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Aging: There are two reasons why older men are more likely to experience erectile dysfunction than younger men. First, older men are more likely to develop diseases (such as heart attacks, angina, cardiovascular disease, strokes, diabetes mellitus, and high blood pressure) that are associated with erectile dysfunction. Second, the aging process alone can cause erectile dysfunction in some men by causing changes in the muscle and tissue within the penis.
It is important that physicians and other health care providers treating patients for chronic conditions periodically inquire into the sexual functioning of their patients and be prepared to offer counsel for those who experience erectile difficulties. Lack of sexual knowledge and anxiety about sexual performance are common contributing factors to erectile dysfunction. Education and reassurance may be helpful in preventing the cascade into serious erectile failure in individuals who experience minor erectile difficulty due to medications or common changes in erectile functioning associated with chronic illnesses or with aging.
Stiffy Solution: Luckily, alcohol-induced impotence (also known by the infinitely less classy alias "whiskey d*ck") is a totally temporary condition, one that should clear up as soon as your dude can once again walk a straight line and recite the alphabet backwards. If your dude has consistent erectile problems from consistently drinking too much, however, he should consider cutting down on the sauce, and possibly talking with a doctor.
He can follow the common general physical advice: Sleep well, eat well, exercise, and moderate or abstain from drinking and drugs. He can also visit the doctor to see if there's any medical reason for his condition (anything from heart disease to diabetes and obesity). Sometimes, impotence is a side effect of prescription drugs. If his anxiety is extreme, it never hurts to see a professional therapist. Whenever there's even a chance of a medical problem, my advice is always: Why not check with a professional?
Treatment. prostatitis or another acute infection affecting the genitalia can cause temporary impotence that clears up in response to antibiotics. The smooth muscle relaxant sildenafil (viagra) was introduced in 1998 as a treatment for organic impotence. Administration of testosterone may be indicated if low levels of this hormone are found in a blood sample. If impotence is organic and does not respond to other therapies, a penile prosthesis can be implanted; this is usually done surgically by a urologist. Other therapies include the use of vacuum tumescence devices and penile injection of pharmacologic agents that cause dilation.
Sexual functioning involves a complex interaction among biologic, sociocultural, and psychological factors, and the complexity of this interaction makes it difficult to ascertain the clinical etiology of sexual dysfunction. Before any diagnosis of sexual dysfunction is made, problems that are explained by a nonsexual mental disorder or other stressors must first be addressed. Thus, in addition to the criteria for erectile disorder, the following must be considered:
Let's admit that not "talking about anything that could possibly be uncomfortable" is a sure-fire recipe for total disaster. Maybe you're exaggerating, but if he can't deal with anything even slightly difficult, then that is a bigger problem than pillow talk. Think about how exactly it would affect everything else in your relationship. He can't choose not to deal. When good things are happening, it's a shame he can't say "I love you0". But when hard things happen, he can't just say: "Um, pass."
Normal erectile function depends on the release of NO and endothelial-dependent vasodilation of the penile arteries. The 'artery size' hypothesis, first described by Dr Montorsi, offers an explanation why men are more likely to develop ED before a myocardial infacrtion. It is believed that atherosclerosis affects all vascular beds equally but smaller arteries are more likely to become occluded than larger arteries.31 32 The penile arteries are 1–2 mm while the coronary arteries are 3–4 mm. Thus, the same degree of endothelial dysfunction and atherosclerosis is more likely to occlude blood flow in the penile arteries compared with the coronary arteries. The penile arteries therefore serve as a sensitive indicator for subsequent CVD. This theory is supported by the fact that ED occurs approximately 3 years prior to cardiac symptoms in virtually all patients with chronic coronary syndrome whereas patients with acute coronary syndrome have a much lower prevalence of sexual dysfunction.32
An approach to the diagnosis and management of the impotent patient is presented in Figure 187.1. Apparent and likely causes of impotence should be considered first and, if possible, eliminated before the work-up continues. For instance, observing the patient for a few weeks off offending medication may be all that is necessary to establish the cause of impotence. When no obvious or remediable cause is present, the next step is based on the clinical impression of the likelihood of organic versus psychologic impotence. If the latter is considered more likely, it is perfectly reasonable to refer the patient directly for sexual therapy, with the option of reconsidering the diagnosis if, after appropriate therapy, there is no improvement. While an occasional patient with organic impotence will be misrouted, many more with psychogenic impotence will be spared an unnecessary and costly evaluation for organic causes. When organic impotence is likely, a serum testosterone level is the initial screening test for hypogonadism and should be obtained prior to urologic referral. Patients with low testosterone levels require further endocrine evaluations as depicted in Figure 187.1.
Causes of impotence are many and include heart disease, high cholesterol, high blood pressure, obesity, metabolic syndrome, Parkinson's disease, Peyronie's disease, substance abuse, sleep disorders, BPH treatments, relationship problems, blood vessel diseases (such as peripheral vascular disease and others), systemic disease, hormonal imbalance, and medications (such as blood pressure and heart medications).
Measurement of the penile vibration perception threshold provides an inexpensive, reproducible, and painless screening test with acceptable sensitivity for detecting neuropathy. Abnormalities at the level of the sacral cord can be documented by sacral latency testing, while upper motor neuron impotence can be demonstrated with genital-cerebral evoked response testing. These latter procedures are not indicated in unselected patients with impotence.
