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Cancer can attack any part of the body; lungs, stomach, reproductory organs and many other parts. A common form of cancer in men is testicular cancer. This is a cancer that occurs in the male sex glands in the scrotum. Testicles produce and store sperms while producing male hormones. Testicular cancer is also known as germ cell tumor and is of two kinds - seminoma or nonseminoma. About 40% of testicular cancer are seminoma type and the other are divided into four sub-types; choriocarcinoma, teratoma, embryonal carcinoma and yolk sac tumors. The cancer can sometimes also be a combination of both cancers, and are called mixed germ-cell tumors. Testicular cancer is prevalent in men aged between 15 and 35 and is more common in white men than Asians and blacks. The exact causes are still unknown, but there are various risk factors that can induce testicular cancer. Underdevelopment of testicles, Klinefelter’s syndrome where the man experiences sterility, small testes, breast enlargement and lesser male hormones and those who have had testicular cancer are all prone developing cancer on the other testicle in the 25 years after the attack. There is nothing that can be done to prevent testicular cancer; the most that could be done is its early detection. Testicular self-exam is a great means of diagnosing testicular cancer; it is always better to test testicles immediately after bathing as this is when the scrotal sac is relaxed. The testicles have to be rolled between the forefinger and thumb for any signs of lumps. Besides a lump, swelling in the testicles or some changes in the feel of the testicle are symptoms for testicular cancer. Accumulation of fluid in the scrotum or pain in the scrotum is also considered as symptoms of testicular cancer. Though these symptoms may signify other conditions, it is always better to have a physician evaluate the condition. Testicular cancer can also be diagnosed through ultrasound of the scrotum or a biopsy. Once testicular cancer is detected, treatment is rendered according to the extent of the condition. Depending on whether testicular cancer is seminoma or nonseminoma, and its stage, is its treatment determined. All treatments involve the removal of the affected testicle. However, as this can affect fertility and sexuality, this has to be discussed with the family. With the removal of a testicle, the other testicle is capable of producing sperms and an erection so that it is possible to father a child. However, any other surgery, radiation and chemotherapy also affect sperm production and ejaculation. So the treatment should be discussed before adapting it. In nonseminomas, the lymph nodes are also removed to find out the extent of tumor spread. However, this is not necessary in seminomas as CT scans provide sufficient information. Radiation is preferable for seminomas, and not for nonseminomas as they are not sensitive to radiation. When giving radiation, the remaining testicle is usually shielded to prevent radiation reaching it as this may hamper its ability in producing sperms. Though sperm count may reduce after radiation, it returns to normal in a few years of treatment. Chemotherapy is administered after surgery through injections or orally to kill any tumor cells there may be in the body. Whatever the treatment adapted, it is necessary to have follow up testing because there is always the chance of a recurrence of a second tumor. There are different follow up testing routines to be adapted; it all depends on the case. pnis enlargement exercise cheap vigrx pills pennis enlargement photo penis enlagement surgeon penis girth elargement do penis enlarement pills work penis enargement pills product buy vigrx

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Researches have established that a diabetes patient is more prone to succumb to erectile dysfunction than a normal person. Erectile Dysfunction besides diabetes can prove a disastrous combination that can have an impending effect on the psychological and physical well being of a man's life. Men who are having erectile dysfunction problem may became so concerned with the inadequacy that they try to avoid the sexual situation altogether. Same time it increases the stress level, frustration and can trigger a bout of depression. It is estimated that more than 50% diabetic patient are suffering from ED. Erectile Dysfunction occur at younger age. Within 10 yrs of the diagnosis of the disease trait of ED begin to surface, although not all diabetics develop ED. Why the diabetics are easy prey to Erectile Dysfunction? Men endowed with healthy blood vessel, nerves, male Harmon and “desire” to perform gets the erection on wish. Diabetes can kill blood vessels and nerves that make the erection possible. Therefore even the normal amount of male hormones and desire to have sex can not help getting a firm erection. Medical people believe