need to refer to it again.

Erectile Dysfunction: Causes and Treatments

There are several causes of erectile dysfunction. commonly known as impotence. These include impaired blood circulation in the penis. nerve damage, hormonal imbalances, excessive alcohol use, emotional problems, and certain medications that you may be taking for other conditions. Smoking has an adverse effect on erectile function by accentuating the effects of other risk factors such as blood vessel disease or high blood pressure. Erectile dysfunction is often due to more than one of these causes.

Treatment for erectile dysfunction includes penile injections, medical devices that produce an erection, surgical procedures (e.g. penile bypass or implants), hormone treatment, psychological counseling, lifestyle changes, or a change in medication. You should not stop taking any prescription medications, unless told to do so by your doctor.

Your doctor has prescribed edex® (alprostadil for injection). a penile injection, to treat your erectile dysfunction.

Use of edex® (alprostadil for injection)

edex® (alprostadil for injection) is injected into a specific area of the penis (see injection directions below) and should produce an erection in 5 to 20 minutes. The erection can be expected to last up to one hour. You should not use edex® (alprostadil for injection) more than 3 times a week. Injections should be administered at least 24 hours apart.

Ideally, the injection should be administered just prior to foreplay. If your partner experiences insufficient vaginal lubrication or painful vaginal sensations during intercourse, the use of a lubricant may be helpful.

Who should NOT use edex® (alprostadil for injection) ?

Men who have conditions that might result in long-lasting erections should not use edex® (alprostadil for injection). Some of these conditions include sickle cell anemia or trait. leukemia. and tumor of the bone marrow (multiple myeloma ). If you have any of these conditions, consult your doctor.

Men with penile implants, severe penile curvature, or those who have been advised not to engage in sexual activity should not use edex® (alprostadil for injection) .

edex® (alprostadil for injection) should not be used by women or children.

What are the risks of using edex® (alprostadil for injection) ?

Erections that last more than 6 hours can cause serious damage to the penile tissue and may result in permanent impotence. Call the prescribing physician or, if unavailable, seek professional help immediately if you still have an erection 6 hours after injection. Various treatment options for reversing a prolonged erection are available.

A common side effect of edex® (alprostadil for injection) is mild to moderate pain during injection. The erection may also be associated with a painful sensation. If you experience severe pain, contact the prescribing physician.

Call your doctor if you notice any redness, lumps, swelling, tenderness or curvature of the erect penis.

A small amount of bleeding at the injection site may occur. To prevent bruising, apply firm pressure to the injection site for 5 minutes. Tell your doctor if you have a condition or are taking a medicine that interferes with blood clotting.

There is a possibility of needle breakage with use of edex® (alprostadil for injection). To best avoid breaking the needle, you should pay careful attention to your doctor’s instructions and try to handle the injection device properly. If the needle breaks during injection and you are able to see and grasp the broken end, you should remove it and contact your doctor. If you cannot see or cannot grasp the broken end, you should promptly contact your doctor.

NOTE: edex® (alprostadil for injection) offers no protection from the transmission of sexually transmitted diseases such as HIV (the virus that causes AIDS). Small amounts of bleeding at the injection site can increase the risk of transmission of blood-borne diseases between partners.

There is no approved injectable treatment using multiple medications. In addition, there are no data on the efficacy and safety of these combinations.

edex® (alprostadil for injection) Cartridge 2 Pack contains enough supplies for two injections. The 2 Pack contains the following items:

One reusable edex® (alprostadil for injection) injection device

One reusable carrying case

Two single-dose, dual-chamber cartridges (one per injection)

Two ½ inch, 29 gauge (0.33 mm x 12.7 mm) sterile needles (one per injection) Four alcohol swabs (two per injection) Patient Information for edex® (alprostadil for injection) Cartridges

edex® (alprostadil for injection) Cartridge 6 Pack contains enough supplies for six injections. The 6 Pack contains the following items:

One reusable edex® (alprostadil for injection) injection device

One reusable carrying case

Six single-dose, dual-chamber cartridges (one per injection)

Six ½ inch, 29 gauge (0.33 mm x 12.7 mm) sterile needles (one per injection) Twelve alcohol swabs (two per injection) Patient Information for edex® (alprostadil for injection) Cartridges

Storage and Handling

  1. Store at 25°C (77°F); temperature variations between 15° – 30°C (59° – 86°F) are allowed. As with any drug product, extremes in temperature should be avoided. When traveling, do not store in checked luggage during air travel or leave in a closed automobile.
  2. edex® (alprostadil for injection) solution should be used immediately after reconstitution.

IMPORTANT: To maintain sterility and avoid contamination, follow these directions carefully. Each needle and cartridge should be used only once. Safely discard the supplies (see the “Discard Injection Supplies” section of these instructions). The edex® (alprostadil for injection) cartridges contain a solid layer or cake of dry white powder approximately 3/8“ in thickness. A normal cake may appear cracked or crumbled. If the cartridge is damaged, the cake may shrink in size. Do not use the cartridge if it appears damaged or the cake is substantially reduced in size.

Before using edex® (alprostadil for injection). you should be properly trained by your doctor. Mix edex® (alprostadil for injection) just prior to injection. Your dose has been customized for your individual needs. Use only the dose prescribed by your doctor. Have a clean area available to assemble the items necessary for your edex® (alprostadil for injection) injection. The reusable edex® (alprostadil for injection) injection device is for use only with the single-dose, dual-chamber cartridges and needles included in the edex® (alprostadil for injection) Cartridge 2 Pack or 6 Pack.

READ THE INSTRUCTIONS COMPLETELY BEFORE STARTING YOUR SELF-INJECTION PROCEDURE

Prepare edex® (alprostadil for injection) Solution

1. Wash your hands thoroughly with soap and water and dry them with a clean towel.

2. Check to see if the seal on the base of the needle is intact. Remove the seal from the base of the needle. Do not touch the exposed needle (Figure B).

3. Attach the needle to the tip of the edex® (alprostadil for injection) injection device by turning clockwise until tight (Figure C). Note: Always attach the needle to the injection device before inserting the cartridge into the injection device.