The lab testing obtained for the evaluation of erectile dysfunction may vary with the information obtained on the health history, physical examination, and recent lab testing. A testosterone level is not necessary in all men; however, a physician will order labs to determine a patient's testosterone level if other signs and symptoms of hypogonadism (low testosterone) such as decreased libido, loss of body hair, muscle loss, breast enlargement, osteoporosis, infertility, and decreased penile/testicular size are present.
But the main challenge to finding the best ED drug for you may turn out to be health insurance rules—not biochemistry. It's a common practice among insurers to limit the number of pills you can obtain per month. After you hit your limit, the out-of-pocket cost for a single pill can be as high as $20. "The main obstacle in my practice is the cost," Dr. Liou says. You'll need to work with your doctor to get the pill you need at a price you can afford.
PDE 5 inhibitors are broken down primarily by enzyme, cytochrome P450enzyme CYP3A4. Medications that decrease or increase the activity of CYP3A4 may affect levels and effectiveness of PDE 5 inhibitors. Such drugs include medications for the treatment of HIV (protease inhibitors) and the antifungal medications ketoconazole and itraconazole. Thus caution is recommended.
Erectile dysfunction (previously called impotence) is the inability to get or maintain an erection that is sufficient to ensure satisfactory sex for both partners. This problem can cause significant distress for couples. Fortunately more and more men of all ages are seeking help, and treatment for ED has advanced rapidly. The enormous demand for "anti-impotence" drugs suggests that erection problems may be more common than was previously thought. Find out more about the causes and treatment of erectile dysfunction here.
The lab testing obtained for the evaluation of erectile dysfunction may vary with the information obtained on the health history, physical examination, and recent lab testing. A testosterone level is not necessary in all men; however, a physician will order labs to determine a patient's testosterone level if other signs and symptoms of hypogonadism (low testosterone) such as decreased libido, loss of body hair, muscle loss, breast enlargement, osteoporosis, infertility, and decreased penile/testicular size are present.
Alprostadil self-injection. With this method, you use a fine needle to inject alprostadil (Caverject Impulse, Edex) into the base or side of your penis. In some cases, medications generally used for other conditions are used for penile injections on their own or in combination. Examples include papaverine, alprostadil and phentolamine. Often these combination medications are known as bimix (if two medications are included) or trimix (if three are included).
Treatments include psychotherapy, adopting a healthy lifestyle, oral phosphodiesterase type V (PDE5) inhibitors (Viagra, Levitra, Cialis, Stendra, and Staxyn), intraurethral prostaglandin E1 (MUSE), intracavernosal injections (prostaglandin E1 [Caverject, Edex], Bimix and Trimix), vacuum devices, penile prosthesis and vascular surgery, and (in some cases) changes in medications when appropriate.
Achieving an erection is a complicated process, requiring transmission of sensations from the genital area to the nervous system and the return of nervous impulses to the muscles and blood vessels of the penis. Anything that interferes with this interchange, such as disease or injury of the blood vessels, muscles, or nerves, can make achieving and maintaining an erection difficult. Psychological factors, such as anxiety and depression, can also interfere with erectile function. Anxiety and depression may also develop as a consequence of impotence.
Fortunately, impotence is usually treatable. A thorough evaluation starting with a history and physical exam is needed to help diagnose the underlying cause. Once the cause of impotence is determined, treatment can be tailored to target that cause and any other contributing factors. Treatments used for impotence may include medications, vacuum devices, surgery, and psychotherapy.
Treatments include psychotherapy, adopting a healthy lifestyle, oral phosphodiesterase type V (PDE5) inhibitors (Viagra, Levitra, Cialis, Stendra, and Staxyn), intraurethral prostaglandin E1 (MUSE), intracavernosal injections (prostaglandin E1 [Caverject, Edex], Bimix and Trimix), vacuum devices, penile prosthesis and vascular surgery, and (in some cases) changes in medications when appropriate.
A meta-analysis of 36 744 men with ED in 12 prospective cohort studies found that the presence of ED significantly increased the risk of CVD, CAD, stroke and all-cause mortality, and the presence of ED was an independent risk factor for CVD. Ponholzer et al found that men with moderate to severe ED had a 65% increased relative risk for developing symptomatic CAD compared with men who did not have ED.26
Occasional successful sexual function and early morning erections do not preclude the possibility of endocrine dysfunction. Since abnormally low levels of testosterone frequently are the primary cause of impotence, it is recommended that determination of the blood level of testosterone be an integral part of the total evaluation of the impotent patient.
Some men report being helped by an oral medication called yohimbine, which comes from the bark of a tree that grows in India and Africa. This drug, which needs to be taken every day, has been reported to help about 20 to 25 percent of the men taking it. A relatively new but widely used oral medication called Viagra requires a careful medical evaluation by your doctor.
The first stem cell study for the treatment of ED was published in 2004. This study used embryonic stem cells to treat ED. At this time, there is a total of 36 published basic studies assessing stem cell therapy for ED, with two clinical trials. The mechanism of action of stem cells is to generate angiogenesis with subsequent increase in cavernosal smooth muscle cells within the corporal bodies.46
Before taking any medication for erectile dysfunction, including over-the-counter supplements and herbal remedies, get your doctor's OK. Medications for erectile dysfunction do not work in all men and might be less effective in certain conditions, such as after prostate surgery or if you have diabetes. Some medications might also be dangerous if you:
The motivation and expectations of the patient and his partner and education of both are critical in determining which therapy is chosen and in optimizing its outcome. If single therapy is ineffective, combining two or more forms of therapy may be useful. Penile prostheses should be placed only after patients have been carefully screened and informed. Vascular surgery should be undertaken only in the setting of clinical investigation and extensive clinical experience. With any form of therapy for erectile dysfunction, long-term followup by health professionals is required to assist the patient and his partner with adjustment to the therapeutic intervention. This is particularly true for intracavernosal injection and vacuum constriction therapies. Followup should include continued patient education and support in therapy, careful determination of reasons for cessation of therapy if this occurs, and provision of other options if earlier therapies are unsuccessful.