that presence of a blood sugar in diabetic prove an impediment to the enzyme that start the series of events which lead to erection. Endothelial nitric acid syntheses (eNOs) enzyme considered responsible to start the chain of vascular events that produce and sustain erection.Enzyme (eNOs) cause the release of Nitric Oxide at the nerve ending in penis. The initial release of NO get a quick and short duration increase in penile blood flow it also cause short time relaxation in penile muscle to get an erection. Enhanced penile blood vessel and smooth penile muscle relaxation increase the blood flow in penis which results in erection. When blood sugar O-GLcNac present in hyper glycemic(high blood sugar) circumstances interrupt eNOs enzyme this may cause permanent penile impairment over time. A patient of diabetes should always take extra care to understand the complexities of his health psychosexual counseling is mandatory in these situations. Sexual therapy is vital for people with diabetes, since the chronic condition is fraught with situational stresses, performance anxiety, and problems in relationships. A range of different modes of medication are available for the diabetics. Penile injection or vacuum erection device therapy has been used by many patients with satisfaction. A penile prosthesis was certainly a viable option in these individuals should they fail those therapies or wish to go directly to penile prosthesis. Obviously one must bear in mind that diabetics have a higher incidence of infection and thus they should be counseled in that regard. Sildenafil is also proving a good source that diabetics can look up to. cheap vigrx pill top pnis enlargement pills do penile enlargment pills work natural penis enlarement pills penis enlargement picture penis enlargement surgery cost male penis enlagement best penis enlargement penis enlarement before and after

Introduction Trieste is an Adriatic coastal city in northeastern Italy, close to the border with Slovenia. The sea in the Gulf of Trieste is very clear and clean, with limestone cliffs and rocky beaches. The centre of the city has a mid-European feel, more Austrian than Italian, Trieste was the seaport of the Hapsburg Empire. Unique Points You can enjoy a combination of a sea/beach holiday and the attractions of a cultural city. It is an ideal destination for a short break but you could easily spend a week here too. The Verdi Theatre hosts an opera season in the winter and an operetta festival in summer. You can swim in the beautiful clear sea, stroll the promenade, and walk along the cliff paths. Take in the wonderful art collection at the Revoltella Museum. You can sip coffee on Piazza Unita Italia with its grand 19th century buildings, which face onto the sea. Getting there Ryanair flies into Trieste from London Standsted. The airport is 35 kms west of Trieste but there is regular public transport on Coach 51 into Trieste. Getting around If you do decide to hire a car, it is worth checking that you can take it into Slovenia and Croatia if you are considering day trips there. Trieste has a good public transport network. There is a "Trieste by Bus" city tour in 13 stops. This is available on Saturdays and Sundays at 2pm from the end of June to mid October. The two and a half hour trip allows you to see the city's main attractions. The cost is around five euros per person. You can take the Opicani tram up to the Carso plateau, 348 metres above sea level. This funicular tramway was built in 1902. The tram leaves from Piazza Oberdan in the city centre up Scorolo hill to the plateau above. History According to folklore Trieste was founded by Tergeste, a friend of Jason and the Argonauts. Ancient Tergeste as a Roman colony is dated to around 178 BC. It became more important during the reign of Octavian when roads were improved. The city has had many rulers during its history: Goths, Byzantines, and Lombards. In the 13th century Trieste was forced to swear allegiance to Venice. To escape Venetian domination, Trieste sought the protection of Duke Leopold of Austria. Trieste was of great importance to the Hapsburg Empire as a seaport and was made a Freeport in 1719. Without customs barriers the port and city flourished. At the end of the First World War with collapse of the Hapsburg Empire, Trieste was returned to Italy in 1918. Trieste was taken over by the Third Riech when Italy withdrew from the Second World Ward in September 1943. Two years later there was a 40-day Occupation by Tito's Yugoslav forces. After 9 years under an Anglo-American government Trieste was handed over to the Italian government. Trieste's history may help explain why 70% of Italians apparently did not know that Trieste was part of Italy in a recent opinion poll! With EU enlargement Trieste is ideally placed as the only natural port in the centre of Europe. Trieste is one of three finalists to host the international Expo of Science, Technology