Evolution Of Current Treatment Approaches

In the 1960s, psychiatric treatment of sexual problems was predominantly psychoanalytic psychotherapy. In the mid- to late-1960s, behavioral therapists began publishing clinical series documenting the successful treatment of sexual problems by the use of classical conditioning techniques. Indeed, the start-stop technique for the treatment of rapid ejaculation was first described by Semans in 1956 (10). However, the major use of behavioral techniques to treat sexual problems began after the publication of "Human Sexual Inadequacy" by Masters and Johnson in 1970 (11). In the 1980s, case reports began appearing in the psychiatric literature about using monoamine oxidase inhibitors and low dose antipsychotic drugs to treat rapid ejaculation (12). However, the use of psychiatric drugs to treat rapid ejaculation became much more common after the introduction of the selective serotonin reuptake inhibitors.

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 area. The previously touted use of androgens in erectile dysfunction has been abandoned as it became clear that androgen administration does not improve erectile dysfunction in eugo-nadal men (15). Interestingly, testosterone replacement in men with age-related mild hypogonadism is not effective in reversing symptoms of hypogonadism (in contrast to the same situation in older men) (15).

The successful introduction of sildenafil contributed to the search for pharmacological treatments for female sexual disorders. Initially, many companies did clinical trials in women with substances that had proven successful in treating erection problems. In general, these trials were unsuccessful. The one exception is a clitoral vacuum erection device, which has FDA approval (16,17). Another approach is the study of androgens to stimulate desire in women. Off-label use of androgen preparations increased significantly after the work by Gelfand and Sherwin (18,19) demonstrated that supraphysiological levels of testosterone increased libido in postmenopausal women (20). The use of androgen preparations to treat desire problems in women is currently undergoing clinical trials. As Rosen (21) pointed out, many large pharmaceutical trials of female sexual dysfunction are unfortunately hindered by various methodological problems, such as the lack of use of physiological outcome measures and the lack of consensus classification system for female sexual dysfunction in determining inclusion and exclusion criteria. There is also no precise and stable definition of normal sexuality available. Definition is also of dubious clinical usefulness.

The lack of success in search for efficacious pharmaceuticals for treatment of sexual dysfunction in women led to the examination and use of various botanical or herbal, and other substances in these indications (22,23); for review see Ref. (24). As Rowland and Tai (24) caution us, the effects of herbals tend to be limited, relatively nonspecific, poorly studied, and associated with unpredictable or unknown side effects.

The recent focus on pharmacological and other biological treatments of sexual dysfunction unfortunately takes away attention and emphasis from psychological treatments. However, as Heiman (9) points out, psychological treatments are efficacious (though their demonstrated efficacy is frequently limited) and needed (for various reasons, such as optimization of psychological treatments, patient choice, low frequency of side effects, etc.). Heiman (9) also cautions that the prescription of a physiologic treatment that ignores the fact that human sexuality is infused with individual meaning may invite further interference with sexual functioning.

Dealing With Erectile Dysfunction

Dealing With Erectile Dysfunction

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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