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Retrograde ejaculation This is when ejaculation is forced back in to erectile dysfunction age 29 order tadalis sx 20mg online the bladder rather than through the urethra and out of the end of the penis at orgasm (Kaplan erectile dysfunction pump for sale discount generic tadalis sx uk, 1974) erectile dysfunction yoga youtube tadalis sx 20 mg for sale. Sexual behaviour surveys have estimated that approximately 8% of men experience orgasmic difficulties (Laumann et al best erectile dysfunction doctor purchase cheap tadalis sx online. Biological factors contributing to male orgasmic disorder include general medical conditions such as diabetes, arteriosclerosis, low testosterone levels, vascular and pelvic pathology and the use of substances such as marijuana and alcohol (Aizenberg et al. Failure of detumescence This is a prolonged erection usually lasting for between 4 hours or greater. It is painful and always unaccompanied by sexual desire despite the fact that it is often preceded by usual sexual stimuli (Kandeel et al. The condition is self-perpetuating and is characterized by diminished perfusion of the corporeal bodies. The first is etiologically based and classifies the condition in to primary (idiopathic) and secondary priapism. Men aged 40-70 years were interviewed in 1987-1989 and reinterviewed in 1995-1997. The combined prevalence of minimal, moderate and complete impotence was found to be 52%. The prevalence of complete impotence tripled from 5 to 15% between subject ages 40 and 70years. They however found consumption of small amounts of alcohol and work or leisure related physical activity as protective factors. Africa is projected to record the highest percentage increase of 169% from 1995 to 2025 (Ayta et al. However a large degree of agreements in research has been established and a large body of evidence which will adjust for all the differences could help in establishing concrete understanding of estimates and risk factors. In the last two decades it has been recognized that endothelial dysfunction and vascular disease are the main causes of erectile problems. It is estimated that between 35- 75% of diabetics have erectile dysfunction and this develops 5-10 years earlier. This data suggests the stronger influence of age on both erectile function and diabetes and this is a well documented and established finding. This impairment could either be related to the hypogonadal-pituitary axis, gonadal 17 Literature Review functions or the penile anatomy itself. For the erectile process to function correctly, several systems of the body need to be healthy. Blood needs to be flowing smoothly and unobstructed throughout the body, nerves need to be firing and sending messages between the brain and the tissues, and libido needs to be present encouraging sexual interest. Being the most common causes of intermittent erectile malfunction in younger populations, psychogenic factors are usually secondary to or they may coexist with organic factors in older populations (Melman and Gingell, 1999). A number of data have recognized some relationship between sexual dysfunction and psychological disorders. In the Massachusetts Male Aging Study, male erectile dysfunction was established to be linked with depressive symptoms. The organic causes of erectile dysfunction can be classified in to systemic diseases, endocrine, neurological, vascular, or 18 Literature Review local penile disorders (Burnett, 2006; Kloner, 2007). Psychological causes may include stress, anxiety, depression or even expectations. Neurological diseases may include Parkinson‘s, Alzheimer‘s disease, diabetic neuropathy, peripheral neuropathy and spinal bifida. Metabolic complications may include hyperlipidemia, diabetes, hypertension, dyslipidaemias, and metabolic syndrome. Artherosclerosis, endothelial dysfunction and vascular injury are possible mechanisms that could reduce adequate perfusion. Neurogenic impotence is not unusual (3–10%) and is observed concomitant with multiple sclerosis, discopathies of lumbosacral tract, after prostatectomy and following spinal cord, pelvic, perineal or penile traumas (Berger, 1993). Psychological causes are frequent (30–40%) and include interactive–experiential problems (depressive– anxious behavior, religious pressure, lifestyle changes, psychological trauma, child abuse etc. Vascular disease, hypertension, peripheral neuropathy and obesity are all more common in people with diabetes than in the general population. This impairs endothelium-dependent relaxation of penile smooth muscle preventing optimal blood flow to and from the penis, and maintenance of an erection. Bartholin glands, which open on the inner surfaces of the labia minora, may be considered functionally within the context of the external genitals, although their anatomic position is not in fact external. The appearance of the female genitalia varies considerably from one woman to another, including variations in size, pigmentations, shape of the labia, location of the clitoris, and location of the urethral meatus and the vaginal