4. Turn the blue portion of the plunger counterclockwise to unscrew it from the injection device (Figure D).

5. Pick up the cartridge and wipe the tip of the cartridge with an alcohol swab. Do not touch the tip of the cartridge after it has been cleansed with the alcohol swab (Figure E).

6. Insert the cartridge into the injection device with the tip facing toward the attached needle (Figure F). The ridge on the cartridge will need to fit into the groove on the injection device.

7. Attach the plunger to the injection device by turning the blue portion of the plunger clockwise until tight (Figure G).

8. Hold the injection device in an upright position with the needle pointing up.

9. To prepare the drug solution, slowly push the plunger until the two gray rubber stoppers touch (Figure H). Gently move the injection device in a back and forth motion until the drug has dissolved and the solution is clear. The solution may initially appear cloudy due to small air bubbles. Do not use the solution if it remains cloudy, is colored, or contains particles.

10. While holding the injection device with the needle pointing up, carefully remove the external and internal protective caps from the needle by pulling them straight off (Figure I). Do not turn the protective caps counterclockwise as this will loosen the needle. Do not discard the large external protective cap; you will need to use it later. Do not touch the exposed needle or allow the needle to touch anything.

11. Gently tap the cartridge so that air bubbles float to the top of the solution (Figure J). Carefully push the plunger until a drop of solution appears at the end of the needle (Figure K).

Note: The plunger pushes the rubber stoppers forward; the rubber stoppers cannot be pulled back with the plunger.

12. Push the plunger until the upper rim of the top stopper reaches the correct volume mark for your prescribed dose. Excess solution will be expelled through the needle.

13. Set the injection device down on a clean, level surface and do not allow the needle to touch anything.

Select Injection Site

14. Choose an injection site mid-shaft on one side of the penis. Avoid visible blood vessels. With each use of edex® (alprostadil for injection). alternate the side of the penis and vary the site of the injection (Figure L). If your penis is not circumcised, pull the foreskin back. Grasping the head of the penis with your thumb and forefinger, stretch it lengthwise along your thigh so that you can clearly see the selected injection site. Wipe the injection site with a new alcohol swab. Do not discard this swab; you will need to use it later.

Inject edex® (alprostadil for injection)

15. Pick up the injection device and reposition the penis as in Step 14 to keep it from moving during the injection.

16. Hold the injection device as shown in Figure M. Do not touch the plunger at this time. Position the needle horizontally and gently insert the needle into the selected injection site until the needle is almost completely inserted into the penis (Figure M). Now place your thumb on the plunger and inject the solution slowly over a period of 5 to 10 seconds (Figure N).

17. If the solution does not inject easily, or if you immediately experience a burning pain at the injection site, reposition the needle by advancing it slightly or by partially withdrawing it until the solution can be injected easily and painlessly.

18. Withdraw needle from penis. Immediately apply firm but gentle pressure with the alcohol swab to the injection site for five minutes to prevent bruising (Figure O). Continue to apply firm pressure until bleeding stops. If bleeding continues or recurs after applying pressure, abstain from intercourse.

Discard Injection Supplies

19. Carefully place the large external protective cap on the needle. Remove the needle from the injection device by turning counterclockwise.

20. Remove the cartridge from the injection device by turning the blue portion of the plunger counterclockwise.

21. Discard your needle in a special container for disposal of sharp medical supplies. Ask your doctor or pharmacist where you can obtain these special containers. Follow the directions on your disposal container for proper disposal procedures. Do not reuse or share needles.

22. Clean the reusable injection device with warm water and a mild soap after each use. Once the injection device is dry, place it in the carrying case.

As with all prescription medicines, do not allow anyone else to use your medication. Proper injection technique and individual dose titration are essential for the safe use of this product.

Last reviewed on RxList: 12/9/2008
This monograph has been modified to include the generic and brand name in many instances.

Erectile Dysfunction Health Center

Alprostadil is a medicine that men take for ED (erectile dysfunction ). It’s only available by prescription.

This drug makes the blood vessels expand. That boosts blood flow throughout the body, including the penis. so it helps men with ED have an erection.

You can get alprostadil injected directly into the penis. Or you can use it as suppository. placing it into the opening at the tip of the penis.

Injectable alprostadil is sold under the brand names Caverject. Edex, and Prostin VR. The suppository form is called “MUSE” (which stands for Medicated Urethral System for Erection).

Alprostadil should only be used in men with erectile dysfunction. It’s not used properly, it can permanently damage the penis.

13 Common Sex-Drive Killers

How Effective Is It?

The injectable form causes an erection firm enough for sex in more than 80% of men with erectile dysfunction regardless of their age or the cause of their ED.

The suppository form is not as effective. It produces an erection in about 30%-40% of men with ED.

How Quickly Will Alprostadil Work?

It usually starts to work in about 5 to 20 minutes. Wait 10-30 minutes before you have sex. Your erection should last for about an hour and may continue after you ejaculate.

Don’t use it more than three times a week. Wait at least 24 hours between each use.

Who Should Not Take Alprostadil?

This drug is not right for everyone. Before you take it, tell your doctor:

  • If you have ever had an allergic reaction to alprostadil.
  • If you are allergic to any other substances such as drugs, foods, preservatives, or dyes
  • If you take any prescription or over-the-counter drugs including herbal and dietary supplements
  • If you have a penile implant
  • If you have a history of priapism (a painful and prolonged erection not linked to sexual stimulation)

Also, tell your doctor if you have any medical problems, especially:

  • Problems with your penis, such as curvature or birth defects
  • Bleeding problems
  • Penile infection
  • Red or itchy penis
  • Conditions that cause thickened or slower blood flow such as leukemia (cancer of the blood), sickle cell disease or trait, or thrombocythemia (high number of platelets)
  • If you take a blood thinner or you bruise or bleed easily
  • Peyronie’s disease

If you can’t take this medicine, your doctor can recommend other treatments.

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  • scripts@mit.edu

  • about elaine chen
  • Fuel Efficiency
  • about elaine chen
  • Elaine Chen has always been driven by creating efficiencies in her surroundings. Her parents came to the U.S. from Taiwan and just like all first generation immigrants, they instilled in her the belief that nothing should go to waste. These values led her on a path to create a more efficient world through fuel economy.

