Effective Treatment for Erectile Dysfunction

Erect At Will Cures ED

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Erect At Will Cures ED Summary


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Medical Treatments for Erectile Dysfunction

Initially, there were few oral treatments for ED, being used by urologists, such as yohimbine based products, trazodone, and bupropion. They had only modest proerectile capability (11). Pharmaceutical companies were inspired to pursue oral treatments with the promise of less intrusiveness and even greater profits. The first visible evidence of fulfilling that promise was the sildenafil launch. Subsequent to Pfizer's success, multiple companies simultaneously pursued clinical trials of easy-to-use treatments for male SD. Among others, these included additional PDE-5 type compounds and other oral treatments, such as ixense (TAP Holdings, Deerfield, IL, USA), and topically applied compounds (MacroChem, Lexington, MA, USA). Additionally, PT-141 (Palatin Technology, Cranbury, NJ, USA) is a nasally administered peptide that is under development, which is presumed to work through a central nervous system mechanism. Currently, there are three highly efficacious PDE-5, FDA-approved treatments...

Activation And Regulation Of Sexual Response Processing of Sexual Information

Basis of a series of priming experiments Janssen et al. (76) presented an information processing model of sexual response. Two information processing pathways are distinguished (cf. 77). The first pathway is about appraisal of sexual stimuli and response generation. This pathway is thought to depend largely on automatic or unconscious processes. The second pathway concerns attention and regulation. In this model, sexual arousal is assumed to begin with the activation of sexual meanings that are stored in explicit memory. Sexual stimuli may elicit different memory traces depending upon the subject's prior experience. This in turn activates physiological responses. It directs attention to the stimulus and ensures that attention remains focused on the sexual meaning of the stimulus. This harmonic cooperation between the automatic pathway and attentional processes eventually results in genital responses and sexual feelings. Disagreement between sexual response components would occur,...

Pharmacotherapy for Men with ED

Few licensed drugs are currently available for the treatment of men with ED. Those that are available elicit their effect by one of two mechanisms. The agent boosts either the neuronal control mechanism or the local control mechanism (13). As we shall see, oral therapies can have their effect on either system, whereas the intracavernosal and intraurethral systems act locally to produce an erection. Oral agents used to treat ED should be reliable, have minimal side effects, and be simple to use (22). The oral therapies currently licensed for ED are the phosphodiesterase 5 inhibitors (PDE5 inhibitors), which have a peripheral mechanism of action, and apomorphine, which acts centrally. These agents require sexual stimulation to initiate the neuronal activation required to start the hemodynamic erectile response. This is in contrast to the PGE mediated response initiated by intracavernosal and intraurethral alprostadil administration that forces an erection (see later). Yohimbine is...

Psychological Therapies for Men with ED

In the majority of cases of ED, psychological factors are involved in either the development of the disorder or the maintenance of the problem. While recognising that many men would not seek a psychological approach to resolving the condition, an outline of performance anxiety about continued erectile failure and the effect this has on their partner and their relationship, is often appreciated by the man. Difficulties with communication and the development of suspicion and mistrust between partners may need discussion, recognition, and specific intervention. In each of these three situations, an integrative approach by the assessing clinician to ensure adequate assessment of both psychological and physical contributing factors may lead to more efficacious outcomes while recognising that the interventions themselves may be multiple, rather than relying on one treatment and progressing in a linear fashion to alternatives because of failure of first line therapy. Helping the man to start...

Erectile dysfunction

Erectile dysfunction (ED) may be defined as the consistent inability to achieve or maintain an erection sufficient to permit satisfactory sexual intercourse. The word consistent is included in the definition because most men experience transient episodes of ED that are temporary and usually associated with fatigue, anger, depression or other stressful emotions. The use of the formerly used term impotence has been virtually abandoned because of its inherent stigma of weakness and lack of power. Erectile dysfunction can occur as part of several r First, it may be useful to understand the mechanisms of normal penile erection. Penile erection occurs essentially when the penis becomes engorged with blood. The anatomical compartments (two corpora cavernosa and one corpus spongiosum) are capable of being distended with seven times their normal amount of blood. When this occurs in association with relaxation of the penile muscles, erection results. The sequence of events resulting in penile...

Surgical Interventions for Men with ED

There are three forms of penile prostheses available semi-rigid, malleable, and inflatable. Typical candidates for a penile implant are patients with chronic disease states such as long-term diabetes and end-organ failure or severe arterio-genic impotence combined with severe veno-occlusive dysfunction and men with treatment unresponsive Peyronie's disease in combination with ED. Typical

Model Of Sexual Response Showing Various Incentives And Motivations To Be Sexual And Arousal Triggering And

The assumption is that the occurrence of sexual motivation, including fantasies, must be the result of sexual information processing of some kind even though in some, or even most cases, the initiating sexual stimulus may not be known. For most people, their sexual response system reacts

Other Unlicensed Treatment Therapies for Men with ED

Several new formulations are being developed, such as topical alprostadil and intranasal apomorphine. New agents are being developed, including selective PDE3 4 5 inhibitors MS-223131 (Bristol-Myers Squibb), T-1032 (Tanabe Seiyaku), TA-1790 (Vivus), sildenafil nitrate (NCX-911) (NicOx) nonselective inhibitors of postsynaptic alpha-adrenoceptors within the corpus cavernosum phentolamine (Vasomax Schering Plough), melanocortin receptor agonists such as melatonan II (Palatin) (s.c. and intranasal) increases erections and sexual drive appetite (phase 2A) and the 5HT1 agonist VML670 (Lily Vernalis).

The Sexual Response Cycle

There are four phases in the sexual response cycle I. excitation, II. plateau, III. orgasm, and IV. resolution (Masters, Johnson, & Kolodny, 1994). In men, phase I (excitation) is characterized by erection of the penis. Phase I takes place more slowly in women and is characterized by the production of lubricating fluid in the vagina, an increase in the diameter of the clitoris, and increased congestion of the labia with blood. For both sexes, phase II (plateau) is marked by a rise in the blood congestion of the pelvis and a strong feeling of sexual tension. A sex flush colors the forehead, neck, and chest, sometimes extending to the abdominal area. Phase III (orgasm) occurs in two stages in men a preejaculatory contraction of the muscles involved in ejaculation, and actual ejaculation. The same muscles are involved in the orgasms of women as those of men. During phase IV (resolution), which is usually completed more quickly in men than in women, the congestion of the blood vessels...


Penile erection is a vascular event, and it is important to recognize that local vasodilatation in the penis is under dual control by autonomic nerves and the endothelium (262). In the periphery major causes of impotence are vascular disease and diabetic autonomic neuropathy. Both neurogenic and endothelium-dependent relaxation of erectile smooth muscle can be impaired in diabetic men with impotence and in experimental diabetes (263,264). Within the corpus cavernosum, reduced levels of NA and decreased innervation by VIP-containing and AChE-positive nerve fibers have been reported in diabetic patients with impotence (265). NO has been proposed as an important neurotransmitter in erection. The production of NO by the corpus cavernosum following nerve stimulation is reduced in patients with vasculogenic impotence (266). In patients with neurogenic impotence a significant reduction in NOS-containing nerve fibers in the corpus cavernosum has been observed (267). Sildenafil, the latest...

Evolution Of Current Treatment Approaches

Urologists have made important contributions to the treatment of erectile dysfunction. Both the Small-Carrion and inflatable penile prostheses were introduced in the 1970s. Although patents for vacuum erection devices were obtained as early as 1917, the introduction of the vacuum erection pump by Osborn in 1974 resulted in this being a common solution for many men before the introduction of other treatment options. Alprostadil intracorporal injections were introduced in the 1980s. However, the popularity of treatment approaches decreased dramatically with the introduction of sildenafil in 1998 and the subsequent introduction of tadalafil and vardenafil. Now a man could take an effective oral agent that allowed sexual behavior to occur in a more natural way. Understandably, as the primary etiology of erectile dysfunction for majority of aging men is vascular (13,14), the main focus of therapeutic oriented research of erectile dysfunction has been the vascular dysfunction insufficiency...

The Molecular Pathogenesis of Human Prostate Cancer

Prostate cancer (PCA) has become the most commonly diagnosed cancer among men in the USA, with an estimated 189,000 cases diagnosed in 2002 (1). Encouragingly, over the past several years, increased use of serum prostate-specific antigen (PSA) screening has increased the fraction of men diagnosed with PCA confined to the prostate gland, leading to more effective use of surgery and radiation therapy for treatment, and to a decline in PCA mortality (2, 3). Despite these improvements, some 30,200 men will likely died of progressive metastatic cancer in 2002 (1). Furthermore, even though men with early PCA can be cured using surgery or radiation therapy, the side effects of treatment frequently include erectile dysfunction, urinary incontinence, or rectal irritation (4-6). New insights into the etiology of PCA are needed so that new strategies for its prevention can be developed.