outlet (Kolodney et al. It begins at the internal meatus and runs anteroinferiorly behind the symphysis with a gentle ventral curvature firmly adherent to the anterior wall of the vagina. Except during the passage of urine, the urethral lumen is stellate in shape and completely occluded. The female urethra is much more readily dilatable than the male urethra (Walsh et al. The clitoris itself contains very sensitive nerves that react when stimulated by either psychological or physiologic factors. It is located at the point where the labia majora meet anteriorly and is made up of two small erectile cavernous bodies enclosed in a fibrous membrane surface and ending in a glans or head. The clitoris is richly endowed with free nerve endings, which are extremely sparse within the vagina. The clitoris is not known to have any function other than serving as a receptor and transducer for erotic sensation. The tip of the clitoris is covered by a small area of tissue usually referred to as the clitoral hood. The size and shape of this hood varies among women and is not related to the amount of sexual pleasure that a woman can receive when she is sexually stimulated (Kolodney et al. The internal genitalia of the female (Figure 3) include the vagina, cervix, uterus, fallopian tubes, and ovaries. These structures may show considerable variation in size, spatial relationship, and appearance as a result of individual differences as well as reproductive history, age, and presence or absence of disease. The mouth of the cervix provides a point of entry for spermatozoa in to the upper female genital tract and also serves as an exiting point for menstrual flow. The endocervical canal contains numerous secretory crypts that 22 Literature Review produce mucus. The consistency of cervical secretions varies during various phases of hormonal stimulation throughout the menstrual cycle. At the time of ovulation, for example, cervical secretions become thin and watery; at other times of the cycle, these secretions are thick and viscous, forming a mucous plug that blocks the cervix (Victor, 1980). The vagina is a soft tube that is several inches long and can extend during sexual intercourse. The walls of the vagina are completely lined with a mucosal surface that is now known to be a major source of vaginal lubrication; there are no secretory glands within the vaginal walls, although there is a rich vascular bed. The lining of the uterus and the muscular component of the uterus function quite separately. The myometrium is important in the onset and completion of labor and delivery, with hormonal factors thought to be the primary regulatory mechanism. The endometrium changes in structure and function depending on the hormonal environment. Under increasing estrogenic activity, the endometrium thickens and becomes more vascular in preparation for the possible implantation of a fertilized egg. The fallopian tubes or oviducts originate at the uterus and open near the ovaries, terminating in fingerlike extensions called fimbriae. The fallopian tube is the usual site of fertilization; the motion of cilia within the tube combined with peristalsis in the muscular wall results in the transport of the fertilized ovum to the uterine cavity (Victor, 1980). Sexual response cycle in females The Master and Johnson (1996) sexual response cycle (Figure 4) is regarded as the most acceptable and consistent description of the physiologic and behavioural aspects of the female sexuality (Spark, 1991). They classified the phases as excitement, plateau, orgasm, and resolution phases by using extensive laboratory studies. These phases are observed in 23 Literature Review both sexes, although the demarcation between stages is somewhat arbitrary for both sexes and is dependent on factors such as age and general well being (Figure 4). Excitement phase This phase occurs in response to sexual stimulation because of either touch (i.
Predictive value of real-time RigiScan monitoring for the Di Rocco A, Tagliati M, Danisi F et al. Atlas of the Urologic plus cyproterone acetate in the treatment of advanced prostatic Clinics of North America 2002;10(1):63-73. The treatment advantages over sildenafil in the treatment of erectile satisfaction scale: a multidimensional instrument for the dysfunction?. Combination of finasteride and doxazosin for the Dorey G, Feneley R C, Speakman M J et al. Expert Opin floor muscle exercises and manometric biofeedback Pharmacother 2004;5(5):1209-1211. Is amlodipine the best initial monotherapy for Continence Nursing 2003;30(1):44-51. Pelvic floor exercises for treating post-micturition dribble in men Dogra P N, Rajeev T P, Aron M. Medicolegal aspects in the with erectile dysfunction: a randomized controlled management of erectile dysfunction. Direct effects controlled trial of pelvic floor muscle exercises and of selective type 5 phosphodiesterase inhibitors alone or with manometric biofeedback for erectile dysfunction. Recovery of sexual function prostatectomy compared with incision of the prostate after prostate cancer treatment. Curr Opin in the treatment of prostatism caused