Men are very susceptible to visual stimulation, particularly as children and teenagers. Seeing anything appealing (say, a person or image) activates pathways in the brain that tell nerves in your lower spinal cord to trigger a release of nitric oxide, which relaxes blood vessel walls and floods your penis with blood, making it hard. Nitric oxide is the key chemical here, as you need a mix released from your nerves AND from your blood vessels to get an erection. If the blood vessels, nerves, or both are damaged, it's difficult to get a hard erection. That's why your doctor may well be interested if you're struggling with erections, as it could be a sign of early heart disease or diabetes.
If PDE-5 inhibitors are not suitable or don't work, other therapies include injections into the base of the penis, which cause flow of blood into the penis and a fairly immediate erection that lasts around an hour. The drugs injected are alprostadil (Caverject and Erectile dysfunctionex) and Invicorp (VIP and phentolamine). Alprostadil may also be inserted as a gel into the opening of the penis. This is not suitable if your partner is pregnant.
Obviously, there are worse problems than a guy saying "I love you" too often, but if it's a problem, it sounds like the two of you need to have a long conversation. You need to understand why he likes to say it so much: Is it because he's insecure or hoping to comfort you or just breathlessly in love? (Or some combination of the three?) And he needs to understand how it makes you feel. So, if it really bothers you, tell him why.
The term "impotence," as applied to the title of this conference, has traditionally been used to signify the inability of the male to attain and maintain erection of the penis sufficient to permit satisfactory sexual intercourse. However, this use has often led to confusing and uninterpretable results in both clinical and basic science investigations. This, together with its pejorative implications, suggests that the more precise term "erectile dysfunction" be used instead to signify an inability of the male to achieve an erect penis as part of the overall multifaceted process of male sexual function.
Erectile dysfunction is often assumed to be a natural concomitant of the aging process, to be tolerated along with other conditions associated with aging. This assumption may not be entirely correct. For the elderly and for others, erectile dysfunction may occur as a consequence of specific illnesses or of medical treatment for certain illnesses, resulting in fear, loss of image and self-confidence, and depression.
Kimberly Hildebrant, ARNP is a board certified Family Nurse practitioner. She graduated with a Bachelor of Science in Nursing from the University of Pittsburgh and a Masters in Nursing from Duquesne University. She has practiced as a nurse practitioner in the field of Infectious Disease as well as HIV for 4 years. She has over 13 years of experience as a critical care nurse. Kimberly is passionate about providing affordable healthcare to all individuals to ensure that all can live their best life. She is an advocate for preventative care and early treatment to avoid lasting illness.
Thanks for your question, Frightened Turtle! To help answer it, we spoke with Dr. Darius Paduch, urologist and male sexual medicine specialist at New York Presbyterian/Weill Cornell Medical Center, and sex therapist Jenni Skyler, Ph.D., director of The Intimacy Institute for sex and relationship therapy in Boulder, Colorado. Here's what they had to say:
For the patient whose history suggests organic impotence, further history, physical and laboratory data will help identify the cause. The classification listed in Table 187.2 is based on the pathophysiologic scheme presented above, and includes mechanical problems that can interfere with erection. Vascular disease is the most common cause of impotence. In advanced cases, Lehriche's syndrome of aortoiliac occlusion will be suggested by bilateral thigh or calf claudication, loss of muscle mass in the buttocks and legs, and impotence. However, the majority of patients with vascular impotence have less severe vascular disease and many will have occlusive disease of the hypogastric-cavernous bed only. Even among patients without claudication, vascular disease is still a likely cause of impotence, especially if risk factors for atherosclerosis are present. Nonatherosclerotic disease is a consideration in the patient with a history of trauma or radiation to the pelvis, both of which cause fibrosis of vessels.
#9 Smokers hell. Bad stimulants such as smoking cigarettes may be having a negative impact on more than just your lungs. That's right, smoking may lead to a lazy penis. One study shows that 40% of men that suffer from erectile dysfunction are smokers. The good news is that 75% of men reported erectile issues disappear after quitting smoking. What better motivation to quit smoking than having amazing sex? [Read: How to keep an erection up for longer in 20 ways]
Although not proven, it is likely that erectile dysfunction can be prevented by good general health, paying particular attention to body weight, exercise, and cigarette smoking. For example, heart disease and diabetes are problems that can cause erectile dysfunction, and both are preventable through lifestyle changes such as sensible eating and regular exercise. Furthermore, early diagnosis and treatment of associated conditions like diabetes, hypertension and high cholesterol may prevent or delay erectile dysfunction, or stop the erectile dysfunction from getting more serious.