Epidemiology Of Sexual Dysfunction

Numerous population surveys in this and other countries indicate a high prevalence of sexual problems in the general population. These surveys indicate that 40 of women have evidence of psychosexual dysfunction. The corresponding number for men is 30 (25). We have more evidence concerning the prevalence of sexual problems in men than women although the data base in both groups is rapidly growing. Correlates of erectile dysfunction in men include diabetes, vascular disease, age, and cigarette smoking. Serum dehydroepiandro-sterone and high-density lipoprotein cholesterol were found to be negatively correlated with erectile problems (26). Depression was correlated with erectile function in cross sectional studies, whereas passive personality traits tended to predict who would develop impotence in a prospective study (27). Studies in other countries have, in general, found somewhat similar rates of erectile dysfunction in the same age population and also that erectile dysfunction tends...

Former Reader in Pharmacognosy University of Bradford UK

According to the old Doctrine of Signatures or Similitudes, a theory apparently derived independently in many parts of the world, a plant would by its colour, shape and characteristics indicate its potential medicinal uses (Court, 1985). Thus ginseng with its man-like appearance was quickly accepted as a tonic, a cure-all with particular value as an aphrodisiac and a treatment for impotence and loss of sexual drive. The more anthropomorphic the better and the price rose accordingly.

Identifying Psychosocial Barriers to Success

There are a variety of bio-psychosocial obstacles to be recovered that contribute to treatment complexity. All of these variables impact compliance and sex lives substantially, in addition to the role of organic etiology (20). There are multiple sources of patient and partner psychological resistance, which may converge to sabotage treatment (i) What is the mental status of both the patient and the partner and how will this impact treatment, regardless of the approach utilized What is the nature and degree of patient and partner psychopathology (such as depression) What are the attitudinal distortions causing unrealistic expectations, as well as endpoint performance anxiety (ii) What is the nature of patient and partner readiness for treatment When and how should treatment begin, and be introduced into the couple's sex life What is his approach to treatment seeking What should be the pacing of intimacy resumption The average man with ED waits 2-3 years, before seeking...

Combination Therapy The Road To Success

Combining sexual pharmaceuticals and sex therapy is the oral therapy of choice to optimize treatment for all SDs. This is true for men with ED, PE, or retarded ejaculation (RE) and will also be true for FSD. Less medication is required when you modify immediate causes while appreciating other psychological obstacles (20). However, CT is by no means a new idea, and sexual medicine is not the first specialty utilizing a broad-spectrum approach to increase efficacy and satisfaction.

Combination Therapy A Brief Relevant History

In urology and many medical specialties, CT usually referred to a, two or more drug regimen, such as the 2003, AUA guidelines for BPH (27). There already is a history of using CT in sexual medicine. In the 1990s, sex therapists worked with urologists combining either ICI or vacuum tumescence therapy. Turner et al. (28a) found that psychological counseling was necessary to augment a pharmaceutically induced erection, for a man with a psychogenic ED. Kaplan managed resistance to ICI, helping five couples find satisfaction with pharmaceutical restoration of potency (28b). Hartmann and Langer (29) integrated injection therapy and sexual counseling concluding that a combined approach was beneficial. Colson described the results of a study integrating cognitive-behavior therapy and ICI technique. Of their patients, 51 were still able to experience satisfactory sexual intercourse after discontinuing injection therapy (30). Lottman et al. (31), integrated short-term therapy with...

Frequency Of Autonomic Dysfunction In Parkinsons Disease

Although the focus of routine follow-up visits between PD patients and neurologists is typically on motor symptoms of the disease, autonomic problems are frequently present and can be identified if patients are specifically asked. In one study of 48 men with PD, 89 had at least one autonomic symptom compared with 43 of elderly control subjects (2). Autonomic symptoms seen in these men with PD included erectile dysfunction (60 ), urinary urgency (46 ), constipation (44 ), dysphagia (23 ), and orthostatism (22 ), and each of these symptoms was more common in PD patients than controls. Siddiqui et al. (3) performed a comprehensive symptom survey of autonomic symptoms in 44 patients with PD, comparing the frequency and severity of these symptoms with 24 aged-matched controls. Using a five point scale to rate symptom severity, the authors tabulated the severity of symptoms in each of five areas GI, urinary, sexual dysfunction, cardiovascular, and thermoregulatory. They found that PD...

Combination Therapy Guidelines Who How and When

Whether or not a physician works alone, as in the first model, or as part of a multi-disciplinary team, as in the second, will be partially determined by the psychosocial complexity of the case. This CT model adapts Althof and Lieblum's Proposed Integrated Model for Treating Erectile Dysfunction (15,40). However, it must be emphasized that this author is advocating a CT model for all SD. The treating clinician would diagnose the patient(s) as suffering from mild, moderate, or severe PSOs to successful restoration of sexual function and satisfaction. This characterization would be based on an assessment of all the available information obtained during the evaluation. This would include an assessment of the issues factors described in this chapter's earlier section on Psychosocial Barriers to Success. This assessment would essentially include the psychosocial (cognitive, behavioral, cultural, and contextual) factors predisposing, precipitating, and maintaining the SD. This would be a...

Patient Preference Sexual Scripts and Pharmaceutical Choice

Healer patient relations, minimize PSOs, and improve compliance. Preliminary comparator data, abstracted from the 2003 European Society of Sexual Medicine, suggested, patient preferences reflected, key marketing messages of the respective pharmaceutical companies (49). Prescribing physicians might take advantage of that hypothesis to increase efficacy. If safety and long-term side effects are the primary concern, sildenafil has the oldest longest database (12). If, pressed by questions regarding hardness of erection in vitro selectivity may or may not translate to clinical reality, yet some patients believe vardenafil provides the best quality erection with the least side-effect (13). What is the physician's experience with their own patients By taking a sex history and evaluating the premorbid sexual script (what used to work sexually), a skillful clinician may make an educated guess, as to which pharmaceutical to first prescribe. This transcends, try it, you'll like it. Knowledge of...

Followup and Therapeutic Probe

Discussions of follow-up most vividly illustrate the importance of integrating sex therapy and pharmacotherapy. Urologists, Barada and Hatzichristou improved sildenafil nonresponders by emphasizing patient education (e.g., food alcohol effect), repeat dosing, partner involvement, and follow-up (52,53). Patient education about the proper use of sildenafil was crucial to treatment effectiveness. Physicians can increase their success by scheduling follow-up, the first day they prescribe. As with any therapy, follow-up is essential to ensure an optimal treatment outcome. Initial failures examined at follow-up reveal critical information. The pharmaceutical acts as a therapeutic probe, illuminating the causes of failure or nonresponse (2,15,20). Retaking a quick current sexual

Case Study Jon and Linda

His Chicago psychopharmacologist referred them to a well-known NYC urologist, when they first moved from Chicago. The urologist prescribed 50 mg of sildenafil, which was increased to 100 mg. There were multiple attempts at 100 mg, which all failed. The urologist then prescribed trimix. They used trimix ICI, 15 times, resulting in three coital erections and orgasms. Neither Jon, nor Linda liked the lack of spontaneity. The urologist recommended a penile prosthesis, but Jon declined and terminated that treatment. Some months later, still on 10 mg of escitalopram, a new, NYCpsychophar-macologist referred Jon to this author. Jon and Linda were seen six times conjointly and three times individually. She was helped to reframe his withdrawal, as insecurity, not rejection or abandonment of her. This reduced her anger and resentment. He was encouraged to be affectionate when not angry at her. Her criticalness was reduced, which led to a reduction in his passive-aggressive behavior. Although...

Traditional Markers Of Sexual Desire

Fantasies, which are a marker of sexual desire in DSM-IV-TR may, in fact, serve as a deliberate means of creating arousal and reinforcing desire. Data confirm the clinical experience that women fantasize to deliberately focus on their sexual feelings and avoid the distractions that are interfering with their sexual response (47).

Vascular Supply Of The Spinal Cord

Spinal Cord White Ramus

Ligation of the great radicular artery during resection of an abdominal aortic aneurysm may result in anterior spinal artery syndrome. Clinical findings include paraplegia, impotence, loss of voluntary control of the bladder and bowel (incontinence), and loss of pain and temperature sensation (although vibration and proprioception sensation are retained).