by small benign Urol 2006;16(6):444-448. Role of transrectal ultrasound guided salvage cryosurgery for recurrent prostate Dorrance A M, Lewis R W, Mills T M. Prostate Cancer & Prostatic treatment reverses erectile dysfunction in male stroke Diseases 2005;8(3):235-242. Is it an effective and safe treatment for localised of ginkgo (ginkgo biloba) during pregnancy and prostate cancer?. Value of noninvasive tests compared with penile versus photon radiotherapy in locally advanced duplex ultrasonography. Evaluation of 1972-1987 single institutional experience: Comparison of side effects of sildenafil in group of young healthy standard radical prostatectomy and nerve-sparing technique. Association of sexual problems with social, psychological, and Droupy S, Hessel A, Benoit G et al. Assessment of the physical problems in men and women: a cross functional role of accessory pudendal arteries in erection by sectional population survey. How, why and when should study of the prevalence and need for health care in the urologists evaluate male sexual function?. Dursteler-MacFarland K M, Stohler R, Moldovanyi A du Plessis S S, de Jongh P S, Franken D R. Sexual Function raloxifene on gonadotrophins, sex hormones, bone Before and After Radical Retropubic Prostatectomy: A turnover and lipids in healthy elderly men. Eur J Systematic Review of Prognostic Indicators for a Successful Endocrinol 2004;150(4):539-546. Sexual dysfunction in male patients with Dubocq F, Tefilli M V, Gheiler E L et al. Diabetic neuropathy: men with benign prostatic hyperplasia: 10-year An intensive review. Can an erectogenic pharmacotherapy regimen after radical prostatectomy improve postoperative erectile function?. Diagnostic value of nitric oxide, lipoprotein(a), and malondialdehyde levels in the peripheral venous and Earle C M, Seah M, Coulden S E et al. Lower urinary tract symptoms in patients with erectile dysfunction: is there a vascular Eden C G, Cahill D, Vass J A et al. Screening for ischemic heart disease in patients with erectile dysfunction: role Eglau Uwe. A risk-benefit assessment of treatment with finasteride in benign prostatic hyperplasia. Apomorphine versus mating behavior in testing El-Bahrawy M, El-Baz M A, Emam A et al. Urology vacuum constriction device in the management of erectile 1995;45(4):715-719. Erectile dysfunction in smokers: a penile dynamic and vascular El-Gabry E A, Strup S E, Gomella L G. Importance of thermal dose and antenna location in transurethral microwave Eri L M, Tveter K J. Effects of pollen extract preparation Prostat/Poltit on lower urinary tract symptoms in patients with chronic Erkan E, Muslumanoglu A Y, Oktar T et al. Dual radioisotopic study: a technique for the evaluation of vasculogenic Emberton M, Neal D E, Black N et al. Mediterranean diet improves erectile function in Englert H, Schaefer G, Roll S et al. Int J Impot Res dysfunction among middle-aged men in a metropolitan area in 2006;18(4):405-410. Sexual functioning in a lifestyle changes on erectile dysfunction in obese men: population-based study of men aged 40-69 years: the good news. Modulation of angiogenesis in patients intracavernous papaverine test always indicate a normal penile with myelodysplastic syndrome. Evaluation of penile hemodynamic status and adjustment of treatment alternatives in Ethans K D, Casey A R, Schryvers O I et al. Invest Med behalf of Gruppo Italiano Studio Deficit Erettile nei Int 1992;18(4):163-168. Diabetes Levine, Stephen B (Ed); Risen, Candace B (Ed); Althof, Stanley Care 1998;21(11):1973-1977. Experience with tranylcypromine in early cavernosography in standardized cavernosometry. Pituitary clinical experience with water-jet dissection (hydro 2004;7(3):145-148. Cadaveric dura mater graft for correction of penile Technologies: Mitat 2002;11(5-6):257-264. Neurobehavioral and psychological Ferraz Marcos, Rochedo Ferraz, Marcia Martins et al. Expert Review of Neurotherapeutics behavior with hydralazine, isradipine or captopril co 2002;2(5):709-716. The role of statins in Vasculogenic Impotence is Partially Resistant to Adenosine erectile dysfunction. Color cryoglobulinemic vasculitis: An update on its etiopathogenesis Doppler sonography in the evaluation of erectile and therapeutic strategies. Aging-related expression of inducible nitric oxide synthase and markers of tissue damage Fitzpatrick J M, Artibani W. Geriatric prostate cancer with the combination of finasteride Nephrology & Urology 1998;8(1):15-19. Clinical & Experimental Hypertension (New York) 1999;21(5 Firoozi F, Longhurst P A, White M D. The value of testing pudendal nerve conduction in evaluating erectile dysfunction in diabetics. Cutaneous temperature measurements in men with penile prostheses: a comparison study. Endothelial and erectile dysfunction, diabetes mellitus, and the metabolic Fitch W P, Easterling W J, Talbert R L et al. Experimental approaches for the development of pharmacological Fitch William, Tecumseh Sherman. Dissertation Abstracts Peet, Malcolm (Ed); Wilson, Catherine (Ed) International: Section B: the Sciences and Engineering 1993;(1993):235 1995;55(7-B):Jan Foresta C, Bettella A, Spolaore D et al. Sexual moderate dose of postoperative radiation on urinary continence dysfunction in men with lower urinary tract and potency in patients with prostate cancer treated with nerve symptoms.
