In this month's Knowledge Link, we are going to investigate the effectiveness of nutritional supplements in enhancing and preserving male sexual performance, and relieving erectile difficulties. Estimated reading time is about 20-25 minutes. FOR REGULAR CUSTOMERS, see the link below. The first link below leads to a brand new site that's chock full of information on health and nutrition; building personal wealth; offers a FREE newsletter: Health and Wealth; provides you with challenging health quizzes; and oh, offers nutritional supplements produced by a company that's been involved in human nutrition since 1893, and currently subsidizes GNC and MetRx! There are business opportunities available as well!
Contents: (1) Erectile Physiology and the Definition of Erectile Dysfunction (2) Conditions/Elements That Can Negatively Affect An Erection (3) Nutritional And Herbal Elements That May Affect Erections (4) Nutritional Supplements Can Benefit Sexual Performance (5) How to Take Your Supplements
ERECTILE PHYSIOLOGY AND THE DEFINITION OF ERECTILE DYSFUNCTION.
Believe it or not, the relaxed or flaccid state of the penis (DETUMESCENCE in medical terminolgy) is largely due to the CONTRACTION of SMOOTH muscles in that organ (1). I know, you think muscle contraction should lead to movement or stiffening, but the contracted muscles in a relaxed penis serve to block off the blood that fills and stiffens the penis following sexual stimulation. With these muscles contracted, the penis only gets enough blood to supply it with oxygen, nutrients, immune cells and chemical regulators necessary to maintain healthy, living tissue.(Note: Smooth muscle is a type of muscle found primarily in body organs that are not under direct voluntary control. Smooth muscle activity is largely automatic, and it's movements are generally a bit slower than striated muscle, from which it is structurally distinct. Striated muscle includes skeletal and cardiac muscle. Cardiac muscle possess a functional combination of the above two characteristics, since it is striated muscle that contracts rapidly like skeletal muscle, but like smooth muscle it is not subject to conscious manipulation. The term "striated" is descriptive for the appearance of muscle cells under microscopic examination.).
The muscular contraction that maintains the flaccid state of the penis is brought about by a part of the AUTONOMIC nervous system called the sympathetic nervous system, via the release of norepinephrine, which is a type of transmitter used by our nervous system to send messages to other body cells (See the Knowledge Link below: Nutrition and Stress, for more information on the nervous system.). Upon sexual stimulation, the PARAsympathetic aspect of the autonomic nervous system overrides, and precipitates relaxation of the muscles that block the penile arteries, via the neurotransmitters acetylcholine and nitric oxide. The penile arteries are then completely unobstructed, providing for the engorgement of the penis with blood. A full erection (TUMESCENCE in medical terminology) is achieved when the blood pressure in the penis is of sufficient intensity to press the relaxed muscles, and a fibrous tissue called the tunica albuginea, against the penis' inner walls, reducing venous outflow (preventing drainage). A flaccid state is once again achieved following orgasm or a reduction of sexual desire. This occurs through a reversal of the aforementioned erectile process: the smooth muscle once again contracts, providing for venous outflow while restricting arterial supply to a minimum.
The process of achieving and maintaining an erection is modulated by testosterone, which helps to maintain the responsiveness of penile smooth muscles to the above mentioned erectile friendly neurotransmitters, acetylcholine and nitric oxide. Testosterone also helps to regulate the level of the nitric oxide transmitter in the penis; and acts within the brain to stimulate sexual desire and initiate erections....
The above describes erectile physiology in a nut shell (no pun intended). However, the erection of a penis is actually a much more complex affair that's only now beginning to be more clearly understood. When some aspect of that complex process consistanly messes up; or when some other physical condition adversely affects the components of the erectile mechanism, you wind up with erectile dysfunction. Erectile dysfunction is basically defined as the inability to achieve an erection; maintain an erection; or develop an erection of sufficient intensity (hardness) to obtain vaginal penetration. This definition assumes the usual heterosexual procedure. If you are suddenly and/or chronically unable to penetrate other things with your penis that you had previously been able to handle, there's obviously still some cause for concern.
And believe it or not, what was originally thought to be a natural, age related decline in male sexual function, is actually a form of erectile dysfunction. There is no reason a man can't use his penis to the satisfaction of his partner and himself, up to an advanced age, if he keeps the organ systems that provide for an erection healthy, through the appropriate application of diet, exercise and other measures. Read on....
