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Review ARticle Erectile dysfunction: A review and herbs used for its treatment Erectile dysfunction ED or male impotence is defned as the inability to have or sustain an erection long enough to have a meaningful sexual intercourse. ED tends to occur gradually until the night time or early morning erections cease altogether or are so faccid that successful intercourse does not occur. Sexual health is an important determinant of quality of life. Today millions of men young and old sufer from ED due to high levels of synthetic hormones known as Xenoestrogens in our diet/environment nutritionally imbalanced diet resulting from poor quality of produces and extremely low levels of testosterone. To overcome the problem of sexual or ED various natural aphrodisiac potentials are preferred. Te present review discusses about aphrodisiac potential of plants its biological source common name part used and references which are helpful for researchers to develop new aphrodisiac formulations. Key words: Aphrodisiac erectile dysfunction Phosphodiesterease INTRODUCTION Erectile dysfunction ED otherwise known as impotency afects more than 30 million men each year yet only about 200000 seek help from a physician. Impotency remains largely unrecognized simply because most men do not discuss sexual problems with their doctors. In addition many physicians do not ask or are uncomfortable dealing with the subject. ED is defned as the inability to sustain an erection well enough to perform intercourse and ejaculation. 1 While almost all men will experience some degree of sexual difculty at one time or another only those who are unable to have successful intercourse 75 percent of the time are considered impotent. Contrary to popular belief ageing is not an inevitable cause of impotency. It does however take elderly men longer to develop erection and the force of ejaculation is diminished. 2 Conventional medicine usually addresses ED issues by prescribing a drug regimen or surgery. Oral medications such as Erecaid or testosterone are rarely efective unless the condition is due to low testosterone levels. Viagra Cialis and Levitra which act to relax corpus cavernosal smooth muscle and facilitate erections are not without their side‑efects. Penile injections of Papaverine or Prostaglandin E1 which affect penile blood flow can result in prolonged erections necessitating other drug therapy to counter act its efects. Additionally the therapy can cause burning and eventual fbrosis of the penis. Lastly malleable or infatable prosthesis are used in severe cases requiring surgical implantation. Such prosthesis ofen need to be surgically re ‑implanted are uncomfortable and are subject to periodic failure. ED can be broken down into primary and secondary impotency. Primary causes are rare and may be associated with low androgen levels genetic defects and severe psycho-pathology . Secondary impotency is much more common and as the name implies results from something else such as diabetes arteriosclerosis neurological disorders psychological issues prolonged stress or previous surgery to the genitalia. Blood pressure medications and antidepressants may also lead to impotency especially in the elderly. Dietary factors largely ignored by conventional medicine also fuel the problem as men with diets high in cafeine sugar and alcohol experience more ED as do men who smoke and use recreational drugs.  3 Psychological causes account for the majority of impotency complaints. A skilled and sensitive physician may ofen uncover this during an interview and suggest corrective measures.

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Men experience three types of erections: • Refexogenic erections are induced by tactile stimulation of the genitals. Men with lesions of the cervical or thoracic spinal cord paraplegics are still able to have this type of erection. A small number of men with complete transection of the spinal cord can also have erections which are psychogenically induced. • Psychogenic erections are induced by visual or memory associations. • Nocturnal erections occur during rapid eye movement sleep and may take place anywhere from three to six times a night lasting from 20 to 40 minutes. Generally nocturnal erections begin with the onset of puberty and diminish in intensity duration and frequency later in life. Erections during arousal and intercourse are ofen achieved as a combination of refexogenic and psychogenic and a defcit in one or both areas can lead to impotency. m ale s ex Ual Dysf UNCTION Sex disorders of the male are classifed into disorders of sexual function sexual orientation and sexual behaviour. In general several factors must work in harmony to maintain normal sexual function. Such factors include neural activity vascular events intracavernosal nitric oxide system and androgens. 