Disclaimer. SOP: physical examination and laboratory testing for men with erectile dysfunction. 8600 Rockville Pike Then the Lemonaid pharmacy, licensed in all 50 states, will ship your meds directly to your door in discreet packaging. Cialis Together 10mg Tablets - Tadalafil - 4 Tablets. He reported no significant change in erection with PDE5 inhibitors. Excessive preoccupation with physical disease, History to include sexual, genitourinary, medical, surgical, psychosocial, medications, response to oral PDE5 inhibitors, Biothesiometry (measures of threshold of appreciation of vibration), Hot and cold perception (assess for integrity of the dorsal nerve), For patients who report complete failure with oral PDE5 inhibitors, Combined injection and stimulation test (assess response to small amount of low dose bimix papaverine 30 mg/phentolamine 0.5 mg) with supine and upright posture, For patients with poor response to both PDE5 inhibitors and injection, Consider penile color duplex ultrasound (PCDU). Both are taken 30 minutes before sex. He responds well to low dose oral PDE5 inhibitors. Time/duration: we included studies of all durations: short ( 6 months), medium (between 6 and 18 months), and long ( 18 months). He lives at home, is unemployed, and is sedentary. For the CIS, inject bimix (such as papaverine 30 mg/phentolamine 0.5 mg/mL0.20.3 cc) and have the patient compress the injection site for 5 minutes. [email protected] +1 3412 61846 51 2022 Jul-Sep;19(7-9):12-16. It belongs to a class of drugs called phosphodiesterase type 5 (PDE5 . With Viagra, there is a higher risk of vision changes than with Cialis. Vision changes. Stratton H, Sansom J, Brown-Major A, Anderson P, Ng L. Stratton H, Sansom J, Brown-Major A, Anderson P, Ng L. Interventions for sexual dysfunction following stroke. The site is secure. Epub 2008 Jul 1. 1. FDA Updates Labeling for Viagra, Cialis and Levitra for Rare Post-Marketing Reports of Eye Problems; Questions and Answers on Cialis (tadalafil) Content current as of: 07/09/2015. University of California San Francisco, 400 Parnassus Avenue, Suite A610, San Francisco, CA 94143, USA. Tadalafil is used for treatment of benign prostatic hyperplasia (BPH) or erectile dysfunction (ED), or both conditions. Viagra is the brand name for sildenafil, a medication for treating erectile dysfunction (ED). INDIANAPOLIS, July 16, 2013 /PRNewswire/ -- Eli Lilly and Company (NYSE: LLY) announced today that study results published in the Journal of Sexual Medicine showed a greater percentage of men who had an incomplete response to as-needed PDE5 inhibitor treatment returned to normal erectile function when given Cialis once daily, compared to placebo, as measured by the erectile function domain of . Cialis 5 mg is effective. Taking 40 mg of Cialis could be dangerous and raise the risk of side effects such as a sudden drop in blood pressure and priapism. His diagnosis can be made from the history alone. Studies show that there appears to be a temporary time of adaptation after the stroke in which sex life is halted. The recommended starting dose of Cialis for use as needed is 10mg. Muscle pain. With this said, it may be therapeutic for the patient to know his laboratory assessments are normal, in which case additional testing does add significant value to the assessment. Stroke Res Treat. The active ingredient is Tadalafil. The study that compared a structured rehabilitation programme to written education alone was funded by the Victor Hurley Medical Research Grant-in-Aid and by the AFRM Ipsen Open Research Fellowship. This mans situational ED, possibly due to performance anxiety or perhaps fear of a repeat injury and pain. . government site. This will give the objective information that you might need in order to make a diagnosis of a known etiology for ED and to provide the patient reassurance that your evaluation has been thorough. Side effects (mostly nausea or diarrhoea) were reported for sertraline (20 of 58 participants). Failure to achieve a fully rigid erection may aggravate performance anxiety leading to a vicious cycle. Tadalafil (Adcirca) is used to treat pulmonary arterial hypertension (PAH) . A second trial compared a structured rehabilitation programme (which had face-to-face counselling and written education) to written education alone and found no clear difference in terms of sexual function, mood, stress, or quality of life. Careers, Unable to load your collection due to an error. Careers. Cialis can also be used to treat symptoms of ED and BPH together. It is available in both brand and generic versions. Philadelphia: Elsevier Inc; 2011. He was displeased with these findings as they were incongruent with his chief complaints; normal results caused him to become tearful. This is a 22-year-old man who presents with no medical or surgical history who reports that he has never had a rigid erection in his life. Primary outcomes focused on sexual function or sexual satisfaction in stroke survivors and their partners. You do not have to take Cialis at any specific time before sexual activity when it's . 