Closer Look At The Biological Basis Of Womens Sexual Desire And Arousability Including The Role Of Androgens

The neuroendocrine basis of sexual desire interest is poorly understood. The effects on sexuality of medications with known or partially known mechanisms of action suggest that more than 30 neurotransmitters, peptides, and hormones are involved in the sexual response. Currently, the most clinically important include noradrenaline, dopamine, oxytocin, and serotonin via 5HT1A and 5HT2C receptors all considered to be prosexual. Serotonin acting via most 5HT receptor sites, prolactin, and GABA, are considered sexually negative. The role of dopamine has been investigated particularly in rodents. Dopamin-ergic input from the ventral tegmental area, particularly to the nucleus accumbens and forebrain is important for cognitive and reward processes. Dopamine administration into the nuclear accumbens has been found to stimulate the anticipatory phase (or appetitive phase) of a sexual activity (54). The paraventricular nucleus and the medial preoptic area of the hypothalamus regulate the...

Biopsychosocial Approach to Therapy

There is a general expectation that modulation of the neurotransmitters involved in sexual arousability and desire from hormonal and nonhormonal therapy, will become available. As there are psychological and interpersonal sequelae of medical disruption of the sexual response, benefit beyond placebo may only be

Classification General Sexual Issues

First, as discussed earlier, some see it as much more useful when considering the sexual sequence experienced by men compared with women (5). Second, the phases are described in such a way as to seem discrete but, in actual fact, they flow into each other. For example, desire is not simply at the beginning of a sexual event, but under ordinary circumstances, continues the whole way through (11). Similarly (although ostensibly less common in men vs. women), desire may follow arousal as, for example, when a man awakens in the morning with an erection and only then becomes sexually interested.

Laboratory Examination

Erectile dysfunction (ED) often occurs together with sexual disinterest and it may not be easy to establish which preceded the other. Under such circumstances, it is wise to investigate common causes of ED by ensuring that the patient does not have diabetes (obtaining a fasting blood sugar), or elevated lipids assessing his total cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), and triglycerides , or abnormal thyroid function investigating his thyroid stimulating hormone (TSH) .

Theoretical Perspectives Biological Psychological and Social

One might look first at differing points of view about sexuality in general. Some view sexual difficulties from primarily a biomedical perspective and regard sex as natural. Kolodny et al. wrote to define sex as natural means just as an individual cannot be taught to sweat or how to digest food, a man cannot be taught to have an erection, nor can a woman be taught to lubricate vaginally. Because the reflex pathways of sexual functioning are inborn does not mean that they are immune from disruption due to impaired health, cultural conditioning, or interpersonal stress (30 p. 479) Some have reworded 'naturally' to mean 'automatically, without purpose or without effort' (31).

Terminology and Definitions

The term andropause indicates a particular type of hypogonadism that is related to aging in men and is said to consist of the following diminished sexual desire and erectile function, decrease in intellectual activity, fatigue, depression, decrease in lean body mass, skin alterations, decrease in body hair, decrease in bone mineral density resulting in osteoporosis, and increase in visceral fat and obesity (24). The word andropause is an attempt to draw a parallel in men to

Treatment General Considerations

Treatment follows diagnostic subtyping (Fig. 1). (A) If HSDD is acquired and generalized, the clinician must make substantial efforts towards finding the explanation(s) for the change. HSDD is sometimes (the frequency appears to be unknown) accompanied by another sexual dysfunction, especially ED, and when both occur together, it may be revealing and useful to find out which came first and to act accordingly. One might envision how a lack of sexual desire can cause erectile problems. However, the opposite is not so clear. The extent to which the presence of ED can result in a generalized lack of sexual desire appears to be entirely unknown. (B) If HSDD is lifelong but situational, a biogenic explanation is unlikely and individual psychotherapy undertaken by a mental health professional seems preferred. (C) If HSDD is acquired but situa-tional, a biogenic explanation is, again, unlikely (with the possibly exception of hyperprolactinemia). In this circumstance, psychotherapy seems...

Individual and Population Examples

Weight, and the huge potential profits for pharmaceutical companies from weight loss medications. Contrast this with the relatively weak and distant driving forces for population-based prevention research and action. These are funded largely from government sources, and the lack of political will due to a short-term political focus and limited public pressure for change remain major obstacles. As discussed later, the driving forces for the obesity epidemic are linked to much broader sectors such as transport, the food industry, education, urban planning, building design, and local government, and this adds to the sense of impotence among health authorities about obesity prevention.

Causes and symptoms

Stimulates the amygdala and causes panic attacks. Another hypothesis is that patients with panic disorder have a hypersensitive internal suffocation alarm. This means that the patient's brain sends the body false signals that not enough oxygen is being received, causing the affected person to increase his or her breathing rate. Panic disorder patients have attacks when their overly sensitive alarm goes off unpredictably. Yohimbine, a drug used to treat male sexual dysfunction, stimulates a part of the brain called the locus ceruleus and induces panic symptoms thus pointing to this area of the brain's involvement in panic disorder. Brain neurotransmitters serotonin and GABA are suspected to be involved in causing the disorder, as well.

What is a Sexual Dysfunction

The experimental evidence and theoretical notions presented earlier strongly suggest that for women, sexual dysfunction is not about genital response. The women in our study who were diagnosed with FSAD according to strict DSM-IV criteria (42) turned out not to be sexually dysfunctional according to these same criteria because their genital response was not impaired. This study demonstrated that it is difficult to be sure that sexual arousal problems are not caused by a lack of adequate sexual stimulation, and that impaired genital response cannot be assessed on the basis of an anamnestic interview. This implies that the current DSM-IV criteria for sexual arousal disorder, which states that genital (lubrication swelling) response is strongly impaired or absent, is unworkable. For most women, even those without sexual problems, it is difficult to accurately assess genital cues of sexual arousal, but this is exactly what the DSM-IV definition of sexual arousal disorder requires. The...

Does He have a Psychogenic Basis to His ED

In the anxious individual, there can be overactivity of the sympathetic system leading to increased smooth muscle tone. Alternatively, signals from the brain of an individual with a psychogenic issue can override the erectogenic parasym-pathetic output from the sacral spinal cord. Psychosexual therapy can help the individual to deal with issues such as performance anxiety, reduced attraction to his partner (which may or may not be linked to a relationship problem), past sexual trauma, misconceptions about normal sexual function, suppressed feelings about sexuality, fear of sexually transmitted diseases or pregnancy. By enquiring about early morning and spontaneous erections, which all healthy men get, one can eliminate a physical cause for ED. Asking about the sort of situations in which the ED manifests itself can also help. For instance, if he is able to masturbate with an erection while alone, but is unable to perform with a partner suggests a situational response. There may be...

Does He have an Endocrinological Cause to His ED

Dysfunctions, Addison's disease, adrenalectomy, Kleinfelter's syndrome, cytotoxic therapies, mumps orchitis, and age related testicular degeneration as well as antiandrogen medications (e.g., cyproterone acetate, spironolactone, etc.). Androgens have also been shown to influence the activity of NOS in the corporal smooth muscle, which suggests a more direct effect of low levels of testosterone on erectile function. Approximately 52 of circulating testosterone is bound to albumin, 46 is bound to sex hormone binding globulin (SHBG), and 2 is unbound. Determination of free testosterone is preferred as it represents the most accurate parameter to reflect a real testosterone deficiency in the respective target cells. However, because the methods used most widely for determination of these parameters (e.g., equilibrium dialysis method) have shown poor reliability and high cost, the standard for evaluating testosterone deficiency remains determination of total testosterone, the free androgen...

Does He have Drug Related Issues

Drugs, whether prescribed or taken recreationally, may be a source of the problem. Commonly prescribed medications are known to affect erectile function (see Table 7.2). In addition, street drugs such as cannabis, cocaine, amphetamines, and heroin have all been linked to decreased erectile function. Alcohol in excess is a well-recognized cause of ED.

Use of Questionnaires

The use of questionnaires, such as the International Inventory of Erectile Function (IIEF), are sometimes of relevance, and are a useful way of measuring improvement over time (18). The IIEF is a self-report tool that has been used in the clinical trials to assess the response of a subject to oral treatments for ED. It comprises 15 questions which cover five key areas of sexual function in men erectile function intercourse satisfaction orgasmic function sexual desire and overall satisfaction. The two key questions in relation to the studies on ED are question 3 which asks about the ability to achieve an erection sufficient for penetration When you attempted intercourse, how often were you able to penetrate (enter) your partner and question 4 which asks about the ability to maintain the erection long enough for satisfactory intercourse During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner Other questionnaires have...

