What is erection problem, impotence, erectile dysfunction (impotence)?

Erectile dysfunction, Impotence, Erectile Dysfunction (Impotance); It is a common male sexual dysfunction. It is the inability to achieve or maintain an erection that can provide a satisfactory sexual activity in the penis. It can be observed occasionally or frequently, with or without a specific cause. Some men with erectile dysfunction may not have an erection at all. Erectile dysfunction is not a life-threatening disorder, but it can negatively affect your or your partner’s quality of life. Erectile dysfunction is a common condition among men of all age groups and ethnicities. The risk of developing erectile dysfunction increases with age. Hardening is a process involving physical, hormonal and psychological elements. It is made of a soft, spongy and elastic tissue that increases in size and hardens as the penis fills with blood. Around the spongy tissue and prostate are nerves that send signals to the blood vessels to supply blood. These signals are controlled by the male hormone testosterone. Erectile dysfunction is a very personal and special situation. Most patients consult multiple sources of information for their erectile dysfunction, such as friends, internet, media, herbalists, pharmacists, psychologists or medical doctors.

Reasons for not going to the doctor for erectile dysfunction

They think they have normal erection,

They assume that they can stop the sexual life and think that the treatment is unnecessary.

They think it is an incurable disease.

Worried about being misdiagnosed

Access to the doctor is not easy.

He and his friends or relatives had a negative experience at the hospital

They do not have enough information about treatment options

They may not have the financial strength

They feel isolated because of their age and situation

Causes-Causes of erection problem

Heart diseases (cardiovascular-Cardiovascular diseases)

Urinary complaints and erectile dysfunction

Psychological Causes-Depression-psychosis

Diabetes (Diabetes)

Nerve damage in the penis or pelvic area

Surgical operation in the pelvic region

Radiation therapy in the pelvic area

Low testosterone level

Parkinson’s-like neurological diseases

drug use

Cardiovascular diseases and Erectile dysfunction: Cardiovascular diseases and erectile dysfunction: they share similar risk factors such as obesity, smoking, high cholesterol, high blood pressure and lack of exercise. Erectile dysfunction can be an early sign of heart disease, as problems with blood flow can also affect erectile function. For this reason, men with erectile dysfunction should consult a cardiologist to be evaluated for heart disease.

Urinary Tract Symptoms and Erectile Dysfunction: Erectile dysfunction is often associated with urination disorders such as urinary frequency, the need to urinate at night, and the urge to urinate. These symptoms are often associated with an enlarged prostate. It’s unclear whether these urinary symptoms cause erectile dysfunction, but they usually get worse as urinary symptoms get worse.

Psychological Risk Factors for Erectile Dysfunction: Social ideas about how to interact between men and women can also cause Erectile dysfunction. These ideas may include unrealistic expectations about love and sexuality and inappropriate role models for men and women. Erectile dysfunction can sometimes be the cause and sometimes the result of a relationship that does not progress correctly or is not satisfied. Often it is difficult to determine which of these started first.

Psychological Factors include the following

Anxiety

Depression

Feeling of lack of self-confidence

low self-confidence

unable to describe their feelings

Stress

DIAGNOSIS

Medical History-Questioning: Your doctor will take your medical history to understand your general health condition. Within the scope of your medical history, your doctor may also ask questions about other problems you may have besides the current situation.

Your doctor may ask you:

Whether you are using any medication

whether you smoke or not

When and how much alcohol you consume

Whether you drink a lot of coffee or alcohol

Whether you regularly use recreational drugs

Whether you have had previous pelvic surgery

whether you have any heart problems

Whether you have a hormonal disorder

whether you have any psychological problems

Questions About Your Sex Life: Your doctor will ask you to describe the hardness and duration of morning and sexual arousal erections. Your doctor will also ask if you have problems with arousal, ejaculation and orgasm. It would be beneficial to attend the interviews with your sexual partner, if any.

In this Inquiry:

The status of your previous sexual relationships

Your current sexual relationships

Your current emotional state

When did your erection problems start?

How long your erection problems last

Whether you have been to another doctor before, especially for SS

Whether you have received previous SS-related treatment

Evaluation Forms: Your doctor may ask you to fill out some evaluation forms to evaluate your sexual life from different perspectives.