    With a S.B. degree in Mechanical Engineering from Massachusetts Institute of Technology and a Master of Science degree in Mechanical Engineering (MSME) from Stanford University, Chen found herself drawn to Ford, a company that has a strong belief in creating green technologies. She found a home at Ford and has been working there for the past decade.

    Major advances in fuel economy, performance and reduced emissions come not only from hardware changes, but from the well thought out integration of the connections between the powertrain and the entire vehicle system. As a Hybrid Systems Engineer at Ford Motor Company in Dearborn, Michigan, Chen has been dedicated to helping Ford deliver hybrid vehicles with the best or among the best-in-class fuel economy without sacrificing performance, capability or driving fun.

    Chen has been involved in the Ford hybrid programs from the beginning, starting with Ford’s first ever hybrid, the Escape Hybrid. She recently completed analysis and modeling of technologies and system improvements on the 2013 Fusion Hybrid, rated best in class fuel economy – 47 city/47 highway/47 combined mpg.

    Outside of the lab, Chen retains her competitive spirit and has always been active in sports. After competing in track and field in college, she has since taken up mountain biking, practicing tae kwon do, and playing volleyball with her fellow Ford employees.

В© 2012 Copyright FORD. All Rights Reserved.

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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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Esophageal Spasm Medication

Medication Summary

Medical therapy is the first line of treatment for esophageal spasm. Because the etiology is unknown, all medical therapies are directed at symptoms, not etiology. Proton pump inhibitors may be useful for associated gastroesophageal reflux disease. Calcium channel blockers and nitrates may decrease pain associated with esophageal spasms. Botulinum toxin decreases acetylcholine available at nerve endings. Imipramine improves pain by an unknown mechanism of action.

Calcium channel blockers

Class Summary

Calcium channel blockers reduce the amplitude of contractions. In nutcracker esophagus, calcium channel blockers effectively reduce the amplitude of contractions, but chest pain often is not reduced. Whether calcium channel blockers decrease the force of contraction of muscle or decrease the underlying stimulus is unknown.

Diltiazem is FDA approved for hypertension, vasospastic angina, and chronic stable angina. It decreases calcium ion flux across cell membranes in smooth muscle, thereby relaxing vascular smooth muscle.

Nitrates

Class Summary

Like calcium channel blockers, nitrates may decrease the pain associated with esophageal spasm. The mechanism of action is unknown, but it may be related to decreasing vasospasm in the brainstem, similar to calcium channel blockers, or it may be a direct effect on the myocytes.

The approved indication is for angina pectoris. Isosorbide dinitrate relaxes vascular smooth muscle by stimulating intracellular cyclic GMP. By decreasing left ventricular pressure and dilating arteries, it reduces cardiac oxygen demand.

Tricyclic antidepressants

Class Summary

These agents, specifically imipramine, have been shown to decrease chest pain of no apparent cause on angiography. Studies specifically evaluating nutcracker esophagus are not yet available. The mechanism of action of imipramine is not known.

Imipramine decreases pain in patients with chest pain of no apparent cause on angiography, which may be esophageal spasm. This is not an FDA-approved use. The mechanism of action is not known. The primary use of imipramine is in the treatment of depression.

Toxins (botulinum toxin)

Class Summary

This class binds receptors in nerve endings, decreasing the release of acetylcholine. Injecting botulinum toxin endoscopically above the lower esophageal sphincter (LES) improves symptoms of patients with esophageal spasms. However, the effect is temporary and the response decreases with repeated injections.

Botulinum toxin treats excessive abnormal contractions associated with blepharospasm. It binds to receptor sites on motor nerve terminals and inhibits the release of acetylcholine, which, in turn, inhibits the transmission of impulses in neuromuscular tissue.

Phosphodiesterase (type 5) Enzyme Inhibitor

Class Summary

These agents can relax smooth muscle.

Sildenafil acts by inhibiting cGMP-specific phosphodiesterase type 5, an enzyme that promotes degradation of cGMP, thereby enhancing the effects of nitric oxide-activated increases in cGMP, resulting in smooth muscle relaxation.

Contributor Information and Disclosures

Ahmad Malas, MD Fellow, Department of Gastroenterology, Providence Hospital and Medical Centers
Ahmad Malas, MD is a member of the following medical societies: American College of Gastroenterology. American Gastroenterological Association. American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Janice M Fields, MD, FACG, FACP Assistant Professor of Internal Medicine, Oakland University William Beaumont School of Medicine; Consulting Staff, Department of Internal Medicine, Section of Gastroenterology, Providence Hospital, St John Macomb-Oakland Hosptial
Janice M Fields, MD, FACG, FACP is a member of the following medical societies: American College of Gastroenterology. American College of Physicians-American Society of Internal Medicine. American Gastroenterological Association. American Medical Association. American Society for Gastrointestinal Endoscopy. National Medical Association
Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.

John Gunn Lee, MD Director of Pancreaticobiliary Service, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, University of California at Irvine School of Medicine
John Gunn Lee, MD is a member of the following medical societies: American College of Gastroenterology. American College of Physicians. American Gastroenterological Association. American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Alan BR Thomson, MD Professor of Medicine, Division of Gastroenterology, University of Alberta, Canada

Disclosure: Nothing to disclose.

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Barium swallow demonstrates diffuse uncoordinated contractions of the esophagus in a patient with diffuse esophageal spasm.

This is normal esophageal manometry tracing with normal amplitude of the contractions. The contractions are coordinated because the contractions in the proximal esophagus (top of image) occur before the contractions further distal in the esophagus.

Esophageal manometry tracing demonstrates diffuse esophageal spasm. Note the multiple uncoordinated contractions in the third tracing from the distal esophagus.

Esophageal manometry tracing demonstrates nutcracker esophagus. Note the excessive amplitude of the contractions.

High-resolution manometric display of a normal esophageal swallow using esophageal pressure topography. Image courtesy of Wikimedia Commons.

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Sildenafil in Esophageal Motility Disorders

Sildenafil in Esophageal Motility Disorders – Hard to Swallow?

