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Modern medical textbooks have all become so much more informative. It can tell complicated things in simple words. Yet, when you look at these books, you are confronted by mountains of facts about increasingly minute processes within the body. Students are expected to be impressed by the depth of knowledge because instead of one sentence approximating how a muscle works, there are now whole chapters devoted to the thin muscle filaments containing multiple proteins. This is my wood-for-the-trees moment.

Erectile dysfunction can now be described in terms of complex chemical interactions and illustrated with wonderful diagrams. There are still all kinds of analogies with hydraulic engineering, but the sophistication of the functional analysis is breathtaking. However, it is not a part of the medical books to observe and describe the entirely human context in which the erection is supposed to operate. A single male may masturbate. Multiple partners may engage in group sex. Many different social taboos would potentially be breached in any more detailed explanation. The greater the pleasure, the greater the incentive to engage in the activity and the greater the disappointment if success is not achieved.

Will medical treatment be asked for and a success? In part, this will be determined by the nature of the relationship. Where the relationship is socially disapproved, the man may well not seek treatment at all because of fear. A physical examination might reveal different types of sexual activity, or a chance remark in the consultation might expose the forbidden practices. This is ironic. Well-established sexual intimacy and commitment preserve the right level of desire and motivate everyone to getting a solution that works well. Were it not for online pharmacies and their willingness to supply medications like cialis without prescription, many partnerships might never be able to get appropriate treatment of any kind.

This is two completely different cultural imperatives in conflict. Men are socially conditioned to believe that they will always be able to have an erection. Any publicly acknowledged failure means shame. Yet they are only allowed to have erections in certain very carefully defined social situations. Step outside those situations and you are into potentially disapproved or even criminal territory. In theory, doctors are bound by duties of confidentiality, but the fear of exposure means that many men and their partners do not get treatment when the research shows that couples who are in love and share a strong commitment to their relationship are the ones who would most benefit from that treatment.

The number of causes of erectial disfunction is much more than you can imagine.

I suppose I’m coming to Diabetes slightly later than I should. Erectile Dysfunction is quite a common early symptom of Type 2 Diabetes, cardiovascular disease or both. If you read some books about this problem 12% of patients who are later confirmed as diabetic first appear in the consulting rooms complaining of ED. Putting this before the horse, the evidence is that treating ED in cardiovascular patients who are also diabetic significantly reduces the mortality rate. So some good can come out of treating ED, usually with Cialis, Viagra or Levitra although, it is better to prevent the onset of the Diabetes if at all possible, say, by reducing excess weight.

The cause of ED in diabetic men usually has both organic and psychological elements. Even if the first cause is not psychological, the onset of organic ED almost inevitably produces serious performance anxiety and, if not treated, depression. The combination inevitably affects the libido and this reinforces the disability.

Disease with decreased flow of blood into the penis through arterial narrowing, hardening and closure, high blood pressure, peripheral nerve damage, hormonal problems, say, because of decreased gonadal function, and obesity are all more common in diabetic men and each one may be the cause of your ED. Another cause of ED is diabetic desease.

So that leaves us with the question of how we treat both the ED and the diabetes.

• Try to control the level of blood sugar can prevent the nerve and blood vessel damage that leads to ED.
• Many of the medications used to treat high blood pressure and depression may cause ED. Sometimes, a simple change can restore function.
• Smoking and other uses of tobacco, (a) constrict and may block your blood vessels; and (b) can also reduce nitric oxide levels, both of which which may limit the flow of blood into your penis.
• Don’t drink to much alkohol.
• Performance anxiety and depression can cause ED. To keep your stress levels under control, you should review your current tasks, and set more reasonable goals and deadlines.
• Join the club or gym to prevent ED.
• If you sleep well, you are less likely to suffer from ED.

I can also consider Viagra, Cialis or Levitra, but these drugs are not safe if you are taking nitrates to treat heart disease or alpha blockers to treat high blood pressure or prostate enlargement This takes us into new territory for these articles. The vacuum constriction device works no matter what the cause of the ED. You also can stick a needle in your penis to maintain erection. Surgery and penile prostheses implantation are highly successful, but there are greater risks of infection when operating on diabetic men.