and Culture in 2008. If its bid is successful there will be more investment in the area and Trieste will become better known on the world map. Literary Connections The Irish author James Joyce lived in Trieste during the early part of the 20th century. When he first arrived he worked as a tutor at the Berlitz School of English. He went on to write "The Dubliners", "The Portrait of an Artist as a Young Man" and start "Ulysses" in Trieste. The rich mix of central European and Eastern Mediterranean culture in Trieste is said to have had a great influence on his writing. Joyce was English tutor to Itali Svevo, the Italian novelist. Svevo was born in Trieste in 1861, his Mother was part of a Triestian Jewish family, and his Father was of German descent. Joyce encouraged and praised Svevo's work and Svevo wrote critiques of Joyce's work. Svevo's book, "The Confessions of Zeno", was virtually ignored in Italy. However Joyce recommended the book to publishers in France, where it was hailed as a masterpiece. The book is an autobiography of Zeno, written for Zeno's psychoanalyst, to help get to the bottom of his smoking addiction. Svevo is credited by Welleck as "an Italian novelist with permanent appeal as a psychoanalytical psychologist and as a portrayer of the inhabitants of Austrian and later Italian Trieste and their often uncertain national allegiance." Jan Morris wrote the book, "Trieste and the Meaning of Nowhere". Morris claims this is her final book, a self- examination based in Trieste. Morris changed gender. Jan Morris first visited Trieste at the end of the Second World War as young Welsh soldier. She describes how the city "curiously haunted her" . She revisited the city as an elderly woman. Morris describes Trieste as "natural capital of the nation of nowhere". By this she means a home for the so-called "Fourth World" . This is a scattered group with the common values of humour and understanding, usually exiles in their own communities but probably numerous enough to form their own nation. I laughed at Clay Risen's comment in his piece about Trieste in the Square Table in Spring 2003. He observed that "Trieste is the only city in Eruope which appears more often in reflective essays than in guide books of newspaper travel sections." Exploring the city The best way to explore the city is to walk around. The Piazza dell' Unita d'Italia is the heart of the city. The square was created towards the end of the 19th century. It houses the City Hall, with its clock tower featuring statues of Mikeze and Lakeze, figures from Trieste folklore; Government House, with its gilded mosaic wall decorations; and the former Head Office of Lloyd Triestino, built in Renaissance style by an Austrian architect. The Victory Lighthouse lights the Gulf of Trieste and commemorates the dead of the First World War. It stands almost 70 metres high with a scaled dome containing a statue of winged Victory. At the base of the column is the anchor of the torpedo boat Audace, the first Italian ship to enter the harbour in 1918. The lighthouse took 4 years to complete and was officially opened in 1927. The Old Stock Exchange is a fine example of neo-classical architecture, resembling a Greek temple. The Old Stock Exchange stands by the so called Grand Canal. However this is rather an misnomer as the canal is very short. There is a statue of Joyce by one of the bridges. The Arco di Riccard is a Roman gate to the city thought to date from 33 AD. It is in Piazzetta di Ricordo in the old city. You can see the Roman amphitheatre at the foot of San Guisto hill. The Verdi Opera Theatre opened in 1801. It is of a similar style to La Scala in Milan. Museums There are many museums in Trieste, most of which are closed on Mondays. Probably the best is The Revoltella Museum, which was founded in 1872 when Baron Revoletta left his home and art collection to the city of Trieste. He also set up an endowment, which enabled a larger collection to be acquired. The Art Gallery has now spread over three buildings in order to house the ever-expanding collection by many Italian and other artists. Other museums include: The Regional Centre for the Study of Ancient and Modern Military History The Civic Museum The Museum of Oriental Art Piccolo Pharmacy Museum The Railway Museum Café society As Trieste is a port it was one of the first European cities to take to coffee in a big way. The first coffee houses in Trieste opened at the beginning of the 18th century. These cafés become very popular with artists and intellectuals. Several of the original cafes are going strong, the Tommeseo and the Cafee degli Specchi. Triestines are very particular about their coffee. If you order a cappuccino the Trieste version will be a black coffee with a little milk. You would need to order an Italian cappuccino. Mixing spirits with coffee is a no-no, viewed as a beverage favoured by foreign lorry drivers! Cultural and Sporting