CONDITIONS/ELEMENTS THAT CAN NEGATIVELY AFFECT AN ERECTION.
Given the emphasis of the penis in some form or another in many societies throughout the world, it is amazing that we are only now beginning to understand how the thing really works. In view of our recently improved understanding, and due to the impact of the penile mystique on the male psyche, it is important to point out that individuals who have experienced or are experiencing erectile difficulties are not weird, odd, crazy, demasculinized or impotent. In fact, the term "impotent" is no longer preferred medically, due to the increased understanding of how a penis becomes erect. Erectile dysfunction, or ED, is the preferred medical description. It is now believed that erectile difficulties are mostly due to PHYSICAL conditions that negatively impinge upon components of the erectile mechanism. A conservative estimation of the number of men who experience or have experienced erectile difficulties is over 30 million (2)...
The Two Main Types of Erectile Dysfunction.
ED is classified as either organic (physcial) or psychogenic. Organic ED can be due to vascular, neuronal, hormonal or smooth muscle abnormalities. Psychogenic ED is assumed to be due to central nervous system inhibition of the erectile mechanism, without any signs of physical anomaly. For those told they have psychogenic erectile dysfunction, they may actually have a physical condition that has yet to be identified. Still, as you know, serious inhibitory thought patterns regarding sexual encounters can mess up your hard on. If you think that's what's going on, see a behavioral therapist and get things worked out. Psychogenic ED is more prevalent among men younger than 35 years (3).
Atherosclerosis Accounts for Many Cases of ED
Atherosclerosis is one of the more common physical causes of ED (4). Having thicker blood so to speak, and/or narrower blood vessels due to high concentrations of fatty material in your cardiovascular system can easily mangle your penile hydraulics. Another reason to keep your saturated fat intake and blood cholesterol levels down. There's no need to panic and stop eating fat altogether however. You need the stuff in your diet in order to synthesize hormones that affect your sexual abilities, such as testosterone. If you have elevated blood cholesterol and triglycerides, talk to a competent nutritionist about lowering your saturated fat intake, especially if your low density lipoptoteins, or LDLs, are significantly elevated. Atherosclerotic disease is the cause of about 40% of ED cases in men over 50 years (5).
Blood Pressure Affects Erectile Function.
Serious blood pressure abnormalities can also precipitate ED. Low blood pressure, high blood pressure, and antihypertensive medications used to treat high pressure can negatively impact erections. Talk to your doctor if you think you need to have such concerns addressed.
Diabetes.
Another major physical cause of ED is diabetes. The impact this disorder has on an erection depends upon your age, how long you've been diabetic, and the severity of the condition. Diabetes can contribute to the degeneration of nerve fibers and blood vessels in the penis that provide for an erection. Again, see a good, competent health care practitioner in order to have such concerns addressed (6).
Testosterone vs The "Endocrine Disruptors".
Another physical concern is decreased levels of testosterone, or decreased binding of testosterone to it's receptors. As you age, your testosterone output can decrease. Some things, such as the right type of exercise and diet, can really help to slow this process down. Even if you are able to maintain significant blood levels of testosterone, there are physical agents that can compete with the hormone for it's receptors, decreasing the amount of testosterone that affects the cell interior. Several environmental agents have been found to do this. They include metabolites of pesticides; components of plastic containers that can leach into foods due to heating or long term storage; and industrial chemicals such as polychlorinated biphenyls(PCBs) (7). Folks who are told their ED concerns are psyhogenic may actually be bothered by this stuff, termed "endocrine disrupters" by medical researchers. In view of this, it's a good idea to review your work and home environment, or your food containers, in order to safeguard your hydraulics (Note: Receptors are located on our body's cells and tissues, and act like hooks that snag chemical signals carried through our blood. The chemical signal is then able to affect the cell's behavior.)
NUTRITIONAL AND HERBAL ELEMENTS THAT MAY ENHANCE AND PRESERVE ERECTILE FUNCTION.
Are there any "natural", easily and confidentially obtainable supplements that you can take to enhance your hydrualics? You are going to see all kinds of stuff out there. Some newer supplements are using the amino acid arginine, and/or the herbs ginkgo and yohimbine as part of their formula. Why? Well, let's look at the biochemistry of each to find out what will or won't help your penile hydrualics. (Note: the term "hydraulics" is NOT considered appropriate scientific lingo!)