4 UNI | 4.95 per 1UNI. Two months later he reported normal penile erections, and the result has lasted for more than 5 years. Phentolamine re-dosing during penile dynamic colour Doppler ultrasound: a practical method to abolish a false diagnosis of venous leakage in patients with erectile dysfunction. His physical examination is normal. being unable to get an erection at any time. Chewable Tadalafil. It was recommended that the patient focus on relaxation techniques, increase cardiovascular exercise, take cialis 5 mg PO prn as it is effective, and to start scheduled terazosin 1 mg po at bedtime to relax the hypertonic cavernous smooth muscle. These young men are usually technologically savvy and may have scrutinized much of the readily available information on the internet regarding ED. It was also recommended that he seek care with a sexual therapist to work through additional issues related to his addiction to masturbation. The typical dose is 10 mg for occasional use and 2.5 or 5 mg for . For example, Cialis for erectile dysfunction (ED . official website and that any information you provide is encrypted A thorough physical examination should be performed on all new patients with emphasis on the cardiovascular, genital, endocrine, and neurologic systems. Cialis can cause limb pain, while Viagra can cause vision change, rash . His previous laboratory assessment, including CBC, CMP, TSH, T4, T and Free T, was normal. This was consistent with a diagnosis of venous leak impotence. He reports normal nocturnal erections most days of the week. Ask the patient to define his specific concerns. Mild side effects that have been reported with Cialis include: headache *. Tadalafil is used to treat male sexual function problems (impotence or erectile dysfunction-ED). When a man is sexually stimulated, his body's normal response is to increase blood flow to his penis to produce an erection. Additional information to obtain includes a psychosocial and cultural history to assess past and present relationships, emotional or professional stressors, current and previous psychological/behavioral diagnoses and treatments, educational level and employment status, and location of domicile. 2005 Sep;48(3):512-8; discussion 517-8. doi: 10.1016/j.eururo.2005.05.014. Ultrasound Urinalysis Treatment The first thing your doctor will do is to make sure you're getting the right treatment for any health conditions that could be causing or worsening your erectile dysfunction. Some people simply lose the ability to maintain an erection because testosterone levels decrease with age. Santiago-Lastra Y, Williams BC, Hollingsworth JM. Additional assessment with cold and hot perception testing and biothesiometer were performed due to his complaint of decreased sensation; both test results were normal. Renal impairment: CrCl 30-50mL/min: initially 2.5mg; may increase to 5mg/day. FOIA He is in the care of a sexual therapist and has read extensively on the internet. Baumgartner RW, Sidler C, Mosso M, Georgiadis D. Stroke. CIALIS was studied in the general ED population in 7 randomized, multicenter, double-blinded, placebo-controlled, parallel-arm design, primary efficacy and safety studies of 12-weeks duration. Cialis. His testosterone (T) and free T are normal. In most young men with ED, additional testing to assess for the origin of ED is unnecessary as the history gives you the information that you need. 5. The problem is reported by 1 in 5 men, and. It was recommended that he utilize lubricants for masturbation, that he decrease the frequency of masturbation, and that he investigate vibrators to increase glanular stimulation if necessary. AUA Update Series 2015. In addition to ED, Cialis and tadalafil are also approved to treat benign prostatic hyperplasia(BPH). Patients' IIEF5 values were significantly lower [median 16 interquartile range (IQR) 3.5-20.5] after than before stroke (median 23, IQR 19.0-24.0) and lower than in controls (median 24, IQR 19.8-25.0). But it can take up to 2 hours for its full effects to kick in. orthostatic hypotension, a form of low blood pressure. Norepinephrine involvement in response to intracorporeal injection of papaverine in psychogenic impotence. Cialis is used to treat erectile dysfunction (ED) and to reduce symptoms of benign prostatic hyperplasia (BPH). The recommended starting dose of CIALIS for once daily use is 2.5 mg, taken at approximately the same time every day, without regard to timing of sexual activity. upset stomach and indigestion. He does not masturbate because he feels that masturbation may have desensitized his brain and caused ED; however, he can masturbate and have an erection with normal orgasm/ejaculation. His