4 Thus malfunctioning of at least one of these could lead to sexual dysfunction of any kind. Sexual dysfunction in men refers to repeated inability to achieve normal sexual intercourse. It can also be viewed as disorders that interfere with a full sexual response cycle. These disorders make it difcult for a person to enjoy or to have sexual intercourse. While sexual dysfunction rarely threatens physical health it can take a heavy psychological toll bringing on depression anxiety and debilitating feelings of inadequacy. Unfortunately it is a problem ofen neglected by the healthcare team who strive more with the technical and more medically manageable aspects of the patient’s illness. 5 Sexual dysfunction is more prevalent in males than in females and thus it is conventional to focus more on male sexual difculties. It has been discovered that men between 17 and 96 years could sufer sexual dysfunction as a result of psychological or physical health problems. Generally a prevalence of about 10 occurs across all ages. Because sexual dysfunction is an inevitable process of aging the prevalence is over 50 in men between 50 and 70 years of age. As men age the absolute number of Leydig cells decreases by about 40 and the vigour of pulsatile lutenizing hormone release is dampened. In association with these events free testosterone level also declines by approximately 1.2 per year. These have contributed in no small measure to prevalence of sexual dysfunction in the aged. Male sexual dysfunction MSD could be caused by various factors. These include: Psychological disorders performance anxiety strained relationship depression stress guilt and fear of sexual failure androgen defciencies testosterone deficiency hyperprolactinemia chronic medical conditions diabetes hypertension vascular insufficiency atherosclerosis venous leakage penile disease Peyronie’s priapism phinosis smooth muscle dysfunction pelvic surgery to correct arterial or infow disorder neurological disorders Parkinson’s disease stroke cerebral trauma Alzheimer’s spinal cord or nerve injury drugs side‑efects anti ‑hypertensives central agents psychiatric medications antiulcer anti-depressants and anti-androgens life style chronic alcohol abuse cigarete smoking ageing decrease in hormonal level with age and systemic diseases cardiac hepatic renal pulmonary cancer metabolic post-organ transplant. 4 Sexual dysfunction takes different forms in men. A dysfunction can be life-long and always present acquired situational or generalized occurring despite the situation. A man may have a sexual problem if he: • Ejaculates before he or his partner desires • Does not ejaculate or experiences delayed ejaculation • Is unable to have an erection sufcient for pleasurable intercourse • Feels pains during intercourse • Lacks or loses sexual desire. MSD can be categorized as disorders of desire disorders of orgasm ED and disorders of ejaculation and failure of detumescence. Disorders of Desire Disorders of desire can involve either a deficient or compulsive desire for sexual activity . Dysfunctions that can occur during the desire phase include: i. Hypoactive sexual desire HSD defned as persistently or recurrently defcient or absent sexual fantasy and desire for sexual activity leading to marked distress or interpersonal difculty. It results in a complete or almost complete lack of desire to have any type of sexual relation. ii. Compulsive sexual behaviours CSBs constitute a wide range of complex sexual behaviours that have strikingly repetitive compelling or driven qualities. They usually manifest as obsessive‑compulsive sexuality e.g. excessive masturbation and promiscuity excessive sex-seeking in association with affective disorders e.g. major depression or mood disorders addictive sexuality e.g. atachment to another person object or sensation for sexual gratifcation to the exclusion of everything else and sexual impulsivity failure to resist an impulse or temptation for sexual behaviour that is

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harmful to self or others such as exhibitionism rape or child molestation. 6 Erectile Dysfunction This is a problem with sexual arousal. ED can be defned as the difculty in achieving or maintaining an erection sufficient for sexual activity or penetration at least 50 of the time for a period of six months. It results in signifcant psychological social and physical morbidity and annihilates his essence of masculinity. 7 Disorders of Ejaculation There exists a spectrum of disorders of ejaculation ranging from mild premature to severely retard or absent ejaculation. DIag NOs Is Epidemiology and Risk Factors Erection is a neurovascular phenomenon under hormonal control. It includes arterial dilatation trabecular smooth muscle relaxation and activation of the corporeal veno- occlusive mechanism. ED has been defned as the persistent inability to atain and maintain an erection sufcient to permit satisfactory sexual performance. Although ED is a benign disorder it afects physical and psychosocial health and has a signifcant impact on the quality of life QoL of suferers and their partners and families. 