Arginine
The neurotransmitter mentioned earlier, nitric oxide, that gets released by the parasympathetic nervous system upon sexual stimulation, and is perhaps the most important external cellular signal for the relaxation of smooth muscles in the penis - is actually derived from arginine. But does this mean that taking supplemental arginine will enhance sexual performance?
Well, arginine is a conditionally essential amino acid, meaning it can be synthesized by your body in sufficient amounts under normal conditions. However, stressful conditions such as infection and/or physical trauma (surgery, accidental injury etc), can increase the need for arginine beyond your body's ability to synthesize it. In order to meet that need, more arginine will be absorbed from your dietary supply than usual.
Further, arginine is metabolized in our gut into chemical signals that help regulate the activities of Gut Associated Lymphoid Tissue or GALT, which plays a major role in immune system function for the gut and the rest of the body.
Arginine may also stimulate growth hormone release through an interaction with your pituitary. Growth hormone can contribute to the oxidation or "burning" of fat and the growth of muscle stimulated by the appropriate type of physical exercise.
So if you take supplemental arginine, it is likely to have several different things happen to it, depending upon your body's need. Any supplemental arginine that winds up in the erectile mechanism of your penis will be what's left over after your body takes care of it's healing, growth and survival requirements. But once there, can arginine significantly and rapidly enhance sexual performance?
There is one advertisement that claims it's product, which includes arginine, is based on "Nobel prize winning research". For the most part, the research being referred to simply indentifies arginine and nitric oxide as important regulators of smooth muscle relaxation and erectile function. The Nobel prize was NOT awarded for using arginine to improve male sexual performance!
One study referred to by this advertisement (8), involved putting a lot of arginine in the drinking water of male rats over a lengthy period; then evaluating the concentration of arginine, and the strength of the rat's "intrapenile pressure" (hard on) following the application of an electrical stimulus. Under these study conditions: a lot of arginine over a long period - high concentrations of arginine was found in the area of the rat's erectile mechanism. The animal's intrapenile pressure, induced by an electrical stimulus, was also significantly higher than non treatment (no arginine) conditions. This is interesting, but it doesn't quite translate to human use, because the safety of long term use of very high doses of arginine is not known, and hopefully, you are not having sex with electrical currents! The study thus fails to provide an evaluation of arginine's effect on an erection obtained by a man, due to sensory stimulation by a human partner. Further, the current applied to the rats could actually enhance the release of nitric oxide in the animal's penis WITHOUT supplemental arginine! Please don't try that at home!...
Another arginine study (9), this one with humans, and not touted by the advertisement, also used what was considered to be high doses of orally applied arginine, 2800 mg, for a two week period. The study participants were bothered by erectile dysfunction. Forty percent of the participants had improvements in their erections. The responders turned out to be among the youngest of the participants, and had better cardiovascular health than the non responders. Note that all of the studies mentioned above required a significant period of time before a measurable effect was obtained. Nothing worked immediately...
Ginkgo biloba is now known by many folks. The active components of this herb has it's primary impact on components of the cardiovascular system. Ginkgo can help to favorable regulate the activity of blood constituents called platelets. Platelets cause blood to become more viscous at certain points, through induction of the blood's clotting mechanisms. Ginkgo can also help to support and even enhance the strength and elasticity of vessels that carry blood to and from the brain and extremities. Since an erection is established and maintained by blood flow, ginkgo's potential cardiovascular effects may be a good thing. Is there any evidence of it enhancing sexual performance in men?
Most of the investigations into ginkgo's effects pertain to blood flow to the brain, brain function and age related brain insufficiencies. There are however, a few documented investigations into the effect of ginkgo on erections. One study (10) did report some SIGNIFICANT improvement of erections in guys who were having problems due to circulation, and were NOT responding to certain drugs.
Regardless of whether the study addressed blood flow to the brain or penis however, in every case, the time needed for an effect to be measured was several weeks or even months...
Yohimbine.
You may be familiar with yohimbine. It is an herb obtained from the bark of a tree, and has been used for a long time by cultural groups in Africa and other countries to enhance sexual behavior in men. Unfortunately, scientists call this type of evidence of supplement efficacy anecdotal, because it offers no delineation of HOW a supplement has an effect; nor does it prove there is any physical effect occurring at all. The effect could be purely psychological, based on belief only. But, when some food or herb is frequently used to achieve some health related effect across multiple generations of people, it is worth looking into.