Six herbs for treating erectile dysfunction Erectile dysfunction can be an embarrassing condition that can leave men unable to achieve an erection or a full orgasm. This MNT Knowledge Center article talks about six different herbal supplements that could help people with erectile dysfunction, including ginkgo biloba, horny goat weed, and red ginseng. Read now
If you have low blood pressure, heart disease, take medicines for heart disease or for high blood pressure, you shouldn't use our service. If you take the medicines we prescribe you'll be at greater risk of serious side effects such as severe dizziness, fainting, heart attack, and stroke. Read the package insert that comes with the medicine for a full list of side effects and warnings.
Obesity and metabolic syndrome can cause changes in blood pressure, body composition, and cholesterol which may lead to ED. Other conditions that may contribute to erectile dysfunction include Parkinson's, multiple sclerosis, Peyronie's disease, sleep disorders, alcoholism, and drug abuse. Taking certain medications can also increase your risk for ED.
The inability to achieve or sustain a sufficiently firm penile erection (tumescence) to allow normal vaginal sexual intercourse. The great majority of cases are not caused by organic disease and most men experience occasional periods of impotence. It is often related to anxiety about performance and is usually readily corrected by simple counselling methods which prescribe sensual massage but forbid coitus. Organic impotence may be caused by DIABETES, MULTIPLE SCLEROSIS, spinal cord disorders and heart disease. Many cases can be helped by the drug SILDENAFIL (Viagra).
Endocrine problems, though uncommon, should be considered in patients presenting with impotence. As a rule, impotence due to hypogonadism will be partial and accompanied by decreased libido. Hypothalmic–pituitary problems, which include tumors, are the most common endocrine disorders causing impotence, followed by primary gonadal failure from one of many causes. Poorly controlled diabetes with polyuria and polydypsia is an important reversible cause of impotence, as is hyperthyroidism. Certain drugs, alcohol included, can lead to impotence as a result of endocrine disturbances.
It's unlikely. Testosterone levels fall as you get older but they have to fall really low to cause erectile problems. Thus assessment for erectile dysfunction includes a testosterone blood test but only replacement if it is very low. Giving someone more testosterone than their body would have made, even at a young age, can cause blood clots due to blood thickening and even reversible infertility. So don't be tempted with homespun remedies.
Only a small proportion of cases of erectile dysfunction are caused by hormone abnormalities. The most frequent hormone abnormality is a reduced level of the male sex hormone testosterone required to get an erection which can be restored by appropriate hormone replacement. It's unwise to take testosterone preparations unless you've had tests that confirm a deficiency.
Erectile dysfunction (ED), also known as impotence, is the inability to achieve or sustain a hard enough erection for satisfactory completion of sexual activity. Erectile dysfunction is different from other health conditions that interfere with male sexual function, such as lack of sexual desire (decreased libido) and problems with ejaculation release of the fluid from the penis (ejaculatory dysfunction) and orgasm/climax (orgasmic dysfunction), and penile curvature (Peyronie's disease), although these problems may also be present. ED affects about 50% of men age 40 and over. This article focuses on the evaluation and treatment of erectile dysfunction.
A lot of the time, the issue is a combination of both. For instance, cortisol – which is an important steroid hormone in the body – is released in greater amounts when we're stressed. It's supposed to briefly shut down non-essential functions like reproduction and fighting off illnesses whilst you deal with the danger at hand. However, the chronic and ongoing stress of modern life increases our background cortisol levels, activating the sympathetic system and stopping an erection.
Diabetes is an example of an endocrine disease that can cause a person to experience impotence. Diabetes affects the body's ability to utilize the hormone insulin. One of the side effects associated with chronic diabetes is nerve damage. This affects penis sensations. Other complications associated with diabetes are impaired blood flow and hormone levels. Both of these factors can contribute to impotence.
High cholesterol and triglyceride levels increase the risk of cardiovascular disease. Getting your cholesterol and triglyceride levels in an optimal range will help protect your heart and blood vessels. Cholesterol management may include lifestyle interventions (diet and exercise) as well as medications to get your total cholesterol, LDL, HDL, and triglycerides in an optimal range.
A study published in May 2014 in The Journal of Sexual Medicine found that some men can reverse erectile dysfunction with healthy lifestyle changes, such as exercise, weight loss, a varied diet, and good sleep. The Australian researchers also showed that even if erectile dysfunction medication is required, it's likely to be more effective if you implement these healthy lifestyle changes.
Stanley A Brosman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Advancement of Science, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Urological Association, Society for Basic Urologic Research, Society of Surgical Oncology, Society of Urologic Oncology, Western Section of the American Urological Association, Association of Clinical Research Professionals, American Society of Clinical Oncology, International Society of Urology, International Society of Urological Pathology
Healthy lifestyle minimizes risk of ED. Erection depends on blood flow through the penis. Anything that impairs it increases ED risk: smoking, diabetes, high cholesterol, high blood pressure, heart disease, being overweight, sedentary lifestyle, more than two alcoholic drinks a day, and fewer than five daily servings of fruits and vegetables. Avoiding these risk factors does not prevent post-50 erection changes, but it preserves erection function and helps prevent ED.
If PDE5 drugs don't work or cannot be used because of potential side effects, your doctor can recommend other therapies. The drug alprostadil (Caverject, Edex, Muse) allows blood to flow more freely in the penis, leading to an erection. The drug can be injected with a tiny needle into your penis. Or, a small pellet (suppository) can be inserted into the opening of the penis. Suppositories and injections are effective in the majority of men.