Paul Harris, BSc(Pharm) and Janet Webb, BSc(Pharm), MSc

Introduction:

The two major functions of the esophagus are the transport of swallowed food to the stomach, and the prevention of retrograde flow of gastrointestinal contents.(1) After swallowing, the transport of food is achieved by coordinated, sequential peristaltic contractions along the length of the esophagus.(1) The two esophageal sphincters, which are zones of high intraluminal pressure, remain contracted between swallows and prevent retrograde flow. Patients complaining of difficulties in swallowing both solids and liquids, possibly accompanied by chest pain and regurgitation, may have an esophageal motility disorder.

Complex coordinated processes ensure that a food bolus is propelled in the proper direction. The upper esophageal sphincter (UES) and upper one-third of the esophagus are composed of skeletal muscle, whereas smooth muscle comprises the lower two-thirds of the esophagus and lower esophageal sphincter (LES). The UES is innervated by excitatory neurons only.(1) In contrast, the esophageal body and LES are regulated by both excitatory (contracting) and inhibitory (relaxing) input. The excitatory neurotransmitters are acetylcholine primarily, and substance P. Nitric oxide (NO) is the principle inhibitory neurotransmitter, with contributions also from vasoactive intestinal peptide. Inhibitory innervation is greater in the distal esophagus than the proximal esophagus.

Loss of NO inhibitory innervation and unopposed cholinergic excitatory activity underlies the pathology of several primary motility disorders. Disorders can be explained by defects in inhibitory or excitatory innervation. In primary esophageal motility disorders dysfunction is defined by standardized testing using manometry which measures pressure changes in different sites in the esophagus.(2,3) Achalasia is a disorder characterized by high LES pressure and nonperistaltic contractions causing dysphagia, chest pain and regurgitation in the patient. In diffuse esophageal spasm, contractions are of high amplitude and are poorly coordinated so that peristalsis is intermittent; patients complain of chest pain and dysphagia. Patients with nutcracker esophagus exhibit hypercontraction of the distal esophagus but peristalsis still occurs; patients have chest pain but dysphagia is uncommon. Other less common motility disorders include hypertensive LES, hypocontracting esophagus, and hypotensive LES.

Pharmacological interventions have met with varying success.(1,2) Treatment of hypocontracting esophagus is primarily directed at controlling acid reflux. Therapy for abnormal peristalsis has targetted relaxation of esophageal and LES smooth muscle. Most clinical trials to date typically involved only small numbers of patients and efficacy has not been clearly established. Anticholinergics are usually of limited value.(4) Agents that relax smooth muscle, such as sublingual nitroglycerin, isosorbide dinitrate, or calcium channel blockers may be helpful in theory.(2,4) Chemical denervaton of cholinergic nerves in the distal esophagus can be achieved with botulinum toxin.(1,3) The antidepressants trazodone and imipramine have been shown to be effective in relieving chest pain in patients with esophageal motility abnormalities.(2) It is suggested that they may modify visceral sensory perception, rather than specifically treating the motility dysfunction.(2,3)

The most effective therapies have been difficult to define, due to the different pathophysiological mechanisms involved and difficulty finding a relationship between motility findings in the laboratory and symptoms experienced by patients.(3) Recently it has been speculated that phosphodiesterase type 5 (PDE5) inhibitors, specifically sildenafil, may be helpful in treating some esophageal motility disorders.

Mechanism:
Nitric oxide (NO) is a major inhibitory neurotransmitter in the gastrointestinal tract.(1,3) It stimulates production of intracellular cyclic guanosine monophosphate (cGMP), resulting in smooth muscle relaxation. By inhibiting the breakdown of cGMP by PDE5, sildenafil prolongs cGMP smooth muscle relaxing activity. It is hypothesized that sildenafil decreases LES, prolongs swallow-induced relaxation, and diminishes the amplitude of peristaltic pressure waves in smooth muscle of the esophagus.(5)

Clinical Trials:
Bortolotti et al. randomly assigned 14 patients with idiopathic achalasia to receive either sildenafil 50 mg or placebo, then measured LES tone, and pressure wave amplitude and propagation over a 60-minute period.(6) Sildenafil decreased the LES tone and residual pressure and lowered pressure wave amplitude compared to placebo, but statistically significant differences were observed for less than 45 minutes after drug administration. Headache was reported in one subject. Small study size, the failure to measure responses to solid foods or liquids, no description of clinical symptoms, and interpatient variability limit the applicability of this data.

In another study by the same authors, 14 patients with symptomatic hypertensive LES were randomly selected to receive either sildenafil 50 mg or placebo, and had esophageal motility and LES tone measured for 60 minutes.(7) LES tone and esophageal wave amplitude in the sildenafil group showed a decrease when compared against baseline and placebo, with the greatest differences noted approximately 10 minutes after drug administration. Differences were found to be statistically significant up to 60 minutes following drug administration. Patient symptoms were not reported.

Eherer, et. al. randomized 6 healthy subjects to either sildenafil 50 mg or placebo then measured LES and esophageal motility.(8) Four subjects underwent ambulatory manometric measurements for 12 hours. Sildenafil significantly reduced LES pressure and amplitudes. In 3 of 4 subjects, the inhibitory effect lasted 8 hours, although statistical analysis was not performed in this phase of the trial. Subsequently in an open design, 11 patients with achalasia, hypertensive LES, nutcracker esophagus or esophageal spasm were given sildenafil 50 mg once daily to control their symptoms. Nine patients showed manometric improvement, but only 4 had symptomatic improvement. Two of those 4 did not wish to continue treatment due to side effects. Two patients had improvement of symptoms not limited by side effects; one with nutcracker esophagus receiving 50 mg daily, and one with hypertensive LES who received 25 mg per day. None of the patients with achalasia showed symptom improvement.

In 9 symptomatic patients with esophageal manometric findings indicative of nutcracker esophagus, 0.8 mg/kg sildenafil in solution or water was administered in a cross-over design.(9) Sildenafil decreased the resting LES pressure within 7.5 minutes of its administration, but the effect was statistically significant only from 7.5 – 30 minutes. The duration of LOS relaxation was only significantly reduced at 30 minutes. Similar results were observed for amplitudes of peristaltic pressure, although propagation velocity was not affected. Although results suggest sildenafil may be effective in lowering LES resting pressure and amplitude of distal esophageal peristaltic pressure waves, clinical efficacy was not assessed.