Yohimbine has been looked into. The potential this herb has to affect an erection is due to it's impact on nerve transmission, particularly in the area of the penis and brain.
As mentioned earlier, the autonomic nervous system (ANS) regulates erections. The sympathetic component of the ANS secretes norepinephrine, which serves to maintain the flaccid state; the parasympathetic component releases acetylcholine and nitric oxide (NO), which leads to an erection. The sympathetic system has receptors that act as feedback inhibitors: the norepinephrine it releases eventually finds these receptors and signals the cessation of norepinephrine release.
Oddly enough, the effect yohimbine was found to have on the above processes involved the BLOCKAGE of norepinephrine's inhibitory receptors, which could lead to a build up of the stuff, and as such, the maintenance of the flaccid state of the penis; or at least make it harder for an erection to occur. The yohimbine induced accumulation of norepinephrine can also have an effect on mood, possibly leading to the enhancement of libido, which may be the reason why yohimbine is touted as a sexual stimulant.
As for documented investigations into the effects of yohimbine on sexual performance, a number of studies (11) found little effect of the herb on fellas with organic causes of erectile dysfunction. There was some relief however, for guys with psychogenic causes of erectile problems. One study (12) actually documented a few guys erectile difficulties worsening while using yohimbine. If you have no problem getting an erection, but want to try to enhance your performance, yohimbine may only intensify your sexual urges. Some consideration also needs to be given to the fact that this herb can be polypharmacologic, meaning it has a bunch of other drug like effects, particularly at high concentrations. These effects can manifest as mood and behavioral changes. Some negative side affects include anxiety, nausea, tremor, heart palpitations and increased diastolic pressure, none of which will help you in bed. Still, a brief encounter with low doses of the herb is not likely to harm you. It may even contribute some additional pleasure to your sexual experience. Habitual use of certain medications, alcohol intake, and your current health status are important considerations prior to using yohimbine (See Nutritional Supplements -Can- Benefit Male Sexual Performanc; and How To Take Your Supplements below for more info).
In the studies mentioned above, doses of 30 mg of yohimbine were used for a period of a couple of weeks, but the participants took the herb under medical supervision...
What does all this mean?
Nutritional Supplements -Can- Benefit Male Sexual Performance.
Before using supplements for sex however, you should assess why you think you need them to enhance your performance.
Are you having erections that provide satisfying sexual experiences for both you and your partner? If so, you should think more along the lines of keeping this ability viable and less along the lines of trying to boost your performance to fantasy stud levels. Drastic, chemically induced changes in any bodily function can frequently come with an unpleasant price. And unfortunately, a man's temptation to seek new levels of sexual performance can be intensified by thoughts of an enhanced reputation, in addition to increased sexual gratification. So when someone comes along with an "all natural" dietary supplement that is "guaranteed" to work, purchasing, and possibly overusing such items is a distinct possibility, due to sexual motivations and the tendency to regard something advertised as "natural" to be inherently safe. As you saw earlier with yohimbine, dietary supplements are not always completely risk free. Therefore, taking purified, concentrated herbal products that have significant pharmacological effects, in an attempt to RAPIDLY impact one area of your body such as your penis, is not a sound idea...
Nutritional supplements that are normal constituents of foods however, are usually far safer since they are constituents of your body's structural components and metabolic processes. They can thus be incorporated into and used by your body to heal and grow as needed, as long as you don't take goo gobs of 'em (Too much of anything is bad - right?).
Often times the preservation and preparation of foods diminishes or changes our food's nutrient make up, which can result in significant nutrient loses that can contribute to all kinds of health anomalies over time. This fact can make using supplements - as part of an effort to prevent diet related diseases that may affect your hydraulics - a rather good idea!
This is not to suggest that herbs are bad and that vitamins and minerals are the best things to supplement. Lots of herbs are very useful and are actually used in Europe by medical doctors. Ginkgo is an herb that's been successfully used all over the world to manage degenerative brain disorders, with almost no side effects! Many herbs even provide vitamins and minerals! The idea here is to encourage you to not blindly heed buzz words such as "natural", "studies" and "research", and rush to purchase something that may not work or, worse yet, cause you problems. Do your own investigation first. Send me an email of your concerns (through the Martino's Supplement Resources link below), and I'll try to help. Note that if something is "guaranteed to work or your money back", that means there is a remedy available to you if the stuff DOES NOT work, so it's really NOT "guaranteed". With regards to health, no nutritional supplement can be guaranteed, since there can be several different mechanisms causing a physical discomfort or symptom. That's why you go to doctors, to get someone to professionally evaluate what's going on, then prescribe some therapy, medication or whatever, that's specifically targeted to your unique situation. Hell, even that's not always guaranteed! It IS way better than making a self diagnosis based on an advertisement however.