Events The Barcolana is held on the second Sunday of October. This is a sailing competition which has run for 30 years and has almost 2000 vessels competing. There are other events during the week such as the Saturday nighttime regatta. The winner is the boat, which can achieve the highest number of laps around the San Guisto basin. The Music Festival takes place for three evenings at the Piazza d'Italie. There is a line up of Italian and international talent and it's free. From October to May the concert and opera season unfolds in the historic neo-Classical Teatro Comunale Giuseppe Verdi (opened in 1801 and designed by Matteo Petch, architect of Milan's La Scala) and the modern Sala Tripcovich. The festival of Light Opera is held in July and August at the Verdi. Figures of international renown congregate in Trieste for performances of such works as Fritz Kreisler's "Sissi", "The Land of Smiles" and Franz Lear's "Judith". Castello Miramare This castle was built for Archduke Maximilian as a residence by the sea. Maxilmilian and his wife, Charlotte of Belgium, came to live here in 1860. However their stay only lasted for 4 years as Maximilian was despatched to Mexico, where he been offered the throne in an attempt to end the Civil War there. Rebel forces killed Maximilian. Charlotte lived at the Castello alone briefly and then returned to her native Belgium. You can visit the castle and gardens. In July and August the tragic love story is brought to life in a "Sons et Lumieres". The voice of the Castle caretaker recounts the love story of Maximilian and Charlotte. Performances in English and German can be requested on Saturdays by phoning +39 40 414177 Castello di Duino This old castle dates from the 11th century, the only recognisable remains are the tower and an arch. The new castle was completed in the 15th century. Legend tells that in medieval times a young princess fell in love with a local boy. Her Father locked her away in a tower and had her lover killed in the courtyard below and the corpse thrown in the sea. In despair the Princess leapt from the tower, her screams turned her to stone as she hurtled down. Near the shore is a rock that looks like a woman's body. Some say that "Dama Biance" still haunts the area searching for her lost love. Duino Castle has only recently opened its doors to the public. Prince Carlo Allessandro and his family still live in the castle. The castle has accommodated many famous guests: Dante, Listz and Struass. The coastal path, the Rilke Promenade from Duino to Sistians is named after the German poet, a guest at the castle from 1911 - 1912. The Grotta Gigante, the Giant Cave This cave is the largest accessible cave in the world. It is estimated that you could fit St Peters Cathedral inside. The cave was first explored in 1840 by Lidner. In 1904, a four- year project started to turn the cave into a tourist attraction. It took 4000 candles to light the cave, electricity was only installed in 1957. There are hourly guided visits. You can find out about opening hours by phoning 040 327312. Swimming The beach at Sistinna Spiaggia is said to be one of the best in Italy. It can be reached by the no. 51 and 21 buses from Trieste. Grignano is closer to Trieste and is reached by the no. 36 bus. Where to eat Harry's Grill in the Hotel Gran Duchi is one of Trieste's most exclusive restaurants. I have eaten at this restaurant. I was even served with a pre-starter, a delicious titbit of stuffed aubergine, and a pre-dessert, a lovely strawberry mousse. The accompanying bread and bread sticks has been freshly baked. My (proper) starter was stuffed pasta, the main course was sea bass, topped off with white chocolate mousse rippled with passionfruit sauce. It is entirely possible to have a lighter meal, if you can resist the temptation. In Summer you can sit out on the pedestrianised square. Main courses cost from 16 - 26 euros. Piazza dll"Unita d"Italia 2, tel: 040 660606 Al Bragozzo is the best-known restaurant at the port, which specialises in seafood. The simply yet creatively prepared meals pay homage to the sea and its heritage by combining the elements of Italian cuisine and the riches of the Mediterranean. Specialties include spaghetti alla Giorgio (with tomatoes and herbs), ravioli stuffed with herbs, monkfish braised with artichokes (and cooked with white wine), and spaghetti with lobster. There are also many preparations of salmon and shrimp. You can eat at the outdoor tables, weather permitting, if you visit in the summer. Main courses cost from 10 - 25 euros. Riva Nazario Sauro 22. tel: 040 303001. There are many buffets in Trieste. These are restaurants which specialise in pork, often in various stews, sausages and soups. Two of the best known are: Re di cappe, Via Geppa 11, tel 040 370330 Da Giovanni, Via S Lazzaro 14, tel 040 639396 Day trips Exploring the Carse The Triestine cares starts at Montefalcone in the north and stretches