Sex is a central part of the human experience and to deny this is to deny our humanity. Whilst some people make a choice to remain celibate and clearly enjoy wholly fulfilling lives, for the vast majority sex remains important to them throughout their adult lives.
Traditionally, ED has been the almostexclusive preserve of the urologist and psychiatrist. In the past 20 years, a new discipline of sexual medicine has evolved, as our scientific understanding of human sexuality has evolved. Read the rest of this entry »

There has been long experience with combinations of different drugs used for intracavernosal injection, although they are unapproved and there is limited evidence for their efficacy and safety. ‘Trimix’ (papverine 30 mg/ml, phentolamine I mg/ml, alprostadil 10 fxg/ml) and ‘bimix’ (papverine 30 mg/mJ, phentolamine I mg/ml) are widely used at varying doses in urological practice in the United States, although less so in Europe. Bimix is offered where the alprostadil component of Trimix causes bothersome penile pain. These combinations have been reported as effective when alprostadil has failed as a single agent. Papaverine was first reported as an effective pharmacotherapy for ED in 1982; with the addition of phentolamine, Bimix has been used since 1983, with Trimix being used rather more recently.

The majority of men who have had a radical prostatectomy will have ED for at least a limited period, and some will have permanent problems that are resistant to oral therapies. They present a particularly challenging group to treat, and management strategies are still evolving.
The likelihood of a man experiencing post-radical prostatectomy ED is influenced by his pre-operative potency, his age (ED is more likely if over 65), and the achievement of intra-operative nerve preservation (ED is more likely if one or both cavernous nerves are sacrificed), Pre-operative counseling about sexual and erectile function should be included in the routine care of men facing radical prostatectomy, and it is preferable to involve their partners too. Read the rest of this entry »

Mode of action: Apomorphine is a centrally acting drug for the treatment of ED; it is not approved in the United States, although it is available in Europe. CNS control of sexual function is thought to be maintained through a balance of inhibitory and excitatory systems, influenced by androgens and by erectogenic stimuli from centers of the brain concerned with sight, sound, smell, touch, and cognition. A variety of neurotransmitters are involved but, simplistically, the primary neurotransmitter of central sexual inhibition is serotonin, and of central sexual excitation, dopamine. Apomorphine activates dopamine D2 receptors in the hypothalamus and has the potential to both initiate an erection and enhance responsiveness to erectogenic stimuli.
Use in practice: Proper counseling about the use of any therapy is vital to a successful outcome, but particularly so with ED therapy. Apomorphine is taken sublingually and it is essential that the patient be told to pop it under the tongue, and to allow it to dissolve slowly rather than suck or swallow it. If it is swallowed, it will probably be ineffective, because of the very high proportion of drug metabolized on the first pass through the liver. The 2’mg tablet is pentagonal, and the 3’mg, triangular. Read the rest of this entry »

Basic sex education: This is the vital first step in effective treatment, leading to a successful outcome, in which the indi’ vidual or couple can enjoy ‘a satisfactory sexual experience’, rather than just get erections. Do not underestimate its impor tance and do not omit it.
Many men, including a large number of doctors, have a lamentably poor understanding of their sexuality and sexual function. Personal sex education is frequently delegated by parents to schools and tends to concentrate on reproductive biology, sexually transmitted diseases, and preventing unwanted pregnancy. We are not educated in how to enjoy our own sexual feelings, or in understanding our partner’s sexual needs and how we might best help them to fulfil them. Read the rest of this entry »

Continuing professional development: In order to be able to provide a high’quality service to men and couples affected by ED, it is essential to maintain the appropriate knowledge and skills. This task should be approached in a holistic manner; to provide high’quality care, the physician needs to have a wide range of resources in sexology, urology, gynecology, and internal medicine.
While factual knowledge can be obtained from reading and personal study, skill acquisition is more difficult. Many doctors will find talking about sexual issues uncomfortable and struggle for appropriate language that is intelligible to clients without being too simplistic or too crude. Read the rest of this entry »

Taking a sexual history presents different challenges to the physician, not least because most physicians have had little or no training or experience in doing so. Many people, both lay and professional, find talking about sex uncomfortable to a greater or lesser degree. Many people, again both lay and professional, have their own beliefs, rooted in the culture and religion of their upbringing, about what is acceptable sexual behavior and what is not. The ability to talk freely about sexual behavior and lifestyles is a skill that must be acquired if the physician is to help people with sexual problems. If, for whatever reason, they find themselves unable to do this, it is better that they acknovsledge the fact and promptly refer people with sexual problems to a colleague. Read the rest of this entry »

Depression: Depression and its treatments are strongly associated with ED and other sexual dysfunctions. Sometimes depression causes these problems and sometimes the problems cause depression. Taking a careful history may help clarify the situation. Both problems warrant treatment and should be managed concurrently. There is evidence that treating ED can improve depressive symptoms. However, depression is a serious, potentially lifc’threatening condition and should be treated aggressively. Read the rest of this entry »

Endocrine disorders may cause ED and, in some cases, may be one of the few etiologies whose resolution might lead to a ‘cure’. Consequently, such disorders should be routinely sought out in the assessment of men with ED. However, as ED is multifactorial in origin, an endocrine disorder might be only a contributory factor to the problem. Endocrine disorders commonly seen in ED patients include diabetes, thyroid disease, androgen deficiency, and hyperprolactinemia.
Diabetes: Diabetes is the most common endocrine abnormality associated as a risk factor for ED. The prevalence of ED is almost three times higher in diabetic men (28%) than in the nondiabetic population (9.6%). Read the rest of this entry »

Hypertension, coronary heart disease and ED frequently coexist.
Around 4 0% or more of ED patients may have some type of cardiovascular disease. Apart from representing a potential causative factor, the presence of underlying cardio’ vascular disease should be taken into consideration in patient management [10].
Hypertension: There is a strong association between hyperteu’ sion and ED. Around 17% of men with mitreated hypertension and 2 4% of men with treated hypertension have ED. It is not only antihypertensive therapy that causes ED, but hypertension itself. Read the rest of this entry »