This leads to the most important consideration: if you are having recurrent erectile problems, don't try to take nutritional supplements to improve this condition. Go to a doctor who is trained in the contemporary diagnosis and management of ED. Poor erections, or no erections at all, may be a sign of a health condition that could be very serious if left undiagnosed and untreated. As mentioned earlier, the ED could be due to diabetes, atherosclerosis, blood pressure abnormalities or a hormonal derangement. Further, surgery on parts of the brain, spinal cord or pelvis, that involve nerves affecting the erectile process, could precipitate erectile difficulties. Cardiovascular surgery may also cause erectile problems. Even radiotherapy for prostate enlargement can negatively impact erections. So before popping some supplements to improve chronically poor hydraulics, evaluate your lifestyle in terms of what you've just read. Do you have a high saturated fat intake? Are there possible environmental contaminants? Any pelvic surgeries? Do you smoke, use alcohol or a lot of caffeine (A future Knowledge Link will address the effect of these commonly used drugs)? If you think any of these factors are a real concern for you, have your health checked by a competent medical professional.
But Supplements Can Really Be Beneficial
If you don't have to address a potentially serious health condition (diabetes?), the best thing to do is to try to lower your blood cholesterol and free fatty acids; or keep them low if they already are. A future Knowledge Link will address supplements and dietary elements you can use to help do this. Of the above mentioned supplements, the best choices are arginine and ginkgo. Ginkgo can help to improve the quality of your cardiovascular system, or help to keep it in a healthy state. Supplemental arginine can help to improve the activity of your immune system, as well as provide extra arginine that can be used to generate erection promoting nitric oxide on demand. Note however, that there is every indication that such effects may take regular supplement use, and won't occur overnight.
Another goal you can pursue involves keeping your testosterone levels from declining. As men age, the production of something called sex hormone binding glogulin, or SHBG, increases. This protein binds testosterone in our blood and renders it inactive, effectively decreasing blood testosterone levels. Physical exercise that keeps weight down can help to keep SHBG levels down, since excess weight and high blood lipids (fat) can increase SHBG. Insulin release, from healthy combinations of carbohydrate and protein foods, can also help to keep SHBG levels down (See the Knowledge Link below: Free Radicals and Bodybuilding, for more info on the use of supplements and diet to appropriately and healthily boost insulin levels).
Finally, the mineral zinc is important to the maintenance of proper testosterone concentrations in body tissues. Zinc is also needed in order for testosterone to have any physiological effect. The hormone just won't work well without the mineral, which is a significant part of over 100 enzymes in our bodies. In view of zinc's critical role in testosterone function, did you know that the male ejaculate can contain anywhere from 1-5 mg of zinc? Did you also know the recommended daily intake of zinc is 15 mg, and that it's estimated that most guys get less than 10 mg of zinc a day from their diet? If you are eating lots of fried and/or highly processed protein foods, as opposed to less harshly prepared/processed meats, fish, poultry, nuts, beans, and whole grains, you are likely not obtaining adequate amounts of zinc. Furthermore, exercise and other physical and emotional stressors can contribute to zinc losses through sweat and urine. Just think of what any combination of the above deficiency factors could be doing to the 10 or so mg of zinc you're likely getting. Proper diet and/or supplementation can replenish zinc loses and thus help to keep your testosterone at healthy, active levels in your body..
How to Take Your Supplements: Follow the instructions on the container. For arginine, up to 2800 mg for about two weeks is OK. After that, the dose on the bottle can be followed. Resist the temptation to consume huge doses if you seem to obtain positive sexual benefits from the arginine. Anyone with a history of schizophrenia should be cautious with arginine, as it may aggravate symptoms.
For gingko, if you are using anticoagulant medications or high doses of aspirin for medical reasons; or have been using high concentrations of garlic for an extended period, talk to your pharmacist or physician about using ginkgo with those medicines. The combination of ginkgo with the above medicines and herb may increase bleeding time inappropriately. Likewise, if you are using MAO inhibitors, talk to your pharmacist or physician if you want to use ginkgo, as the herb may potentiate the activity of these drugs.
