Erectile Dysfunction Holistic Treatment

Mental Impotence Healer

The Mental Impotence Healer is a real revolution in the men health genre because the author Mike Miller wrote this program based on scientific facts which link erectile dysfunction to mental condition. And the author taps into this topic in a positive way and he leads the men to truly be connected with their mental power and heal their condition. The program itself is easy to follow and anyone could do the exercises and understand the instructions easily. The mental impotence healer is consisted of the main book with a lot of illustrations to help the reader follow understand the exercises and follow them. The mental bonus which is a great book in of itself because it helps you tab into your mental power more and more because to harness your mental power means you become the best version of yourself. The last but not the least is a free membership to monthly subscription which holds a great deal of information and it provides you with a lot of inspirational posts and new ideas. If you learn about the mental impotence you will know that no man should be impotent and this program is intended to achieve that goal for all men Read more here...

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Penile erection monitoring

Penile erection monitoring has been used to distinguish organic from psychogenic causes of impotence. In the latter, erections during sleep are retained, in contrast to organic disorders. Different patterns of abnormalities are seen in vascular and neuropathic disorders.

Male Sexual Dysfunction Male Erectile Disorder

Sion ads, this disorder has become the definitive example of sexual disorders that affect men. Male Erectile Disorder (ED) is defined by an inability to attain or maintain an erection until completion of sexual activity, and is associated with marked distress or interpersonal difficulty (American Psychiatric Association ApA , 2000). Epidemiological studies have not typically included assessment of sexual disorders, but sex researchers who have studied the prevalence of ED in community samples have found rates ranging from 3 to 9 of men of all ages (Spector & Carey, 1990). 1994). Previous estimates of ED complaints in clinical samples have indicated that from 36 to 48 of men who present for treatment in sex clinics have a primary diagnosis of male erectile disorder (Ackerman & Carey, 1995). Current estimates of clinical prevalence are missing, and may be important in describing the change in treatment for erectile dysfunction from sex therapy to pharmacology....

Impaired sleeprelated penile erections

Penile erections occur predominantly during REM sleep, although they may persist into NREM sleep and after awakening. In adults their absence indicates either an alteration in sleep architecture with reduction or fragmentation of REM sleep, as in severe obstructive sleep apnoeas, or an organic cause for impotence. This may be diabetes mellitus or drugs, including selective serotonin re-uptake inhibitors and tricyclic anti-depressants, and beta blockers and REM-suppressant drugs, including amphetamines and related drugs. Erections during sleep and on waking are retained with most psychogenic causes of impotence.

Types of Penile Prosthesis

Penile implants are currently available in a variety of forms, which can be categorized into two major types semi-rigid, or inflatable, with a silicon or Inflatable implants are available in two-piece or three-piece models. Two-piece implants are made by AMS and by the Mentor Corporation. The AMS Ambicor prosthesis consists of a pair of inflatable cylinders, which are implanted into the corpora cavernosa, and a pump, which is implanted into the scrotum. The cylinders and pump are preconnected during the manufacturing process and the system is prefilled with sterile saline. To achieve an erection, the scrotal pump is squeezed and released several times. This inflates the cylinders by transferring saline solution from a small reservoir located at the end of each cylinder into each cylinder shaft. The newly developed Mentor two-piece penile prosthesis is called the Excel Resist device. It consists of a pair of inflatable cylinders, which are implanted into the corpora cavernosa, and a...

Diagnosis of Erectile Dysfunction

Male sexual dysfunction encompasses many areas. These include desire or libido disorders, erectile dysfunction and ejaculatory dysfunction. This chapter focuses specifically upon the standards for the diagnosis of male erectile dysfunction (ED). The patient-oriented approach to the evaluation and treatment of male ED is the preferred and accepted approach for the majority of men with ED, and serves as the basis for this chapter 1 . This implies that the history and physical exam are the paramount factors contributing toward the successful diagnosis of ED. The American Urological Association ED guidelines panel also accepts this scheme 2 . The treatment of male ED is based upon the patients' personal goals, and is covered elsewhere in this textbook.

Current Status of Human Erectile Dysfunction Therapy Trials

Table 10.2 Gene therapy approaches for the treatment of erectile dysfunction. Table 10.2 Gene therapy approaches for the treatment of erectile dysfunction. Table 10.3 Gene therapy approaches for the treatment of erectile dysfunction. tant requirement by the FDA). In the first two groups of 500 and 1000 mg (suboptimal dosing as per comparative rat model studies where 10-20-times higher doses were safely used for efficacy), there was no evidence of efficacy as determined by the international index of erectile function (IIEF) and Rigiscan data. However, in the third group (5,000 mg), one participant reported significant improvement as per Q3 and Q4 of the IIEF at three months after transfer. This benefit has been corroborated by his partner. These investigators plan sequential instillations at two higher doses in the near future. The efficacy and safety of this first gene transfer study will undoubtedly direct future research efforts in the field of gene therapy for ED in the years to...

History and Epidemiology of Male Sexual Dysfunction

It seems paradoxical that among the physiologic functions of the human body, sexual function has generated the greatest popular awareness and curiosity, but the least scientific inquiry. Despite the considerable human behavior, both virtuous and evil, that has been motivated by human sexuality, restrictive social attitudes and taboos have severely inhibited scientific investigation of human sexual function. Working within a restrictive social environment, a few irrepressible investigators and observers of human behavior have changed the course of modern social science and philosophy through their interests in sexual medicine and sexual psychology. Sigmund Freud brought new concepts of the importance of sexuality to the forefront of Western creative thinking at the end of the 19 th century and beginning of the 20th century 1 . As early as 1896, the aphrodisiac effects of yohimbine were reported by Leopold Spiegel, who extracted this substance from the bark of the West African yohimbe...

Epidemiology of Erectile Dysfunction

The scale and potential social impact of erectile dysfunction may be best understood by an appreciation of its international frequency. In 1995, it is estimated that there were 152 000 000 men worldwide suffering from erectile dysfunction. Because of the accelerating aging of the world population, coupled with the high prevalence of erectile dysfunction in men over 50, the world population of men with erectile dysfunction is expected to increase to 322 000 000 by the year 2025 21 . With this high prevalence, erectile dysfunction will become a progressively more common and compelling public health problem throughout the world. Many studies on the prevalence of erectile dysfunction have been published in recent years but their conclusions vary widely. The reasons for the varying results include differences in the design and methodology of the studies, the methods of selecting subjects for the study, the age and health of the cohort studied, the questions that are asked, how the...

Indications for Treatment of Erectile Dysfunction with VCD

European Sexual Dysfunction

Of its mechanism resulting in a more unnaturally perceived erection 5 . On the other hand there may be couples preferring VCD, as was reported by Chen et al., with one-third of men, who had been successfully treated with VCD and who had tried sildenafil with satisfactory erections, finally opting for VCD 6 . Vacuum therapy may also be used in conjunction with other therapies to enhance results. So, for example, the addition of 100 mg sildenafil with VCD improved sexual satisfaction and penile rigidity in patients unsatisfied with VCD alone, after radical prostatectomy 7 . Combination treatment of psychotherapy and VCD showed greater beneficial response in men with ED than either therapy alone 8 .

Models of male sexual dysfunctions

Erectile dysfunction Male rats that do not perform sexually are typically taken out of behavioral studies, so there is very little known about their actual erectile responsiveness. This proportion is generally low, especially if the males are pre-exposed to the test chambers prior to their initial sexual experiences. Some of these males do not display any interest in the female, and do not initiate any kind of sexual activity. However, other males display sexual interest and mount repeatedly, but do not achieve vaginal intromission. The lack of intromission may stem from an inability to achieve erection. Indeed, erectile responses in isolation and intromissions during copulation are both very sensitive to disruption by several classes of drug, including psychomotor stimulants, dopamine and noradren-ergic antagonists, and opioid agonists. Acute or chronic treatment with selective serotonin reuptake inhibitors (SSRIs) does not appear to alter erectile responses or the number of...

Psychotherapy of erectile dysfunction

Men with lifelong and acquired erectile dysfunctions typically achieve significant gains initially and over the long term, following participation in sex therapy. Men with acquired disorders tend to fare better than those with lifelong problems. Masters and Johnson 3 reported initial failure rates of 41 and 26 for lifelong (primary) and acquired (secondary) erectile dysfunction, respectively. Their 2-5 year follow-up of this cohort indicated sustained gains. In a review of the studies of treatment for erectile dysfunction, Mohr and Bentler 10 wrote, The component parts of these treatments typically include behavioral, cognitive, systemic and interpersonal communication interventions. Averaging across studies, it appears that approximately two-thirds of the men suffering from erectile failure will be satisfied with their improvement at follow-up ranging from six months to six years.