Materials and Methods

This study was an open-label, historically controlled, single center phase IIa study in which men diagnosed with HG PIN were treated with 60 mg day oftoremifene for 120 days. The study primary objectives were to determine whether toremifene was able to reduce HG PIN in men with HG PIN, to evaluate its effect on other intermediate endpoints including serum total PSA and free PSA, as well as its safety and impact on male hormonal status. The effects of toremifene on quality of life issues, i.e., changes in libido, erectile function, and hot flashes were also assessed. Once informed consent was obtained, subjects were referred to the study if any prostate biopsy within the last 6 mo had HG PIN (at least 6 prostate cores were needed to be included in the study). The prostate pathology was re-evaluated to confirm HG PIN. Subjects who had HG PIN and fulfilled all of the eligibility requirements were enrolled in the study. At study day 120, subjects underwent transrectal...

Definition Of Female Orgasmic Disorder

Most studies examining orgasmic dysfunction in women refer to orgasm problems as either primary orgasmic dysfunction or secondary orgasmic dysfunction. In general, the term primary orgasmic dysfunction is used to describe women who report never having experienced orgasm under any circumstances, including masturbation. According to the DSM-IV-TR, this would refer to those women who meet criteria for lifelong and generalized anorgasmia. Secondary orgasmic dysfunction relates to women who meet criteria for situational and or acquired lack of orgasm. By definition, this encompasses a heterogeneous group of women with orgasm difficulties. It could, for example, include women who were once orgasmic but are now so only infrequently, women who are able to obtain orgasm only in certain contexts, with certain types of sexual activity, or with certain partners. Regarding women who can obtain orgasm during intercourse with manual stimulation but not intercourse alone, the clinical consensus is...

Open Simple Prostatectomy

This operation is reserved for BPH where the prostate weighs over 50-75 g. It is also appropriate where there is concomitant benign bladder disease requiring treatment such as a symptomatic diverticulum or a large stone. Potential risks are urinary incontinence, erectile dysfunction, retrograde ejaculation and urinary tract infection. The advantages over TURP are complete removal of the gland (therefore no recurrence) and no risk of dilutional hyponatraemia. However, there is an increased risk of intraoperative haemorrhage and a longer hospital stay. Previous prostatectomy, prior pelvic surgery and prostate cancer are contraindications to the operation.

Radical Prostatectomy

Surgery should be deferred for at least six weeks following needle biopsy and twelve weeks following TURP to allow any inflammatory adhesions or haematoma to resolve. In retropubic prostatectomy, a midline extraperitoneal lower abdominal incision is made from pubis to umbilicus and, after appropriate dissection, a bilateral pelvic lymphadenectomy is performed. This is a staging rather than a curative procedure and, in some centres, the surgeon may ask for a frozen section lymph node analysis, halting the operation should tumour be detected in the node. Prostatectomy proceeds with dissection of the periprostatic fascia, division of the pubo-prostatic ligaments, dorsal vein complex, urethra and bladder neck and excision of the seminal vesicles. Newer nerve-sparing surgical techniques are possible, with the aim of maintaining erectile function postoperatively. These involve preserving the neurovascular bundles, which run between two layers of periprostatic fascia (prostatic and levator)....

Longterm Effects Of Cancer Diagnosis And Treatment On Survivors Family Members

The literature on the effect of cancer diagnosis and treatment on family members is sparse.74 Of studies in this area, most have focused on the impact of cancer soon after diagnosis, during recurrence, or at the terminal phase of the disease.75-77 One study shows that partners of men with prostate cancer, generally from small convenience samples, report more distress than their sick partners, but also believe that their partners are more distressed. The only reviewed study of long-term prostate cancer survivors found that couples' health-related QOL was associated with marital satisfaction.61 Distress was inversely related to levels of family support. The men's focus of concern, on their sexual functioning (i.e., impotence), was not shared to an equal degree by their non-sick partners.78,79 The most relevant study included

Drug Delivery System Complications

To increase gastrointestinal motility, stimulant laxatives, such as bisacodyl, are beneficial. Increased retention time allows for greater fluid extraction and stool softeners, such as docusate, or bulk-forming laxatives, such as psyllium, counteract these effects. Sexual dysfunction is another adverse effect that should be monitored in both men and women. Levels of thyroid functioning, cortisol, and testosterone or estrogen should be obtained and followed if loss of libido, difficulty achieving or maintaining an erection, or amenorrhea develops. Some patients may require hormone replacement and the use of steroids.

Reproductive Biology

Lecithotrophic (nourished by stored yolk), but are later plank-totrophic, spending 1-4 weeks in the water column. Settling is triggered by the presence of a filamentous substrate (bry-ozoans, hydroids, algae). Growth rate in culture may be as much as 3 in (80 mm) per year. Life span may be as long as 24 years. Hybridizes with the Mediterranean Mytilus galloprovin-cialis in northern Europe.

Postmenopausal Dyspareunia

As women approach middle-age and menopause, physiological aging, psychosocial factors, and declining levels of endogenously produced sex hormones caused by ovarian senescence can exert significant effects on their sexual response cycle. As such, comprehensive enquiry of dyspareunic pain characteristics and history, climacteric symptoms, as well as changes in sexual functioning, urogenital anatomy, marital partner relations that have occurred are essential in the assessment of post-menopausal dyspareunia. The many anatomical changes, within but not limited to the urogenital region, experienced by aging women (e.g., reduced vaginal and or clitoral size, loss of fat and subcutaneous tissue from the mons pubis, arteriosclerosis) can result in decreased sexual arousal, vaginal dryness, and dyspareunia (23). Dyspareunia may also result from iatrogenic efforts, including pelvic or cervical surgery and radiotherapy, and pharmacotherapy (24). Moreover, it is considered a secondary symptom of...

Integrating Diagnostic Levels

In addition, even if the character or personality structure is not fully intact, the specific nature of the characterological context that is impaired by a psychotic or organic process can be specified. If an organic impairment is found, it is useful to clarify whether it is mild or profound, acute or chronic. The characterological context in which the organic impairment occurs is essential to report, as is the presence of any neurotic symptoms that have appeared. This kind of specificity can have a significant bearing on prognosis and intervention. For example, if a phobia or sexual impotence is linked to a symptom level of functioning in an organically impaired patient, quite different implications would be drawn than if these phenomena appeared to derive from the organicity itself.

Bladder Bowel and Sexual Disturbances

Sexual symptoms are also common among MS patients. Men most often experience erectile dysfunction, but may also suffer from problems with ejaculation (135,144). These symptoms typically accompany abnormal micturition. Women most typically experience difficulty in achieving orgasm, but may also complain of problems with lubrication (145). Both men and women may also complain of diminished libido. In contrast, a recent case of episodic hyperlibidinism has been reported (146).

Other Special Situations

The second problem with glaucoma medications in younger patients is a greater frequency of, or sensitivity to, psychological and sexual side effects. These can include depression, anxiety, confusion, sleep disturbances, drowsiness, weakness, fatigue, memory loss, disorientation, emotional lability, loss of libido, and impotence. Central nervous system side effects of CAIs have been primarily associated with their systemic use and can be described as a complex consisting of general malaise, fatigue, weight loss, depression, anorexia, and loss of libido. Once again, careful instruction on nasolacrimal occlusion can result in reduced dosages of medications and decreased systemic absorption. This is especially important when topical medications are prescribed for pregnant or lactating women.

The Interactional View

The interactional view assumes that vaginistic complaints have a function in maintaining the balance between partners, or in the emotional functioning of the woman herself. In this sense, the complaint can form a solution There are very few authors who explain the phenomenon of vaginismus fully on the basis of this view. However, much of the literature mentions the behavior and the personality structure of the male partner. He comes forward as a low self-confidence, anxious, passive, dependent person who is afraid of failure and for whom sex is a loaded subject (27,38,39). The partners of vaginistic women are believed to often suffer from sexual problems themselves, such as impotence and premature ejaculation (29,35,39,40). Despite these problems, the couple usually look very harmonic on the outside. They give the impression of being very well suited (18,37). In a recent study, rates of parital discord were equal to the general population (3). It speaks for itself that within the...