Alprostadil self-injection. With this method, you use a fine needle to inject alprostadil (Caverject Impulse, Edex) into the base or side of your penis. In some cases, medications generally used for other conditions are used for penile injections on their own or in combination. Examples include papaverine, alprostadil and phentolamine. Often these combination medications are known as bimix (if two medications are included) or trimix (if three are included).
While erectile dysfunction can occur at any age, the risk of developing erectile dysfunction increases with age. According to the Massachusetts Male Aging Study, the prevalence of erectile dysfunction was 52% in men 40-70 years of age. The prevalence of complete erectile dysfunction increases from 5% at 40 years of age to 15% among men 70 years of age and older.
Before taking any medication for erectile dysfunction, including over-the-counter supplements and herbal remedies, get your doctor's OK. Medications for erectile dysfunction do not work in all men and might be less effective in certain conditions, such as after prostate surgery or if you have diabetes. Some medications might also be dangerous if you:
Only a small proportion of cases of erectile dysfunction are caused by hormone abnormalities. The most frequent hormone abnormality is a reduced level of the male sex hormone testosterone required to get an erection which can be restored by appropriate hormone replacement. It's unwise to take testosterone preparations unless you've had tests that confirm a deficiency.
Men with erectile dysfunction require diagnostic evaluations and treatments specific to their circumstances. Patient compliance as well as patient and partner desires and expectations are important considerations in the choice of a particular treatment approach. A multidisciplinary approach may be of great benefit in defining the problem and arriving at a solution.
ED can be caused by either physical and/or psychological factors like stress, anxiety, or depression. Importantly, ED can be the first sign of heart or other health conditions, including cardiovascular disease and diabetes. We offer the optional order of a lab test to investigate whether you might have more serious underlying health problems. Our doctors can order investigative labs in all the states we operate in apart from AZ, NY, NJ and RI. You'll need to go to a Quest Diagnostics center to have these tests done. When we get the test results back, we can help you understand what they mean.
Not to give your already stressed-out dude one more thing to worry about, but stress is the cause of 20 percent of all erectile problems, from one-off boner blunders to a lingering inability to get and maintain an erection. Of course, sex difficulties are just the tip of the stress-induced health problem iceberg — sustained stress can also lead to insomnia, stomach troubles, chest pains, anxiety, and more severe health issues in the long term.
The mechanisms by which testosterone plays a role in erectile function are not completely understood. A study evaluating the effect of testosterone on erections in surgically castrated rabbits and control animals, in which the rabbits' intracavernosal pressures were compared after cavernosal nerve stimulation, determined that castrated rabbits had much lower pressures after stimulation than control rabbits did. [21] Notably, the pressures increased when castrated rabbits received exogenous testosterone replacement.
In patients with low testosterone, testosterone treatment can improve libido and erectile dysfunction, but many men still may need additional oral medications such as sildenafil, vardenafil, or tadalafil. Some studies suggest that men with ED and low testosterone may respond better to PDE5 inhibitors when given testosterone therapy; however, this is controversial.
You've heard of—and probably experienced—the numbing effect alcohol has on your mind, body, and (unfortunately) penis. If you fail to rise to the occasion on a regular basis and you're drinking has gone from occassional weekend binge to a Monday through Friday ordeal, consider cutting back—way back. Heavy drinking proportionately increases your risk of ED, according to research from the Indian Journal of Psychiatry.
Exercise and lifestyle modifications may improve erectile function. Weight loss may help by decreasing inflammation, increasing testosterone, and improving self-esteem. Patients should be educated to increase activity, reduce weight, and stop smoking, as these efforts can improve or restore erectile function in men without comorbidities. Precise glycemic control in diabetic patients and pharmacologic treatment of hypertension may be important in preventing or reducing sexual dysfunction. [49]
Because of the difficulty in defining the clinical entity of erectile dysfunction, there have been a variety of entry criteria for patients in therapeutic trials. Similarly, the ability to assess efficacy of therapeutic interventions is impaired by the lack of clear and quantifiable criteria of erectile dysfunction. General considerations for treatment follow:
It doesn't really matter what they are — sexual turnoffs vary wildly from person to person. But if the person you're getting it on with is doing stuff that's taking you out of the mood — even if it's stuff you feel like you're supposed to enjoy — it's time to swallow your pride and say something. Keeping it a secret might be saving you an awkward conversation in the short term, but in the long term, it could be seriously undermining your sex life.
Let's admit that not "talking about anything that could possibly be uncomfortable" is a sure-fire recipe for total disaster. Maybe you're exaggerating, but if he can't deal with anything even slightly difficult, then that is a bigger problem than pillow talk. Think about how exactly it would affect everything else in your relationship. He can't choose not to deal. When good things are happening, it's a shame he can't say "I love you0". But when hard things happen, he can't just say: "Um, pass."
Achieving an erection is a complicated process, requiring transmission of sensations from the genital area to the nervous system and the return of nervous impulses to the muscles and blood vessels of the penis. Anything that interferes with this interchange, such as disease or injury of the blood vessels, muscles, or nerves, can make achieving and maintaining an erection difficult. Psychological factors, such as anxiety and depression, can also interfere with erectile function. Anxiety and depression may also develop as a consequence of impotence.
When stimulated by the nerves, the spongy tissue arranges itself in such a way that more blood can be stored in the penis. The veins running through the outer sheath of the penis then compress which stops the blood from leaving the penis. As the blood is stopped from flowing out, the penis fills with blood and stretches within the outer casing, giving an erection.