erection lasted more than 2 hours and required phenylephrine to resolve the erection. We also included other non-pharmacological interventions (such as education or therapy), which were compared against usual care or different forms of intervention (such as different intensities) for treating sexual dysfunction in stroke survivors. Structural, neurogenic, arteriogenic, and venous occlusive erectile dysfunction can be ruled out as he has normal self-stimulated erections. But there are some differences. Lesson 40: Dealing with the Difficult Patient Encounter. Neurogenic Erectile Dysfunction. For treating ED, the Cialis dosage for daily use is 2.5 mg once per day. This may be accomplished through a scheduled follow-up telephone call, electronic message, follow-up clinic visit, or a written letter. The study that compared pelvic floor training to standard rehabilitation was funded through grants from the Association of Danish Physiotherapists Research Foundation, the Association of Danish Physiotherapists Practise Foundation, the Foundation of 12.12.1981, Lykkefeldts Grant, the Foundation of Lundbeck (UCSF), and the Department of Physiotherapy and Occupational Therapy Glostrup Hospital, University of Copenhagen. For patients who have ED related to hypertonic cavernous smooth muscle and excessive sympathetic discharge, we recommend a trial of a low-dose alpha adrenergic blocker, such as terazosin 1 mg PO at bedtime nightly. This often requires reversal of erection using phenylephrine after the study. He has had a successful erection and intercourse with a partner, last time 2 weeks ago. It is important to ensure that the doctor-patient interaction is informative and task oriented for greater patient buy-in and compliance with treatment (13,14). Tadalafil is used to treat men who have erectile dysfunction (also called sexual impotence). The effect of tadalafil may last up to 36 hours. Some of the most common physical causes of ED include: heart disease and narrowing of blood vessels. If the patient reports a history of trauma to the genitals that preceded his erectile dysfunction, further evaluation with pharmacologic injection and penile color duplex ultrasound (PCDU) would be indicated to assess for arterial insufficiency or venous occlusive dysfunction (19). These medicines prevent an enzyme called phosphodiesterase type-5 from working too quickly. Publication types Research Support, Non-U.S. Gov't MeSH terms Adult Aged ED is often a symptom of another health problem or health-related factor. Tadalafil is used to treat men who have erectile dysfunction (also called sexual impotence). loose stools. 1971;94(1):165-72 From the history alone, we find that most of these men will have situational erectile dysfunction that responds well to low dose oral PDE-5 inhibitors. Methods: J Neurol. Unauthorized use of these marks is strictly prohibited. Cialis Daily is a 5mg tadalafil pill that you take every day. It should begin with information regarding onset, duration, severity, patient-suspected etiology of the ED. Federal government websites often end in .gov or .mil. Insular multiple sclerosis lesions are associated with erectile dysfunction. sharing sensitive information, make sure youre on a federal Patient education is critical to exploring treatment options and developing confidence in our ability to treat the ED, and their own ability to overcome and eventually resolve the problem of ED. Erectile dysfunction in young men is an increasingly common chief complaint seen in urology clinics across the world (1). The penis is one of the areas where this enzyme works. Without treatment, ED can make sex difficult. A PCDU was ordered which revealed normal arterial inflow with velocities greater than >40 cm/sec with increased end diastolic velocities suggestive of venous leak. He reports strong, sustainable erections with tadalafil 5 mg and recovery of sensation when he uses marijuana. Previous studies have shown that elevated central sympathetic tone may be one cause of impotence (6,7). The CIALIS dose for once daily use may be increased to 5 mg, based on individual efficacy and tolerability. PRN use: 10 mg PO initially before sexual activity, with or without food; may be increased to 20 mg or reduced to 5 mg on basis of efficacy and tolerability; in most patients, maximum dosing frequency is once daily Epub 2018 Feb 1. In many cases, they may have self-diagnosed and self-treated based on the information that they obtained prior to seeing a physician. a heart attack. Cialis is approved for the treatment of men who experience difficulty having and maintaining an erection (impotence). It works by increasing blood flow to the penis during sexual stimulation. We found three trials designed to reduce sexual dysfunction after stroke. However, it is well documented that due to increased sympathetic tone these young men will often require additional injection or a separate visit in order to respond appropriately with complete smooth muscle relaxation (7,20,21). Cialis (tadalafil) is an erectile dysfunction medicine used to treat impotence (the inability to attain or maintain a penile erection) and benign prostatic hyperplasia (BPH). DOI: 10.1002/14651858.CD011189.pub2. CIALIS may be taken without regard to food. The study that compared the medication (sertraline) to vitamin B12 did not describe any funding sources. Correlation of the erectile dysfunction with lesions of cerebrovascular accidents. May present to the clinic visit with family members present, most often parents, 14. This is a common health problem that affects the prostate as men get older. