Colour Doppler ultrasound of the penis.

Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. A number of disease processes, including Peyronie's disease, penile fractures and penile tumours, are clearly visualized with ultrasound. An assessment of priapism can also be made using spectral Doppler waveform technology. Furthermore, dynamic assessment of cavernosal arterial changes after pharmaco-stimulation allows diagnosis of arterial and venogenic causes for impotence. This pictorial review illustrates the range of diseases encountered with ultrasound of the penis.

Disorders of ejaculation.

The physiology of ejaculation includes emission of sperm with the accessory gland fluid into the urethra, simultaneous closure of the urethral sphincters, and forceful ejaculation of semen through the urethra. Emission and closure of the bladder neck are primarily alpha-adrenergically mediated thoracolumbar sympathetic reflex events with supraspinal modulation. Ejaculation is a sacralspinal reflex mediated by the pudendal nerve. The most common ejaculation disorder is premature ejaculation, but there is little agreement regarding the definition of this disorder or its etiology, diagnosis, and treatment options. Premature ejaculation is in fact classically considered psychogenic in nature. However, recent data have demonstrated that prostatic inflammation/infection has been found with high frequency in premature ejaculation, suggesting a role of prostatic pathologies in the pathogenesis of some cases of failure of ejaculatory control. Rarer disorders are emission and ejaculation failure and urine contamination of semen. The new use of diagnostic procedures and the availability of pharmacological aids place this topic in the mainframe of medical sexology.

Current and future trends in the oral pharmacotherapy of male erectile dysfunction.

The promising clinical data on the use of the first orally active phosphodiesterase inhibitor Sildenafil Citrate ( Viagra ) (Viagra) for treatment of male erectile dysfunction have been accompanied by an increase in research activities on the physiology of the male erectile mechanism. This included both peripheral intracellular signal transduction in the corpus cavernosum as well as central brain and spinal cord pathways that control penile erection. This work provided the basis for the development and introduction of several new therapeutic modalities into the management of erectile dysfunction that is now offered to the patients. Since the concept of 'taking a pill' as a cure for an illness or the relief of symptoms of a disease has become widely accepted by consumers, the pharmacological treatment of erectile dysfunction has primarily focused on selective, orally available drugs that act via influencing intracellular or central regulatory mechanisms, combining a high response rate and the advantage of an 'on-demand' intake. These agents are regarded as more efficacious, have a faster onset of drug action in the target tissue and an improved effect-to-side effect ratio than sildenafil. The purpose of this review is to describe the major novel and evolving pharmacological advances in the field of oral pharmacotherapy for the treatment of male erectile dysfunction.

Female sexual dysfunction: state of the art.

Female sexual dysfunction, a common, multifactorial, and often undertreated medical condition, attracted the attention of the medical community with the successful introduction of medical therapy for male erectile dysfunction. This review discusses the updated classification systems and definitions, epidemiologic aspects, and new pathophysiologic and therapeutic implications of this sexual disorder. erectile dysfunction Role of the cardiologist: clinical aspects of managing erectile dysfunction.

Erectile dysfunction (ED) is often a marker for serious underlying cardiovascular disease (CVD), and cardiologists are increasingly involved in the care of men with ED. It is important to ask specifically about ED when evaluating men with CVD, since they may be embarrassed to volunteer this information. During the clinical workup, it is also important to check for contributing factors to ED such as diabetes, depression, stress, alcohol abuse, and cardiovascular risk factors. Patients should be advised that many treatment options are available for ED, including the phosphodiesterase type 5 (PDE5) inhibitors. The PDE5 inhibitors are safe and effective in most patients with CVD, including those taking multiple antihypertensive drugs. Furthermore, they have no deleterious effect on exercise capacity, heart rate, or extent of exercise-induced ischemia. In the future, the PDE5 inhibitors may have a role in reducing pulmonary hypertension in persons with primary pulmonary arterial hypertension (PAH) or congestive heart failure. The one major precaution for men taking PDE5 inhibitors is to avoid concomitant administration of therapeutic and recreational nitrate preparations. Patients with chest pain suggestive of a heart attack need to inform emergency room (ER) personnel if they are taking a PDE5 inhibitor. Similarly, before giving nitrates, ER personnel need to ask patients if they have used PDE5 inhibitors. Nitrates should not be given for at least 24 h after a patient uses Sildenafil Citrate ( Viagra ) or Vardenafil ( Levitra ) and at least 48 h after a patient uses Tadalafil ( Cialis ) .