The most commonly used of these are:

International Erectile Function Form (IIEF)

Male Sexual Health Assessment Form (SHIM) • International Prostate Symptom Score (IPSS)

Clinical Depression Scale

Physical Examination: The doctor will perform a complete physical examination to evaluate for abnormalities of the penis, scrotum, and testicles. To assess for heart disease, the doctor will measure your blood pressure and heart rhythm and order a blood test to measure your cholesterol level. Your doctor will feel the size, shape and consistency of the prostate by performing a digital rectal examination and, if necessary, measure the level of prostate specific antigen (PSA) in your blood. To evaluate diabetes, the doctor may order a test to measure the level of sugar in the blood. Your testosterone level may also need to be measured. All of this is done with a blood test.

Cardiac Risk Assessment: Due to the close relationship between erectile dysfunction and heart diseases, the doctor usually performs a cardiac risk assessment as part of the diagnosis. Your doctor may refer you to a cardiologist for further evaluation for special heart-related tests, such as a “stress test.”

Other Tests: These are not commonly used tests in the initial evaluation of Erectile dysfunction and are only needed if your doctor needs additional information when assessing your personal situation. If necessary, your doctor may refer you to a neurologist, a psychiatrist, or an endocrinologist for further evaluation.

Nocturnal penile tumescence and rigidity (NPTR) test

Intracavernous injection test and penile doppler USG

Contrast-enhanced X-ray evaluation to evaluate your blood vessels

Medical imaging of the penis

TREATMENT

Erectile dysfunction is a common problem. Although not life threatening, it can negatively affect your quality of life. It’s important to get the right treatment as it can be associated with other conditions, such as heart disease. There are different treatment methods for erectile dysfunction, discuss with your doctor the best treatment option for your situation.

1-Education and Evaluation of Couples

An important part of treatment is understanding this condition and the consequences it can have on your close relationship. For erectile dysfunction treatment, your doctor usually recommends a combination of physical and psychological approaches. In the past, doctors focused mainly on treating the physical aspect of erectile dysfunction. Today, the psychological and emotional aspects are also evaluated. Treatments that include psychological approaches have proven to be more effective than just treating physical symptoms. This approach has also been shown to be effective in single patients or in situations where the partner is not involved. If you are in a serious relationship, it will be in your best interest to have your partner approve of the type of treatment, know how it works, and be able to talk about it. Remember that treatment is tailored to your situation, and treatments that work for others may not always work for you. If you have another health problem related to erectile dysfunction, your doctor may refer you to a specialist for evaluation and further treatment. Lifestyle recommendations Improving your general health can reduce your complaints. Your doctor will advise you to stop smoking, drink less alcohol, and exercise regularly. Depending on your personal situation, your doctor may recommend that you adjust your diet. It is important that you discuss this with your doctor first. As a general rule, try to eat a diet low in sugar, salt, and fatty foods.

2-Phosphodiesterase 5 inhibitors (PDE5I):

Phosphodiesterase 5 inhibitors (PDE5I) are a group of drugs used in the treatment of erectile dysfunction. These drugs increase blood flow by relaxing the smooth muscles of the vessels in the penis. They do not cause an erection without a sexual stimulus. PDE5Is are the most prescribed drugs for erectile dysfunction. All PDE5I variants can be equally effective. Which drug is best for you depends on how often you want to have sex and your personal experience. Because PDE5Is are very effective in the treatment of SS, there are many imitation drugs on the market. These drugs are not approved for sale, they can be poisonous and can harm your health. Always talk to your doctor or healthcare provider before using or purchasing medication for your erectile dysfunction.

PDE5Is can cause headache, skin rash, heartburn, nasal congestion and dizziness. Vardenafil can cause vision changes, while Tadalafil and Avanafil can cause back and muscle pain. All these side effects go away after you stop using the drug. The use of PDE5I is not recommended if you are using nitrate-containing drugs or alpha-blockers. They can cause a sudden drop in blood pressure. If you have questions, consult your doctor.

There are 4 types of approved PDE5Is:

sildenafil

tadalafil

vardenafil

Avanafil

Sildenafil: Sildenafil is the oldest known PDE5I and is sold as a pill. It is offered for sale in doses of 25, 50 and 100 mg. Dose adjustment can be made according to your needs. You start to feel the effects 30-60 minutes after taking the medicine. Its effect can last up to 12 hours. If you eat fatty foods just before taking sildenafil, the effect of the drug will decrease.