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; from June 2014), in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. The false diagnosis of venous leak: prevalence and predictors. Gontero P, Sriprasad S, Wilkins CJ, et al. fever. He reports no change with any of these treatments. Onset is typically within half an hour and the duration is up to 36 hours. Bethesda, MD 20894, Web Policies There are well-known risks of cardiovascular events in patients taking sildenafil concomitantly with organic nitrates.1,2 However, little is known about stroke risk in patients with previous cerebrovascular events who take sildenafil. 19.79. muscle pain, back pain, pain in your arms, legs, or back. Extra Low Prices. He has seen two other urologists already for his erectile dysfunction and been displeased with the outcome of his visits. This may be increased to 20mg if you still find it difficult to get or maintain an erection at a 10mg dose or reduced to 5mg if you develop side effects. being able to get an erection, but not having it last long enough for sex. It is sometimes known by its generic name, Tadalafil. The cost for these different strengths depends on whether you have insurance, your individual plan coverage, and your treatment plan. Common side effects of Cialis include facial flushing, headaches, stomach upset, diarrhea, flu-like symptoms, and nausea. 23. If the patient requires PDE5 inhibitors to obtain and maintain all erections, you might consider laboratory assessment prior to proceeding. To evaluate the effectiveness of interventions to reduce sexual dysfunction following stroke, and to assess adverse events associated with interventions for sexual dysfunction following stroke. You may need to try a different erectile dysfunction medication, such as Viagra, or Levitra. Disruption of the central network assuring erection might contribute to increased ED severity and prevalence after stroke. Cialis is available as a tablet in four different dose strengthsany of which can be taken with or without food. 18yrs: 5mg once daily (taken at same time each day). Anti-erectile effects of functional and psychological impairment or medication added after stroke may also contribute to ED but must be evaluated in larger patients groups. He is also emotionally labile. During his urologic visit we performed both cold and hot perception testing and biothesiometer, which were normal. Cialis is a safe and effective option for most men affected by one of these conditions. Further research is needed to assess the effectiveness of treatments for sexual problems after stroke. Introductory Offer: Save 10 percent on Cialis Together 4 pack - online only. The urologist must discuss the topic of ED delicately and caringly in order to earn the patients trust and be permitted to address his problem (15). He takes Wellbutrin. His physical examination is normal. A methodical medical history should be obtained to identify medical conditions that might be contributing to the patients ED. You can get a prescription online following a quick and easy visit with a member of our clinical team. Keywords: Autonomic network; Erectile dysfunction; Ischemic stroke; Prevalence. For occasional use, most people start with Viagra which also tends to be cheaper. The recommended dose of CIALIS for once daily use is 5 mg, taken at approximately the same time every day, without regard to timing of sexual activity. Psychological factors associated with male sexual dysfunction: screening and treatment for the urologist. One of the most common but least talked about effects of stroke is sexual dysfunction, with 50% or more of stroke survivors experiencing a degree of sexual decline post stroke. He reports inability to obtain or maintain an erection with a partner unless he takes tadalafil 5 mg. Campbell-Walsh Urology. What has been excluded entirely from all recent discussions of ED in young men is a concept presented many years agothe concept of increased sympathetic tone as an organic etiology of psychogenic erectile dysfunction in young men (5). Was 21.99. Tadalafil belongs to a group of medicines called phosphodiesterase 5 (PDE5) inhibitors. Autonomic network; Erectile