Penile Prosthesis Surgery

Penile prosthesis placement for Peyronie's disease is best reserved for men with combined Peyronie's disease and erectile dysfunction, in particular those men with erectile dysfunction that are non-responsive to oral or local pharmacotherapy. Some authorities have suggested that men with hourglass deformity be considered for penile implant surgery because of anecdotally-based reports of poorer outcomes for patients undergoing lateral plaque incision and grafting procedures. The advantages of penile prosthesis surgery in the Peyronie's disease patient include excellent rigidity and, in patients with mild to moderate curvature, excellent deformity correction without the need for intraoperative adjuvant maneuvers (vide infra). The disadvantages of this approach are the complications of penile prosthesis surgery (see section on penile prosthetic surgery). Table 14.5 Outcomes with penile prosthesis surgery in Peyronie's disease (1996 to 2005). Table 14.5 Outcomes with penile prosthesis...

Treatment of Post Radical Prostatectomy Erectile Dysfunction

Treatment of post-RP ED follows the same principles as for any other ED. The first therapeutic option is oral treatment with PDE-5 inhibitors (PDE-5i) or vacuum device, when there is a contraindication for the use of oral agents. Second-line treatment includes the intraurethral alprostadil suppository or intracavernosal injection therapy. When pharmaco-logic treatment does not restore the patient's erectile ability or there is a preference for a surgical treatment, penile implant may be the option. Although the prevalence of post-RP ED is considerable, many patients remain untreated. Herkommer et al. reported that 59.3 of German patients with post-RP ED wished to be treated however only 30.3 of the patients received long-term therapy 19.8 of the patients using oral medication, 1.7 intraurethral alprostadil, 26.7 intracavernous injections, 50.9 a vacuum constriction device, and 0.9 a penile implant. Only 28.9 of the patients reported being satisfied with treatment 67 .

Female Sexual Dysfunction

Dysfunctions in female sexuality may occur in each phase of the sexual response cycle desire, arousal, and orgasm or resolution. in addition, there may be pain or muscle spasm that prevents penile penetration or enjoyment of coitus. All can occur at random, during specific situations, or as a primary dysfunction in which the disorder has always been present.

Erectile Dysfunction

There may be several causes of erectile failure due to antidepressant drug treatment. Sympathetic and parasympathetic components contribute to erections. Erection occurs when venous outflow is prevented and arterioles open to allow blood to flow into the corpora cavernosa. The penis remains in its normal flaccid condition as a result of tonic a-adrenergic stimulation. Erectile problems are not commonly reported with SSRIs but have been widely reported with TCAs and MAOIs, mainly in single-case reports or small-case series. TCAs that have been reported to cause erectile difficulties include amitriptyline, imipramine, clomipramine, desipramine, nortriptyline, and protriptyline.82 The physiology would predict problems from excessive noradrenergic tone maintaining venous outflow or from the functionally equivalent effect of cholinergic blockade. Both effects could result from the pharmacology of the tricyclic drugs. In the analysis of pooled data on rates of sexual dysfunction in...

Penile erection

Experimental research on penile erection dates from at least the 19th century, with the work of pioneer physiologists such as Eckhardt, Langley and Anderson. Subsequently, during the 20th century significant advances were achieved thanks to the work of Semans and Langworthy in the 1930s, veterinary researchers performing experiments in conscious bulls and stallions in the 1970s, Sjostrand using plethys-mography to quantify penile erection in the rabbit, and then work by Lue's and Goldstein's groups in the 1980s, providing the scientific and medical community with experiments conducted in dogs, monkeys and rabbits that show the vascular component of penile erection and the crucial role of cavernosal smooth muscle fibers. Quinlan then introduced the first rat model to measure penile erection. More recently, investigations of penile erection have been performed in mice, opening the door to studies conducted with genetically modified animals. there is a close similarity between local...

Penile prosthesis

Penile prosthetic surgery is an option for patients with post-RP ED who do not respond to more conservative treatments or prefer a surgical and definitive treatment. There is no randomized study on penile implant in this population, but overall satisfaction rates after penile implants in men with vari Ramsawh et al. examined the satisfaction and quality of life (QOL) of patients who had simultaneous placement of a penile prosthesis at the time of RP 89 . Those patients reported greater overall QOL, erectile function and more frequent sexual contact than a comparison group of men who underwent RP alone. They proposed that placement of penile prosthesis at the time of radical prostatectomy may be an option for men with prostate cancer in whom a nerve sparing procedure may not be ideal. Mulhall et al. studied 114 patients who underwent penile prosthesis surgery 90 . Sub-groups evaluated included patients with Peyronie's disease (24 ), post-radical prostatectomy (38 ), patients with body...

Sexual function assessment in the male

The essential components of sexual function assessment in the male always include erectile response (onset, duration, progression, severity of the problem, nocturnal morning erections, self-stimulatory and visually erotic-induced erections), sexual desire, ejaculation, orgasm, sexually related genital pain disorders and partner sexual function, if available. Often, a dysfunction in one phase may precipitate a dysfunction in another. For instance, men with erectile dysfunction may report a loss of sexual desire or the onset of premature ejaculation. Brief symptom scales or self-report questionnaires may assist the clinician in recognizing and diagnosing the sexual problem. These measures may also permit patients to acknowledge the problem and to initiate a clinical discussion with their health provider. Scales and questionnaires are also a valuable tool in clinical trials and outcomes research for male sexual dysfunctions. Although valuable in recognizing and identifying sexual...

Intrinsic and extrinsic factors druginteractions

Both with aspirin 150 mg and warfarin, no increase in bleeding time was observed with the PDE-5 inhibitors. After heparin, sildenafil showed an additive effect on bleeding time in rabbits, but this interaction trial was not conducted in humans. Sildenafil Tadalafil Vardenafil 1CYP 3A4 inhibitors erythromycin, ketoconacole, itraconacole up to 3-10 fold increases in the plasma concentrations of the respective PDE-5 inhibitors. Cimetidine 56 increase in sildenafil plasma concentrations not valid for vardenafil tadalafil not reported. 2CYP 3A4 inhibitors protease inhibitors ritonavir, indinavir, saquinavir increase in plasma concentrations of the respective PDE-5 inhibitors between 1.5-fold (tadalafil) and 16-fold (vardenafil). CYP 3A4 inducers Rifampin decrease of PDE-5 inhibitor plasma levels up to 88 (reported for tadalafil) Sildenafil 25 mg simultaneously applied with doxazosin 4mg resulted in symptomatic postural hypotension, which was also the case with tadalafil 20mg 56,57 . After...

Present Role of VCD in the Era of Oral Pharmacotherapy

Its main advantage is that almost every case, regardless of the underlying ED etiology, may be managed successfully with VCD, regarding the establishment of an erection 29 . Efficacy depends on correct individual instruction and it needs at least two teaching sessions for patient learning 11,33 .

Benefits of androgen therapy

Morales et al. showed that T therapy is an effective treatment for hypogonadal impotence, with improvement in sexual attitudes and performance in 61 of patients 56 . In another study, T monotherapy has been observed to improve erectile function in only 36 of the hypogonadal patients consulting for ED 18 (see also pp. 203-2). T therapy may have more significant effects on libido than on erectile function 170 . In one study, normalization of serum T levels in hypogonadal men with ED resulted in only short-term improvement (one month) in erectile function and sexual satisfaction, while improvement of sexual desire was statistically significant for the six months of the study, making the use of T therapy alone questionable in this population 74 . However, T monotherapy did improve sexual performance, desire, and motivation in men with hypogonadism, in clinical trials with transdermal T-gel formulation. Maximal improvement occurred on day 30 and continued for...

Pregnenolone 17OH Pregnenolone

Patients with pure veno-occlusive dysfunction compared with patients with other etiologies 265 . More data are however requested to determine if hypo- or hyperestrogenism may be deleterious for sexual function in men. Presently there is no need for routine estradiol determination in male sexual dysfunctions, unless breast symptoms or signs are present.

Cavernosometry and Cavernosography

Prior to 1998, cavernosometry and cavernosography 38,39 were widely used for the diagnosis of male erectile dysfunction. However, with the launch of a new oral drug treatment sildenafil (Viagra ), 40 , the need to diagnose cavernous insufficiency has changed greatly. What was the reason for this Quite simply stated, the treatment of ED was no longer a function of any testing. Rather, the introduction of the oral phosphodiesterase type 5 inhibitors (PDE-5i) changed the diagnostic and treatment paradigm. Invasive diagnostic testing was no longer required for the introduction of treatment of ED. Essentially, if a man complained of ED, then he was offered a PDE-5i for his ED. The distinction between organic and psychogenic ED became blurred and the etiology of the ED, be it arteriogenic, neurogenic or venogenic was no longer a prerequisite for treatment.

Drug combinations for selfinjection therapy

Penile Self Injections Demonstration

For instance, in vitro studies on human and rabbit cavernosal strips demonstrated that phentolamine significantly potentiated relaxation induced by sildenafil, VIP and PGE1. These vasodilators also significantly enhanced relaxation induced by phen-tolamine in the cavernosal tissue strips. The enhancement of VIP and PGE1-induced relaxation (cAMP-mediated) by phentolamine suggests a syn-ergistic interaction, while the interaction between phentolamine and sildenafil (cGMP-mediated) appears to be additive 47 . The same investigators were also able to show that sildenafil and PGE1 has additive and synergistic effects, respectively, with phentolamine-induced relaxation. Therefore, in combination therapy using phentolamine as an adjunct, the efficacy of vasodilators that initiate erection via independent relaxant pathways is increased due to a reduction in adrenergic tone, through the a-adrenoceptor blockade. self-injection therapy with 100mg sildenafil, was reported in 34 32 of 93 patients...