8 Epidemiology Recent epidemiological data have shown a high prevalence and incidence of ED worldwide. The first large scale community‑based study of ED was the Massachusetts Male Aging Study MMAS. The study reported an overall prevalence of 52 ED in non‑institutionalized 40‑ to 70‑year‑ old men in the Boston area in the USA specifc prevalences for minimal moderate and complete ED were 17.2 25.2 and 9.6 respectively. In the Cologne study of men aged 30‑80 years old the prevalence of ED was 19.2 with a steep age-related increase from 2.3 to 53.4. 9 In the National Health and Social Life Survey NHSLS the prevalence of sexual dysfunctions not specifc ED was 31. The incidence rate of ED new cases per 1000 men annually was 26 in the MMAS study 65.6 mean follow‑up of 2 years in a Brazilian study and 19.2 mean follow-up of 4.2 years in a Dutch study. Diferences between these studies can be explained by diferences in methodology and in the ages and socio-economic status of the populations studied. Risk factors ED shares common risk factors with cardiovascular disease e.g. lack of exercise obesity smoking hypercholesterolaemia metabolic syndrome some of which can be modifed. In the MMAS men who began exercising in midlife had a 70 reduced risk for ED compared to sedentary men and a significantly lower incidence of ED over an 8‑year follow‑up period of regular exercise. A multicentre randomised open label study in obese men with moderate ED compared 2 years of intensive exercise and weight loss with a control group given general information about healthy food choices and exercise. 10 Signifcant improvements in body mass index BMI and physical activity scores as well as in erectile function were observed in the lifestyle intervention group. These changes were highly correlated with both weight loss and activity levels. However it should be emphasized that controlled prospective studies are necessary to determine the efects of exercise or other lifestyle changes in prevention or treatment of ED. Post‑radical Prostatectomy Erectile Dysfunction Radical prostatectomy RP in any form open laparoscopic or robotic is a widely performed procedure for patients with clinically localized prostate cancer PCa and a life expectancy of at least 10 years. This procedure may lead to treatment‑specifc sequelae afecting health ‑related QoL. This outcome has become increasingly important with the more frequent diagnosis of PCa in younger patients. Research has shown that about 25-75 of men experience post‑operative ED. Post‑RP ED is multifactorial. Cavernosal nerve injury induces pro-apoptotic loss of smooth muscle and pro‑fbrotic increase in collagen factors within the corpora cavernosa. These changes may also be caused by poor oxygenation due to changes in the blood supply to the cavernosa. Because pre-operative potency is a major factor associated with the recovery of erectile function afer surgery patients being considered for a nerve ‑sparing radical prostatectomy NSRP should ideally be potent. It is also clear that cavernosal nerves must be preserved to ensure erectile function recovers afer RP . In addition the role of vascular insufciency is of increasing interest in post‑operative ED. 11 Advances in basic and clinical research in ED during the past 15 years have led to the development of several new treatment options for ED including new pharmacological agents for intracavernous intraurethral and more recently oral use. Treatment strategies have also changed following the poor outcomes seen in long-term follow-up of reconstructive vascular surgery . 12 An increasing number of men are seeking help for ED due to the great media interest in ED and the availability of efective and safe oral drug therapy. However there are many physicians evaluating and treating ED without appropriate background knowledge and clinical experience. Thus some men with ED may receive litle or no evaluation before treatment and will therefore not receive treatment for any underlying

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disease that may be causing their ED. Other men without ED may be requesting treatment simply to enhance their sexual performance. Given this situation these European Association of Urology guidelines for the diagnosis and treatment of ED are a necessity Figure 1. Treatment of Erectile Dysfunction The primary goal in the management strategy of a patient with ED is to determine the aetiology of the disease and treat it when possible and not to treat the symptom alone. ED may be associated with modifable or reversible factors including lifestyle or drug‑related factors. These factors may be modifed either before or at the same time as specifc therapies are used. As a rule ED can be treated successfully with current treatment options but cannot be cured. The only exceptions are psychogenic ED post‑traumatic arteriogenic ED in young patients and hormonal causes e.g. hypogonadism hyperprolactinaemia which can be potentially cured with specifc treatment. Most men with ED will be treated with treatment options that are not cause‑specifc. This results in a structured treatment strategy that depends on efcacy safety invasiveness and cost as well as patient preference.  