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New insights into erectile dysfunction: a practical approach

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Abstract

Erectile dysfunction (ED) is the most common sexual problem in men, after premature ejaculation, affecting up to 30 million in the United States. In a society in which sexuality is widely promoted, ED impacts on feelings of self-worth and self-confidence and may impair the quality of life of affected men and their partners. Damage to personal relationships can ensue; and the anger, depression, and anxiety engendered spill over into all aspects of life. Patients are often embarrassed or reluctant to discuss the matter with their primary care practitioners. Unfortunately, many physicians fail to take the opportunity to promote open discussion of sexual dysfunction. They too, may avoid the topic through personal embarrassment. Since the National Institutes of Health (NIH) Consensus Conference on Impotence in 1992, the inadequate level of public and professional understanding of ED has begun to be addressed. As a first step in breaking down the communication barriers between patients and practitioners, it is important that physicians have a thorough understanding of the wide variety of conditions associated with ED and how the different risk factors for ED may be readily identified. This review addresses the diagnosis of ED and identifies diagnostic tests that can be used by primary care physicians to determine the patients most at risk and the treatments most suited to meet the patients’ and their partners’ goal for therapy.

Section snippets

Anatomy of the penis and mechanisms involved in achieving and maintaining an erection

Penile erection is a hemodynamic event in which central (cerebral and spinal) and local factors (smooth muscle and endothelium) are integrated in a complex manner involving a delicate balance between vasoconstrictor and vasodilator stimuli 9, 10. An understanding of the anatomy of the penis and the mechanisms regulating erections will aid physicians in determining the causes of ED in individuals.

Risk factors

Patients’ reluctance to seek treatment for ED may be due to mistaken beliefs about its causes and potential for treatment, a feeling of embarrassment, or the perception that, compared with other medical problems, ED is a low-priority concern. Unfortunately, some of the same problems arise with many primary care physicians 4, 21, 22. This is regrettable since primary care practitioners regularly evaluate and treat men and can, therefore, initiate discussion of sexual dysfunction. Evaluation and

Diagnosis

The importance of obtaining a detailed sexual history by sensitive but comprehensive questioning cannot be overestimated because, in addition to providing almost all the needed information, it assures patients that physicians are dealing seriously with the problem. Indeed, selecting the most appropriate therapy, considering the risk factors for the condition and the desires of the couple, can often be achieved without the need to undertake extensive testing. In this context, a variety of

Treatment

Although this review is not primarily directed at therapy, recent events require a description of currently available therapies. For a more detailed appraisal of some of the classical therapies, the reader is referred to the American Urological Association Erectile Dysfunction Clinical Guidelines 66, 67. These guidelines are, of course, written with urologists in mind, but nevertheless may provide some information of value to the practitioner.

In deciding what treatment options to discuss with

Conclusion

Erectile dysfunction is a common, readily treatable condition. It causes serious personal and social consequences that have finally begun to receive the attention they deserve. In particular, the misconception was widespread that ED was an inevitable consequence of aging and that treatment was difficult and unpalatable. If primary care physicians remain uncomfortable about opening discussions of sexual function, the condition will remain underdiagnosed and undertreated. Clearly, improving the

References (84)

  • H.B. Moss et al.

    Sexual dysfunction associated with oral antihypertensive medicationsa critical survey of the literature

    Gen Hosp Psychiatry

    (1982)
  • D. Nghiem et al.

    Factors influencing male sexual impotence after renal transplantation

    Urology

    (1983)
  • A. Melman

    Iatrogenic causes of impotence

    Urol Clin North Am

    (1988)
  • D.M. Quinlan et al.

    Sexual function following radical prostatectomyinfluence of preservation of neurovascular bundles

    J Urol

    (1991)
  • A.R. Johnson et al.

    Is routine endocrine testing of impotent men necessary?

    J Urol

    (1992)
  • D.K. Montague et al.

    False diagnosis of venous leak impotence

    J Urol

    (1992)
  • E.S. Pescatori et al.

    A positive intracavernosus injection test implies normal veno-occlusive but not necessarily normal arterial functiona hemodynamic study

    J Urol

    (1994)
  • D.K. Montague et al.

    Clinical Guidelines Panel on Erectile Dysfunctionsummary report on the treatment of organic erectile dysfunction

    J Urol

    (1996)
  • A.A. Sidi et al.

    Patient acceptance of and satisfaction with vasoactive intracavernosus pharmacotherapy for impotence

    J Urol

    (1988)
  • P. Werthman et al.

    MUSE therapypreliminary clinical observations

    Urology

    (1997)
  • P. Kunelius et al.

    Is high-dose yohimbine hydrochloride effective in the treatment of mixed-type impotence? A prospective, randomized, controlled double-blind crossover study

    Urology

    (1997)
  • C. Teloken et al.

    Therapeutic effects of high dose yohimbine hydrochloride on organic erectile dysfunction

    J Urol

    (1998)
  • U. Kurt et al.

    The efficacy of antiserotonergic agents in the treatment of erectile dysfunction

    J Urol

    (1994)
  • I.G. Lawrence et al.

    Correcting impotence in the male dialysis patientexperience with testosterone replacement and vacuum tumescence therapy

    Am J Kidney Dis

    (1998)
  • C.F. Donatucci et al.

    Erectile dysfunction in men under 40etiology and treatment choice

    Int J Impotence Res

    (1993)
  • R.T. Segraves et al.

    Characteristics of erectile dysfunction as a function of medical care system entry point

    Psychosom Med

    (1981)
  • M.F. Slag et al.

    Impotence in medical clinic outpatients

    JAMA

    (1983)
  • Impotence

    JAMA

    (1993)
  • W.L. Furlow

    Prevalence of impotence in the United States

    Med Aspects Hum Sex

    (1985)
  • M. Jønler et al.

    The effect of age, ethnicity and geographical location on impotence and quality of life

    Br J Urol

    (1995)
  • Current Population Reports (1992). Population Projections of the Population by Age, Sex, Race and Hispanic Origin....
  • K.E. Anderson et al.

    Physiology of penile erection

    Physiol Rev

    (1995)
  • G.J. Tortora et al.

    Principles of Anatomy and Physiology

    (1990)
  • Dail WG. Autonomic innervation of male reproductive genitalia. In: Maggi CA, ed. The Autonomic Nervous System. Nervous...
  • De Groat W, Booth AM. Neural control of penile erection. In: Maggi CA, ed. The Autonomic Nervous System. Nervous...
  • A.L. Burnett

    Role of nitric oxide in the physiology of erection

    Biol Reprod

    (1995)
  • N. Kim et al.

    A nitric oxide-like factor mediates nonadrenergic noncholinergic neurogenic relaxation of penile corpus cavernosum smooth muscle

    J Clin Invest

    (1991)
  • M.H. Schmidt et al.

    The ischiocavernosus and bulbospongiousus muscles in mammalian penile rigidity

    Sleep

    (1993)
  • A.T. Guay

    Erectile dysfunction. Are you prepared to discuss it?

    Postgrad Med

    (1995)
  • C.P. Broekman et al.

    The patient with erection problems and his general practitioner

    Int J Impotence Res

    (1994)
  • W.H. Masters et al.

    Human Sexual Inadequacy

    (1970)
  • R.C. Kolodny et al.

    Sexual dysfunction in diabetic men

    Diabetes

    (1973)
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