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1958 · New York
by Samuel, Howard D. and Lynne Rhodes
New York: the union, 1958. 66p., wraps, illus., 8.5x11 inches. (Inventory #: 66809)
by [League of Revolutionary Struggle]San Francisco : Unity , 1978
by Sillen, Samuel, edNew York : Masses & Mainstream , 1951
You can be confident that when you make a purchase through ABAA.org, the item is sold by an ABAA member in full compliance with our Code of Ethics. Our sellers guarantee your order will be shipped promptly and that all items are as described. Buy with confidence through ABAA.org.

subset: commoncrawl


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Kitchen Cabinet Led Lighting Under Counter Led Lights
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Who is Joseph Stalin? (8 photos)
Quite an interesting project, which aims to tell the youth of today that,
Who was and what role in the history of our country played Joseph Stalin.
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Saturday Tournament Update: The final tournament brackets will be posted after the final season games on January 26th and 29th. A few play-in games could be played on Thursday, January 31st if needed. The first round games will begin Saturday, February 2nd (some age could play two rounds). The remaining games will be played February 4th, 5th, and 9th. Some divisions with multiple teams will be divided into more divisions during the tournament. CLBBY will award trophies for regular season champions and tournament Champions and runner-up...
JEWELRY: No Player shall wear jewelry (watches, bracelets, rings, necklaces, earrings, metal hair bows, no cast - hard or soft) NO EXCEPTIONS & NO TAPED EARS! Please see the NFHS rules concerning jewelry for further information regarding jewelry.
Jerseys: Each Player must wear a jersey that matches the rest of the team (same style & color). A legible legal number MUST be on the front and back of the jersey. Legal numbers are: 0, 00, 1, 2, 3, 4, 5, 10, 11, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 30, 31, 32, 33, 34, 35, 40, 41, 42, 43, 44, 45, 50, 51, 52, 53, 54, 55 (the numbers 0 & 00 are legal, but cannot be used at the same time). No Player will be allowed to enter a game without a matching jersey, and no two (2) Players may wear the same number. No jersey will be allowed to be altered in any way (i.e. taping numbers, sharpie, etc.). Teams with indistinguishable jerseys shall wear pinnies (provided by the Host church), with the Home team having the option of wearing or not wearing the pinnies. Appropriate attire is required, as jerseys will be worn, gym/basketball shorts will be worn properly secured at the waist, & proper court footwear must be worn. Undershirts, if worn, must be white only. Sweat (Head/Wrist) Bands are permitted, but must be the same color as the dominate color of the jersey or white (only a manufacturer's logo will be permitted on any sweat band). No compression sleeves will be allowed, unless the Player has a muscle injury & the CLBBY has been notified of the injury & a statement from the Attending Physician has been received by the CLBBY.
This website is designed to give you easy access to all of your sports information. As the season progresses, you will find it easy to follow your schedules, standings, and any changes or new information regarding your leagues and upcoming events. Be sure to bookmark this website for quick and easy access to all our sports information.
Gene Hawkins, League Commissioner
864-517-4445 / firstname.lastname@example.com
Mites - Girls (2nd - 3rd Grades)
Mites - Boys A (2nd -3rd Grades)
Mites - Boys B (2nd - 3rd Grades)
Minor - Girls A (4th - 5th Grades)
Minor - Girls B (4th - 5th Grades)


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Weekend Guide
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G.T.B. Nagar
65, Ring Road, GTB Nagar, New Delhi, North West Delhi, Outram Lines, GTB Nagar, New Delhi, Delhi 110009, India
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Reviews of G.T.B. Nagar •
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• You can enjoy the lunch at GTB Nagar. There are many cafes and restaurants that have the best food with an affordable rate. Serving all Italian, continental, Mexican, Indian etc you can add more and more to your plate. The yellow line connects directly to the GTB Nagar metro station.
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Mall Road, Mussoorie, Uttarakhand
the mall road
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hudson lane
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D-33, Kamla Nagar, Block G, Kamla Nagar, Delhi, 110007, India
chache di hatti
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isbt kasmiri gate
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where to go in delhi for what: 20 jugaad markets to visit if you're looking for something specific
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Ligue Reg.tir Du Centre
- Address: 154 Rue des Fossés, 45400 Fleury-les-Aubrais, France
- Ticket Price: Free
- Tags: Point Of Interest
This page offers up-to-date information of Ligue Reg.tir Du Centre in the city of Fleury-les-aubrais, France. On this page, you can find the most important logistical information about Ligue Reg.tir Du Centre like its address, phone number and location. You can click on the map view to know the exact location of the place on the maps.
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Club sympa, bonne ambiance, et sécurité assurée !
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expired Free Impressed Almond Mylk Yoghurt via Flybuys @ Coles
Last edited 13/12/2018 - 22:31
This is my first post so please be kind and hope I've done it right. This is targeted but not sure how to make the blue targeted tag appear. I've never had almond milk yoghurt before but will definitely check it out since it's free!
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- +1 vote
This is targeted but not sure how to make the blue targeted tag appear
FYI click "Report", select "Targeted Offer", click "Submit". A mod will add the tag for you.
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Almond Milk Yoghurt
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This taste any good?
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Precious metal clay
From GoldRefiningWiki
Error creating thumbnail: Unable to save thumbnail to destination
|This article is a stub. You can improve Gold Refining Wiki by expanding it.