New oral drugs for erectile dysfunction.

In 1998, we concluded that Sildenafil Citrate ( Viagra ) (Viagra--fizer Ltd), a selective phosphodiesterase type 5 inhibitor, appeared to offer advantages over other medical approaches for erectile dysfunction in terms of ease of administration and cost. Oral drug treatment is now widely advocated as first-line therapy for erectile dysfunction, except where the cause is clearly psychological. In the past 4 years, three more oral preparations have been licensed in the UK for the treatment of men with erectile dysfunction. A sublingual preparation of the dopaminergic agonist apomorphine (Uprima--Abbott Laboratories Ltd) is the first centrally acting drug to be licensed. Tadalafil ( Cialis ) (Cialis--Eli-Lilly) and Vardenafil ( Levitra ) (Levitra--Bayer PLC) are phosphodiesterase type 5 inhibitors. Here we review the place of these preparations for men with erectile dysfunction.

Future options for combination therapy in the management of erectile dysfunction in older men.

The prevalence of erectile dysfunction (ED) has dramatically increased in parallel with the aging of the Western industrialised population. The estimated prevalence of ED worldwide in 1995 was 152 million men. As the population in industrial nations ages, an estimated 322 million men will be affected by ED by the year 2025. Oral drug therapy with the phosphodiesterase (PDE) type 5 inhibitor Sildenafil Citrate ( Viagra ) fails in some patients with ED; however, several different classes of drugs demonstrate efficacy in treating ED, creating the potential for pharmacological combination therapy. Pharmaceutical products that lead to the activation of or an increase in cyclic nucleotides (cyclic adenosine monophosphate and cyclic guanosine monophosphate), with or without nitric oxide donors or nitrates, as well as alpha-adrenoceptor antagonists, have been used to treat ED. Sildenafil Citrate ( Viagra ) has been used in combination with alprostadil (prostaglandin E1) and administered via intraurethral or intracavernous route. Successful intercourse using this combination of agents varies from 47% to 100% following failed monotherapy. Various combination therapies for ED are being studied using PDE5 inhibitors, together with other agents, alpha-adrenoceptor antagonists, and testosterone replacement therapy for men with hypogonadism. The combination of centrally acting agents with PDE5 inhibitors, e.g. a regimen of apomorphine plus PDE5 inhibitor, is an attractive approach because the two therapies target different mechanisms. New PDE5 inhibitors such as Vardenafil ( Levitra ) should be tried first as therapy for Sildenafil Citrate ( Viagra ) nonresponders before exploring any combination therapy options. Preliminary observations of combination therapy have been encouraging and provide a scientific rationale for prospective, randomised clinical trials with adequate numbers of patients.

Diagnosis and treatment of diabetic autonomic neuropathy.

Diabetic autonomic neuropathy (DAN) is associated with a markedly reduced quality of life and poor prognosis. The manifestations of DAN cause multiple symptoms and involve the 1) cardiovascular system: resting tachycardia, reduced heart rate variability and circadian rhythm of heart rate and blood pressure, painless myocardial ischemia/infarction, orthostatic hypotension, exercise intolerance, perioperative instability, sudden death; 2) respiratory system: reduced ventilatory drive to hypercapnia/hypoxemia, sleep apnea; 3) gastrointestinal tract: esophageal motor dysfunction, diabetic gastroparesis, gallbladder atony, diabetic enteropathy, colonic hypomotility, anorectal dysfunction; and 4) genitourinary tract: diabetic cystopathy, erectile dysfunction. Treatment is based on four cornerstones: 1) causal treatment aimed at near-normoglycemia; 2) treatment based on pathogenetic mechanisms; 3) symptomatic treatment; and 4) avoidance of risk factors and complications. Pharmacologic treatment of symptomatic DAN may be difficult, due to limited efficacy and frequent adverse reactions. First-line treatments include midodrine for orthostatic hypotension, prokinetic drugs for gastroparesis, broad-spectrum antibiotics for diabetic diarrhea, and Sildenafil Citrate ( Viagra ) for erectile dysfunction. Prior to an adequate symptomatic treatment a thorough risk-benefit estimate, aimed at maintaining the patient's quality of life, is required. erectile dysfunction Overview of phosphodiesterase 5 inhibition in erectile dysfunction.