Prostaglandins From Euroform Healthcare

Intracavernous injection of papaverine for erectile failure Lancet 1982 2(8304) 938 2 Virag R, Frydman D, Legman M, Virag H. Intracavernous injection of papaverine as a diagnostic and therapeutic method in erectile failure. Angiology 1984 35(2) 79-87. 7 Adaikan PG, Kottegoda SR, Ratnam SS. A possible role for prostaglandin E1 in human penile erection. In Abstracts of the 2nd World Meeting on Impotence, Prague, 1986 2 6. 8 Ishii N, Watanabe H, Irisawa C, Kikuchi Y, Kawamura S, Suzuki K, Chiba R, Tokiwa M, Shirai M. Studies on male sexual impotence. Report 18. Therapeutic trial with prostaglandin E1 for organic impotence. Nippon Hinyokika GakkaiZasshi 1986 77(6) 954-962. 9 Adaikan PG. Investigations and management of male impotence. In Proceedings of the XXI MalaysiaSingapore Congress of Medicine. Academy of Medicine, Malaysia, 1987, pp. 103-109. 10 Virag R, Adaikan PG. Effects of prostaglandin E1 on penile erection and erectile failure. J Urol 1987 139 1010. 11 Lin JS, Lin...

Postoperative management

Following discharge from hospital, the patient should be followed-up within a few weeks for wound assessment. At further follow-up meetings, assessment of residual erectile function should be made. While postulated, the role of strategies for penile fibrosis minimization (oral colchicine) and penile length preservation (vacuum device) is unclear in the absence of outcomes data. Any conversation with the patient regarding the use of erectogenic medications (phosphodiesterase-5 (PDE-5) inhibitors, intra-urethral agents, intracavernosal injection agents) must include discussing the fact that men with a history of priapism using such agents must be carefully monitored. Patients using erecto-genic medications must be monitored closely. While intriguing, the animal data supporting reduction in priapism events in sickle cell mice with chronic PDE-5 inhibitor administration is preliminary and no human studies have been conducted to date. priapism. Sixteen patients (32 ) reported a history of...

Complications of penile prosthetic surgery and their management

Erectile Radiology

Diagnosis of complications is based on clinical history and physical examination, but imaging techniques may be useful to plan a surgical approach. MRI is the most valuable imaging technique for diagnosis of penile prosthesis complications 31 . MRI is radiation-free, demonstrates penile anatomy in three orthogonal planes, and is superior to any other imaging method in demonstrating soft tissue contrast 30,31,56 (see Figure 12.3). All penile implants except the now-discontinued Omniphase and Duraphase models, are compatible and safe with MRI field strength Tesla 1.5 and 3.0. The Omniphase or Duraphase prostheses are unsafe during MRI scanning due to their metallic components 60,61 . thema of the incision or genitalia, and or cutaneous fixation of prosthesis components, such as the pump to the scrotal skin 25 . This is the most feared complication after penile implant surgery. The use of antibiotics alone has not been successful in eradicating postoperative infections. It is difficult,...

Rectification of terms

Penile reflex tests (physiologic erectile function responses to somatosensory stimulation) Noncontact erections (psychogenic erectile function responses to primary or secondary conditioned sexual cues) Copulatory measures latency to mount, intromit or ejaculate (shorter latency greater arousal) Enforced interval effect (model of premature ejaculation) Coolidge effect (increased arousal by changing sexual stimuli)

Intraoperative neurostimulation

This technique was initially described by Lue 44 and was later formally developed as an intra-operative tool (CaverMap, Bluetorch Technologies, Ashland, MA) for nerve stimulation and tumescence monitoring. The tip of this device, which contains an array of electrodes, is placed over the (suspected) cavernous nerve and current is applied 45 . Tumescence is monitored by the presence of a penile strain gauge, which records changes in penile girth. The strain gauge system is sensitive enough that it can detect a 0.5 change (increase or decrease) in circumference. The initial study on Cavermap was reported by Klotz, in 21 men with functional erections prior to RP, who had application of the device intra-operatively. Postoperative erectile function assessment was performed using a questionnaire 45 . Of the 19 patients who had erectile function assessed postoperatively, the two men who had no intraoperative Cavermap response failed to have return of functional erections after surgery....

Routine laboratory tests

These should include a blood sugar and a fasting lipid profile in all men with ED without a diagnosis of diabetes mellitus or dyslipidemia, respectively. A PSA should be determined in the case of abnormal findings during palpation of the prostate, or as per the physicians' PSA screening protocol. A urinalysis is also helpful to look for glucose, ketones and protein-uria, as well as blood and white blood cells. Other data suggests that hypogonadism may affect the ability of the erectogenic agents to fully restore erectile function. Shabisgh et al. 27 have shown that the addition of testosterone to hypogonadal men with testosterone deficiency, who additionally have had a suboptimal response to PDE-5 inhibitors, was highly beneficial. Thus, a total and or free morning serum testosterone level may be indicated as a blood test for men with ED.

Penile Length Alterations

There are a total of three analyses on this issue in the literature. Fraiman et al. studied 100 men less than six months after radical prostatectomy, and took preoperative and postoperative flaccid and erect measurements and demonstrated an overall mean reduction in erect penile length of 9 but a mean reduction in volume of 22 1 . Munding et al. studied 31 men and measured penile length in the stretched flaccid state (accepted as equivalent to erect length) and showed that 71 had a decrease in penile length compared to preoperatively, with 48 of men demonstrating greater than a 1 cm loss and a range of loss of 0.5-4cm 2 . Finally, Savoie et al. studied 63 patients with preoperative measurements followed by repeat measurement, at three months postopera-tively, and demonstrated that 68 of patients had some degree of length loss. The authors also showed that in this population there was no difference between patients with erectile dysfunction (ED) and those without, postoperatively 3 ....

Guidelines for Research in Surgical Management of Priapism

1 Outcomes analysis of shunt surgery as it pertains to erectile function 2 Defining the correlation between duration of pri-apism and erectile function 3 Outcomes analysis of immediate penile prosthesis surgery 4 Erectile function outcomes following ligation of arteriocavernous fistula The committee recommends that erectile function outcomes following surgical intervention for venoc-clusive and arterial priapism be assessed using a validated instrument, with an attempt to have the patient document pre-priapism function and to follow this after the priapism event. It is believed that this is the only way in which we can accurately document the optimal approach to surgical management of these patients. There are a variety of questionnaires available, but at the time of writing the international index of erectile function (IIEF) is the most frequently utilized and is the questionnaire recommended for erectile function assessment. The committee hopes that erectile function analysis, as...

Alprostadil PGE1Caverject Edex Viridal

The effect of PGE1 on the human corpus cavernosum (CC) was first described in 1975 by Karim & Adaikan 3 . Of more than 30 prostaglandins tested in vitro on the human CC, PGE1 is the only compound that produced relaxation conducive for erection 4 . All other prostaglandins produced either a dual effect (contraction and relaxation) or contraction only. The relaxant effect of PGE1 on the human CC has been further demonstrated in vitro 5,6 . Initial studies on the effectiveness and mechanism by which IC administration of PGE1 produced erection were very encouraging 7-10 . Several investigators have assessed, in large groups of patients, the effectiveness of PGE1 for the treatment of erectile failure in man. In the meta-analysis involving literature review and personal experience in 4577 patients with erectile failure, PGE1 showed a response rate of more than 70 (Table 8.1) and compared to the mixture of papaverine and phentolamine, a considerably lower risk of priapism (0.35 versus 6 ,...

Introduction and History

It was probably Leonardo Da Vinci who first recognized the importance of blood supply for penile erection 1 . In 1923 the French surgeon Leriche first described arterial vascular impotence in the syndrome of thrombotic obliteration of the aortic bifurcation 2,3 . During the following years several operative strategies were developed to save or reconstruct the internal iliac artery during abdominal vascular surgery for the purpose of maintaining or restoring erectile function 4 . The same problem exists for venous surgery in the treatment of erectile dysfunction (ED). The idea that pathologic venous outflow from the corpora during sexual excitement may cause ED was initiated some 140 years ago when the Italian dermatologist Parona published the first report on percutaneous scarification of the dorsal penile vein in ED believed to be of venogenic origin 6 . vasive radiologic procedure, which could be used alone, or in combination with open operative procedures 4 . Even arterialization...

Treatment of men with sexual dysfunction and hyperprolactinemia

The literature contains some observations of marked improvement of sexual dysfunctions associated with HPRL following non-specific treatments such as psycho- or sex-therapy 250 or, as concerns ED, sildenafil 241,253 . However, PRL-lowering dopamine-agonists (bromocriptine, lisuride, quina-golide, and cabergolide, the latter one being effective following a single administration per week) 254 most often not only normalize all aspects of sexual function, but also shrink the possible pituitary ade

Alterations in Orgasm

Most of the post-radical prostatectomy sexual dysfunction literature has focused specifically on erectile dysfunction, and changes in orgasm have been reported in post-prostatectomy patients 14-16 . Orgasm, which is often considered to be a goal and reinforcer of sexual behavior, remains the least understood phase of the sexual response cycle. Alterations in orgasm, and in particular its absence, are associated with significant reductions in emotional and physical satisfaction, which in turn may lead to sexual avoidance behavior and secondary relationship discord 17-18 .