13 To counsel patients properly with ED physicians must be fully informed of all treatment options. The assessment of treatment options must consider the efects on patient and partner satisfaction and other QoL factors as well as efcacy and safety. Lifestyle Management in Erectile Dysfunction with Concomitant Risk Factors The basic work‑up of the patient must identify reversible risk factors for ED. Lifestyle changes and risk factor modifcation must precede or accompany ED treatment. The potential benefts of lifestyle changes may be particularly important in individuals with ED and specifc comorbid cardiovascular or metabolic diseases such as diabetes or hypertension. 14 Besides improving erectile function aggressive lifestyle changes may also benefit overall cardiovascular and metabolic health with recent studies supporting the potential of lifestyle intervention to beneft both ED and overall health. Although further studies are needed to make clear the role of lifestyle changes in the management of ED and related cardiovascular disease lifestyle changes can be recommended alone or combined with Phosphodiesterease PDE5 therapy. Some studies have suggested that the therapeutic efects of PDE5 inhibitors Figure 1: Managing ED: Implications for everyday clinical practice Patient with Erectile Dysfunction self-reported Medical and psychosexual history use of validated instruments e.g. IIEF Focused Physical Examination Laboratory tests Identity other than ED sexual products Identity common causes of ED Identity reversible risk factors for ED Assess psychological status Penile deformitiesProstatic disease Signs of hypogonadism Cardiovascular and neurological status Glucose lipid profile if not assessed in the last 12 months Total testosterone morning sample If available: Bio-available or free testosterone instead of total

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may be enhanced when other comorbidities or risk factors are aggressively managed. However these results have yet to be confrmed in well ‑controlled long‑term studies. Because of the success of pharmacological therapy for ED clinicians need to provide specifc evidence for the benefts of lifestyle change and hopefully future research will show this. Erectile Dysfunction afer Radical Prostatectomy Use of pro-erectile drugs following RP is very important in achieving erectile function following surgery . Several trials have shown higher rates of erectile function recovery afer RP in patients receiving any drug therapeutic or prophylactic for ED. Historically the treatment options for post ‑ operative ED included intracavernous injections urethral microsuppository vacuum device therapy and penile implants. Intracavernous injections and penile implants are still suggested as second- and third-line treatments respectively when oral compounds are not adequately efective or contraindicated for post ‑operative patients. The management of post‑RP ED has been revolutionized by the advent of PDE5 inhibitors with their demonstrated efcacy ease of use good tolerability excellent safety and positive impact on QoL. At present PDE5 inhibitors are the frst ‑line choice of oral pharmacotherapy for post‑ RP ED in patients who have undergone a nerve‑sparing NS surgical approach. The choice of PDE5 inhibitors as frst ‑line treatment is controversial because the experience surgical volume of the surgeon is a key factor in preserving postoperative erectile function in addition to patient age and NS technique. 15 In fact PDE5 inhibitors are most efective in patients who have undergone a rigorous NS procedure which is more commonly performed by the largest-volume surgeons. The early use of a high dose of sildenafl afer RP is associated with the preservation of smooth muscle within the human corpora cavernosa. Daily sildenafl also resulted in a greater return of spontaneous normal erectile function post RP compared to placebo following bilateral nerve- sparing RP NSRP in patients who were fully potent before surgery. The response rate to sildenafl treatment for ED afer RP in diferent trials ranged from 35 to 75 among those who underwent NSRP and from 0 to 15 among those who underwent non-NSRP. 16 The efectiveness of both tadalafl and vardenafl as on ‑demand treatment has also been evaluated in post‑RP ED: • A large multicentre trial in Europe and USA studied tadalafl in patients with ED following a bilateral NS procedure. Erectile function was improved in 71 of patients treated with tadalafl 20 mg versus 24 treated with placebo while the rate of successful intercourse atempts was 52 with tadalafl 20 mg versus 26 with placebo • Similarly vardenafl has been tested in patients treated with ED following either an unilateral or bilateral NS procedure in a multicentre prospective placebo- controlled randomised North American study. 