Conclusion:
By blocking the degradation of cGMP, sildenafil potentiates NO mediated relaxation of smooth muscle. Sildenafil lowers LES pressure and propulsive forces in the esophagus of healthy subjects, as well as patients with nutcracker esophagus, hypertensive LES and achalasia, but although the majority of patients demonstrate a good manometric response clinical improvement has not been satisfactorily demonstrated.(8) Speculation on the value of sildenafil is based solely on surrogate markers (manometric measurements). There are no studies demonstrating the clinical efficacy of sildenafil in esophageal motility disorders and side effects may be a limiting factor. While intriguing, further investigation is required to determine whether there is any role for PDE5 inhibitors in the treatment of these abnormalities.

  1. Mittal RK, Bhalla V. Oesophageal motor functions and its disorders. Gut. 2004;53:1536-1542.
  2. Castell DO. Diffuse esophageal spasm and nutcracker esophagus. In: Rose BD, editor. Wellesley (MA): UpToDate; 2005 (updated 2004 Jun 30; cited 2005 Jun 01). Available from: www.uptodate.com.
  3. Richter JE. Oesophageal motility disorders. Lancet. 2001;358:823-828.
  4. Goyal RK. Diseases of the esophagus. In: Kasper DL, Braunwald E, Fauci AS, et al, editors. Harrison’s principles of internal medicine. 16th ed. Toronto:McGraw- Hill; 2005. p. 1739-46.
  5. Rhee PL, Hyun JG, Lee JH, Kim YH, Son HJ, Kim JJ, Paik SW, Rhee JC, Choi KW. The effect of sildenafil on lower esophageal sphincter and body motility in normal male adults. Am J Gastroenterol. 2001;96:3251-3257.
  6. Bortolotti M, Mari C, Lopilato C, Porrazzo G, Miglioli M. Effects of sildenafil on esophageal motility of patients with idiopathic achalasia. Gastroenterology. 2000;118:253-257.
  7. Bortolotti M, Pandolfo N, Giovannini M, Mari C, Miglioli M. Effect of sildenafil on hypertensive lower oesophageal sphincter. Eur J Clin Invest. 2002;32;682-685.
  8. Eherer AJ, Schwetz I, Hammer HF, Petnehazy T, Scheidl SJ, Weber K. Krejs GJ. Effect of sildenafil on oesophageal motor function in healthy subjects and patients with esophageal motor disorders. Gut. 2002;50:758-764.
  9. Lee JI, Park H, Kim JH, Lee SI, Conklin JL. The effect of sildenafil on oesophageal motor function in healthy subjects and patients with nutcracker oesophagus. Neurogastroenterol Motil. 2003;15:617-623.

©2005 B.C. Drug and Poison Information Centre

Originally published in BCPhA Tablet. 2005;14(6):5.

Achalasia is an ambiguous disorder of the esophagus with a disturbed passage of food. Symptoms usually become servere with increasing duration of the disease. Dysphagia (Problems in swallowing) is usually the main symtom, but other symptoms such as thoracic spasms (Heartburn) can occur. In some patients these spasms occur before all other symptoms, which in turn can falsely be interpreted as cardiac problems.

People sufffering fram achalasia are often in a very difficult situation: Achalasia is a very ambiguous disorder and physicans often misinterpret the mentioned symptoms as being relatdet to psychosomatic issues as far as the underlying disorder is concerned. In many cases patients receive esophagoscopy, but unfortunately achalasia is hard zu be seen and diagnosed in early stages and cannot be diagnosed by this investigation alone. Following this, patients often receive test results showing no major abnormalities, which in turn often makes them seek help from mental health professionals. However, patients often doupt themselves because they experience real and serve problems in swallowing along with thoracic spasms. In our opinion this is probably the worst case: Affected people experience serve limitations related to daily necessities such as food intake, and the problem is, that nobody believes them. Isolation and social withdrawal can result of this.

The underlying reason for the swallowing problems can be a dysfunction of the lower esophagus sphincter muscle responsible for opening and closing the esophagus (detailed information here). Moreover, the transport of the food from the mouth to the stomach is not sufficiant. The muscles are relaxed, and they contract insufficiently while the overall pressure of the muscles is low. As a result, the food remains in the esophagus. This can lead to vomiting and passive movement of the food back towards the mouth (so-called regurgitations ). Moreover, particularly at night, food can get into the lung creating serious aspiration pneumonia .

The problems in swallowing lead to a significant weight loss in almost all affected patients over the time.

The course of the disease can be quite different. In some patients the disease is rapidly progressing, were as in others the progress can be rather slowly. There is one thing all patients have in common: Without sufficient treatment their condition is getting worse.

TV-ReportAchalasia (German) – EVK Castrop-Rauxel

The diagnosis can be verified by doing a pressure measurement in the oesophagus (so-called manometry). Another investigation involving the swallowing of contrast agents while doing a chest x-ray can show a rather classical picture (it looks a little bit like a wine-glass). However, this particular measurement alone may not be sufficiently accurate to diagnose achalasia in early stages of the disease. The pressure measurement/manometry and the contrast x-ray cannot only be relied on. It is required that an endoscopy is performed in order to rule out other reasons for the outlined problems.

Contrast X-ray images of the different forms of achalasia.

The following options are available:

1) Pharmacologic treatment: i.e. calcium-antagonists, etc.

2) Interventional strategies: pneumatic balloon dilatation of the sphincter muscle, injection of Botulinum-toxine in the sphincter muscle

3) Operative strategies: Laparoscopic myotomy of the sphincter muscle (Hellers Myotomy)

Pharmacologic agents used to treat achalasia decrease the tonus of the muscles of the oesophagus. These drugs were mostly originally designed to treat other disorders (i.e. high blood pressure, etc.), which is the reason why some side-effects can occur. For example, calciumantagonists (i.e. nifedipin) and nitrates are used for pharmacological treatment of achalasia and can lead to lowered blood pressure, nausea and above all discontinued treatment because of such side effects.