Tissue Engineering and ED

Various surgical techniques have been developed to restore genital abnormalities, e.g. epispadias, micropenis, penile carcinoma, genital trauma, corporal fibrosis, and Peyronie's disease. In many of these cases there is a limited amount of cavernosal tissue and surgeons have relied on prosthetic devices to recover the patient's erectile function 2 .

Role of sexual satisfaction of the female partner of sexually dysfunctional men

The role of the female partner in both treatment seeking behavior and treatment success has been recently highlighted. The female partner is an important agent in motivating the man to seek treatment for his ED 15 . ED also has an impact on female sexual response. Sexual desire, arousal, orgasm and

Patient evaluation prior to surgical intervention

A comprehensive discussion should be held with the patient concerning the risks and benefits of the surgery, and clear documentation of this discussion and, in particular the risk of permanent erectile tissue damage and long-term erectile dysfunction, must be placed in the medical record, and an informed consent form signed by the patient or his guardian, preferably in the presence of a witness. It is recommended that all medical records should be both dated and timed because of the emphasis on chronology of events in medico-legal cases pertaining to priapism. Although it is universally accepted that the longer a priapism event the more likely a man is to experience long-term erectile dysfunction, at what time this becomes inevitable is unclear. There is evidence that 12 hours of priapism leads to overt histologic changes in corpus cavernosal smooth muscle, as seen by light microscopy. The longer the venocclusive priapism event the greater the chance of permanent erectile dysfunction.

Medical Aspects of the ED Evaluation

The epidemiology of male ED, which is discussed in another chapter, provides guidance to the clinician faced with the ED patient. In as much as many men with ED will have a variety of medical problems, the astute clinician should recognize that ED is a significant part of these medical diseases. Indeed, recent epidemiologic data provides guidance to the clinician regarding the prevalence of ED in men with four medical diseases 16 . These diseases are hypertension, hyperlipidemia, diabetes and depression. Thus, it is incumbent upon the physician to delineate the extent of these four diseases in men with ED. As can be seen in the table, these four diseases were clearly noted to be present in men identified with ED in a large, managed-care database (Table 6.8). Several chronic medical diseases impact negatively on male erectile function, again highlighting the need to ask about ED in men with these conditions. Newer areas of study include associations between ED and obesity, as well as...

How is psychogenic ED diagnosed

Variability of erectile function is the hallmark of psychogenic ED. Take the example of the man who reports excellent morning erections, moderately good erections with fantasy or masturbation, and poor erections with foreplay and attempts at intercourse. This man, by history, has clear psychogenic ED. No physical scenario can explain the variability of erectile function. Note that in this example the patient's function worsens as he becomes involved with a partner, suggesting the role of performance anxiety or interpersonal anxiety. Psychologic and relational variables can enhance or inhibit the physiologic aspects of sexual response. There is, however, great variability in men's vulnerability to sexual dysfunction and likewise ability to compensate for these factors. Psychologic factors can help men resist declining erectile function. For example, a man with good self-esteem, broad sexual experience, and a loving and arousing partner can partially compensate against organic factors...

Overlapping Diseases and Points of Confusion

And twenty men with ED or benign prostatic hyperplasia (BPH) were divided into three groups. Group 1 had ED only, group 2 had BPH only, and group 3 had both ED and BPH. Patients were screened for depressive symptoms using Primary Care Evaluation of Mental Disorders (PRIME-MD) and the Beck Depression Inventory (BDI). They were also surveyed for comorbidity, marital status, severity of ED, levels of libido, prior ED treatment choice (if any), success of treatment, and others. Depressive symptoms were reported by 26 (54 ) of 48 men with ED alone, 10 (56 ) of 18 men with ED and BPH, and 7 (21 ) of 34 men with BPH alone. Patients with ED were 2.6 times more likely to report depressive symptoms than men with BPH alone (P < 0.005). Patients with depressive symptoms reported lower libido than other patients (P < 0.0001). Severity of comorbidities did not differ among the three groups. The conclusion is that ED is associated with high incidence of depressive symptoms, regardless of age,...

Chronic daily dosing of PDE5 inhibitors

Although all three PDE-5 inhibitors were developed and approved for as-needed use, many experts in this field moved to daily dosing, provided the patients could afford it. Daily dosing of PDE-5 inhibitors at bed time became a successful treatment option in early sexual rehabilitation of patients after nerve-sparing radical prostatectomy 116-118 . But beyond this indication, daily dosing with PDE-5 inhibitors turned out to be very successful in non-responders to on-demand treatment 113 , supported by personal observations and also increased nocturnal erection events in healthy men 119-120 . According to personal experience with more than 100 patients currently on daily dosing with tadalafil 5-10 mg, this concept is very promising for organic ED patients with several cardiovascular risk factors, and relieves the patients from scheduling sexual activities. This is especially welcomed by their partners. In addition, chronic dosing with PDE-5 inhibitors, either short-acting (here...

Cavernous nerve interposition grafting

The first report was by Kim et al. from Baylor discussing their experience with nine men, with excellent preoperative erectile function, who underwent non-nerve-sparing RP for locally extensive, highgrade prostate carcinoma 52 . All underwent bilateral sural nerve interposition grafting (SNG). Postoperative erectile function was assessed using patient interview, a questionnaire and Rigiscan analysis. Of the nine patients, one had spontaneously functioning erections at 14 months postopera-tively. This experience demonstrated feasibility and encouraged these investigators to continue to accrue patients for SNG. The following year, they reported on their experience in 12 men in whom SNG and genito-femoral nerve interposition grafting (GNG) was performed 53 . The data from this analysis indicated that erections unassisted by medication and sufficient for sexual intercourse occurred in one third of patients partial erections occurred in 42 , while the remainder had no return of erections....

Neuromodulatory drugs

Fig. 17.1 Memorial Sloan Kettering Cancer Center approach to penile rehabilitation in the radical pelvic surgery patient. C, Cialis ICI, intracavernosal injection therapy L, Levitra PDE5i, PDE5 inhibitor QIW, four times per week V, Viagra. Burnett et al. are the first group to demonstrate that rats exposed to unilateral cavernous injury randomized to saline or FK506 have fared better when FK506 is used 64,65 . The use of this drug has resulted in greater intracavernosal pressure recovery and reduction in the structural changes within the cavernous nerve. This group has also shown that FK506 binding proteins are expressed in the major pelvic ganglion of the rat proximal to the cavernous nerve, and are upregulated close to normal after cavernous nerve injury. There is great interest in the development of this field, and not just FK506 and GPI compounds have been looked at drugs such as rapamycin, minocycline and erythropoietin have also been explored. While there has been a suggestion...

Rationale and technical considerations

Titan Piece Penile Implant

The Michal II procedure probably works best in young patients with post-traumatic arteriogenic erectile dysfunction. In patients with systemic arte-riosclerotic disease, arterial run-off is limited by multiple peripheral stenoses, and low flow rates will lead to early anastomotic thrombosis. As most candidates for revascularization procedures have systemic arteriosclerosis, an alternative to pure arterio-arterial bypasses was needed 15 . 17,18,19 (see Fig. 12.1). These further modifications involve ligation of circumflex and emissary collaterals or destruction of valves in the dorsal vein. The rationale of all these procedures is to create retrograde filling of the corpora with arterial blood through emissary veins. At the same time, venous outflow is reduced, making these techniques theoretically applicable to patients with arteriogenic, venogenic and mixed arteriogenic and venogenic erectile dysfunction 17 . However, there is no study in peer-reviewed journals, which objectively...

Melanocortin receptor MCR agonists

The five MCRs only two (MC3R and MC4R) are expressed in cerebral regions known to be involved in the modulation of erectile function. The origin of both a-MSH and ACTH is the pro-opiomelanocortin (POMC) gene, and the biologic effects of these two hormones are mediated via activation of one or more of the five MCRs. All five MCRs use cAMP as the second neurotransmitter mediating the final biologic (physiologic) effects upon their activation. Recently the results with the intranasal melanocortin receptor agonist PT-141 in an at home, multi-center, double-blind, placebo-controlled parallel-arm study in 271 sildenafil-responsive patients were reported, with improved erections in 66-67 with the 10-20mg dose 5 . As shown in Fig. 9.1 there was no dose-dependent efficacy between 10 and 20 mg. In two further Rigiscan studies with a subcutaneous (s.c.) application of PT-141 in doses between four and 10 mg, efficacy was reported even in a small group of patients (n 25) with a history of...

The importance of receptivity

Explain the androgen deficiency-like symptoms in aging in the presence of relatively mildly reduced T levels, it has been hypothesized that the efficacy of androgen action at the level of receptor and postreceptor mechanisms is diminished in old age compared to younger age. Arguing against this is that, with regard to the anabolic actions of T, elderly men are as responsive to T as young men 8 . While male sexual functioning in (young) adulthood can be maintained with lower-than-normal values 9,10 , there are indications that the threshold required for behavioral effects of T increases with aging 11 . The fact that libido and erectile function require higher T levels in old age compared to younger age has been recently confirmed 12 , and this is also apparent from clinical observation 13 and from metaanalysis 14 .