Male Reproductive Effects

Mammalian male reproductive function can be affected through a direct effect on the testis, resulting in decreased or altered sperm production, through impairment of the accessory sex gland secretions, and or indirectly through the neuroendocrine system, causing hormonal imbalance. Adverse effects on male fertility include altered genetic material of sperm, contributing to altered spermatogenesis, pregnancy loss, or genetic disease in offspring. Common endpoints for assessment of male reproductive function include size of testis, semen quality, secretory function of the prostate and seminal vesicles, reproductive endocrine function, impotence or reduced libido, and fertility. When evaluating reproductive effects of a certain metal on human males, one must take into account possible influences of concomitant exposures to other toxic and essential metals these may act addi-tively, synergistically, or antagonistically. Moreover, the influence of age and lifestyle factors particularly...

The effect of different attachment patterns on the counsellor

Individuals with a dismissive style of dealing with life will minimise or ignore significant events and emotions. They may appear cold and distant, shutting out the counsellor, or they may be reactive and defensively brittle and appear to fight every idea discussed. Such an interview can feel barren, with no meaningful exchange. The counsellor is then left feeling that it was not possible to get through to the patient, as if a door had been closed. The seeming rejection of help can trigger feelings of frustration, hopelessness and professional impotence in the counsellor. One way of understanding this is that the patient is unconsciously forcing his early experiences (which can not be spoken) onto the counsellor, who then feels the anger and the sensation of being ignored, just as the patient had in childhood. This explains how there can be a recreation and a re-enactment in the present of an earlier interaction, as if the patient were saying, 'I can't tell you how things have been...

Side Effects Of Hormonal Therapy Similarities And Differences

Hormonal therapy for prostate cancer eventually produces decreases in libido and potency in virtually all patients regardless of the modality used.34,124 Additional side effects include lethargy, depression, anorexia, breast swelling with or without tenderness, hot flashes, anemia, and osteoporosis with potential for pathological fracture.14,125-130 Most side effects, including impotence and infertility, are slowly reversible with cessation of therapy. However, reduced bone mineral density often does not reverse after prolonged hormonal suppression. There is a consensus that irreversible changes occur more often after suppression of longer than 18-24 months.

Cardiovascular Disease in the Medico Legal Era An Introduction

Other types of litigation such as personal injury (e.g. automobile accident), or product liability (e.g. adverse drug affects, or claims that cars or tires were defective leading to an accident) often also require knowledge of cardiovascular disease. For instance, an automobile accident may apparently lead to the death of the driver as a result of trauma however, if the driver actually had an arrhythmic cardiac arrest prior to the accident (e.g. coronary artery ischemia or cardiomyopathy) and then crashed, this would mitigate if not eliminate the liability of insurers or the automobile manufacturer. In another instance, a so-called drug adverse effect may represent the natural consequences of the underlying disease for which the drug was prescribed, rather than a complication of the drug. An example of this phenomenon is sudden cardiac death during sexual activity of an individual with diabetic cardiomyopathy, who is taking Viagra for erectile dysfunction secondary to diabetic...

Diabetic Neuropathy

Animal models have been used extensively in research in the field of diabetes. Studies of rats made diabetic by administration of streptozotocin (STZ) have provided a wealth of evidence for diabetes-induced changes in autonomic nerves throughout the vasculature and visceral organs. In erectile tissue a similar loss of VIP and neurogenic relaxation has been demonstrated in human male diabetics with impotence and in experimental diabetes (264,297). In the rat proximal colon, an initial increase in NA and VIP is followed by a loss of NA and VIP at a later stage in STZ-induced diabetes (298). Similarly, in human skin from patients with diabetes of different duration, an early increase of VIP in autonomic nerve fibers precedes a later depletion (299). In the rat ileum 8 weeks after induction of diabetes, no VIP release can be detected on electrical field stimulation of myen-teric nerves despite the fact that VIP levels in diabetic tissue are more than twice that of controls (300). Thus, an...

Gross Description

Mycotic Cerebral Aneurysms Aorta

There are complications of aneurysm in addition to fatal rupture. Aneurysms frequently thrombose and the thrombus may fragment and embolize into the distal circulation of the lower extremities leading to acute ischemia. If the aneurysm is fusiform, and the thrombus continues to aggregate, there may be partial or complete obstruction of the lower abdominal aorta. This can cause lower extremity ischemia, intermittent claudication, or gangrene. When there is lower extremity ischemia involving the thigh and below, in association with impotence, the Leriche syndrome (obstruction of the distal aorta) must be considered. In the absence of significant thrombosis, the ulcerative, atheromatous surface of an aneurysm may be the source of cholesterol and plaque emboli. These usually affect smaller vessels in the distal extremities, but may lead to toe and foot gangrene, or the so-called 'trash foot'.

Shrinking Of The World

Physical movement also is restricted as the environment shrinks. Contrary to the dictates of human health requirements, older persons become more sedentary and engage in less exercise. Part of this reduced physical activity results from reduced participation in the environment because of physical or environmental barriers. Environmental barriers can include the structure of the home, its layout, and the presence of stairs. Storage spaces and appliances may be difficult to access or use, thus cutting back on the person's activity. Shrinkage of the environment due to the nature of the environment itself means that there is a lack of fit between the person and the environment. Such a lack of consonance means that the person is less stimulated by the environment and finds it to be more of a frustration. Increasingly, drawing away from the environment and curtailing their ability to manipulate the environment to their own best advantage results in persons losing control of their lives and,...

The Role Of Glutamate Receptor Subtypes In Opiate Withdrawal

The dose of LY293558 that was able to suppress most of the withdrawal-induced activation of LC neurons in anesthetized animals only suppressed the physical signs of opiate withdrawal by about 50 . Although anesthesia could account for some of this difference, another possibility is the participation of AMPA receptors in other brain areas in the genesis of morphine-withdrawal symptoms. Other potential brain sites include those with the highest density of AMPA receptors (i.e., hippocampus, layers I-III of the cortex, dorsal lateral septum, striatum, and the molecular layer of cerebellum (88,89) . Another area may be the central nucleus of the amygdala. The central nucleus of the amygdala has been hypothesized to play a role in aversive states (90) and morphine withdrawal (30). Indeed, local infusion of CNQX into the central nucleus of the amygdala also significantly attenuated many morphine-withdrawal symptoms, including irritability, ptosis, lacrimation, penile erections, wet-dog...

Vacuum constriction devices and constriction rings for men with

This device is useful as a treatment for men with ED who are unable to use oral therapies. It also avoids the use of ICI therapy, which some men find objectionable. It is fairly simple to use although it is somewhat obtrusive. One drawback of use with the constriction ring is that the erection pivots about the ring making it less natural. Its use has been studied in men with diabetes, SCI, explanted penile prosthesis, and requiring dialysis for various reasons. These studies have all reported high success rates of VCD use with approximately three-quarters of men. Partners too find the device an acceptable compromise. For a few individuals who are able to achieve an erection but not maintain it, they can use the constriction ring without the vacuum tube. This will enhance the firmness and size of the penis. In all cases where a constriction ring is used, a time limit of 30 min must be strongly emphasized.

Introduction The False Dichotomy

The 20th century marked huge strides in our knowledge of sexual disorders and their treatments, however, advancements were followed by periods of reductio-nistic thinking. Etiology was conceptualized dichotomously, first as psychogenic and then organic. Early in the 20th century, Freud highlighted deep-seated anxiety and internal conflict as the root of sexual problems experienced by both men and women. By mid-century, Masters and Johnson (1) and then Kaplan (2) designated performance anxiety as the primary culprit, while providing a nod to organic factors. Together, they catalyzed the emergence of sex therapy, which relied on cognitive and behavioral prescriptions to improve patient functioning. For the next two decades, a psychological sensibility dominated discussions of the causes and cures of sexual dysfunctions (SDs). However, during the late 1980s, there was a progressive shift toward surgical and predominantly pharmaceutical treatments for male erectile dysfunction (ED). By...

Pharmacological Treatment of the Paraphilias

Relapse is common upon cessation of the medication. Treatment with antiandrogens may result in erectile dysfunction, although many individuals maintain adequate sexual functioning. As with the SSRIs, the goal of antiandro-gen medications is to augment the individual's ability to achieve behavioral control (10).

Does He have a Vascular Basis to His ED

Diabetes, smoking, hypertension, hyperlipidaemia, and so on, are all underlying causative factors for vascular impairment. Since the erectile response is a hemo-dynamic event, it is hardly surprising that damage to the vessels will result in partial or complete loss of the ability to not only achieve but also maintain an erection long enough for it to be useful to its owner and his partner. A standard vascular examination can reveal important clues that may not only indicate a vascular reason for loss of the ability to have an erection, but may also point to major undetected pathology.