The substance sildenafil (Viagra) was used in patients with achalasia because of its muscle-relaxing properties. The therapeutic effect was better as regards the problems with swallowing (36.4%) when compared to the classical pharmacologic treatments. However, the observed side effects were also more severe (nausea, headache, low blood pressure).

Above all, the clinical benefit of pharmacologic agents used to treat achalasia so far must be considered as rather limited. Because of this, the use of pharmacologic treatment is rather limited to the beginning of the disease and for patients who did not respond to interventional or surgical treatment.

Operative myotomy of the sphincter muscle is also a standard procedure (Heller myotomy). It was described in 1903 by Heller and has been used a lot since its introduction as a surgical technique. Until the mergence of endoscopic techniques it was the standard procedure to treat achalasia. Open surgery using Heller myotomy were shown to have good long term results (Info).

Because of the availability of laparoscopic techniques (info) one can now offer rather low invasive interventional strategies. This combines the good long-term results of open Heller myotomy (info) with the advantages of laparoscopic surgery (info).

The muscles layers of the oesophagus sphincter are cut lengthwise a few centimetres while the mucosa layer will not be affected. In combination with an antireflux plasty (info) in order to prevent the reflux of liquids and food from the stomach to enter the oesophagus this way of treatment

Both diseases affect the muscles of the esopageal body over of the cardia. Lower esophgeal sphincter is usually not affected.

In the diffuse esophageal spasm in the muscles simultaneously contract most of the time without pumping motion during swallowing. The amplitude of the contractions are normal or high.

In contrast, we found a forward pumping motion with high or very high amplitude of pressure in the Nutcracker-Esophagus.

Both forms of disease can occur combined in rare cases.

Typical symptoms of both diseases are stress-independent chest pain and / or swallowing disorders (dysphagia), similar to symptoms of achalasia.

The therapy consists in a drug relaxing the esophageal muscles, but the effect of drug therapy is often but not convincingly. As a further treatment option, BOTOX injection in the esophageal muscle may reduce symptoms – these therapy is in experimental stage yet.

In severe cases, myotomy via laparoscopy and/or thoracoscopy my help, to reduce symptoms. In open surgical technique published long-term results report a relieve of symptoms in 85% of the cases.

X-Ray Barium Swallow of a patient with a combined disease: Nutcracker-Esophagus with diffuse esophageal spasm (Quelle: Dr.Zimmermann, GE)

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Viagra

By Mary Bellis. Inventors Expert

"Life might seem cruel, but they are paid to work for the company and the company owns their inventions. Literally hundreds of people at Pfizer have been involved in developing the drug. You can't really point to two individuals and say they spawned Viagra." – Pfizer Pharmaceuticals spokesperson on naming the inventors of Viagra

Peter Dunn and Albert Wood

According to the British Press (but not exactly according to Pfizer or others involved), Peter Dunn and Albert Wood both of Kent, England are named as the inventors of the process by which Viagra was created.

Continue Reading Below

Their names appeared on an application by Pfizer to patent (WOWO9849166A1) the manufacturing process of Viagra or Sildenafil Citrate.

Peter Dunn and Albert Wood are both employees of Pfizer Pharmaceuticals at the Pfizer run research laboratories in Kent and employees are not allowed to discuss their status or non-status as inventors. "I can't say anything, you'll have to talk to the press office. " – Albert Wood

Bell, Brown & Terrett – Treating Heart Problems

In 1991, inventors Andrew Bell, Dr David Brown and Dr Nicholas Terrett (also Pfizer employees at Kent) discovered that chemical compounds belonging to the pyrazolopyrimidinone class were useful in treating heart problems such as angina.

Nicholas Terrett was named in the 1991 British patent for Sildenafil (tradenamed Viagra) as a heart medicine, and some experts consider him as the father of Viagra.

Nicholas Terrett is also not allowed to discuss whether he considers himself the real inventor of Viagra as he is still a Pfizer employee. "There were three patents put forward for Viagra. Basically me and my team discovered how useful the drug might be. they (Wood and Dunn) created a way of mass producing it only" – Dr Nicholas Terrett

Continue Reading Below

Increased Blood Flow

By I994, Nicholas Terrett and colleague Peter Ellis discovered during the trial studies of Sildenafil as a heart medicine that it also increased blood flow to the penis, allowing men to reverse erectile dysfunctions. The drug acts by enhancing the smooth muscle relaxant effects of nitric oxide, a chemical that is normally released in response to sexual stimulation. The smooth muscle relaxation allows increased blood flow into the penis leading to an erection when combined with something naughty.

Making the Pill

Peter Dunn and Albert Wood then worked on the crucial nine-step process to synthesize a Sildenafil (Viagra) compound into a pill. It was approved by the FDA on March 27, 1998, as the first pill to treat impotence.

Paper Shortage

Pfizer claims that hundreds of inventors were involved with the creation of Viagra and there was not enough room on the patent application to name them all, so only the department heads were listed. Dr Simon Campbell, who until recently was the Senior Vice President Of Medicinal Discovery at Pfizer and oversaw Viagra's development, is considered by the American press to be the inventor of Viagra. However, Simon Campbell would rather be remembered as the father of Amlodipine, a cardiovascular drug. "I'm like Columbus. "- Dr Simon Campbell on Viagra's development.

Steps In Making Viagra

  1. Methylation of 3-propylpyrazole-5-carboxylic acid ethyl ester with hot dimethyl sulfate
  2. Hydrolysis with aqueous NaOH to free acid
  3. Nitration with oleum/fuming nitric acid
  4. Carboxamide formation with refluxing thionyl chloride/NH4OH
  5. Reduction of nitro group to amino
  6. Acylation with 2-ethoxybenzoyl chloride
  7. Cyclization
  8. Sulfonation to the chlorosulfonyl derivative
  9. Condensation with 1-methylpiperazine

Empirical formula = C22H30N6O4S
molecular weight = 474.5
solubility = 3.5 mg/mL in water

Viagra & Lawsuits

One billion dollars in sales were made in Viagra's first year of production.

Many lawsuits surround Viagra and Pfizer including the suit filed for $110 million dollars on behalf of Joseph Moran, a car dealer from New Jersey, who claimed that he crashed his car into two parked cars after Viagra caused him to see blue lightning coming from his fingertips, at which point he blacked out. Joseph Moran was driving his Ford thunderbird home from a date at the time.