Etiology of Hypoactive Sexual Desire

Times, the decrease or absence of sexual desire occurs with no other sexual dysfunction or recognizable pathology. In any event, it is critical that the clinician identifies this condition lack of success in treatment of other sexual dysfunctions, like erectile dysfunction, can sometimes be explained by the presence and lack of proper treatment of HSD. The list included in Table 13.4, taken from Meuleman & Van Lankvled (2005) 2 , is a summary of the causes of HSD seen frequently in clinical practice. Hypoactive sexual desire is frequent in men with erectile dysfunction. In a series of 428 men with erectile dysfunction, Corona and co-workers (2004) 5 reported that 43.3 of their participants had the condition. This group found no correlation for patient or partner's age. Men with HSD in this study were not diagnosed as hypogonadic more frequently than men without HSD however ANOVA showed a significant (P < 0.005) difference of total, free testosterone and prolactin levels among...

Nature and prevalence of late onset hypogonadism

There are different threshold values for different biologic effects. Testosterone has a number of physiologic functions in the male. In adulthood it is responsible for maintenance of reproductive capacity and of secondary sex characteristics. T has positive effects on mood and libido, anabolic effects on bone and muscle, and affects fat distribution and the cardiovascular system. Threshold serum values of T for each of these functions are becoming established. The studies of Bhasin et al. and of Kelleher et al., analyzing the dose-response relationships between serum T and biologic effects, show that low-to-mid-normal serum levels of T suffice for most biologic actions of T 8,36 . Another consideration is whether these threshold values change over the life cycle. Theoretically, it is possible that in old age normal androgen levels suffice for some but not for all andro-gen-related functions. With regard to anabolic actions, elderly men are as responsive to T as young men 8 ....

Genital sexual arousal

Reliable and standardized models to study the physiology pharmacology of female vaginal sexual arousal have been described in dogs, rabbits and rats. In these models, vaginal sexual arousal along with clitoral tumescence is induced by peripheral electrical neural stimulation, while direct measurements of various vaginal physiologic variables are performed. These models have been useful to initiate the exploration of the peripheral physiology of female genital sexual response as well as the consequences of various experimental pathophysiologic conditions (e.g. atherosclerosis or hormonal deprivation).

Surgical ligation procedures

Shapiro et al. reported on two cases requiring surgical ligation of the fistula. In each patient, angio-graphic embolization was attempted but abandoned because the distal artery feeding the fistula could not be safely catheterized. Both patients were definitively treated with surgical ligation of the arteriovenous fistula, guided by intraoperative ultrasound. Two surgical approaches were used, one extracorporal and the other transcorporal, with successful preservation of erectile function. Kim et al. reported on two patients with arterial priapism that occurred after blunt perineal trauma and lasted for a mean duration of 38 days. Cavernous arterial blushes were demonstrated on selective internal pudendal arteriograms and angioembolization was achieved by autologous clot. Both patients experienced return of pre-morbid erectile function and no local or systemic complications occurred.

Type 5 Phosphodiesterase PDE5 inhibitors

Several authors have reported their experience with PDE5 inhibitors alone or in combination with SSRIs as a treatment for PE 62-66 . The proposed mechanisms for the effect of sildenafil on ejaculatory latencies include a central effect involving increased NO and reduced sympathetic tone, smooth muscle dilatation of the vas deferens and seminal vesicles, which may oppose sympathetic vasoconstriction and delay ejaculation, reduced performance anxiety due to better erections, and down-regulation of the erectile threshold to a lower level of arousal so that increased levels of arousal are required to achieve the ejaculation threshold. Most of these studies are uncontrolled and the results are confusing and difficult to interpret. The only double-blind placebo-controlled multicenter study showed no significant difference in the IELT of sildenafil-treated subjects compared to placebo, but did demonstrate significant improvements in the ejaculatory control domain and the ejaculatory function...

Treatment of Hypoactive Sexual Desire

Treatment of HSD is directed to the putative cause of the condition. There are no effective symptomatic treatments for HSD, as there are for erectile dysfunction (i.e. phosphodiesterase-5 (PDE-5) inhibitors). Bupropion, an antidepressant medication that has an effect in the re-uptake of dopamine and norepinephrine 41 , has been studied, and it has shown a modest effect on women with HSD when compared to placebo (using the slow-release form starting 150 mg day for one week and then 300 mg day) 42,43 . An early report by Crenshaw and co-workers 44 included men and women who were not depressed, but who had some form of psychosexual dysfunction (inhibited sexual desire, inhibited sexual excitement or inhibited orgasm), and indicated some positive effect on patient's rated libido and global improvement, which was statistically significant compared to placebo unfortunately, it is not clear from the report how many men responded. The response rates, though statistically significant when...

Nonresponders to PDE5 inhibitors

Quite frequently this veno-occlusive dysfunction (syn venous leak or cavernous insufficiency) is associated with severe impairment of the penile arterial blood supply in the penile color Doppler findings. But many so-called non-respon-ders may be rescued by appropriate counseling, by treatment of concomitant diseases or change in medication use. The definition of a real non-responder is justified if no success is seen under the following conditions use of at least four tablets with the highest dose of the respective PDE-5 inhibitor, at four different occasions, under optimal conditions (appropriate sexual stimulation, appropriate interval between tablet intake and sexual activity, with sildenafil and vardenafil fasting conditions for two hours, and with tadalafil keeping an interval of at least two hours between intake and sexual activity) (personal experience). 2 Optimal treatment of concomitant diseases, such as optimal diabetes control (elevated gycosylated hemoglobin...

Cardiovascular Risk Factors

More than 20 years ago the vascular surgeon Vaclav Michal from Prague recognized that chronic arterial disease, compromising the blood flow in the cavernous arteries, can be a significant cause of ED 11 . Atherosclerosis appears to be the most common cause of vasculogenic erectile dysfunction. Smoking, hypertension, diabetes mellitus and dyslipidemias have been shown to initiate the cascade of events resulting in atherosclerosis. These include endothelial injury, cellular migration, and smooth-muscle proliferation 12 . These same risk factors leading to the manifestation of ED are shared with coronary artery disease (CAD). Studies suggest ED as a strong predictive factor for CAD 13,14 . Vasculogenic impotence has been reported to be the first sign of a generalized arteriopathy suggesting that physicians should check ED patients for ischemic heart disease, which can be diagnosed by stress ECG or other investigations prior to starting treatment for ED 15,16 . The presence of silent...

Ischemic Priapism Treatment

Alternatives are first attempted, especially in cases of less than six hours duration. Previous recommendations for priapism episodes associated with sickle cell disease included prolonged treatments with oxygen, analgesics, and intravenous hydration, prior to in-tracorporal therapy or surgical intervention, due to the often repetitive and self-limiting nature of their priapism episodes. Unfortunately, this regimen is often unsuccessful and results in an increased rate of corporal fibrosis and erectile dysfunction, and is no longer recommended. In very select cases of pri-apism associated with sickle cell disease, the successful use of exchange transfusions to reduce the fraction of abnormal HbS hemoglobin, and hypertransfusion with packed red blood cells to double the hematocrit and diminish the fraction of HbS present, has been described to achieve detumescence. Early hemoglobin electrophoresis to determine the fractional percentage of HbS present serves as a useful guideline for...

Methodology of Diagnostic Research

Subjects should be involved in a stable, monogamous heterosexual relationship, prepared to attempt intercourse on a regular basis, and provide written informed consent. The presence of comorbid erectile dysfunction (ED) should be evaluated using a validated instrument such as the international index of erectile function (IIEF), and patients with any degree of ED should be either excluded from the study or treated as a separate subgroup. Patients with hypoactive sexual desire or other sexual disorders, urogenital infection, major psychiatric disorders, a history of drug and alcohol abuse or contraindications to the study drug should be excluded from the study.

The role of anxiety in sexual dysfunction

More recent studies have suggested that it may not be the subjective role of anxiety, per se, that causes and maintains sexual dysfunction but rather the manner in which anxiety affects an individual's ability to focus on, and process sexual stimuli. Barlow 5 has offered a theoretical model explaining why anxiety may operate differentially in men with and without erectile dysfunction. His model emphasizes the role of cognitive interference in male arousal. In general, what appears to distinguish functional from dysfunctional responding is a difference in selective attention and dis-tractibility. What sex therapists consider performance demand, fear of inadequacy or spectatoring are all forms of situation-specific, task-irrelevant, cognitive activities which distract dysfunctional individuals from task-relevant processing of stimuli in a sexual context 6 . Recommendation 2. Ascertain the degree to which anxiety, distraction or the inability to maintain focus on sexual stimulation...