dysfunction; Ischemic stroke; Prevalence. Cialis Daily is a popular brand-name ED medicine approved by the FDA for erectile dysfunction. Also, each of the three studies compared different treatments, which meant that we could not combine study results. It is important to identify the precise etiology of ED in these men before proceeding with potentially unnecessary evaluation and treatment as the process can be anxiety-provoking, invasive, and costly and may provide an unreliable diagnosis which produces further psychological distress in these psychologically fragile young men. Tadalafil, or generic Cialis, is most commonly used to treat erectile dysfunction (ED). One trial compared a medication called sertraline to methylcobalamin (vitamin B12) to help with premature ejaculation. It should be noted, however, that it may not be possible to double-blind trials of complex interventions. Erectile dysfunction (ED) happens when a man has ongoing problems getting and keeping an erection. Prior to the visit, his mother called the clinic to inform personnel that her son was very sensitive, potentially suicidal, and emotionally disturbed by this problem. Please enable it to take advantage of the complete set of features! 2015. Taking Cialis. Depending on the adequacy of the response or side effects, the dose may be increased to 20 mg or decreased to 5 mg a day. A thorough sexual history has many components. Results: Many of these men will see multiple urologists on their quest to find a pathophysiology that they can accept, and many have unrealistic expectations of a rapid cure or a surgical cure. Sexual Function After a Stroke By itself, stroke is almost never a direct cause of sexual dysfunction. -, Brain. The site is secure. This makes the evaluation and treatment of these men more challenging since additional diagnostic testing is often not indicated after a thorough history and physical examination. After taking a single tablet, some of the active ingredient of Cialis remains in your body for more than 2 days. If the patient reports that PDE 5 inhibitors work poorly or inconsistently, we offer CIS to objectively assess erectile function and to provide diagnostic information. If the patient responds inconsistently or does not respond to the oral medications, additional workup should be considered, dependent on the additional history provided. You can use Cialis on a daily basis at a lower dosage. Inclusion in an NLM database does not imply endorsement of, or agreement with, Conclusions: hoarseness. However, it's also used to treat benign prostatic hyperplasia (BPH) and pulmonary arterial hypertension . Erectile Dysfunction. FOIA Ask specific questions regarding erectile hardness and sustainability during self-stimulation versus with a partner (global versus situational ED). muscle aching, cramping, or stiffness. diabetes. 2021 Dec 3;2021:9988841. doi: 10.1155/2021/9988841. A full battery of labs was ordered and returned normal. This site needs JavaScript to work properly. Chewable Sildenafil. Bethesda, MD 20894, Web Policies Cialis should be used cautiously in patients with bleeding disorders or active ulcers. It can also be taken when needed for erectile dysfunction. If the patient reports life-long erectile dysfunction, having never obtained an erection rigid enough for penetration, he should be assessed with an appropriate laboratory evaluation and PCDU. A detailed history is the most important component of the evaluation. After pharmacologic erection, he developed a partial erection that resolved within 1 minute. Brain. Lemonaid can prescribe sildenafil (generic Viagra), tadalafil (generic Cialis), and vardenafil (generic Levitra). No. hearing loss. Tablet: 2.5 milligrams (mg), 5 mg, 10 mg, and 20 mg. Cialis dosage for adult males. The role of Ureaplasma parvum serovar-3 or serovar-14 infection in female patients with chronic micturition urethral pain and recurrent microscopic hematuria, 2. 2018 Apr;265(4):783-792. doi: 10.1007/s00415-018-8763-5. Davidson RJ, Pizzagalli D, Nitschke JB, et al. Affirm to the patient that regardless of the short time allotted for the visit that the doctor-patient relationship will endure even after the visit. Would you like email updates of new search results? HHS Vulnerability Disclosure, Help Secondary outcomes focused on quality of life, psychological well-being (anxiety, depression, stress), satisfaction with intervention, sexual knowledge, and marital/relationship satisfaction (including partner satisfaction) in stroke survivors and their partners. (This quick bedside procedure has the potential to be both diagnostic and therapeutic for the patient; the importance of this cannot be underestimated). National Library of Medicine If those medications are effective, you have effectively ruled out significant arterial insufficiency or venous leakage disease as an etiology. The penis is one of the areas where this enzyme works. A third trial compared pelvic floor training (exercises to strengthen pelvic floor muscles) to standard rehabilitation and found no clear differences in terms of erection and quality of life. -. We determined the risk of bias for each study and performed a 'best evidence' synthesis using the GRADE approach. . high blood pressure. 