Precious metal clay is a relatively recent invention and consists of a metal powder and a binder that makes up a clay that can be used to form objects of. After drying the clay is sintered in an oven where the binder is burned off and the metal fuses together into a solid object. Metals used varies but common is gold, silver, copper and bronze.
Already burned objects can be treated just as other jewellery. Fresh or dried up clay should at first be incinerated to burn off any binder, oil and water. After that treated as jewellery scrap.
- US patent 5328775, Moldable mixture for use in the manufacturing of precious metal articles.


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Playing tracks by
Just Brothers, Shirley Ellis, Tony Clarke, Jackie Day, The Precisions and more.
Chart positions
This show was 18th in the global northern soul chart and 54th in the global funk - soul - jazz chart.
On this months Music For Modern Living Radio Show we have something a little different to the normal format - A Northern Soul Special.
No new discoveries on this show and nothing you probably haven't heard before. Just celebrating, what we consider to be some of the best music ever made. So clear the lounge room floor, pour yourself a drink and get ready to dance to a show jam packed with Northern Soul Stompers!
1 The Just Brothers - Sliced Tomatoes
2 Shirley Ellis - Soul Time
3 Tony Clarke - Landslide
4 Jackie Day - Before It's Too Late
5 The Precisions - If This is Love
6 Mel Williams - Can it be me
7 Casanova Trio - We Got To Keep On
8 Vernon Garrett - If I Could Turn Back The Hands of Time
9 Big Maybelle - Quittin Time
10 Major Lance - Ain't No Soul in these old shoes
11 Roy Hamilton - Crackin up over You
12 Larry Williams & Johnny Watson - Too Late
13 Billy Butler - Right Track
14 Casualeers - Dance Dance Dance
15 Buddy Miles - Just A Kiss Away
16 Millie Jackson - My Man is a Sweet Man
17 Willie Tee - Walking up a one way Street
18 Edwin Starr - Headline News
19 Winfield Parker - Stop Her On Sight
20 Chuck Wood - 7 Days is Too Long
21 Ella Fitzgerald - Get Ready
22 Mary Love - You Turned My Bitter Into Sweet
23 Betty Everett & Jerry Butler - Getting Mighty Crowded
24 Archie Bell & The Dells - Here I Go Again
25 Alice Clark - You Hit Me Right Where It Hurt Me
26 JJ Barnes - Real Humdinger
27 The Vibrations - Cause Your Mine
28 The Marvelettes - I'll Keep Holding On
29 The Majorlettes - Too Hot To Hold
30 Cliff Nobles - Love is Alright
31 James Lewis & The Case of Tyme - Manifesto
32 Candy & The Kisses - The 81
33 Garnet Mimms - Prove It To Me
34 Rodger Collins - She's Looking Good
35 Melba Moore - The Magic Touch
36 Darrell Banks - Open The Door To Your Heart
Listening to this while I sit in the Singapore departure lounge, drinking a pint, ready to fly to the National. Thanks for the perfect accompainment! xo


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There either is or is not, that's the way things are. The colour of the day. The way it felt to be a child. The saltwater on your sunburnt legs. Sometimes the water is yellow, sometimes it's red. But what colour it may be in memory, depends on the day. I'm not going to tell you the story the way it happened. I'm going to tell it the way I remember it.
The Lizzie Bennet Diaries is an innovative, original episodic video and social media series produced for the web. Adapting Pride and Prejudice to the modern era, Lizzie Bennet tells the classic Jane Austen tale from the point of view of an Elizabeth "Lizzie" Bennet who grew up in a world of cell phones, video cameras, and social media. The series was created by popular YouTube personality Hank Green and Streamy Award winning web video writer Bernie Su.
The holiday season is bringing more than cheer for actress Jessica Capshaw. The Grey's Anatomy star announced on Monday that she and her husband, Honest Company co-founder Christopher Gavigan, are expecting their fourth child. "The holidays have certainly arrived … All of our lives are being added to by the lights, the music and cheer!!" she captioned a photo of her family at a Christmas tree farm on Instagram. "This year our family has reason to further broaden our smile … baby number four is on the way!! I am a lucky, lucky girl…"
The quickest way to tell whether an actor is serious about his or her career is to look at their "headshot".Is it a professional photo? Or is it a snapshot taken on prom night? If you're using a snapshot, it's like showing up to race the Indy 500 in a VW Beetle. Nobody is going to take you seriously. I'm sorry, people… you can send me as much angry e-mail as you want about this, but it's true! Don't tell me you're destined to be a major Hollywood star but you cannot scrape together the cash to get professional headshots.
The Grinch from Dr. Seuss' How the Grinch Stole Christmas! The Musical stole the spotlight at the Empire State Building's 86th Floor Observatory December 14, 2012, to promote the musical's limited holiday engagement. Discover the magic of Dr. Seuss' classic holiday tale as it comes to life on stage. Featuring the hit songs "You're A Mean One, Mr. Grinch" and "Welcome Christmas," The Grinch discovers there's more to Christmas then he bargained for in this heart-warming holiday classic.
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New tractor sales held 'steady' in 2018 – FTMTA
Sales of new tractors are holding steady. Figures for 2018 have just been released;…
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Kristalina Georgieva, Chief Executive Officer of the World Bank, discusses legal and regulatory disparities in access to and usage of formal financial institutions and highlight how well designed dig…
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Panelists discuss global public opinion of the United States and the direction of U.S. economic and foreign policies under President Donald J. Trump's administration.