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How Long Does Viagra Last?

Many people wonder, "How long does Viagra last?" In most people, Viagra lasts for about four hours. Generally, it starts to lose its effectiveness after a couple of hours. There are a number of factors that can increase or decrease how long Viagra lasts. Some factors that increase the amount of time Viagra stays in the body include being over 65 years old, having severe kidney disease, and taking certain other medicines. Among the factors that can decrease how long Viagra lasts are taking it with a high-fat meal or certain other medicines, such as rifampin.

How Long Does Viagra Last?

Many people thinking of taking Viagra ® (sildenafil citrate ) wonder, "How long does Viagra last?" The answer is that it depends on a number of factors and will vary between individuals. However, in most people, Viagra will last for about four hours — although it generally starts to lose its effectiveness after a couple of hours.

The time it takes for Viagra to start working will also vary based on the individual. In clinical studies, Viagra began to work in as little as 14 minutes. For most people, though, it began working within 30 minutes.

Factors Affecting How Long Viagra Lasts

There are a number of factors that can increase or decrease how long Viagra lasts. Some factors that increase the amount of time Viagra stays in the body include:

  • Being over 65 years old
  • Having severe kidney disease or liver disease
  • Taking certain other medicines (see Viagra Drug Interactions ).

There are also factors that can decrease how long Viagra lasts. Some of these factors include:

  • Taking Viagra with a high-fat meal
  • Taking Viagra along with certain other medications, such as rifampin.

Written by/reviewed by: Kristi Monson, PharmD; Arthur Schoenstadt, MD

How Long Does Viagra Last?

by ADAM CLOE Last Updated: Aug 16, 2013

Adam Cloe has been published in various scientific journals, including the “Journal of Biochemistry.” He is currently a pathology resident at the University of Chicago. Cloe holds a Bachelor of Arts in biochemistry from Boston University, a M.D. from the University of Chicago and a Ph.D. in pathology from the University of Chicago.

Viagra Time Line

As a general rule, Viagra takes effect 30 minutes after it’s taken, though this delay can be as short as 17 minutes for some users. Once Viagra has had its effect, it usually works for approximately 4 hours. However, the effects begin to diminish after 2 hours of effectiveness. Its effectiveness can be extended with higher doses (Viagra is available in doses ranging from 25mg to 100mg). Viagra on its own will not cause an erection; the penis will require some sort of sexual stimulation (be it visual or tactile) in order to become erect.

Interactions

A number of things can alter the time line of Viagra’s effectiveness. Taking Viagra with a large meal, especially one with a high fat content, can delay its effects. Similarly, its effects can be hastened by taking the meal on an empty stomach. Viagra’s effects may also last for longer if you are over 65 years old or have kidney or liver problems, as this will slow the rate at which Viagra is broken down by your body. If you are taking certain medications such as rifampin (an antibiotic used to treat tuberculosis), Viagra won’t last as long. For a listing of all medications that Viagra can interact with, see the links in the References section.

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Viagra Complications

One of the dangers of taking Viagra is a condition known as priapism. Priapism is a medical condition that consists of an erection that lasts for longer than 4 hours. This is a serious condition that can be very painful and cause lasting damage to the penis and other organs. It requires immediate medical attention. In addition, taking multiple doses of Viagra in one day can lead to a drop in blood pressure, as Viagra works by expanding the blood vessels. This risk is compounded by taking certain other blood pressure medications, such as nitrates, and should be avoided.

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How long does viagra last

viagra

Sure, sometimes, a man might last 15 minutes, 30 minutes, even an hour, but 75% of all males have an orgasm within 2 minutes of beginning penis-vagina (p-v) sex. I wonder if you’ve asked your partner how long she would like you to last. Are you thinking that if you last longer, somehow she’ll have an orgasm during p-v sex? The fact is that most women DON’T orgasm during p-v sex.

anyway, that night i also accidentally also found a load of kamagra pills (viagra bought online). my initial thought was that he was some kind of sex freak, using his many hours in the day takin viagra and watching porn. it turns out he says hes had erectile dysfuntion for many years and has been using viagra all this time without me knowing. he says he can get an erection but cant maintain it.

Yes and don’t forget your vitamin D, just get yourself out in the sun and you can pack your body with it, its free that way, they say you only need 15 minutes a day to get enough of it. me I’m out in it all day long here in Greece, and most of the time naked. And the last thing I got my wife a **** ring for Xmas, it’s a Hardwear Ice made of glass and works really well, once you get used to wearing it, and can give you some fantastic boners that are really strong.

When you have sex with your gf, your penis should feel a great sensation the entire time, so strong that you feel like you can climax from thrusting real fast but you the entire you don’t because you’re holding back your climax. That’s how sex should feel, condom or no condom. How do I know this. Well for years I had your problem. In fact, I would lose my erection during sex.

Can someone answer this. How long does hydrocodine show up in your system for a drug test. I take this drug for the pain I get with Lymes Disease. I’m starting a new job and they will ask for a drug test. How soon do I need to get off of them so it don’t show up on my test. Thanks.

Yes and don’t forget your vitamin D, just get yourself out in the sun and you can pack your body with it, its free that way, they say you only need 15 minutes a day to get enough of it. me I’m out in it all day long here in Greece, and most of the time naked. And the last thing I got my wife a **** ring for Xmas, it’s a Hardwear Ice made of glass and works really well, once you get used to wearing it, and can give you some fantastic boners that are really strong.

The sexual side efects on prozac only lasted about a week, and then it was smooth sailing, if not BETTER sex like viagra or something. i have used viagra once got it from a buddy, dont advocate that just keepin it real. Prozac does not boost my energy level, but i dont want that, for me that leads to no or hard fought sleep, or needing a sleep aid. That combo i think is what would make one tired the next day.

Second, Viagra does not create sexual desire. Sotalol is in a group of drugs called beta-blockers. Beta-blockers affect the heart and circulation (blood flow through arteries and veins). Sotalol is used to help keep the heart beating normally in people with certain heart rhythm disorders. Common side effects reported include cough, decreased sexual desire, trouble sleeping, reduced concentration, altered taste, dry skin, or muscle aches. Sotalol is also associated with a lessening of energy.