The Effects Of Drugs On Womens Orgasmic Ability

Nitric oxide stimulates guanylate cyclase release, which triggers the conversion of guanosine triphosphate to cGMP. cGMP activity relaxes the smooth muscles of the penile tissue allowing vasocongestion and erection. Sildenafil (Viagra ) potentiates the activity of cGMP by inhibiting phosphodiesterase type 5, the endogenous substance responsible for cGMP deactivation. This increases and prolongs cGMP activity, which increases and prolongs vasoconges-tion, and enables erection. There have been mixed reports of the effects of sildenafil on women's orgasmic function. Caruso et al. (43) found improved sexual arousal and orgasm with sildenafil. However, only a minority of women responded positively in several other studies (44,45). A number of case studies have reported a reversal of antidepressant-induced anorgasmia with sildenafil (46-49) but, to date, no placebo-controlled studies have been conducted.

Significance to humans

Atelidae are represented in the art and legends of the people they live nearby. Their large body size and social habits have probably always made them a source of prized meat. The large testes of Brachyteles were associated with sexual potency, and made into purses by hunters.

Triangular Test And Further Work

The triangular test has now been used in a wide variety of clinical studies concerned with many therapeutic areas. Examples include trials of corticosteroids for AIDS-induced pneumonia (41), of enoxaparin for prevention of deep vein thrombosis resulting from hip replacement surgery (42), of isradipine for the acute treatment of stroke (43), and of implanted defibrillators in coronary heart disease (44). In pediatric medicine, the triangular design has been used to study the use of surfactant to alleviate respiratory distress in infants (45) and in a trial concerning gastrointestinal reflux (46). An evaluation of the drug Viagra in the treatment of erectile dysfunction after spinal injury also used the method (47), and it has been implemented in animal studies of medical techniques (48). An interesting combination of the triangular test with the play-the-winner rule was applied in a study of spinal anesthesia during cesarean section (49). Within oncology, besides the renal and lung...

Ginseng And Aphrodisiac Activity

The reported occurrence of oestrone, oestradiol and oestriol in liposoluble fractions of ginseng extracts, based on TLC results, was not confirmed. Some workers likened tail erection produced in test animals to aphrodisiac agent effect. 0ther workers suggested that increased deoxyribonucleic acid (DNA), ribonucleic acid (RNA) and protein formation due to ginsenoside administration offered an explanation. The hormone-like phenomenon was also related to the superficial structural resemblance of steroid hormones and digitalis cardioactive glycosides to the ginsenosides, but closer investigation of the spatial conformations of such compounds clearly shows that the ginsenosides are quite different and would not interfere with the steroid hormone receptors and, under physiological conditions in human subjects, the ginsenosides do not interfere with the progesterone receptors. Thus, despite the many reports of the use of ginseng in the treatment of impotence and penile dysfunction, no simple...

Anatomy and Physiology

When Masters and Johnson (10) published their account of the physiology of the sexual response, they opposed Freud's theory of the transition of erogeneous zones in women. According to these famous sexologists, nerve endings in the vagina are extremely sparse. Therefore, during coital stimulation the clitoris is stimulated indirectly, possibly through the movement or friction of the labia. Hite's data supported this point of view. Almost all women who reached orgasm through stimulation from coitus alone had experienced orgasm through masturbation. Many women needed additional manual stimulation to orgasm during coitus, and an even larger number was unable to orgasm during coitus at all (12). There remain large gaps in our understanding of the central nervous control of female sexual function. Most of the animal work relates to receptive behavior in female rats and very little to the control of genital responses. According to McKenna (32), the autonomic and somatic innervation of the...

Is Absent or Impaired Genital Responsiveness a Valid Diagnostic Criterion

Organic etiology may underlie sexual disorders in women with a medical condition. There are only a handful of studies that have employed VPA measurements in women with a medical condition. The only psychophysiological study to date that found a significant effect of sildenafil on VPA in women with sexual arousal disorder was done in women with SCI (46), suggesting that in this group there was an impaired genital response that can be improved with sildena-fil. Another study compared genital response during visual sexual stimulation of women with diabetes mellitus and healthy women, showing that VPA was significantly lower in the first group (47). A very recent study measured VPA in medically healthy women, in women who had undergone a simple hysterectomy, and in women with a history of radical hysterectomy for cervical cancer (48). Only in the last group was VPA during visual sexual stimuli impaired, whereas the women with simple hysterectomies reported to experience more sexual...

Anatomy And Physiology Of Erection

The nervous system of the penis is in three parts. The parasympathetic nerves are branches of spinal nerves S2-S4, which give rise to the so-called pelvic splanchnic nerves that pass around the posterior aspect of the prostate gland, forming the prostatic plexus. Passing forward, they form the cavernous nerves, which branch into the body of the penis. It is this parasympathetic system that is able to elicit an erection. The sympathetic nerves are branches of the sympathetic chain at levels T11-L2. These pass through the inferior mesenteric plexus, the superior hypogastric plexus, and the pelvic plexus and branch off to the organs involved in ejaculation. Overactivity of the sympathetic system (e.g., in the stressed individual) maintains a persistent state of detumes-cence, although not all sympathetic activity is inhibitory. The sensory nerves of the penis and scrotum are all branches of the pudendal nerve, which can be traced back to branches of S2-S4. With these systems in mind, it...

Models For Treating Sexual Dysfunction Sex Therapy

Sex therapy rapidly morphed into weekly sessions provided within a solo MHP's office based practice. Treatment continued to emphasize sensate focus exercises and the reduction of performance anxiety. By the 1980s, sex therapy reflected a cognitive-behavioral theoretical bias, while typically utilizing Masters and Johnson variations, such as Kaplan's, four phase model of human sexual response desire, excitement, orgasm, and resolution (1,4,5). The models were not necessarily linear and causes could become effects. For instance, an ED might cause diminished desire. However, generally speaking, sex therapy was and is, the diagnosis and treatment of disruptions in any of these four phases and or the sexual pain and muscular disorders. These dysfunctions occurred independent of each other, yet they frequently clustered. Sex therapy was an efficacious treatment for primary anorgasmia in women, some erectile failure in men, and was probably efficacious for secondary anorgasmia, , vaginismus...

Ginseng And The Ageing Process

As people's lives become longer, particularly in the more civilised societies which have adequate medical and preventative services, ageing presents many problems. As we age we become less physically fit, we show obvious changes such as whitening or loss of hair, wrinkled skin which recovers more slowly from the pinch test, weakened hearing and vision, general slowing down of physical activities and we become more liable to suffer from various illnesses. Less obvious is the deterioration of the body organs prompting glandular disorders, reduction of hormone output leading to sexual impotency, gradual mental deterioration and breakdown of the immune system. Any life style, drug or medicine that can delay or slow this inevitable decline and improve the quality of life is therefore important. The ancient Chinese were convinced that ginseng was the tonic that fulfilled this role. After all, it is an adaptogen coping with stress, it is a metabolism regulator for proteins, carbohydrates and...

Biological Theories of the Paraphilias

Early biological hypotheses regarding the paraphilias included Epstein's theory of phylogenetic preparedness of fetishism (120). He observed that a rubber boot, but not leather, evoked penile erection and ejaculation in a chimpanzee, suggesting that the fetishistic attraction to an unusal object is not limited to humans. Epstein speculated that the wet surface of the boot bore a relationship to the female chimpanzee's genitalia during rear mount sexual behavior.

Medical Letter In Reference To Erical Dysfunction

Human Sexual Response. Boston Little, Brown & Co, 1966. 15. Levin RJ. Sexual desire and the deconstruction and reconstruction of the human female sexual response model of Masters & Johnson. In Everaerd W, Laan E, Both S, eds. Sexual Appetite, Desire and Motivation Energetics of the Sexual System. Amsterdam Royal Netherlands Academy of Arts and Sciences, 2001 63-93. 43. Caruso S, Intelisano G, Lupo L, Agnello C. Premenopausal women affected by sexual arousal disorder treated with sildenafil a double-blind, cross-over, placebo-controlled study. Int J Obstet Gynaecol 2001 108 623-628. 44. Kaplan SA, Reis RB, Kohn IJ, Ikeguchi EF, Laor E, Te AE, Martins AC. Safety and efficacy of sildenafil in postmenopausal women with sexual dysfunction. Urology 1999 53 481-486. 45. Berman JR, Berman LA, Lin H, Flaherty E, Lahey N, Goldstein I, Cantey-Kiser J. Effect of sildenafil on subjective and physiologic parameters of the female sexual response in women with sexual...