Tadalafil: Tadalafil is sold as a pill. It is available in doses of 5, 10, and 20 mg. The dose can be adjusted according to your needs. You start to feel the effects 30 minutes after taking the medicine. It reaches its most effective level after 2 hours. Its effect can last up to 36 hours. Compared to other PDE5Is, what you eat has no effect on the effectiveness of Tadalafil.

Vardenafil: Vedanafil is sold as a pill or as a water-soluble tablet. It is offered for sale in doses of 5, 10 and 20 mg. Dose adjustment can be made according to your needs. You start to feel the effects 30 minutes after taking the medicine. If you eat fatty foods just before taking Vardenafil, the effect of the drug will decrease.

Avanafil: Avanafil is the newest PDE5I. It can be found in doses of 50, 100, and 200 mg. Dose adjustment can be made according to your needs. You start to feel the effects of the medicine 15-30 minutes after you take it. Anything you eat with the medicine can delay the effect of the medicine.

If you think that PDE5Is are not useful to you, you should first determine the reason for this situation. To do this, you must answer the following questions:

Have you used this drug at least 4 different times?

Did you use the maximum dose of the drug?

Was there enough sexual stimulation when you took the drug?

Have you waited long enough for the medicine to take effect?

Did you wait too long before starting the sexual stimulus?

If you do not see any benefit despite using the highest dose and correct PDE5I, discuss other possible treatment alternatives with your doctor.

3- Local-Topical Treatment

Topical therapy means applying drugs to the skin. Two specific formulations of alprostadil are approved for topical treatment. The first of these is a drug in the form of urethral pellets placed from the tip of the penis (intraurethral). The second is a drug in cream form applied to the external opening of the urethra at the tip of the penis. Alprostadil is a well-known drug used in the treatment of erectile dysfunction. Although they are generally seen as part of second-line therapy, they may also have uses in first-line therapy. The most important advantage of alprostadil cream is that systemic side effects are very rare and there is no restriction in its use with other drugs (for example, used in the treatment of high blood pressure or blood thinners such as heparin, warfarin). Alprostadil is absorbed from the urethra and increases blood flow by relaxing the smooth muscles of the penile vessels. Alprostadil cream contains a permeation enhancer to facilitate the absorption of alprostadil. Its mechanism of action is similar to that of intraurethral alprostadil.

You should not use alprostadil if you have any of the following or are allergic to alprostadil: – sickle cell anemia or sickle cell anemia carrier – leukemia – bone marrow tumor (multiple myeloma) – crooked or malformed penile – penile fibrosis or Peyronie’s disease – penile prosthesis.

Side effects: The most common side effects associated with intraurethral alprostadil are local pain and dizziness, usually accompanied by low blood pressure. Although urethral bleeding and urinary tract infections can be observed in some patients, penile fibrosis and priapism are very rare. Topical alprostadil may only have local side effects such as penile redness, penile burning and pain, and systemic side effects are very rare.

To make sure it is safe for you to use alprostadil, tell your doctor if you have:

a history of an event related to a blood clot,

heart disease, high blood pressure (hypertension),

bleeding or clotting disorder;

a disease that can be transmitted through the blood (such as hepatitis or HIV) Use a condom to prevent the transmission of this medicine to your sexual partner.

4-Vacuum curing device (VED)

A vacuum erection device (VED) is a cylindrical device with a rubber or silicone ring that tightens around the penis. VED provides hardening and its preservation. You should consider VED when PDE5Is are not effective. You can also consider VEDs as an alternative treatment if you are also unable to use PDE5I or do not want to use medication for Erectile Dysfunction.

Vacuum is created by placing the cylinder on the penis and removing air from the device by hand or with an electronic pump. This process allows blood to accumulate in the penis, thus first swelling and then hardening. To maintain the erection, you must place the rubber or silicone constrictor ring at the base of the penis after removing the pump. Never leave the ring attached for more than 30 minutes. It is important to know that the blood drawn into the penis will be dark in color. As a result, your penis feels colder to the touch and looks slightly blue when the ring is in place. Some people don’t mind this, but if it bothers you or your partner, you should talk to each other and your doctor about it. It is very important that you know that the ring must be removed after 30 minutes. The blood drawn into the penis is low in oxygen, and the lack of oxygen can damage the penile skin. If you want to use a constrictor ring without VED, make sure the ring is made of a flexible material such as rubber or silicone. Never choose hard materials such as steel or hard plastic; such substances can be difficult to remove.