Since the early 1980s, research on the mechanisms of penile erection has done much to clarify erectile physiology and pathophysiology. More recent studies have identified the importance of neurochemical mediators in erection. These include the nitric oxide-cyclic guanosine monophosphate (cGMP) cell-signaling system-a complex molecular pathway that mediates smooth muscle relaxation in the corpus cavernosum. Phosphodiesterase 5 (PDE5) inactivates cGMP, which terminates nitric oxide-cGMP-mediated smooth muscle relaxation. Inhibition of PDE5 is expected to enhance penile erection by preventing cGMP degradation. Development of pharmacologic agents with this effect has closely paralleled the emerging science. The prototype of this new therapeutic class of PDE5 inhibitors is sildenafil, which was approved for treatment of erectile dysfunction in 1998. Tadalafil ( Cialis ) and Vardenafil ( Levitra ) are new agents in this class. These agents have demonstrated improvement in erectile function and have been shown to be well tolerated in diverse populations comprising thousands of men worldwide. Profiles of these 3 PDE5 inhibitors are reviewed herein.

The psychological and interpersonal relationship scales: assessing psychological and relationship outcomes associated with erectile dysfunction and its treatment.

Erectile dysfunction (ED) is associated with complex psychological and interpersonal issues. A new measure of treatment outcome, the Psychological and Interpersonal Relationship Scales (PAIRS), was developed to evaluate the broader psychological and interpersonal outcomes associated with erectile dysfunction and its treatment. Initial items were generated based on literature review, focus groups and market research, interviews with patients and partners, and consultation with expert clinicians. Domains of Sexual Self-Confidence, Spontaneity, and Time Concerns were identified and subsequently confirmed by factor analysis. A series of validation studies was performed with four separate samples, including assessment of internal consistency and test-retest reliability, convergent and discriminant validity, and treatment responsiveness. Samples for these studies included men recruited from clinical trials for ED in several countries ( N =413) and a community sample ( N =801). Findings from these studies indicate that PAIRS demonstrates adequate psychometric properties and appears well suited for use in further clinical studies of treatments for ED. It provides a broader assessment of treatment outcome than current measures of erectile function.

Genito-sexual dysfunction in patients with a medullary lesion

Multiple dramatic consequences follow medullary lesions. Not only are voluntary motor control and sensitivity of the body segment below the lesion lost, but it also becomes impossible to control erection and ejaculation as well as urinary and faecal continency. The first investigations into genito-sexual function in paraplegics have brought about the idea, commonly admitted in the medical world, that this kind of patient is impotent and sterile. Fortunately this idea is disappearing gradually and many data have demonstrated that appropriate treatment is required and some therapies efficient. This is particularly important in the case of the population concerned, namely young men in 70% of the cases, since the usual age bracket at trauma is between 25 and 35 years old. At this time of life, sexual activity is often at its peak, so that the fertility potential becomes erased.

Diagnosis and treatment of diabetic autonomic neuropathy.

Diabetic autonomic neuropathy (DAN) is associated with a markedly reduced quality of life and poor prognosis. The manifestations of DAN cause multiple symptoms and involve the 1) cardiovascular system: resting tachycardia, reduced heart rate variability and circadian rhythm of heart rate and blood pressure, painless myocardial ischemia/infarction, orthostatic hypotension, exercise intolerance, perioperative instability, sudden death; 2) respiratory system: reduced ventilatory drive to hypercapnia/hypoxemia, sleep apnea; 3) gastrointestinal tract: esophageal motor dysfunction, diabetic gastroparesis, gallbladder atony, diabetic enteropathy, colonic hypomotility, anorectal dysfunction; and 4) genitourinary tract: diabetic cystopathy, erectile dysfunction. Treatment is based on four cornerstones: 1) causal treatment aimed at near-normoglycemia; 2) treatment based on pathogenetic mechanisms; 3) symptomatic treatment; and 4) avoidance of risk factors and complications. Pharmacologic treatment of symptomatic DAN may be difficult, due to limited efficacy and frequent adverse reactions. First-line treatments include midodrine for orthostatic hypotension, prokinetic drugs for gastroparesis, broad-spectrum antibiotics for diabetic diarrhea, and Sildenafil Citrate ( Viagra ) for erectile dysfunction. Prior to an adequate symptomatic treatment a thorough risk-benefit estimate, aimed at maintaining the patient's quality of life, is required.