Richard Balon

To increase libido in women with hypoactive sexual desire disorder, and the combined use of anti-androgens and serotonergic antidepressants to treat paraphilias. The wide spread usage of effective biological therapies for sexual disorders has contributed to the increasing emphasis on biological models concerning etiology, often to the neglect of psychological factors. In the 1960s, it was commonly assumed that most sexual problems were psychogenic in etiology (1). However, the advent of effective biological therapies has shifted the focus to organic causes of erectile dysfunction (2). These changes in assumed etiology have had profound effects on treatment and conceptualization of the origins of sexual disorders. Many patients who used to be treated by behavioral therapy are now being treated pharmacologically. The rapid development of biological models of therapy has brought valuable help to many individuals who previously had minimal treatment choices. However, a number of factors...


The diagnosis is usually readily made on the basis of the patient's history and the presence of the DSM-IV-TR diagnostic criteria. Male orgasmic disorder may be part of a complex of sexual malfunctioning that may include erectile dysfunction, abnormalities in ejaculation (such as premature ejaculation or retrograde ejaculation), and hypoactive sexual desire disorder. In order to differentiate between the various potential disorders, the physician may request laboratory tests and or may perform further diagnostic evaluations. Blood plasma levels of testosterone are of help in diagnosing hypogonadism. A number of tests of thyroid, pituitary and adrenal function are available to diagnose hormonal abnormalities of those glands. A test for nocturnal penile erections may be performed to diagnose erectile dysfunction.


Impotence and Infertility. In Atlas of Clinical Urology. Volume 1. New York Current Medicine, 1999. Masters, William and Virginia Johnson. Masters and Johnson on Sex and Human Loving. New York Little, Brown, 1986. Steidle, Christopher P., MD. The Impotence Source Book. Los Angeles Howell House, 1998.

Diabetes Mellitus

Evidence of autonomic neuropathy impotence, hypertension, neurogenic bladder, lack of sweating, orthostatic hypotension, resting tachycardia, absent variation in heart rate with deep breathing, painless myocardial ischemia, gastroparesis (vomiting, diarrhea, abdominal distention), asymptomatic hypoglycemia, prolonged QT interval, and sudden death syndrome.

Sexual Dysfunction

Though PD patients rarely complain of sexual difficulties, if specifically asked, dysfunction in this area is very common. Bronner et al. (65) performed a comprehensive assessment of sexuality in 75 patients (32 women, 43 men) with PD who did not complain of problems in this area. Using specific sexual function scales, they asked patients to rate their sexuality currently and retrospectively before the onset of their PD. They found that in men, 68 had erectile dysfunction, 65 were dissatisfied with their sexual life, and 40 had difficulty reaching orgasm. In women, the major problems were difficulty getting aroused (88 ), difficulty reaching orgasm (75 ), and decreased sexual desire (47 ). Comparing scores before PD onset to the present, most patients reported a deterioration in sexual functioning with the progression of PD. Using stepwise regression, the authors found that in men, associated disease, medications, and severity of PD predicted sexual dysfunction, whereas in women,...

When to Refer

A 32-year-old Italian man was suffering from primary ED. Roberto had two hypospadias operations at ages 3 and 6. He reported at 8 years old, circumcision removed 'excess skin'. He remembered friends teasing, about his urinating from the underside. He had primary ED and 2 years ago (as a visiting student), he consulted a US urologist who prescribed sildenafil. The urologist reportedly told Roberto that he would never function normally, because of his congenital hypospadius. Roberto left that consultation devastated, fearing he was sexually handicapped for life. No great surprise, the sildenafil did not work when he used it with masturbation. He was afraid to date women. The same urologist observed on follow-up that Roberto seemed depressed and was not using the sildenafil, or dating. He referred Roberto to the author. Accurate information incorporated within a cognitive-behavioral sex therapy, improved Roberto's self-esteem, reduced his fear of rejection, decreased performance anxiety,...

Traditional Uses

Cinnamon has been traditionally used by ancient healers from many backgrounds for stomach cramps, flatulence, nausea, vomiting, diarrhoea, infant colic, common infections and also female reproductive problems such as dysmenorrhoea, menor-rhagia, lactation, and pain in childbirth. It has also been used as an ingredient in topical preparations for pain and inflammation. Cinnamon is often used in combination with other herbs and spices for most of these indications. In TCM it is considered to warm the kidneys and fortify yang, so is used for impotence among other indications.

Intimacy Difficulty

Schiavi et al. compared 17 physically healthy men with HSDD to 17 age-matched non-dysfunctional volunteers (34). All were 25-55 years old. The HSDD men were described as having a generalized and persistent lack of sexual desire. Men with HSDD who did and did not have accompanying erectile problems, were also compared. The authors found that men with HSDD had significantly lower plasma total T levels (but not FT, PRL, LH, or estradiol) measured hourly throughout the night, when compared with controls. As well, they also reported that the men with secondary erectile problems had a different nocturnal penile tumescence (NPT) pattern than those whose erections were not problematic. The authors concluded that there was a relation between the decrease in T and the diminution in sexual drive and speculated that NPT findings may reflect a central biological abnormality. In support of the latter idea, they cited another study in which they found that men with HSDD had a higher prevalence of...

Pelvic Surgery

Bladder and bowel dysfunction can greatly affect patients' quality of life. The mechanism of injury to these organs from surgery in the pelvis is obvious, however, operations to remove tumors involving the brain and spinal cord can also impact urinary and bowel control. Urinary continence can be affected by any procedure in the pelvis, but prostatectomy and hysterectomy are the most common culprits. Pelvic muscle exercises and medications such as oxybutanin or tolterodine can be helpful, but some patients need further surgical intervention such as the implantation of prosthetic urethral sphincters. Damage to the autonomic nerves, such as during a prostatectomy, can also cause erectile dysfunction which may require pharmacologic or surgical management.

Urogenital Diaphragm

Pelvic Outlet Diaphragm

In males, the bulbospongiosus (bulbo-sponje-o'sus) muscles are united surrounding the base of the penis. They assist in emptying the urethra. In females, these muscles are separated medially by the vagina and constrict the vaginal opening. They can also retard the flow of blood in veins, which helps maintain an erection in the penis of the male and in the clitoris of the female.


O'Donohue et al. surveyed the sex-related literature on the psychological treatment of male sexual dysfunctions (55). They explicitly excluded studies that relied only on medical intervention. In a clear statement concerning the treatment of sexual desire problems, the authors concluded that no controlled treatment-outcome studies were found for the treatment of sexual aversion disorder and hypoactive sexual desire disorder in men. Several studies in the O'Donohue review had a mixture of diagnoses and some included men with HSDD. In one such group the results were not reported separately for men and women. Another looked at 40 couples in which the men experienced erectile dysfunction and or loss of sexual interest, and compared the effectiveness of three treatments weekly couple counseling, monthly couple counseling, and T (56). Subjects were divided into two groups, with high or low levels of sexual interest. Each group was randomly allocated to (i) testosterone or placebo therapy...


O'Carroll's survey uncovered only one study describing the therapeutic use of a hormone alone. This investigation involved a double-blind crossover comparison of T and placebo in a group of men with normal circulating T levels (59). Ten men complained principally of loss of sexual interest and 10 men complained of erectile failure. The authors found a significant increase in sexual interest produced by T in the first group but qualified this by saying that in only 3 10 of the subjects was it considered to be an adequate form of treatment, and in the others, the changes were either small or did not generalize to the sexual relationship. O'Carroll concluded his review by saying that T may have a modest role to play in the treatment of some men who present with low sexual interest but he also cautioned others in the interpretation of the data to remember that this study involved a group of only 10 men (50).

Chest Radiation

Pelvic radiation can damage the autonomic nerves responsible for erection. As a result, erectile dysfunction is common after radiation for prostate, rectal, and anal cancers.43 Improvement often occurs over the first year after treatment but then stabilizes. As important as evaluating the degree of erectile dysfunction is evaluating how much this bothers the patient some patients are untroubled by complete loss of function while others are extremely distressed by even relatively subtle changes in sexual function such as retrograde ejaculation. Erectile dysfunction can be managed with oral agents like sildenafil, tadalafil, and vardenafil, but sometimes requires external suction devices, penile injection therapy, or implantation ofpenile prostheses. Referral to a urologist specializing in male sexual health can be very helpful.