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Efficacy and safety of desmopressin for treatment of nocturia: a systematic review and meta- analysis of double-blinded trials impotence in women discount tadalis sx 20 mg mastercard. Desmopressin orally disintegrating tablet effectively reduces nocturia: Results of a randomized erectile dysfunction treatment in sri lanka generic 20 mg tadalis sx mastercard, double-blind erectile dysfunction treatment himalaya purchase tadalis sx overnight, placebo-controlled trial erectile dysfunction kaiser generic tadalis sx 20 mg amex. Long-term effect of loxoprofen sodium on nocturia in patients with benign prostatic hyperplasia. Celecoxib for treatment of nocturia caused by benign prostatic hyperplasia: a prospective, randomized, double-blind, placebo-controlled study. The role of nocturia in the quality of life of men with lower urinary tract symptoms. The early postoperative morbidity of transurethral resection of the prostate and of 4 minimally invasive treatment alternatives. Tamsulosin versus transurethral resection of the prostate: effect on nocturia as a result of benign prostatic hyperplasia. Effect of increasing doses of saw palmet to extract on lower urinary tract symptoms: a randomized trial. Nocturia: a blinded, randomized, parallel placebo-controlled self-study of the effect of 5 different sedatives and analgesics. Traditionally, the now well-accepted relationship was attributed to the coincidently high prevalence of both conditions in aged men. The associ- ation between these two diseases has also garnered attention because investigators have hypothesized a common pathophysiology to explain the idea that they are causally linked. This common theme hypothesis has taken on a life of its own as pharmaceutical companies have expanded the indications for their drugs for both diseases. We expect these concerns to increase in importance in many parts of the world as the population ages and the obesity epidemic spreads. This will place increased demands on services for treatment, and necessitate the incorporation of evidence-based medicine. Men are remaining sexually active later in life, and the percentage of men who rated sex as being very important or extremely important was found to be over 60% in several countries in a worldwide study of 27,500 adults aged 40–80 years (1). With medical therapies, most reports of changes in sexual function come from adverse event reporting. Additionally, changes in sexual function among the proportion of men who were sexually active at baseline are nearly always ignored, thus the effects of treatment are muted, since data is generally reported as a mean for the entire group, which includes those men whose sexual function cannot decrease any further. It is therefore important to review some of the issues affecting the reporting of sexual function scores (and other continuous scales) in the literature: ??These scales are not usually open ended, i. Scores worsening, but a decrease from 18 to 6 is only that start off very low at baseline can therefore a 33% improvement. Some on whether reports were elicited from patients experts therefore advocate the use of percent- by letting them report observed adverse drugs age change values, thinking this will better events/reactions spontaneously or by prompt- reflect the impact of change on a scale. But ing them with a list of possible side effects, with reporting symptom improvement and wors- this latter strategy resulting in higher reported ening using percentages may over-emphasize incidence. These levels of evidence were published in 2009 and updated in 2011 (Tables 1 and 2). Step 1 Step 2 Step 3 Step 4 Step 5 Question (Level 1*) (Level 2*) (Level 3*) (Level 4*) (Level 5) Systematic Local and current review of surveys How common is random sample Local non-random that allow Case-series** N/A the problem? However, in the last decade, several data have supported the involvement of different contributing factors (12). Increased sympathetic tone results in penile flaccidity and antago- nizes penile erection. Rat models have demonstrated an effect on prostatic growth and differentiation through manipula- tion of autonomic activity. Spontaneously hypertensive rats had an overabundance of sympathetic fibres innervating the bladder, prostate, and penis, and showed improvement in erectile function after antihypertensive therapy. Smooth muscle alterations in the bladder, prostate, and penis of animal models of hypercholesterol- emia and pelvic ischemia show similarities (23). Ejaculation requires a complex interplay among somatic, sympathetic, and parasympathetic pathways, involving predominantly central dopaminergic and serotonergic neurons. Both medical and surgical treatments have been reported to have a significant impact on sexual function compared with watchful waiting. In the same study, an improvement or a