down adjacent to the Slovenian border. The area is known as a paradise for botanists with a mixture of continental flora and Mediterranean vegetation. There is talk of the area achieving national park status. The Carsic house in Rupingrande has a collection of traditional furniture and local costumes. During the first week in May the works of local painters are exhibited during the Majence Festival, in San Dorligo delle Valle. The best known event is the Carsic Wedding, every second year on the last Sunday of August in Monrupino. There are dances every night of the preceeding week. On the wedding day the bridal procession, all dressed in traditional costume, walk to the fortress church for the marriage ceremony. Grado and Aquiliea Aquiliea was founded in the first century BC. It occupies a strategic defence location. It became a Patriarchs's seat andmany beautiful churches were built. The Bascilica is considered to be one of the most important monuments of early Christianity. There are two museums to visit there. Grado was the extreme southern part of the port of Aquileia. Now it a beautiful island city joined to the mainland by a causeway. It boasts 20 kms of fine sandy beaches. Grado was very popular as a spa during the days of the Austrio Hungarian Empire with its healing sands. Grado can be reached by the no 21 bus from Trieste. There is also a boat service during the Summer. Muggia Muggia is a pretty coastal town just south of Trieste, which can be reached by ferry from Trieste during the summer. The town is of Venetian origin, surrounded by medieval walls with a 14th century castle and a pretty port. Slovenia The Slovenian border is just a few kilometres from Trieste. The Lipica Stud and Riding School is under a half hour drive from Trieste. It was originally founded in 1580 by Archduke Charles for breeding royal horses for the Austrian court. Now you can tour the stud farm (6 Euros) or have a riding lesson, starting at 16 euros. Croatia Croatia can be easily reached through by passing through the narrow strip of coastal Slovenia. Wine Country Every Sunday during April, May and June you can visit specific wineries in the area to try their products. There are various wine itineraries you can follow. Venice Venice can be reached by direct train from Trieste. The journey takes around two hours. The train takes you right into the centre of Venice. penis elargement pills review enlargement forum free matter penis size manual penile enlargement exercise real pnis enlargement penis enargement without pills penis girth enhancement penis enlargment device top penile enlargement pills penis enlarement before and after

Why are some people naturally magnetic? Are you ready to make potent first impressions? Release stuck energy from your entire body and crank up your magnetic love energy. Stress, Fear and Anxiety Block Satisfying Sex When you experience stress, fear or anxiety, sex is usually the last thing on your mind. Work dilemmas, relationship woes, family issues and money problems can be devastating to your libido. It's hard to feel sexy when you are worried about the mortgage payment. Fear and anxiety associated with sex itself can also be problematic. Worrying about everything from STDs to fear of pregnancy to sexual performance, dampen your sex drive and hampering your chances to have a satisfying sexual experience. Fear, anxiety and depression about aging can also affect your sex drive. Are you worried about getting older? Stuck Energy Causes Depression According to medical experts, depression is caused by an imbalance of brain chemicals, along with other factors. Energetically speaking, the root cause of depression stems from foreign energy being stuck in your body. When foreign energy dims and over-shadows your energy, you become de-pressed! Do you remember being attracted to someone special in your life? You are attracted to someone because you admire something unique about them. You might think they are handsome, funny or even poised. You like how you feel around them. With every passing day, you start to adopt their energy as your own. When this happens, and you don’t release it back to them, your own energy becomes de-pressed and your relationship takes a nose-dive. Like with computers, you cannot use MAC software in a PC or vice-verse. They each require their own unique software to operate and process their functions. The same is true for people. The very vibe that attracted you to another person, is the very thing that makes you sexually non-responsive, argumentative and emotional. It can affect your attitude, your health and your libido. Viagra Doesn’t Work On Low Self Esteem Viagra only increases blood flow to the genital area to enhance physical sexual stimulation in women or men. It cannot affect your body image, relationship or emotional issues that impede sexual function. Most people dislike some aspect of his or her body. Do you think you have