Conclusions and Recommendations

An important step forward has been achieved with the antibiotic coating of penile prostheses. Nevertheless, implant infection remains a threatening complication, especially in re-operations and for patients having simultaneous penile reconstruction and penile prosthesis implantation. It would be useful to define standard operating procedures for systemic antibiotic therapy and local antiseptic measures for penile implant operations. At the present time, there exists consensus on the general need for preopera-tive prophylactic antibiotic coverage against Gram-negative and Gram-positive bacteria, and the prohibition of prosthetic surgery when systemic, cutaneous or urinary tract infections are present 60 . Manufacturers of penile prostheses are continually trying to decrease mechanical failure rates. New devices with modified pump systems and cylinder coating will have to prove their value in future studies after at least five year follow-up. From the literature 46 , suggestions have...

Penile rehabilitation

Nization of the corpus cavernosum smooth muscle, while at the same time decreasing the level of PGE1, which may help protect from fibrosis. Since hypoxia of cavernous tissue is related to the blood supply, and the greatest blood supply occurs at time of erection, any neural damage that results in ED may expose the cavernous tissues to longer periods of hypoxia. Leungwattanakij et al. demonstrated in a cavernous neurotomy rat model that sharp neural injury resulted in an increase in hypoxia inducible factor-1 (HIF-1 a) and TGF-P1 as well as increase in cavernous tissue collagen synthesis 8 . In a landmark study, Montorsi et al. based a study on the assumption that the events of nocturnal erection supply the cavernous bodies with oxygenation that might protect them from developing fibrotic changes during the transient period of erectile dysfunction following nerve-sparing radical prostatectomy 58 . In their study they treated patients with three times per week intracavernosal injections...

Results of penile revascularization

The literature on results of penile revascularization has been summarized for several consensus meetings on ED. The first relevant consensus statement was extracted from the consensus conference on ED at the National Institutes of Health (NIH) in 1993 35 . This review evaluated 34 studies with more than 1700 patients, which were detailed in two further publications 20,21 . Reported success rates were found to range between 33 and 100 , with a median of 72 . Only seven studies included objective follow-up parameters. It was concluded that only highly selected patients may benefit from these operations, which should only be performed in an investigational setting in specialized centers. In 1996 the ED Guideline Committee of the AUA stated For venous and arterial surgery, the measures of success are nonstandardized and unpredictable 36 . The 2005 AUA ED guideline recommends that Arterial reconstruction is a treatment option only in healthy individuals with recently-acquired erectile...

Nocturnal Penile Tumescence NPT Testing

This method is useful for select individuals. NPT testing takes advantage of the fact that men with normal erectile function have 4-6 episodes of involuntary, nocturnal erections lasting 20-50 minutes during a 6-8 hour sleep cycle. These erections occur mostly during REM (rapid eye movement) sleep. NPT testing in the diagnosis of ED has been described and is known worldwide 50 . NPT is best used to distinguish between organic and psychogenic ED.

Pharmacologic profile

Arteries and on presynaptic a2 -adrenoceptors, which are localized on -adrenoceptors of sympathetic nerve endings 3 (see also Fig. 3.7, p. 37). At these presynaptic a2-adrenoceptors, a2-blockers inhibit erection-suppressing impulses mediated by sympathetic aj-adrenoceptors, which facilitates initiation of erection. Yohimbine at higher doses is also reported to act on cholinergic, vasoactive intestinal peptidergic (VIPergic) and dopaminergic receptors 2 , and to exert antagonistic or inhibitory properties on serotonin receptors, monoamino-oxidase and the rapid sodium channels 4 . Based on these multiple, partly complex pharmacologic properties, yohimbine has three principal mechanisms of action in the treatment of erectile dysfunction.

Guidelines for Research in the Surgical Management of Peyronies Disease

Ence of associated deformities, and preoperative erectile hemodynamics status. Furthermore, patients with Peyronie's disease should be separated from patients with congenital penile curvature when assessing outcomes with plication-type procedures. The committee encourages all authors to declare the degree of residual deformity after penile reconstructive surgery. It was felt that residual deformities greater than 15 degrees were unaccept-ably high and warranted secondary procedures intraoperatively. Investigators are encouraged to define erectile function postoperatively using validated instruments. It is hoped that the future will see the development of a validated instrument specifically for Peyronie's disease, and especially for the assessment of postoperative patient satisfaction levels.

Epidemiology and Risk Factors

Data from a probability sample study of sexual behavior in a demographically representative, 1992 cohort of US adults, known as the National Health and Social Life Survey, and that included 1749 women and 1410 men aged 18 to 59 years at the time of the survey, was analyzed by Laumann and colleagues 7 . A latent class analysis (LCA) was used to evaluate the syndromal clustering of individual sexual symptoms. Latent class analysis is a statistical method well suited for grouping categoric data into latent classes 8 . Latent class analysis tests, whether a latent variable, or specified as a set of mutually exclusive classes, accounts for observed covariation among manifest, categoric variables 9 . This study reports a 5 prevalence of low sexual desire, which should be compared to the 5 prevalence reported for erectile dysfunction. Table 13.1 presents the risk factors reported for this population.

Recommendations for screening and therapy

Testosterone levels needed for normal sexual function may vary between individuals. Some men may have normal sexual function even if their T levels fall into the age-adjusted lower normal range 221 . However, in patients with ED and or hypoactive sexual desire, T testing is recommended to screen for hypogonadism. T therapy is appropriate when clinical indications and biochemical evidence of hypogonadism exist 168,222 . In men with ED, determining T levels only in case of either low sexual desire or abnormal physical examination overlooks many patients with

Populations for combination therapy and screening

Fig. 18.5 Algorithm for androgen therapy in a man presenting with erectile dysfunction. ED, erectile dysfunction PDE5i, phosphodiesterase 5 inhibitor T, testosterone. Fig. 18.5 Algorithm for androgen therapy in a man presenting with erectile dysfunction. ED, erectile dysfunction PDE5i, phosphodiesterase 5 inhibitor T, testosterone.

General reviews on animal models

McKenna KE, Adams MA, Baum M, Bivalacqua T, Coolen L, Gonzalez-Cadavid N, Hedlund P, Park K, Pescatori E, Rajfer J, Sato Y. Experimental models for the study of male sexual function. In Lue TF, Basson R, Rosen R, Giuliano F, Khoury S, Montorsi F, eds. Sexual Medicine. Health Publications, 2004. Meisel RD, Sachs BD. The physiology of male reproduction. In Knobil E. Neil JD, eds. The Physiology of Reproduction. New York Raven Press, 1994, vol. 2. pp. 3-105. Pfaus JG, Kippin TE, Coria-Avila G. What can animal models tell us about human sexual response Ann Rev Sex Res 2003 14 1-63.

Premature Ejaculation

Although premature ejaculation (PE) is considered the most frequent self-reported male sexual dysfunction, there is a lack of a universally accepted definition 5 . This has led to a wide range of prevalence estimates and the development of proposed guidelines for the use of the varied psychologic and pharmacologic therapeutic interventions 6 .

Visual Sexual Stimulation VSS

During Doppler duplex ultrasound, to achieve a maximum erection response and thus to be able to draw conclusions on the maximum relaxation ability of the corpora cavernosa. VSS facilitates relaxation of the cavernosal tissue and overcomes potential psychogenic barriers toward the creation of an erection during vascular testing 37 .

Phosphosdiesterase Type 5 inhibitors

The efficacy of PDE-5i for the treatment of post-RP ED has only recently been studied. Sildenafil is the most studied PDE-5i in this subgroup of patients. However, despite this there does not exist data from a multi-center, randomized, placebo-controlled study evaluating sildenafil in patients with post-RP ED. Montorsi and McCullough found eleven studies in a systematic research on MEDLINE and CANCERLIT (1998-2004) with discrete data sets of post-prostatectomy patients with erectile dysfunction treated with sildenafil monotherapy 68 . From their analysis they concluded that with sildenafil, more than one-third of patients with post-RP ED achieved erections sufficient for intercourse. The odds of responding improved 12-fold with preservation of at least one neu-rovascular bundle. Early treatment failure does not necessarily imply lack of efficacy in the future, and patients should be encouraged to continue trying sildenafil, titrating up to 100 mg as needed. Using multivariate...

Self Injection Therapy

The demonstration by Virag in 1982 that intracav-ernous (IC) injection of papaverine produced a fully-rigid erection in normal males, introduced a new route of administration in the clinical management of pharmacologic agents for the treatment of erectile failure 1,2 . Intracavernous injection of a vasoac-tive agent that readily produces erection has greatly simplified the multidisciplinary diagnostic investigations and management of erectile dysfunction (ED). Three groups of drugs are presently used for self-injection therapy worldwide, or at least in some parts of the world. These include papaverine, a-adrenoceptor blocking agents such as phentolamine or moxisylyte, and prostaglandin E1 (PGE1). These compounds have proven to be effective in all etiologies of erectile failure such as psychogenic, neuro-genic or vasculogenic impotence. Up to 1998, self-injection therapy was the only effective pharmacologic treatment in ED and was considered a first-line option in this indication. But...