17 Following bilateral NSRP erectile function improved by 71 and 60 with vardenafl 20 mg and 10 mg respectively. An extended analysis of the same patients undergoing NSRP has underlined the beneft of vardenafl compared to placebo regarding intercourse satisfaction hardness of erection orgasmic function and overall satisfaction with sexual experience. A randomized double-blind double-dummy multicentre parallel- group study in 87 centres across Europe Canada South Africa and the USA compared on- demand and nightly dosing of vardenafl in men with ED following bilateral NSRP . In patients whose IIEF erectile function domain IIEF‑EF score was ≥26 before surgery vardenafil was efcacious when used on demand supporting a paradigm shif towards on ‑demand dosing with PDE5 inhibitors in post‑RP ED. Patients who do not respond to oral PDE5 inhibitors afer NSRP should be treated with prophylactic intracorporeal alprostadil. A penile prosthesis remains a satisfactory approach for patients who do not respond to either oral or intracavernous pharmacotherapy or to a vacuum device. 18 Curable Causes of Erectile Dysfunction Hormonal causes An endocrinologist’s advice is essential for managing patients with hormonal abnormalities. Testosterone deficiency is either a result of primary testicular failure or secondary to pituitary/hypothalamic causes including a functional pituitary tumour resulting in hyperprolactinaemia. Testosterone replacement therapy intramuscular oral or transdermal is effective but should only be used afer other endocrinological causes for testicular failure have been excluded. Testosterone replacement is contraindicated in men with a history of prostate carcinoma or with symptoms of prostatism. Before initiating testosterone replacement a digital rectal examination DRE and serum Prostate‑specifc antigen test should be performed. Patients given androgen therapy should be monitored for clinical response and the development of hepatic or prostatic disease. There is no contraindication for testosterone therapy in men with coronary artery disease who have been properly diagnosed with hypogonadism and/or ED. However the haematocrit level should be monitored and a dose adjustment of testosterone may be necessary especially in congestive heart failure. Hormonal treatment is not always efective in the management of ED associated with hypogonadism. 19 Post‑ traumatic arteriogenic ED in young patients In young patients with pelvic or perineal trauma surgical penile revascularization has a 60‑70 long‑term success rate. The lesion must be demonstrated by Duplex ultrasound and confrmed by penile pharmacoarteriography. Corporeal veno-occlusive dysfunction is a contraindication to

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revascularization and must be excluded by dynamic infusion cavernosometry or cavernosography. Vascular surgery for veno-occlusive dysfunction is no longer recommended because of poor long-term results. 20 Psychosexual counselling and therapy For patients with a significant psychological problem psychosexual therapy may be given either alone or with another therapeutic approach. Psychosexual therapy takes time and has had variable results. First‑line Therapy Oral pharmacotherapy The PDE5 enzyme hydrolyzes cyclic guanosine monophosphate cGMP in the cavernosum tissue of the penis. Inhibition of PDE5 results in increased arterial blood fow leading to smooth muscle relaxation vasodilatation and penile erection. Three potent selective PDE5 inhibitors have been approved by the European Medicines Agency EMEA and the US Food and Drug Administration FDA for treatment of ED. They are not initiators of erection and require sexual stimulation to facilitate an erection. Sildenafl Sildenafl launched in 1998 was the frst PDE5 inhibitor available on the market. Efcacy is defned as an erection with rigidity sufcient for vaginal penetration. Sildenafl is efective from 30 to 60 min afer administration. Its efcacy is reduced after a heavy fatty meal due to prolonged absorption. It is administered in 25 50 and 100 mg doses. The recommended starting dose is 50 mg and should be adapted according to the patient’s response and side‑efects. Efcacy may be maintained for up to 12 h. Adverse events are generally mild in nature and self-limited by continuous use. The drop‑out rate due to adverse events is similar to placebo. Afer 24 weeks in a dose ‑response study improved erections were reported by 56 77 and 84 of men taking 25 50 and 100 mg of sildenafl respectively compared to 25 of men taking placebo. Sildenafil statistically improved patient scores in IIEF sexual encounter profle 2 SEP2 SEP3 and general assessment question GAQ and treatment satisfaction. The efcacy of sildenafl in almost every subgroup of patients with ED has been successfully established. In diabetic patients 66.6 reported improved erections GAQ and 63 successful intercourse atempts compared to 28.6 and 33 of men taking placebo respectively. 