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Kai-Fu Lee discusses the advances in artificial intelligence technology, the effects on the future of work, and the technology race between the United States and China.
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The Paul C. Warnke Lecture on International Security was established in 2002 and is endowed by a number of Council members and the family and friends of Paul C. Warnke.
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Speakers examine the growing opioid epidemic in the United States and compare global responses to opioid addiction, discuss the effects on the U.S. economy and labor force, and explore potential medi…
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Corporate - Model Risk Governance and Review Group – Central Challenger Team - Associate
Job Details
Company Chase is a leading global financial services firm with assets of $2.5 trillion and operations in more than 60 countries. The firm is a leader in investment banking, commercial banking, financial services for small business and consumers, financial transaction processing, asset management and private equity.
The Model Risk Governance and Review Group (MRGR) oversees model risk at Company, conducts independent model and non-model reviews and provides guidance around model and non-model's appropriate usage. MRGR is composed of 4 distinct units: Model Review Group (MRG), Model Governance Group (MGG), Chief Operating Officer (COO) and Central Challenger Team (CCT). The Central Challenger team has a firm-wide purview for independently assessing and driving improvements in the following areas:
1. Forecasting methodologies developed by various lines of business (LOBs) for the Firm's Capital Stress Testing and Budgeting process.
2. Key assumptions and pro-forma financial results across material entities, primarily in the context of the Firm's Resolution and Recovery process.
3. Key financial calculations across the Firm, including those related to capital measurement, stress testing & reporting, and product valuations.
The team partners with the Corporate Capital Stress Testing, Recovery & Resolution, LOBs, Regulatory Policy, Financial Reporting, Quantitative Research and various other Finance and Risk teams on various firm-wide initiatives.
Position Overview
The primary role of Central Challengers is to (i) constructively challenge and improve existing forecasting methodologies used across the Firm and (ii) review implementation accuracy and soundness of financial calculations. The Associate will support Pillar Leads on model and non-model reviews. Ability to think critically, take ownership of the review process and communicate effectively (both spoken and written) are critical to this role. Specialized roles may require fluency in statistics and model development.
Job Summary:
- Work with the Pillar leads to independently review and challenge key estimation methodologies and analytics/tools for firm-wide capital stress testing, resolution & recovery, budgeting and related processes
- Develop expertise in Asset & Wealth Management, and Commercial and Retail banking industries, products & services
- Review model and non-model documentation and write assessment reports
- Interact with teams across Finance and Risk functions, lines of business (front/middle/back office) and reporting groups.
- Stay abreast of regulatory and industry requirements in finance / risk / accounting to manage reviews and changes in processes.
The role and responsibilities of the successful candidate will be determined based on qualifications, prior experience and demonstrated skills.
- Graduate degree in a Finance, Economics, Business Management, Accounting, Engineering, Math/Statistics or related discipline
- Ability to think critically (question and argue logically; gather, assess and interpret relevant information in a diligent manner; challenge assumptions and explore alternatives), based on strong qualitative and quantitative analytical skills and independent research
- Strong communication (spoken and written) and organizational skills
- Extreme attention to detail
- Inquisitive and intellectually curious
- Self-starter who is able to perform effectively in a fast paced, results-driven environment
- Background or experience with quantitative and qualitative-based estimations, including pricing, capital, and/or financial forecasting models
- Knowledge of financial products, financial markets and regulatory requirements
- Control mindset (ability to identify control gaps and/or issues)
- Strong Excel skills required (VBA / SQL is a plus)
- Experience in statistical modeling software a plus (SAS, EViews, R, Matlab etc.)
Sign up and search through 93,822 curated jobs in the Finance & Investment Edition:
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Model Risk Management Validation Analyst
JOB SUMMARY A Model Risk Management Validation Analyst supports the implementation and execution of Bank wide model governance policy (MGP). This includes the review of complex models used within the organization, model documentation...
Central Bank Account Relationship Manager, Associate-Sr. Associate - Markets Group
What we do: The New York Fed, on behalf of the Federal Reserve System, offers correspondent banking and custody services to central banks, monetary authorities and certain international organizations to facilitate their official...
Director, Regulatory and Risk Governance Management
Company Description Common Purpose, Uncommon Opportunity. Everyone at Company works with one goal in mind - making sure that Company is the best way to pay and be paid, for everyone everywhere. This is our global vision and the common...
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Senior Vice President, Model Risk Inventory Systems
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So, how do you deal with these situations in life? The following might actually help:
- Sleep Over It
Believe it or not, this actually works. A good sleep is a cure for almost any problem that may be disturbing you, at least temporarily. This certainly does not imply resorting to sleeping pills, but to clear your mind, get some rest, and start all over again. With failure and stress that's all you can do – get over it.
- Try Positive Reframing
Denial, venting and cribbing about failure will only drag you further into the pit. Instead, try acceptance and optimism. In other words, start preaching that everything happens for good. Meditation is a good way of keeping stress at bay, and bringing in positive, motivational energies.
- Follow Your Dreams, Not Goals
If it was all about goals, there would not be even a single person on this planet who wouldn't have tasted failure. But when it comes to dreams even failure seems like a chapter from which you learn and grow stronger. With dreams, stress is replaced by excitement and the drive to achieve the ultimate.
- Don't Let Any One Bother You
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- Take a Break
Go for a vacation. A place that lets you breathe easy would be good. Choose the mountains or sea-side instead of a place brimming with people, a place that leaves you exhausted every passing day.


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