VEDs can be uncomfortable, make ejaculation difficult during orgasm, cause bruising and numbness of the penile skin. Keeping the constrictor ring for more than 30 minutes can cause serious damage to the skin of the penis.

5-Extra body shock wave therapy (ESWT)

Extracorporeal shock wave therapy (ESWT) is a treatment in which very low-intensity focused shock waves are delivered to the penis in short intervals to improve erectile function. It is applied in multiple sessions and can be repeated if necessary. ESWT is a new treatment method under investigation for erectile dysfunction. It is not a standard treatment option. Special ESWT devices are required for erectile dysfunction treatment. If you have mild Erectile dysfunction and do not want to use PDE5I, your doctor may recommend ESWT. However, keep in mind that ESWT is not currently the primary standard treatment for erectile dysfunction. ESWT causes minor damage to the penile tissue. During the healing process, new blood vessels are formed and blood flow to the penis increases. This increases the capacity to provide and maintain hardening. Click for more information about Shock Wave Therapy: https://www.hakkiperk.com/tr/hizmet/detay/183/Sok-Dalga-Tedavisi-ESWT

6-Intracavernous injections

Intracavernous injections are a treatment option in which the drug is injected into the spongy tissue in the penis to open the vessels for the treatment of erectile dysfunction. Intracavernous injections are a treatment option used when initial lifestyle changes or PDE5Is do not work. Although most men are afraid of the idea of ​​having their penis injected, people who choose this treatment soon realize that a small needle hole is not so important in the face of the benefits of the injection. Drugs used in intracavernous injection increase blood flow by causing relaxation in the smooth muscles of the vessels of the penis. Thus, 10 – 15 minutes after the injection, erection occurs even if there is no sexual stimulus. The most commonly used drug for intracavernous injection is alprostadil. In some cases, your doctor may recommend a combination of drugs to increase the effect or reduce the side effects. Doses may vary and can be adjusted as needed.

Commonly used drugs include:

papaverine,

phentolamine,

vasoactive intestinal peptide,

atropine

forskolin

Your urologist will train you in his practice on how to inject yourself. In some cases, your partner may also need training. During the training, the urologist also determines the appropriate dose for you. The place of injection is important. Be sure to inject between 2 and 4 o’clock or between 8 and 10 o’clock to avoid damaging the base of the penis, the urethra, nerves and blood vessels in the penis. . Then apply gentle pressure to the injection site for 2 – 5 minutes to avoid bruising. If the correct dose is applied, hardening will occur within 10-15 minutes.

You should not use intracavernous injection if you are hypersensitive to any ingredient in the drug, if you are at risk for priapism or if you are using anticoagulant medication. Your urologist can give you more in-depth information about these contraindications and discuss your personal situation. The most common side effect of injections is pain in the penis during erection. This happens in one of every 10 injections and ends with the end of the hardening. Another mild side effect is bruising at the injection site. The most serious side effect is priapism. An erection that lasts longer than 4 hours and is painful. Priapism can damage smooth muscle cells in penile vessels and worsen erectile dysfunction. It is very important to contact your doctor if your erection lasts longer than 2-3 hours. In general, priapism can be effectively treated with an injection of an antidote (a substance that blocks or counteracts the harmful effects of any poison or drug).

6-Penile Prosthesis

Penile implant, also called penile prosthesis, is a medical device that is placed in the erection chambers of the penis in case of severe erectile dysfunction. If you’ve tried PDE5I and intracavernous injections but have had little effect on your SS, a penile implant is an option you might consider. It may also be recommended if you are unable to use PDE5I or injection drugs. If you have tried PDE5I and injection and are not satisfied with the result and want a permanent solution, a penile implant may be a suitable option for you.

There are two types of penile implants: semi-rigid, non-inflatable implants and inflatable implants.

Semi-rigid implants consist of two bendable rods inserted into the erectile chambers of the penis. They can be bent into the appropriate position during sexual activity. In the presence of such implants, the penis is always semi-rigid and can be difficult to hide.