21 Tadalafl Tadalafl licenced for the treatment of ED as of February 2003 is efective from 30 min afer administration with peak efcacy afer about 2 h. Efcacy is maintained for up to 36 h and is not afected by food. It is administered in 10 and 20 mg doses. The recommended starting dose is 10 mg and should be adapted according to the patient’s response and side‑efects. Adverse events are generally mild in nature self‑limited by continuous use. The drop‑out rate due to adverse events is similar to placebo. 22 Vardenafl Vardenafl commercially available as of March 2003 is effective from 30 min after administration. Its effect is reduced by a heavy faty meal 57 fat. It is administered in 5 10 and 20 mg doses. The recommended starting dose is 10 mg and should be adapted according to the patient’s response and side‑efects. In vitro it is 10-fold more potent than sildenafl though this does not necessarily mean greater clinical efcacy. Adverse events are generally mild in nature and self-limited by continuous use with a drop-out rate similar to placebo. Afer 12 weeks in a dose ‑response study improved erections were reported by 66 76 and 80 of men taking 5 mg 10 mg and 20 mg of vardenafl respectively compared with 30 of men taking placebo. Vardenafl statistically improved patient scores for IIEF SEP2 SEP3 and GAQ and treatment satisfaction. Efcacy was confirmed in post-marketing studies. Vardenafil improved erections in difficult‑to‑treat subgroups. In diabetic patients 72 reported improved erections i.e. improved GAQ compared to 13 of patients taking placebo and the fnal IIEF ‑EF score was 19 compared to 12.6 for placebo. 23 Choice or Preference between the Different PDE5 Inhibitors To date no data are available from double‑ or triple‑blind multicentre studies comparing the efcacy and/or patient preference for sildenafl tadalafl and vardenafl. Choice of drug will depend on the frequency of intercourse occasional use or regular therapy 3-4 times weekly and the patient’s personal experience. Patients need to know whether a drug is short- or long-acting possible disadvantages and how to use it. On‑demand or Chronic Use of PDE5 Inhibitors Animal studies have shown that chronic use of PDE5 inhibitors improves or prevents significantly the intracavernous structure alterations due to age diabetes or surgical damage. In humans a randomised study n145 showed that daily tadalafl led to a signifcantly higher IIEFEF score and higher completion of successful intercourse atempts compared to on ‑demand tadalafl. Two major double‑blind randomised studies using daily 5 and 10 mg tadalafl for 12 weeks n268 24 and daily 2.5 and 5 mg tadalafl for 24 weeks n286 showed that daily dosing was well tolerated and signifcantly improved erectile function. However these studies lacked an on- demand treatment arm. An open-label extension was carried out of both studies in 234 patients for 1 year and 238 patients for 2 years. Tadalafl 5 mg once daily was

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shown to be well tolerated and efective. Tadafl 5 mg once daily therefore provides an alternative to on-demand dosing of tadalafl for couples who prefer spontaneous rather than scheduled sexual activities or who anticipate frequent sexual activity with the advantage that dosing and sexual activity no longer need to be temporally linked. Nevertheless in the 1-year open-label 5 mg tadalafil extension study followed by 4 weeks of wash-out erectile function was not maintained after discontinuation of therapy in most patients about 75. A double-blind placebo-controlled multicentre parallel-group study was conducted in 236 men with mild ‑to‑moderate ED randomised to receive once‑daily vardenafl 10 mg plus on-demand placebo for 12 or 24 weeks or once-daily placebo plus on‑demand vardenafl 10 mg for 24 weeks followed by 4 weeks of wash-out. Despite preclinical evidence the results suggested that once-daily dosing of vardenafl 10 mg does not ofer any sustainable efect after cessation of treatment compared to on-demand administration in patients with mild‑to‑moderate ED. Other studies open-label randomised cross-over studies with limited patient numbers showed that chronic but not on‑demand tadalafl treatment improved endothelial function with sustained efect afer its discontinuation. This was confrmed in another study of chronic sildenafl in men with type 2 diabetes. Recently in the frst double ‑blind placebo-controlled study enrolling 298 men with diabetes and ED for 12 weeks once‑daily tadalafl 2.5 mg and 5 mg was efcacious and well tolerated. This regimen provides an alternative to on-demand treatment for some diabetic men. However when patients have the choice it seems that they prefer on-demand rather than continuous therapy. 