Failure of normal erections occurs with advancing age and it is estimated that around 20% of men between 50 and 70 years of age have moderate or severe ED. The cause of this impotence may be psychogenic, but organic causes (such as diabetes, smoking and peripheral vascular disease) are more likely with increasing age. The mainstays of treatment are the phosphodiesterase type 5 (PDE 5) inhibitors, such as sildenafil, vardenafil and tadalafil. These drugs inhibit breakdown of cyclic guanosine monophosphate (cGMP), thereby enhancing the normal erectile response. They are effective in psychogenic and organic ED. Other modalities of treatment are occasionally necessary including intracaver-nosal prostaglandin E1 and intraurethral vasoactive drug therapy, and vacuum constriction devices. An uncommon side effect of drug therapy for ED is a prolonged erection lasting several hours (priapism), which may lead to ischaemic injury to the erectile tissue in the corporeal bodies. If priapism does occur, the blood must be drained from the corpora cavernosa by direct aspiration, or by surgical formation of a shunt with the corpus spongiosum, or a saphenous vein. Priapism may also occur as part of a sickle cell crisis or in a patient with leukaemia.
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