Our society does a terrible disservice to men by raising them to think that their penis has to be 10 inches long. hard as a rock and last all night. It’s no wonder that many men feel insecure about their sexuality. Great sex involves your whole body; in fact, having great, mutually satisfying sex is usually quite the opposite of what you see in those performance-oriented sex videos. The more you think of sex as being about performance, the more worries you’ll have.

I have several questions. one is about the shaking. does this go away? Also, the Klonopin. how long before it will help with these tremors? She is taking these meds for depression as well as anxiety disorder. She is feeling better mentally. with the depression but these tremors start about two hours after she takes the Zoloft.

Honey, my best advice is to just forget about "when". it’s so subjective. if someone tells you tomorrow. then you believe that to be your truth. then if it doesn’t happen. set up for disaster. This is your unique journey. Journal about it. It’s very helpful to look back on. to either help others or help yourself by remembering exactly what you went through and when, and remember that next time, IT WILL be worse. For a little while you’ll be living in addict brain mode.

Other side effects include weight gain, high cholesterol (on my last blood test TOTAL chol went from about 200 to 266),sexual side-effects (low libido),fatigue and worst of all my last blood pressure reading was high (150/100). On the plus side, this beta-blocker seems to provide the best heart rate control and did not cause me sleep problems, nightmares, cold hands and feet etc.

Thank you for the informative message. His doctor said he has erectyle disfunction and gave him some Viagra. Viagra works, but not always and now I think more and more it’s something in his mind after it worked with some other "help". I did all you said about arousing him. We did talk alot about our problem. I never "put him down" and always encourage him and totaly support him. But after 4 years of trying, I am out of "inspiration". I don’t know what else to do.

The testosterone seemed to help but caused this shrinkage, dizziness, irritability, sweaty, sad thing – little fella went into hiding on me. Viagra works pretty well but does not sit well with the flushing and eyesight issues. I am also worried about taking it with BP meds. Funny thing D, I was just talking to my wife a day or so ago about the "good old days" —- when I was ON TREATMENT. Can you believe that?

Ive always wanted to do so much and still do, be a writer, a photographer I just bought a Nikon D5100 package for $1500 (therefore you see the moon as my picture I took that), a weight trainer, a lover, a man with a degree, and good in bed with out pills (pills are like a new form of viagra to me they make me last much longer and please many many women the same thing happens when I body build/exercise too) I am being held back a grade by using pills in a matter of speaking except in this case p

I hate myself and sometimes get depressed. It is very hard being like this. can u please tell me how to stop this. Do i have a weak mind since i cant stop.

As you may know I have yet to start tx but from the different questions that I glance at I came across one that is unsettling. First of all how does the medicine get to you? Is is shipped? Shipped weekly? Am I going to be on the phone ordering this everyweek? Once the paper work/authorizations are approved will they be shipped every time automatically?

When he finally did seek help, none of the usual drugs (cialis, viagra. etc.) worked. Our intimacy drastically suffered, and for a long time we felt more like room mates. We entered couples counseling and discovered we both bring our own problems to the relationship. We discontinued therapy and found a medicine that actually works. I don’t know the name, but it is in shot form, through a company called Boston Medical Group.

get a vibrator for your personal satisfaction during sex, you control it, and have your hubby get on zoloft it will make him last long. have more control, and be satisfied. This is no joke, zoloft has worked for me in the same, similar, problem.

husbands takes care of Her in the evenings when he gets home and so I get to take a bath or do whatever I need to do like laundry etc. Veronika seems to get the same fits as Quinn does. except she may lasts little longer and she does not necessary cries just fusses alto!

Yea it could be viagra but still in order to get an erection with viagra or no viagra, something sexual has to go thru his mind. Perhaps he thinks about sex or something sexual constantly. And there is nothing wrong with that. However, if he is not taking viagra, he shouldn’t experience an erection once every hour but if he is taking viagra then yea he can. Either way, it doesn’t matter. This is not a medical condition. He has a good and healthy penis for his age.

It might not be as bad as you have already envisioned. He has been willing to give you your meds for now – How long. If he shows he has changed his mind and is changing your contract, then you will know for sure. But, maybe he hasn’t. Give that avenue a chance before throwing it away completely. Your pain is very real, but you know as well as I that the narcotics amplify all pain, so that you need more and more. The addiction to the benzo’s is far more dangerous.

Most recently i got him humping away on the couch to a video when he told me he was staying up late to watch TV. He has had little interest in me and had to start using viagra although he is very healthy. About a year ago i caught him and he promised to stop. He claims he has and is not addicted and just did not really realize how much it hurt me.

Hi, just google long term effect of Viagra. you find that its not a good thing in the long term of thing, you could end up with some bad side effects. As for enemas, just google it you should lots of info on them, like how to how often, and how much to use, if not find a nice helpful trained nurse who will oblige you for a fee. Do hope this helps.

I am currently in a very similiar circumstance, my partner of 13years recently lied to me (im not sure how long 4) but he has been having secret contact with an ex of his which was before my time. I saw a missed call a few days back from a woman with the same name as the ex and although i did wander what if this is her, i put it at the back of my mind and gave him the benefit of the doubt and carried on with everyday life.

i can fool around and get hard but it wont last long. if i start having sex i can sometimes keep it hard. i have only not used the viagra after the first couple times this happened. i’m also on hydrocodone 10/325 and soma 350 for the past 2 years. i have a titanium bone replace ment in my arm and have 9 bulging discs and a broken neck in 4 spots. but the last accident was more than a year ago. there was a total of 6 in the past 2 years.

sounds like you are taking the correct approuch by trying to talk to him. How long have you been together, if not very long maybe it is a confidence thing. My exboyfriend had a similar problem but after about 6 months he pulled right out of it. I know it would be difficult but did you ever thing of a male enhancing product?

There is no history of diabetes in my immediate family. I have a varicoscele since childhood. 1) How long should it take for symptoms from medication to wear off? 2) How effective is Viagra, Cialis, and Levitra in treating these problems? 3) Can a varicoscele cause ED problems and in what way? 4) How much time do I have to get treated? I’m concerned about being able to recover.

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