25 Nitric Oxide Donors Nitric oxide NO is a physiologic signal essential to penile erection and disorders that reduce NO synthesis or release in the erectile tissue are commonly associated with erectile dysfunction. NO synthase NOS catalyzes production of NO from L-arginine. 26 While both constitutively expressed neuronal NOS nNOS and endothelial NOS eNOS isoforms mediate penile erection nNOS is widely perceived to predominate in this role. Demonstration that blood‑fow ‑dependent generation of NO involves phosphorylative activation of penile eNOS challenges conventional understanding of NO-dependent erectile mechanisms. Regulation of erectile function may not be mediated exclusively by neurally derived NO. Blood- fow ‑induced fuid shear stress in the penile vasculature stimulates phosphatidyl-inositol 3-kinase to phosphorylate protein kinase B which in turn phosphorylates eNOS to generate NO. There are many herbal drugs that have been used by men for ED with varying degrees of success. Most potent herbal aphrodisiacs are available and have litle or very litle side efects Table 1. Thus nNOS may initiate cavernosal tissue relaxation while activated eNOS may facilitate attainment and maintenance of full erection. 1. L-arginine 2. Nitroglycerin paste 3. Paroxetine NOS inhibitor Other Oral Agents Several other drugs have been used in the treatment of ED with various mechanisms of action 27 but today there is no place for these drugs in the treatment of ED. Table 1: Herbal approaches in the treatment of erectile dysfunction name of plant c ommon name Family Part used Reference Allium sativum L. Garlic Liliaceae Bulb 30 Asparagus racemosus Willd. Asparagus Liliaceae Root 31 Boerhavia diffusa L. Punarnava Nyctaginaceae Root 32 Chlorophytum tuberosum Baker. Safed musli Liliaceae Whole plant 33 Cocculs cardifolia Linn. Guduchi Menispermaceae Stem leaf root 34 Fadogia agrestis Schweinf. Ex Heim Black aphrodisiac Rubiaceae Stem 35 Myristica fragrans Houtt Nutmeg Myristicaceae Seed 36 Panax ginseng Ginseng Araliaceae Root 37 Turnera aphrodisiaca Damiana Trneraceae Areal part 38 Withania somnifera Linn. Ashwagandha Solanaceae Leaf root 39 Pausinystalia yohimbe Yohimbine Rubiaceae Bark 40 Ginkgo biloba Ginkgo Ginkgoaceae Leaves seeds 41 Tribulus terristeris Caltrop Zygophyllaceae Seeds 42‑ 44 Asphaltum bitumen Shilajit – Pitch 45 Mucuna pruriens Kapi kacchu Fabaceae Seed 46 Asparagus racemosus Shatawari Liliaceae Root 47 Erythroxylem catuaba Catuaba Erythroxylaceae Bark 48 Ipomoea digitata Vidari kandha Convolvulaceae Root 49 Anacyclus pyrethrum Akarakarabha Compositae Root 5051 Allium tuberosum Chienese chive Zingiberaceae Seed 5253

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• Yohimbine is a centrally and peripherally active alpha‑2 adrenergic antagonist used as an aphrodisiac for almost a century. • Delequamine is a more specifc and selective alpha ‑2 adrenergic antagonist than yohimbine. • Trazodone is a serotonin reuptake inhibitor anti ‑ depressant associated with prolonged erections and priapism. It is also a non‑selective alpha‑adrenergic antagonist in the corporal smooth muscle cells. • L‑arginine is a nitric oxide donor and nalmefene/ naltrexone is an opioid-receptor antagonist. • Red Korea ginseng is a formulation with an unknown mechanism of action though it may possibly act as a nitric oxide donor. 28 • Limaprost is an alprostadil derivative for oral use. • An oral formulation of phentolamine non‑selective alpha‑adrenergic antagonist has undergone phase III clinical trials. Randomised trials have shown that yohimbine and trazodone have a similar efcacy to placebo in patients with organic causes of ED 99. Oral phentolamine had efcacy rates erections sufcient for intercourse of about 50 but possible carcinogenesis in animal models stopped further development. Efcacy data on Red Korea ginseng suggested it might have a role in treatment of ED. 29 There are no efcacy data on the other drugs listed above. CONCl Us ION Sexual function is an important component of quality of life and essential for subjective well being in humans. Sexual problems are widespread and adversely afect mood well being and interpersonal functioning. Sexual problems are related to sexual desire and male erectile dysfunction. Successful treatment of sexual dysfunction may improve not only sexual relationships but also the overall quality of life. Thus this review has dealt with various approaches by which the screening of medicinal plants can be achieved. This is very important because of the side‑efects associated with other treatment options and the readily availability of medicinal plants now that the world is fast turning into the use of medicinal plants for managing sexual dysfunctions. Moreover the side-effects occur through the use of allopathic drugs may limit the use of such drugs therefore the use of herbal drugs can be used as an alternative as there are less side efects in herbal medications.

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