Intraurethral alprostadil

Intraurethral delivery of alprostadil was first introduced by Padma-Nathan et al., in 1997, who claimed an overall efficacy rate of 44 for post-RP ED 77 . Raina et al. in a retrospective study, reported a 48 rate of significant improvement in all domains of the Sexual Health Inventory for Men (SHIM) after a mean of 2.2 years in 27 patients with post-RP ED treated with intraurethral alprostadil, although seldom reaching pre-operative scores, and 52 of patients had discontinued after a mean of eight months, mainly due to inadequate response or side effects 78 . Mulhall et al. reported a lack of consistency in the erectile response of patients treated with this therapy. They showed that only 51 of patients that had a rigid erection in an office-test could obtain the same response at home, although this was not confined to patients post-RP 79 . Intraurethral al-prostadil is a safe alternative for the treatment of PRPED, but with a low efficacy, high dropout rate, and inconsistent results....

General considerations for the three PDE5 Inhibitors

Regarding the general assessment question (GAQ) Has the treatment you have been taking improved your erections This efficacy tool does not really tell whether the patient is able to attain an erection sufficient for sexual intercourse or not. This relatively weak efficacy measure is widely used, especially by pharmaceutical companies, because usually it yields the highest success rates. International index of erectile function (IIEF) 48 The IIEF was originally developed to evaluate the clinical efficacy of sildenafil (Viagra ) and became the most accepted and used efficacy tool for drugs assigned to treat ED world wide. It comprises 15 questions in five domains, addressing erectile and orgasmic function, sexual desire, sexual satisfaction and overall satisfaction. Each question has six response options scoring between zero (worst) and five (best result). For evaluation of the erectile efficacy of a drug the IIEF erectile function (EF) domain, comprising questions 1-5 and 15,...

Vacuum constriction device VCD

Et al. published one the few papers on the subject VCD and post-RP erectile dysfunction 75 . To assess the efficacy of VCD following RP they conducted a prospective study 74 patients were randomized to VCD use and 35 to observation without any erecto-genic treatment. In the treatment arm 60 74 patients successfully used their VCD with a constriction ring for vaginal intercourse at a frequency of twice week, with an overall spousal satisfaction rate of 55 (33 60). After a mean use of three months, 14 74 (18 ) discontinued treatment. Also, VCD has been reported to be used in combination with sildenafil to improve erectile response in patients with post-RP ED 76 .

Daily treatment with selective serotonin reuptake inhibitors

Daily treatment can be performed with paroxetine 20-40 mg, clomipramine 10-50mg, sertraline 50-100mg, and fluoxetine 20-40mg 19,45,46 (Figure 16.2) Paroxetine appears to exert the strongest ejaculation delay, increasing IELT approximately 8.8-fold over baseline 44 . Ejaculation delay usually occurs within five to10 days, but may occur earlier. Adverse effects are usually minor, start in the first week of treatment, gradually disappear within two to three weeks and include fatigue, yawning, mild nausea, loose stools or perspiration. Diminished libido or mild erectile dysfunction is infrequently reported. Significant agitation is reported by a small number of patients, and treatment with SSRIs should be avoided in men with a history of bipolar depression.

Diagnosis of Hypoactive Sexual Desire

Some patients present themselves as having low sexual desire, which in fact is a result of another sexual dysfunction. Erectile dysfunction is sometimes confused by the patient as a sign of diminished desire. Likewise, the avoidance pattern that follows the frustration generated by a persistent dysfunction, like severe premature ejaculation or erectile dysfunction, can also be reported as absence of desire. These clinical situations demand a careful evaluation from the clinician before arriving at a clinical diagnosis.

Selfadministered questionnaires

Sexual function symptom scales should be used routinely to assess functional level (e.g. ability to respond, level of interest) and to determine the impact of therapy. The most frequently used type of instrument is the self-administered questionnaire. As with all psychometric instruments, the fundamental requirements for psychometric validity include reliability and validity. Reliability refers to the consistency or replicability of data, while validity reflects the degree to which an instrument or scale measures what it intends or claims to measure. Two essential indicators of validity for measures of sexual function are sensitivity to diagnostic status (e.g. functional versus dysfunctional) and sensitivity to treatment change. Both are crucial features of any scale that is designed to serve as a diagnostic and or efficacy measure in either clinical or research settings. Validated symptom scales are available for the assessment of male sexual dysfunction, as well as couple and...

ED Minimizing Maneuvers Nervesparing surgery

Nerve injury can occur at four time points during radical retropubic prostatectomy at the time of urethral dissection, during lateral pedicle division, during dissection along the base of the prostate, and at the time of seminal vesicle dissection. Nerve trauma is classically thought of as occurring with cautery, ligation or avulsion however, overly aggressive traction may lead to neuropraxia, and even this temporary trauma may result in structural sequelae in the corporal bodies that may limit the recovery of erectile function 7,8,33 . Donohue et al., using a rat model of cavernous nerve injury, demonstrated that nerve exposure alone without any direct manipulation results in a significant reduction in erectile function as measured by intracavernous pressure generation in response to cavernous nerve stimulation 34 . There is a plethora of robust data supporting the concept that the greater the volume of nerve tissue preserved the better the spontaneous erectile function and the...

Eusebio Rubio Aurioles

In contrast with other conditions related to the sexual life, the key clinical determinants of this diagnosis are not as concrete and readily identified as erection or ejaculation for instance, in the case of HSD these clinical features refer to a variety of expressions of sexual desire, since the occurrence of sexual desire is an internal and subjective experience. Because of this, HSD has been historically either not identified 1 , or erroneously diagnosed and presented (and treated) as other sexual dysfunctions like erectile dysfunction 2 . The DSM IV, in its current edition, defines HSD disorder as persistently or recurrently deficient (or absent) sexual fantasy and desire for sexual activity, leading to marked distress or interpersonal difficulty 6 . However, since the DSM IV is a psychiatric classification, its definition excludes HSD when it is caused by another medical disorder, or even another sexual dysfunction. There is some discussion in the literature as to this...

Surgical options

They had painful priapism more than four hours in duration that was refractory to conservative management, ultimately requiring a surgical shunt. Of the 28 patients included in the study, 13 (46 ) required more than one operation for failed detumes-cence, of which 12 (92 ) initially underwent a Winter shunt. Only 2 20 men (10 ) with available follow-up reported preservation of pre-morbid erectile function. Three men (15 ) achieved partial erection without the assistance of oral or injectable agents, while the remainder 15 20 (75 ) had erectile dysfunction. In his original report on his procedure, Ebbehoj discussed 18 patients treated for priapism using his technique. Eleven obtained complete relief and follow-up examination of the 18 patients demonstrated normal erectile function in 11 cases 3 . In cases where proximal shunt fails, some authorities advocate performing a saphenous vein bypass procedure (Grayhack procedure) 6 , whereby the saphenous vein is interrupted below its...

Painful ejaculation

Characterized syndrome and may be associated with benign prostatic hypertrophy (BPH), infection, or inflammation from acute prostatitis, chronic pro-statitis chronic pelvic pain syndrome, seminal vesi-culitis, seminal vesicular calculi, or ejaculatory duct obstruction, a treatable cause of male infertility 122-125 . Nickel reported that 18.6 of men with lower urinary tract symptoms (LUTS) diagnosed with clinical benign prostatic hyperplasia reported painful ejaculation 123 . Men with BPH and painful ejaculation have more severe LUTS and reported greater bother, and had a higher prevalence of erectile dysfunction and reduced ejaculation, than men with LUTS only 78 . Treatment of men with LUTS with a-blocking drugs may be associated with painful ejaculation. A lower incidence of pain has been reported with the uroselective a-1 blocking drug, alfuzosin 126 .

Penile Angiography

Until the mid 1980s, penile angiography was regarded as the gold standard in the diagnosis of arteriogenic impotence. This technique was mainly developed at the end of the 1970s by Ginestie and Romieu, whose standard work on this topic remains valid today 44 . As a result of standardization of vascular diagnostic in erectile dysfunction, using non-invasive Doppler and duplex ultrasound, penile angiography is no longer a standard diagnostic test (45). The only remaining indications for penile angiography is in younger men under 50 years of age in whom an isolated vascular occlusion with the absence of further risk factors makes the option of penile revascularization appear logical. Penile angiography is used for arterial embolization in cases of high-flow priapism 46 .

Physical Examination

The physical examination (Table 6.5) should include specific attention to the genitalia. The examination starts preferably in a standing position as possible gynecomastia, abnormal pubic fat-deposition with shortening of the penis and varic-ocele, are best visible and palpable in the upright position. On occasion, pathologic conditions may be encountered. Carbone et al. 10 found the following pathology in 207 patients (average age 60 years, range 17 to 88 years) who consulted a physician exclusively because of erectile dysfunction. These men had undergone a complete urologic status, including urinalysis, rectal examination, PSA and ultrasound, before initiating specific ED diagnostic methods. Although the 15 incidence of urologic malignancies is unusually high in this study with only ED patients, it highlights the importance of the general urologic physical examination in men with ED. Other pathologic findings may include Peyronie's plaques, testicular atrophy, varicocele, inguinal...