Also, if you are managing blood pressure abnormalities or diabetes, definitely discuss the use of ginkgo with your health care professional.
See the links and other stuff below the references for more information.
Conclusion: Nutritional supplements, in this case gingko and arginine, can possibly enhance the strength of an erection, due to their effects on the vasculature and musculature comprising the erectile mechanism. If you are having healthy, satisfying sex, those 2 supplements, plus adequate zinc nutriture, can help to preserve your sexual performance as you age. In the event of chronic erectile dysfunction, see a doctor, since that could be a symptom of a more serious disorder that is adversely affecting your erectile mechanism. Talk to your Dr. or pharmacist before taking any unsusual nutritional supplements if you are taking medications to manage a pre-existing health condition.
Martino's Supplement Resources, www.vitamin-tim.com, offers excellent sources of gingko and arginine that will be laid right at your front door! You don't have to detour one bit from your tight, daily schedule. Just click the link below, then click on "Catalog Index" then "Amino Acids" for the arginine; or click "Specialty Formulas" for the gingko. It's best to select the Gingko Biloba Extract, since it's been standardized to provide 24% flavone glycosides and 6% terpene lactones. These are the concentrations of the active ingredients identified to provide the health promoting effects mentioned above. To order zinc, from the Catalog Index, click on either "Chelated Minerals" or "Mineral Aspartates". All orders are encrypted and secure!
About me: I work as a professional Biologist. I am also a bodybuilder and a martial artist. I assert my belief in the efficacy of nutritional supplements due to my personal, practical and professional experience with nutrition and nutritional biochemistry. My intent on this site is to convey the value of nutritional supplements and proper diet with facts - not hype. I also hope I provide you with some information you can actually use, and supplements that can help to make a positive difference in your life...
References
1) Anderson, KE; Wagner, G: Physiology of penile erection. Physiol. Rev. 75: 191, 1995 (2) Brien, SE; Wheaton, JP; Racz, WJ; Adams, MA: Effect of environmental antiandrogen on erectile function in an animal penile model. J. Urol. 163: 1315-1312. 2000 (3) Segraves, KB; Segraves, RT: Psycogenic impotence, In: Impotence: Diagnosis and Management of Erectile Dysfunction. Edited by AH Benett. Philadelphia: WB Sanders. Philadelphia, Chapt 6 pp 92-105, 1994 (4)Melman, A; Gingell, C: The epidemiology and pathophysiology of erectile dysfunction. J. Urol. 161: 5-11 1999 (5) Kaiser, FE; Viosca, SP; Morley, JE; Mooradian, AD; Davis, SS; Korenman, SG: Impotence and aging: clinical and hormonal factors. J. Amer. Geriatr. Soc. 36: 511 1985. (6)Kolodny, RC; Kahn, SB; Goldstein, HH; Barnett, DM: Sexual dysfunction in diabetic men. Diabetes, 23:306, 1974. (7) Hakim, LS; Goldstein, I: Diabetic sexual dysfunction. Endocr. Metab. Clin. N. Amer. 25:379, 1996 (8) Brotons, JA; Olea-Serrano, MF; Villabos, M; Pedroza, V; Olea, N: Xenoestrogens released from modified polystyrene. Environ. Health Perspect. 103: 608, 1995 (9) Espir, ML; Hall, JW; Shirrifs, JG; Stevens, DL: Impotence in farm workers using toxic chemicals. Br. Med. J. 14:423, 1970 (10) Melman, A: L-Arginine and penile erection (review article) J. Urol. 158:686, 1997 (11) Zarigniotti, AW; Lizza, AF; Effect of large doses of nitric oxide precursor L-arginine on erectile failure. Int. J. Impot. Res. 6:33-34, 1994 (12) Sikara, R; Sohn, M: Ginkgo biloba extract in the therapy of erectile dysfunction. J. Urol. 141:188A, 1989 (13) Reid, R; Surridge, DH; Morales, A: Double blind trial of yohimbe in the treatment of psychogenic impotence. Lancet. 2:42-43, 1987 (14) Susset, JG; Tesier, CD; Winze, J: Effect of yohimbine hydrochloride on erectile impotence: a double blind study. J. Urol. 141:1360-1363, 1989 (15)Morales, A; Heaton, JP; Johnson, B; Adams, M: Oral and topical treatment of erectile dysfunction: present and future. Urol. Clin. North Am. 22:879886, 1995.
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