AB25. What would YES (Morning Erection/Sleep-related Erection) be without NO (Nitric Oxide) induced by Teststerone?

As you know, for penile erection, a sufficient amount of testosterone-induced nitric oxide is needed in the smooth muscle of the penile arterial wall. With aging, LOH syndrome and so on, the serum testosterone level decreases, resulting in a decline of penile erectile function. Furthermore, it is known that the enzyme PDE5 in the penile artery wall also inhibits that function. Even so, it may be safe to say that decreasing testosterone is the major factor for erectile dysfunction, excepting severe diabetic arterial sclerosis. Currently, however, almost all doctors treat ED cases with a PDE5-Inhibitor only. From my understanding of the above-mentioned mechanism of erection, I think this medical treatment is not scientific and only a half measure. Cases in which PDE5-inhibitors alone are effective are limited to those in which sufficient NO is maintained to barely induce erection unless inhibited by PDE5. Aging males, especially, have lower NO levels caused by low testosterone. These cases cannot be cured satisfactorily by PDE5 inhibitors alone, even if the men can somehow achieve sexual intercourse. Therefore, I cannot understand or agree with the treatment method using a PDE5-Inhibitoralone without checking the testosterone level. Furthermore, simple temporal recovery of sexual activity does not revitalize the male fundamental physiology, that is, sleep-related erectionand morning erection. And a more important problem is that latent psychological disorders should be thoroughly investigated for patients consulting about so-called ED. It is even said that it is lucky for a patient to have a chance to consult about ED, since it means that the doctor will check for other disorders; for example, metabolic syndrome so on. More aged men are beginning to feel loss of motivation and poor physiological condition after the climacteric stage, with loss of morning erection, even if they do not express complaints. These problems are mostly caused by a decline in testosterone, which latently accelerates arterial sclerosis and vascular disorders, shortening the male life span. Such patients with low levels of free testosterone complaining of ED should be treated with testosterone substitution and a PDE9-inhibitor (especially long-acting Cialis) for a period of at least 2-3 months. This treatment will restore the male physiological functions of sleep-related erection and morning erection and as well as treating many symptoms of LOH syndrome at the same time. However, the most important effect of revitalization of male physiology is surely the restoration of the self-actualization and dignity of maleness to patients. That should be considered the most clinically significant outcome.