jiggly thighs, a curved penis, small breasts, fat belly or a hairy back? While you might not be 100% satisfied with the way you look, you have learned to live with the perceived flaw. This perception may actually create an energetic block that affects the sexual image of yourself and your ability to express yourself. The reality is however, that to have good feelings about sex, you have to have good feelings about your body. Release Negative Self Talk with Grounding Whenever you find yourself having a negative thought about your body, release it down your grounding cord or put it inside a symbol and explode it. For example, if you're obsessing on your extra roll of belly fat, stop yourself. Throw that thought down your grounding cord or explode inside a firecracker. Then fill yourself up with a shimmering gold sun of self-appreciation and sex appeal. As you start to feel better about yourself and feel a little sexy -- no matter what you look like -- your sex drive will improve. Learn to love yourself for who you are, warts and all. Only then will you be able to have a really satisfying sex life and magnetically draw people who love and appreciate you. Grounding Visualization for the Entire Body To experience self-love and appreciation, release energy by grounding the entire body. Your natural magnetic energy will be stimulated, kicking you into high gear. 1. Create a grounding cord. 2. Visualize a 2nd grounding cord from the bottom of your feet to the main grounding cord coming out from your spine. 3. Allow gravity to pull out any dark colors, white light or any colors you intuitively know are not your energy to be pulled out. 4. Release anything that prevents healing. 5. Ground your ankles, legs, knees, thighs, hips, and abdomen. Release any energy stored in those body parts. 6. Ground your sex organs. Ask yourself, “Is there anyone’s energy stored there?” Do you get a sense of thoughts or judgments from: former teachers, lovers, partners, or friends sitting on your skin or inside these areas? Release both positive and negative energies. If someone likes the shape of your butt, their energy stays with it. And, here you thought it was because of all of the chocolate you ate. 7. Replenish your body and organs with a golden sun by putting some of your own energy back in your body. SECRET TIP -- Positive or negative energy can also block the optimum energy function. What is Past is Past! Don’t get stuck on it. Allow past energy release. It’s no fun to be stuck in the past. It’s no fun to be a victim. Stay present so you can let go, move on and attract the type of loving relationship you desire. You can release the emotional charge of molestation through visualization. Ensure a Healthy Body and Love Life Learn to release stress, fear and anxiety to ensure a healthy body. Eat a balanced diet, drink plenty of water, sleep at least eight hours a night, exercise regularly and practice relaxation techniques such as meditation or yoga. If you won't do it for your general health, do it for your sex life! Amirah © 2006 All Rights Reserved. You have permission to publish this article electronically or in print, free of charge, as long as the bylines are included. 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Male sexual dysfunction is one of the most common health problems affecting men and is more common with increasing age. Chronic ED affects about 5% of men in their 40s and 15-25% of men by the age of 65. Transient ED and inadequate erection affect as many as 50% of men between the ages of 40 and 70. In around 95% of the cases, a suitable treatment can be found. Erectile dysfunction is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful treatments for erectile dysfunction. Viagra, Levitra and Cialis Currently, there are three oral medications approved by the Food and Drug Administration (FDA) for the treatment of erectile dysfunction: sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). All these agents block the enzyme phosphodiesterase type 5 (PDE-5) and belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Viagra was the first and is probably the most famous of the three PDE-5 inhibitors used to treat erectile dysfunction. Viagra was approved as an effective agent for treating erectile dysfunction in March 27, 1998. Viagra is manufactured by Pfizer, Inc. Levitra was the second PDE-5 inhibitor to come to market in the United States, and it was approved by the FDA in August 19, 2003. Levitra is manufactured by Bayer Pharmaceuticals Corporation. Cialis was the third PDE-5 inhibitor to come to market and was approved by the FDA at the end of November 21, 2003. Cialis is manufactured by Lilly ICOS LLC. The major advantage of PDE-5 inhibitors is that they do not cause an erection at inappropriate times, because they act only in response to sexual stimulation. If there is no sexual stimulation drug remains in the background. All three are taken orally prior to planned