Inflatable penile implants are fluid-filled devices, consisting of two inflatable cylinders placed in the erectile chambers of the penis, a hand-controlled pump placed in the scrotum, and a reservoir that stores fluid when the penis is not erect. The device is inflated by transferring the liquid from the reservoir to the cylinders by squeezing the pump several times. Then, the pump is used to transfer the liquid back to the reservoir. You need to have surgery for both implants. Both implants are placed completely inside the body. Inflatable implants are used more often because they provide a more natural result. In complicated cases, semi-rigid implants may be more appropriate. Discuss with your urologist which of the two types of implants you will choose.

How to prepare for the procedure: Your doctor will give you detailed information on how to prepare for the procedure. To prepare for anesthesia, you should not eat, drink or smoke 6 hours before the operation. Let your doctor know if you are using a prescription medication. You may need to stop this medication a few days before the surgery.

How Penile Prosthesis Surgery is Performed: You can receive general anesthesia or spinal anesthesia for penile implant surgery. In addition, a urinary catheter is inserted to be withdrawn one day after the surgery. While under anesthesia, your doctor makes an incision on your penis or between the penis and scrotum. Through this incision, your erection chambers are seen and the surgeon measures these chambers to place the correct length of penile implant. After the rollers are in place, the reservoir is behind the abdominal wall and the pump is placed in the scrotum, between the testicles, in such a way that it is hidden. Finally, all parts are connected and the incision is sutured. The wound is cleaned and a pressure dressing is applied. Most surgeons keep the penile implant in the inflated position for one day. Some surgeons may prefer to place a drain to be removed the day after the procedure.

In general, you can be discharged one day after the surgery after the pressure dressing is opened by your doctor and the implant is removed. For a few days to a few weeks after surgery, you may experience pain and soreness in the penis and swelling in the penis and scrotum. This condition is normal and can be treated with pain relievers or cold application. There may be a small amount of discharge from the incision in the first 2-3 days after the operation, it usually goes away on its own; does not require treatment.

For 4 – 6 weeks after the surgery: – Do not lift anything heavier than 5 kilograms – Do not do heavy exercise and do not ride a bike – Do not take a thermal bath or sauna – Discuss prescribed medications with your doctor

Your doctor will give you an appointment to have the implant inflated for the first time. This procedure is done after the swelling and pain subsides, that is, approximately 4 months after the surgery.
done a week later. After this appointment, you can engage in sexual activity.

Inform your urologist if: – If the swelling is excessive or does not go away – If you have a large amount of discharge every day – If the pain gradually increases or does not go away – If you notice increasing redness or tenderness at the incision site – If you have a fever

The advantages of penile implant surgery are: – Mechanical failure is rare – The device is discreetly inflatable – Inflatable implants are easy to conceal – No risk of priapism – More satisfactory results than all possible treatment modalities – If the patient and partner are properly informed about what to expect from the implant, all erection The disadvantages of penile implant surgery are: – This surgery is irreversible – If the device needs to be removed, it is not possible to restore the erection function – Low risk of infection – Low risk of device failure: In general, inflatable implants 10 – 15 It has a lifetime of years. If the device fails, it can be replaced. – Very low postoperative risk of uncontrollable bleeding and re-operation – Very low risk of scar tissue formation – Very low risk of tissue loss (erosion) that will require removal of the implant – The glans does not grow during erection – Penile Implants do not enlarge the penis or correct loss of penile length due to radical prostatectomy, radiation therapy, aging, weight gain or long-term erectile dysfunction. 7-Treatment of Erectile Dysfunction After Prostate Cancer Treatment

Prostate cancer is a malignant tumor of the prostate gland. This is the most common type of cancer in older men. There are several treatment options for localized prostate cancer. Two of the most common treatments are radical prostatectomy and radiation therapy. These treatment options can affect sexual health, and men often experience erectile dysfunction after treatment. The prostate gland lies just below the bladder and is surrounded by nerves and blood vessels. These nerves and blood vessels are essential for normal erection. Much research has been done to understand where these nerves are located and to prevent damage during surgery or other treatments. The risk of erectile dysfunction after prostate cancer treatment depends on the surgical technique or the type of radiation used by your doctor, but at the same time, the following characteristics affect you: – Age – Body composition – Characteristics of the disease – Pre-treatment sexual health status