Thus, there are well-established systems for treating both diabetes and ED. There is no need to suffer in silence. Your sex life can be restored in most cases, albeit that sometimes, you cannot rely on a simple pill to solve the problems.

A few years back, the Massachusetts Male Aging Study (MMAS) of men aged between forty and seventy years found that 28% of men with diabetes had ED - about three times the incidence in the general population. Averaging out the later surveys over the age range, ED develops between ten and fifteen years earlier in men with diabetes. Above the age of 50 years, between 50-60% of men with diabetes will have difficulties with an erection. Above 70 years, it is almost certain that diabetic men will have some difficulty with erectile function.

At the meeting of the American College of Cardiology held in Chicago this March, Merck & Co released some clinical data from the Phase III trials for their proposed competitor to acomplia (rimonabant). This new medication, still going by its generic name of taranabant, targets the same cannabinoid system as acomplia. It is therefore interesting to compare results since, if it gains regulatory approval, it will be a direct competitor to acomplia.

The randomised, double-blind and placebo-controlled trials recruited more than eight hundred participants who all had at least BMI 27. Merck & Co disclosed the preliminary results calculated at the end of year one of what is intended as a two year trial. In conjunction with a diet and exercise program, 28% of those taking a 2mg dose of taranabant lost more than 10% of their body weight, while 57% lost 5% of their body weight. Almost 8% of those on placebo also lost 10% of their body weight through diet and exercise alone. In terms of averages, participants taking a 2mg dose of taranabant lost 14.5 pounds compared to 5.7 pounds on placebo. Depending on how you view these things, this could be viewed as a failure because Merck & Co announced in advance that it was aiming for a minimum 5% body weight loss in all participants taking their medication.

In 2004, Acomplia’s results were that 32% on Acomplia lost more than 10% of their body weight while 62.5% lost more than 5% of their body weight. But these results were obtained at the higher dosage of 20mg as opposed to 2mg taranabant. The reason for the difference in the dosage levels is that acomplia is a CB1 receptor antagonist that blocks endogenous cannabinoid binding to neuronal CB1 receptors, while taranabant acts as a selective cannabinoid-1 receptor inverse agonist, binding to CB1 receptors. I am glad we have got that clear.

Merck & Co also tested higher doses of 4mg and 6mg but admitted problems with psychiatric side effects. It confirmed that taranabant would probably only be brought to the market at the lowest 2mg dose. Because the FDA has already expressed concern about similar side effects in acomplia, the Merck trials looked more specifically for evidence of the effects. It seems that 28% of participants on the 2mg dose reported side effects but it is not known how severe they were.

Because both medications work in a similar way, it always seemed likely that they would have similar problems with central nervous system side effects. Given that acomplia was given a rough ride by the FDA, it would seem unlikely that taranabant will fare any better on the information so far made public. Although both seem to improve the levels of high-density cholesterol and to bring down the level of triglycerides which will help to reduce the risk of heart disease, the fact that both have been associated with feelings of depression and, in some cases, suicide will probably mean that neither will be approved in the US in the near future. Even if the current trials for acomplia produce results with few or no central nervous system side effects, the results of taranabant may still drag acomplia down. If taranabant is also producing unacceptable levels of psychological disturbance at 4mg, acomplia does not look so good at higher dosages.

Nevertheless, this must be placed in a proper context. Acomplia has, of course, been available on prescription in Europe for two years and there is no emerging evidence of problems sufficiently serious to justify withdrawing approval. Indeed, it has just been given a further level of approval in the UK. If acomplia continues to accumulate a positive safety record, this may offset any prejudicial implications in the US from the taranabant trials. What should be relatively uncontroversial is that the use of the cannabinoid system for the treatment of obesity should remain firmly on the research agenda. Acomplia continues to offer an effective supplement to diet and exercise regimes. As its effects are better understood, the reported side effects may be better controlled.