Papaverine

As a good smooth muscle relaxant, papaverine has shown to evoke relaxation of isolated CC strips, penile arteries, cavernous sinusoids, and penile veins in vitro papaverine caused marked vasodilation of the penile arteries and decreased venous outflow, as recorded by Doppler 2 . Furthermore, papaverine also attenuated contractions induced by stimulation of adrenergic nerves and exogenous noradrenaline 25,26 . An IC injection of 80mg papaverine in normal volunteers and patients with psychogenic impotence produced rigid erections. At the cellular level, papaverine is a nonspecific phosphodiesterase inhibitor that causes increases in intracellular cAMP and cGMP, resulting in corporal smooth muscle relaxation and penile erection. It may also modulate cavernosal smooth muscle tone through inhibition of voltage-dependent L-type Ca2+ channels independent of cAMP, as reported in tra-

Psychogenic

Finally, the evaluative performance aspect of sex with a partner often creates sexual performance anxiety for the man, a factor that may contribute to IE. Such anxiety typically stems from the man's lack of confidence to perform adequately, to appear and feel attractive (body image), to satisfy his partner sexually, and to experience an overall sense of self-efficacy 91,92 . The impact of this anxiety on men's sexual response varies depending on the individual and the situation, but in some men it may interfere with the ability to respond adequately. With respect to IE, anxiety surrounding the inability to ejaculate may draw the man's attention away from erotic cues that normally serve to enhance arousal. Apfelbaum,

Metabolic syndrome

Metabolic syndrome, such as blood pressure elevation, hyperlipidemia, obesity, and or elevated blood sugar take time to extract its metabolic toll on the body. Montorsi et al. documented that ED symptoms were present several years before manifest coronary disease 405 . This was predicted a number of years before when Pritzker performed cardiac stress tests on 50 men with ED, but no history or symptoms of heart disease, and was surprised to find that 56 of the men failed the stress test because of silent ischemia 406 . He postulated that ED might be the early factor that could predict heart disease, and that pursuing this vigorously might enable physicians to practice primary cardiac prevention. Few studies have looked at the incidence of the metabolic syndrome in an ED population, by looking at the specific NCEP ATPIII criteria themselves. Bansal etal. evaluated the specific criteria in 154 consecutive consultations for ED 412 . Three of the five criteria for metabolic syndrome were...

Sexual functioning

Aging is the most robust risk factor predicting erectile difficulties. It is obvious that aging per se is associated with a deterioration of the biologic functions mediating erectile function hormonal, vascular, and neural processes. This is often aggravated by intercurrent disease in old age, such as diabetes mellitus, cardiovascular disease, and use of medical drugs. T is only one of the elements which may explain sexual dysfunction with aging.

DHEA therapy

DHEA therapy in healthy aging subjects The age-related decline in DHEA production has prompted study of the effects of DHEA administration in healthy elderly adults. One of the first studies looking at beneficial effects of DHEA supplementation in aging subjects found an improved overall sense of well-being in male and female subjects taking DHEA compared with placebo, but was based on rather poor methodology 304 . Several subsequent studies failed to find any benefit regarding overall well-being, mood, or cognition with DHEA supplementation 305-308 . The same negative findings extended to muscle strength and in muscle and fat cross-sectional areas 309 . Regarding improvement in sexual function, the effects of DHEA administration have been conflicting, demonstrating benefits in women over 70 years old, after more than six months of chronic administration, but no benefits in aging men 308,310,311 . The authors of a randomized, placebo-controlled trial in 40 ED patients claimed to have...

Nicotine abuse

Smoking has been shown to be an important risk factor for ED, whether in the long or short term. The detrimental effects of smoking on sexual function have been shown to be independent of other nicotine related health problems. Long-term cigarette smoking has been shown to be an independent risk factor for arteriogenic impotence 29 . Juenemann et al. suggested that smoking could significantly interfere with the cavernous veno-occlusive mechanism 30 . Smoking cigarettes directly before an intracavernous injection of papaverine significantly reduced the erectile response to the medication 31 .

Vignette A

Joseph, aged 50, developed ED three years ago. He has been married to Martha, aged 45, for 20 years. Over the past three years Martha has recognized that Joseph's erectile function is no longer reliable. Joseph has difficulty acknowledging that something was happening to his erections. He tells Martha that he is too tired or too stressed at work. She however insists that he consult his primary care physician. Routine testing revealed a previously undiagnosed diabetes mellitus that surprised both the doctor and Joseph. After initial control of the diabetes mellitus and treatment with PDE-5i, Martha and Joseph recovered the intensity of their sexual life. Joseph is thankful to Martha for insisting that he seek professional consultation for their problem.

Thyroid hormones

330 found ED in 64 and 15 , respectively (associated with hypoactive sexual desire and retarded ejaculation in most of the hypothyroid patients), and premature ejaculation in 7 and 50 , respectively. After return to normal levels of serum thyroid hormones for eight to 12 weeks, the prevalence of premature ejaculation fell from 50 to 15 in the hyperthyroid patients, while that of retarded ejaculation was reduced by half in those with hypothy-roidism. The mean ejaculation latency time doubled in the former and significantly decreased in the latter, suggesting the possibility of a direct involvement of thyroid hormones in the physiology of ejaculation. In 38 patients referred for ED and found to be hypothyroid, Baskin 331 reported that erectile function returned in the majority following thyroid hormone substitution. Conversely Wortsman et al. 332 did not observe any sexual improvement following thy-roxin treatment in a short series of ED patients with primary hypothyroidism. In...

Partner evaluation

The partners of men with ED are affected, to a lesser or greater degree by the ED, as is the male. As alluded to by Dr Wagner and colleagues 21 , quality of life (QoL) has become one of the important parameters in the evaluation of treatment and assessment of medical conditions, and it may be an important tool in determining the urgency of the need for therapeutic intervention for ED. It is important to evaluate the QoL of the couple, because men and women alike will suffer as a result of male erectile disability. As discussed by Dunn 23 , the new modes of pharmacologic therapy give health care practitioners an unprecedented opportunity to treat patients with erectile dysfunction. Yet even with a portfolio of effective treatment modalities, such as phospho-diesterase type 5 (PDE-5) inhibitors, nonpharma-cologic interventions should be considered as a means to support and augment the effects of these agents. Of equal value and necessity is the involvement of the man's partner in both...

History

The concept of vacuum device therapy in the treatment of erectile dysfunction (ED) goes back as early as 1874 when the American physician John King described a method of improving erections by a small vacuum pump. The first patent for a vacuum device was granted in 1914 in Germany and 1917 in US to Otto Lederer. In 1960 the American entrepreneur Geddings Osbon started to produce a vacuum device and founded his own company for manufacturing the device he had invented. Finally in 1982 he was granted permission from the Food and Drug Administration to produce this device, which was named Erec-Aid 1 . Nadig et al. published the first report on efficacy and safety of vacuum constriction devices (VCD) in 1986 2 .

Future aspects

The challenge will be to find ways to integrate drug treatment and behavioral psychotherapy into a multi-dimensional treatment plan. Both drug treatment and psychotherapy are limited in that they represent symptomatic treatments for controlling and delaying ejaculation. Furthermore, the irreversible nature of surgical procedures relegates them to lastresort strategies. The goal of treatment should be to improve the level of sexual satisfaction of both sufferer and partner by offering a variety of tools and treatment options that afford greater self-efficacy over their sexual response with their partner. To this end, further investigation into the ways in which biomedical and psychologic strategies can combine to achieve optimal outcomes is greatly needed.

Postoperative ED

Procedures frequently resulting in the manifestation of ED include radical pelvic surgery, such as radical prostatectomy (non nerve sparing), or cystectomy, abdominoperineal resection of the rectum and aorto-iliac bypass surgery. With knowledge of the anatomical course and identification of the cavernous nerves from the spinal center to the erectile tissue, and with the possible aid of intraoperative neurostimulation, the cavernous nerves may be identified and preserved, thereby preventing iatrogenic impotence 54,55 .

Lifestyle

(SHIM), also known as IIEF-5 (5-item version of the International Index of Erectile Function), by 0.141, independent of age (P 0.005) 5 . In a study of 593 men 30 to 70 years old, midlife lifestyle modification appeared to be too late to reverse the adverse effects of nicotine, obesity, and alcohol consumption on sexual function, while physical activity appeared to be effective in reducing the risk of ED even if initiated in midlife 6 . A controlled study in obese men (BMI > 30) revealed that increase of physical activity from 48 to 195 min week, and a decrease in BMI from 36.9 to 31.2 over two years, resulted in an increase of the International Index of Erectile Function (IIEF) score from 13.9 to 17 (P< 0.001) 7 .

Larginine

L-arginine is the precursor of NO synthesis (Fig. 7.1). Zorgniotti et al. conducted a placebo-controlled study with 2800mg L-arginine per day in 20 impotent men for two weeks. Of the 15 men who completed the study, six reported an improvement in the ability to achieve an erection, nine experienced no improvement 137 .

Dyslipidemia

In clinical studies pathologic HDL and LDL (low density lipoprotein) values were associated with vascular ED and veno-occlusive dysfunction 25,26 . Lowering elevated total, and especially LDL, cholesterol levels, either by dietary measures or by administration of cholesterol lowering drugs (statins), resulted in a significant improvement of erectile function in both animals and humans 27,28 .

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Whether you call it erectile dysfunction, ED, impotence, or any number of slang terms, erection problems are something many men have to face during the course of their lifetimes.

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