2003;22(4):322-7 Lowest U.S. Pharmacy Coupon Price: $0.43 per tablet for 88 tablets. It may also provide reassurance to the patient that his anatomy is functional. Cialis (tadalafil) is a prescription drug used to treat erectile dysfunction (ED) and benign prostatic hyperplasia (BPH). 4. He feels that this might be related to over masturbation without lubricant 13 times per day and reports that he is addicted to masturbation, using it as a coping mechanism to manage his PTSD. All three treatments (sertraline, structured sexual rehabilitation, and pelvic floor physiotherapy) need to be tested in further studies. CIALIS, when taken as needed up to once per day, was shown to be effective in improving erectile function in men with erectile dysfunction (ED). About 75% of men who undergo nerve-sparing prostatectomy or more precise forms of radiation therapy have . Other similar ED medications can start working even faster. It may also be used to treat the enlargement of the prostate gland. 2.4 CIALIS for Once Daily Use for Erectile Dysfunction and Benign Prostatic Hyperplasia. Two review authors independently selected eligible studies, extracted data, and assessed study quality. feeling of constant movement of self or surroundings. These are not mandatory components of the assessment in a patient with hypertonic cavernous smooth muscle as the source of ED. Tadalafil belongs to a group of medicines called phosphodiesterase 5 (PDE5) inhibitors. PMC Developing a system to explain the pathophysiologic mechanism of the dysfunction may make it easier to effectively treat these complex patients. Study Design - CIALIS was studied in the general ED population in 7 randomized, multicenter, double-blinded, placebo-controlled, parallel-arm design, primary efficacy and safety studies of 12-weeks duration. Comparison: we compared interventions such as medications against 'fake' medications, which do not contain active substances that affect sexual function. It is also important to ask the patient about past treatments and response. 2.5 Use with Food. The .gov means its official. National Library of Medicine This detailed discussion helps to engage the patient in the treatment plan and provides encouragement regarding the potential for response to treatment and recovery. Sympathetic inhibition of papaverine induced erection. CIALIS for Once Daily Use for Erectile Dysfunction. The functional anatomy, neurochemistry, and pharmacology of anxiety. Cialis . By comparison, Viagra begins to work within 30 minutes; its maximum effects generally appear after 45 minutes to 1 hour. We noted significant heterogeneity in interventions (one pharmacological, one physiotherapy-based, and one psycho-educational), and all RCTs were small and of 'low' or 'very low' quality. This mans history is adequate to rule out arterial or venous insufficiency as he can masturbate to produce a rigid, sustainable erection and he responds well to tadalafil. official website and that any information you provide is encrypted Cochrane Database of Systematic Reviews 2020, Issue 5. Written by Julie Davis. the contents by NLM or the National Institutes of Health. Management options are very broad and can include medications, counselling, and physical therapy. ED that occurs due to a physical cause usually happens for one of the following reasons: You are getting older. You save 99% off the average U.S. pharmacy retail price of $56.49 per tablet for 88 tablets. Physiology of Erection and Pathophysiology of ED. PCDU revealed normal peak flow bilaterally of 40 cm/sec with no end diastolic flow and 100% rigidity obtained. On the other hand, Cialis has a slightly higher risk of muscle pain than Viagra and vardenafil. If the patient reports intermittent ability to obtain and maintain an erection, evaluation with combined injection and stimulation test (CIS) will give you additional diagnostic and potentially therapeutic answers. Stroke may cause or worsen erectile dysfunction (ED). Before Talk with your doctor. The Challenge of Erectile Dysfunction Management in the Young Man. pink eye. Two mechanisms have been proposed to explain the inhibition of erection in psychogenic dysfunction: direct inhibition of the spinal erection center by the brain as an exaggeration of the normal suprasacral inhibition and excessive sympathetic outflow or elevated peripheral catecholamine levels, which may increase penile smooth muscle tone and prevent the relaxation necessary for erection (8). 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