Treatment of erectile dysfunction after prostate cancer surgery: Radical prostatectomy is a surgical treatment option in which the entire prostate and surrounding tissue are removed. If the tumor is limited to the prostate gland, the surgeon will try not to touch the nerves of the penis during the operation. This is called nerve-sparing surgery. Even if nerve-sparing surgery is successful, temporary erectile dysfunction is common after radical prostatectomy. The reason for this is that the nerves are very sensitive, so they are affected by the slightest damage. If any damage occurs during the surgery, the signals of the nerves to the blood vessels of the penis stop. Nerves can take up to 2 years to heal. The blood vessels that supply blood to and from the penis may also be affected by the surgery. As a result, less blood goes to the spongy tissue of the penis, damaging it. Because of this damage, erectile dysfunction may be more difficult to heal. In some cases, nerve-sparing surgery is not possible in cases where the tumor has spread outside the prostate or for other reasons. Recovery of erectile function is not expected after non-nerve-sparing surgery, but it is not impossible. Discuss your concerns and possible treatment options with your doctor.

Treatment of erectile dysfunction after radiation therapy: Radiation, a type of cancer treatment, is used to control or kill malignant cells. This can be done outside the body or by placing the radiation source inside the prostate. Nerves and blood vessels leading to the penis around the prostate can also be damaged, as radiation can cause healthy cells to die as well. Although there is a risk of erectile dysfunction after radiation therapy, technical developments have increased the sensitivity of the beam.

8-Living with Erectile Dysfunction

Almost every man can experience short-term problems with erectile function. In almost all cases it is related to certain and particular life circumstances, problems or stress. Often, these erectile dysfunction problems are resolved by solving or changing the condition. Usually there is no need to go to the doctor. If you have erectile dysfunction for more than 6 months, you should seek professional help. Your doctor can help you find the cause by performing physical and psychological tests. You can get more detailed information on this subject in the Diagnosis of Erectile Dysfunction section. Erectile dysfunction can have a negative impact on quality of life. Quality of life encompasses both physical and mental health. It is important not only to feel healthy, but also to not have the psychological discomfort of living with erectile dysfunction. Another important issue is that different people may experience the same symptoms differently. Therefore, your personal experience and quality of life should not be overlooked; because they are as important as diagnostic tests and treatment results.

Personal Relationships: A close relationship between two people is complex and requires many aspects. Erectile dysfunction can affect or change your relationship with yourself or your partner. You may feel ashamed or guilty, which can make it difficult to talk to your partner about the situation. Erectile dysfunction can have a direct impact on a serious relationship. Erectile dysfunction can negatively affect your sex life. It is difficult to feel attractive and self-confident or to be close with your partner when you feel that you cannot bring pleasure to your partner. This trust can also have an impact on intimacy and intimacy. Intimacy as well as daily interaction can be affected by this.

You may feel emotionally and physically alone because you fear that there will be no satisfactory sexual activity. While this behavior can be a sign of disappointment and humiliation, your partner may feel that you are losing interest in them. This can negatively affect their self-esteem and sense of attractiveness. Dealing with these changes can be very difficult because for most men, sex and erection are important their whole life. You may even be in denial and become depressed. Therefore, the effect of erectile dysfunction on quality of life should not be ignored. Many men may find it inappropriate to admit that they need affection and hugs.

It is important that you address the issue by talking to your partner. This can prevent emotional and physical distance and provide the comfort and emotional support you need. Your partner may have associated their attractiveness and sexual attraction with their ability to turn you on. They may feel vulnerable and rejected, and may fear betrayal and abandonment. These feelings are exacerbated as you cannot experience satisfactory sexual activity due to erectile dysfunction. While erectile dysfunction treatment can resolve the physical aspect of the problem, the psychological consequences for you and your partner may also need to be addressed. Consulting a therapist may help. Your partner can be distressed even if they don’t express it, so it is very important that you talk openly with your partner about the best way to deal with this situation.

Erectile dysfunction does not only affect the sex life of men in a serious relationship. Single men who suffer from erectile dysfunction often avoid intercourse for this reason. Discussing your sex life with a urologist or a sexologist can be uncomfortable, but it is the most effective way to deal with your concerns. Together with your doctor, you can determine what is important in your sex life and choose the best treatment option for a satisfying sex life. If you have a partner, it is important that they also participate in these consultations.

‘eau is quoted from the patient information section’

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