sexual activity, acting to increase blood flow in the penis in response to sexual stimulation. However, there are important differences between the three, differences that could influence safety, specificity, duration of action, adverse effects, and ultimately, public acceptance within this class of drug. Mechanism of Action PDE-5 inhibitors do not directly cause an erection of the penis, but they alter the body's response to sexual stimulation by enhancing the effect of the nitric oxide, a chemical that is normally released during stimulation. Nitric oxide causes relaxation of the muscles in the penis, which allows for better blood flow to the penile area. Effectiveness of PDE-5 Inhibitors All 3 PDE-5 inhibitors have demonstrated excellent efficacy. Viagra, at 84%, is slightly more effective than Cialis at 81% and Levitra at 80%. Pharmaceutical Forms, Onset of Action and Duration of Effect Viagra and Levitra differ only minimally in terms of their structure, while Cialis differs markedly from Viagra and Levitra in terms of its molecular structure, which is also reflected in pharmacokinetic differences. Viagra: 25 mg, 50 mg 100 mg tablets Onset of action: 30 minutes (effect delayed if taken with food) Duration of action: 4 to 5 hours Levitra: 2.5 mg, 5 mg, 10 mg, 20 mg tablets Onset of action: 25 minutes (effect delayed by fatty meal) Duration of action: 4 to 5 hours Cialis: 5 mg, 10 mg, 20 mg tablets Onset of action: 16-45 minutes (effect NOT delayed by food) Duration of action: 36 hours All three drugs require sexual stimulation to be effective. Viagra should be taken on an empty stomach it works better if you do not eat a high-fat meal around the time you take it. Levitra may be slightly less effective if you eat a high-fat meal, but a moderate-fat meal does not reduce its effectiveness. Cialis works without regard to what you eat. Viagra and Levitra have similar half-lives, and onset and duration of action. Cialis has a slower onset of action and longer duration of action, which is attributed to its longer half-life. Patients who wish for spontaneity may opt for Cialis, which may allow for successful intercourse up to 36 hours postdose, even though it takes longer to reach peak effect. The considerably longer duration of effect for Cialis will likely allow less frequent dosing and greater impulsiveness between partners, but also could potentially prolong adverse effects. Dosage The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for either Levitra or Cialis is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. A lower dose of 5 mg is available for patients who take other medicines or have conditions that may decrease the body's ability to use the drug. Levitra is also available in a 2.5 mg dose. None of these PDE-5 inhibitors should be used more than once a day. Possible Side Effects Although all three drugs are generally well tolerated, side effects are still possible. Most common side effects: Viagra: facial flushing, headache, indigestion Levitra: facial flushing, headache Cialis: headache, indigestion Less Common Side Effects: Viagra: altered vision, dizziness, nasal, congestion Levitra: indigestion, nausea, dizziness, nasal congestion Cialis: back pain, muscle aches, nasal congestion, facial flushing, dizziness Precautions and Contraindications All PDE-5 inhibitors are absolutely contraindicated in persons who take organic nitrates. Alpha-blockers Viagra has precautionary labeling advising against taking 50 mg or 100 mg doses within four hours of taking a alpha-blocker. The 25 mg dose of Viagra has not been shown to significantly decrease blood pressure and in patients who take 25 mg of Viagra, use of any of the alpha-blockers is considered safe. Levitra is contraindicated in patients taking alpha-blockers. Cialis is contraindicated in patients taking alpha-blockers, except for tamsulosin (Flomax). Since both Viagra and Levitra have moderate vasodilatory and hypotensive effects, they should not be given in the presence of marked arterial or orthostatic hypotension, and should only be administered with caution in aortic stenosis or hypertrophic obstructive cardiomyopathy. Men who have had a heart attack or stroke within the past 6 months and those with certain medical conditions (e.g., uncontrolled high blood pressure, severe low blood pressure or liver disease, unstable angina) that make sexual activity inadvisable should not take Cialis. Dosages of the drug should be limited in patients with kidney or liver disorders. Conclusions The differences between the 3 drugs are not great. All appear to be effective and safe. Levitra has less side effects compared to Viagra and lasts about the same time as Viagra in the body. Cialis has few side effects and lasts longer in the body. This allows increased spontaneity and less frequent dosing than either Levitra or Viagra. However, the longer half-life of Cialis imposes increased risk for drug interactions.