Case Example Joyce

She experienced desire arousal and orgasm when they were sexual. She was frustrated when their sex became aversive to her but decided to tough it out, assuming, she supposes in retrospect, that her sexual response would improve given enough time and love. Joyce also hoped that the state of being married would also help her response since she had some guilt over nonmarital sex and expected to feel a postmarital reduction in the anxiety she associated with sexual behavior. She married Bill after dating for 2 years.


The term male menopause is sometimes applied to the structural and functional changes that occur with age-related reductions in the production of testosterone during later life, but there is no scientific justification for this term (Kolodny, Masters, & Johnson, 1979). Changes in the structure and functioning of the sex organs are also typical of older males, but the notion that all men eventually experience a male menopause akin to that in women is inaccurate. Among the changes that occur in older men are a slight shrinkage of the testes, the production of fewer sperm, and an increase in the size of the prostate gland. Older men require longer to achieve an erection, have a softer erection, and lose it more quickly after ejaculation. They experience fewer genital spasms, the force and volume of the ejaculate are less,

Sex Therapy

The rapid but effective treatment of sexual inadequacy was pioneered by Masters and Johnson (1970). Many of the patients seen by them and their students were older adults who had stopped having sexual intercourse because of a misunderstanding about the normal biological changes that accompany aging. An illustrative case is described in Report 6-1. After 1 week of therapy, this couple had regained confidence and sexual functioning. The therapy helped them to realize that the increased time to attain an erection and the reduction in seminal fluid by the man, in addition to the decreased vaginal lubrication by the woman, were normal problems of aging with which they could deal. The couple became convinced that, despite these problems, they could continue to enjoy sexual intercourse. Additional procedures for treating sexual dysfunctions are described by Masters et al. (1994). In treating impotence and other problems in older adults, sex therapists may advocate a variety of techniques...


Sildenafil is the first pharmacological treatment that has been investigated on a reasonable scale in controlled studies with female subjects. In the very first laboratory study, 12 healthy premenopausal women without sexual dysfunction were randomized to receive a single oral 50 mg dose of sildenafil or matching placebo in the first session and alternate medication in a second session (107). Although sildenafil was found effective in enhancing vaginal engorgement (VPA) during erotic stimulus conditions, these changes were not associated with an effect on subjective sexual arousal. The first large controlled at home study in 557 estrogenized and 204 estrogen-deficient pre- and postmenopausal women with sexual problems that included, but were not limited to, sexual arousal disorders, found no improvement with 10-100 mg of sildenafil on subjective sexual arousal and subjective perception of genital arousal, as assessed by several different measures (108). Women identified as having...

Ian Mac Innes

Pharmacotherapy for Men with ED 166 Psychological Therapies for Men with ED 181 Psychosexual and Relationship Therapies for Men with ED 182 Other Unlicensed Treatment Therapies for Men with ED 183 Surgical Interventions for Men with ED 183 Special Situations Requiring Interventions for Men with ED 184

Sexual dysfunctions

These conditions, in which some aspect of sexual performance fails to satisfy the subject or partner, may be categorized in several ways but perhaps most clearly by relating them to the five stages in the model of normal sexual response described by Masters and Johnson. Erectile dysfunction terms 'frigidity' and 'impotence' are imprecise and judgemental, and should be


Clarke and Deane (47) compared cabergoline to bromocriptine in a meta-analysis of five randomized, double-blind, parallel-group studies in 1071 subjects. Cabergoline produced benefits similar to bromocriptine in off-time reduction, motor impairment and disability ratings, and levodopa dose reduction over the first three months of therapy. Dyskinesia and confusion were increased with cabergoline, but otherwise the frequency of adverse events and withdrawals from treatment were similar with the two agonists. Side effects of cabergoline are similar to other dopamine agonists, but also include severe restrictive mitral regurgitation and male sexual dysfunction (48).


Counts below the reference value, prior to treatment.21 With a hockey stick port, the remaining testicle receives 3 to 5 of the tumor dose. Added shielding against the direct beam and a testicular clamshell to reduce scatter from the thighs can reduce the contralateral testicular dose to less than 1 . This 1 represents internal scatter and can be diminished only by distance or by decreasing the tumor dose. The use of only a para-aortic field supplies this distance. With the hockey stick port, reversible azoospermia is induced in all men whose contralateral testicle is exposed to 1 to 6 Gy, but this recovery takes 1 to 5 years, depending on the dose.22 The para-aortic field stopping at L5 allows less than 0.01 Gy to the contralateral testicle. In my opinion, loss of libido and sexual potency is underrated in men who have undergone post-orchiectomy irradiation.


Constitution and a weak ejaculatory system. Schapiro described two types of premature ejaculation, type B in which early ejaculation existed from the first intercourses and type A, which led to erectile dysfunction. Many years later, both types became distinguished as the primary (lifelong) and secondary (acquired) forms of premature ejaculation (20).


Premature ejaculation is often cited as being the most common male sexual dysfunction. The exact prevalence, however, is unknown as this appeared difficult to determine. Although it has been estimated that as many as 36 of all men in the general population experience premature ejaculation (24), other estimates have been lower. For example, Gebhard and Johnson (25), from a reanalysis of the Kinsey data, determined that 4 of the men interviewed reported ejaculating within 1 min of intromission. The large differences in prevalence numbers are mainly due to the use of various and often totally different definitions of premature ejaculation that have been used. Only by the general use of an empirically defined definition and identical tools to measure the ejaculation time, methodologically correct epidemiological studies can provide reliable prevalence data. Such studies have not been performed yet.

Saw palmetto

Historical note Saw palmetto was used traditionally as a treatment for urogenital irritations, impotence and male infertility, among other conditions, and was described by the American Eclectic physicians as the 'old man's friend'. Between 1 906 and 1 917 saw palmetto was listed in the US Pharmacopoeia and between 1 926 and 1 950 it was in the National Formulary as a treatment for urogenital ailments however, it fell out of favour for several decades as pharmaceutical medicines came to the forefront of mainstream medicine. Not so in Europe where, in the 1960s, French researchers began to chemically analyse the saw palmetto berry, and a breakthrough lipophilic preparation was eventually developed and subjected to countless clinical trials.

Diagnostic workup

A patient may be suspected of having HIVM if he has a spastic-atactic gait, hyper-reflexia with positive Babinski sign, disturbance of sphincter control, erectile dysfunction, and slight signs of sensory dysfunction in a glove and stocking distribution. The diagnosis of an independent HIVM should only be made when concomitant cognitive impairment is significantly less prominent than myelopathy. Electro-physiological tests, which show increased latencies of somatosensory evoked potentials (SEP) and motor evoked potentials on transcranial magnetic stimulation, are compatible with the diagnosis. CSF, microbiological and spinal imaging studies are inconspicuous or unspecific, and they have their importance in the exclusion of differential diagnoses, as listed in Table 4. Spinal imaging should include MRI of the cervical and, possibly, the thoracic cord.

Prostate Cancer

It is common practice to surgically remove many cancerous prostates, even though subsequent pathological examination of the excised tissues suggest that some surgeries could have been avoided 13,68 . Radical prostatectomy is a challenging procedure because of anatomical variability and the presence of adjacent vital structures, including the external urinary sphincter and neurovascular bundles. There is significant risk of serious morbidity in the form of urinary incontinence and impotence. The crux of the practice dilemma 13 is the need for improved noninvasive preoperative techniques that can more accurately measure tumor volume and extent, and thereby more clearly indicate the need for surgery. Several measures of the pathologic state of prostate cancer have been proposed to allow stratification of patients into either treat-

Sexual Functioning

Schover and colleagues were among the first to describe sexual functioning among survivors of non-seminomatous (n 121) and seminomatous (n 74) testicular cancer.41-43 Their findings indicated that impaired sexual functioning was common among survivors. Survivors commonly reported erectile problems, reduced orgasmic intensity, and reduced libido.43 In addition, patients with nonseminomatous testicular cancer had less sexual activity, reduced libido, more frequent erectile dysfunction, and reduced orgasmic intensity when compared to healthy controls.41 Rieker and colleagues19 reported similar findings. They found that ejaculation problems were among the most commonly reported impairments of sexual functioning 37 of survivors reported that not being able to ejaculate had been a problem more than 50 of the time in the previous 6 months. Inability to ejaculate was also highly correlated with fertility concerns and overall sexual dysfunction and overall sexual dysfunction was related to...

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