reduction of penile rigidity was reported by 11% and 6% of men, respectively. Other investigators reviewed the effect of finasteride on sexual function and found that in the placebo group, the incidences of impotence, ejaculation disorders, and decreased libido were 3. However, in the long run, sexual function tends to deteriorate (Level 1a, Grade A). The mechanism was initially thought to be retrograde ejacu- lation, but it appears that there is failure of emission and ejaculation (24). Silodosin was not available at the time of that meta-analysis, but a recent random- ized, placebo-controlled trial comparing tamsulosin 0. These include relaxation of the smooth muscle of the bladder neck (resulting in retrograde ejaculation), a direct effect on the seminal vesicles, and a central effect (33). However, clinical studies strongly suggest that retrograde ejaculation does not happen, as evidenced by the absence of sperm in the urine (37). The overwhelming evidence instead seems to suggest that the primary effect of these drugs on ejaculation is in fact to cause an ejaculation (38,39), and that this effect is mediated via alpha-1A receptors (40). Randomized, placebo-controlled clinical trials have shown that there is a potential effect on penile erection, ejacu- lation, and sexual desire. There seems to be no significant difference between the two agents that are currently available (finasteride and dutasteride). While it was originally thought that the effects were fully reversible, there have been reports of persis- tence of sexual side effects following cessation of therapy when these drugs have been used to treat male pattern baldness (48). The veracity of this finding is still unclear, but it has been proposed that the mechanism may involve changes to steroid biochemistry in the central nervous system and within the prostate (47). There seems to be no signifcant difference between the two agents that are currently available (Level 1a, Grade A). It was originally thought that the effects were fully reversible, but there have been reports of persistence of sexual side effects following cessation of therapy when these drugs have been used to treat male pattern baldness. The veracity of this fnding is still unclear, and no recommendation can be made based on the literature (Level 4, Grade D). Broadly speaking, the sexual side effects of this combination are more than simply the additive effects of the two drugs separately. When adding select alpha-blockers, the sexual side effects on EjD are additive (Level 1a, Grade A). However, a number of small studies have been reported, and they show varying effects on sexual function, as shown in Table 7. In the human urinary bladder, M2 and M3 are the main receptors responsible for detrusor contrac- tion. Adverse effects associated with antimuscarinics include dry eyes, blurred vision, dry mouth, confusion, tachycardia, urinary retention, and constipation (56). However, the effect of anticho- linergics on sexual activity is unclear, with few data reported in the literature. Cholinergic innervation of the prostate gland has an important role in the regulation of growth and secretion of the prostate epithelium (57–59). Muscarinic receptors have been found to be localized exclusively in the glandular epithelium of the human prostate, consistent with the lack of contractile effects of muscarinic receptor–active drugs on human prostate preparations (60). Muscarinic receptors in the prostate appear to be involved in processes other than control of smooth muscle contraction. Evidence of the clinical effects of anticholinergics on prostate secretion and sexual function is lacking. The influence of the parasympathetic nerve on the contraction of the seminal vesicle has seldom been investigated. In animal models, the M3 subtype has been found to be involved in seminal vesicle contraction (61). Other models have demonstrated that sympathetic and parasympathetic innervations both trigger contraction of the seminal vesicle and work independently (62). They also found that the M3 subtype is the dominant muscarinic receptor responsible for the effects of para- sympathetic stimulation on the seminal vesicle in rats. Evidence of the clinical effects of antimusca- rinics on the function of the seminal vesicle is incomplete.
Sexual health is an integral part of overall health, and sexual dysfunction can have a major impact on quality of life as well as psychosocial and emotional well-being. To provide evidence-based and expert-opinion consensus guidelines for the clinical management of sexual dysfunction in men. An international consultation in collaboration with major urologic and sexual medicine societies was convened in Paris in July 2009. More than 190 multidisciplinary experts from 33 countries were assembled into 25 consultation committees. Following an exhaustive review of available data and publications, the committees developed evidence-based guidelines in each area. New algorithms and guidelines for the assessment and treatment of sexual dysfunctions were developed. These guidelines were based on the work of the previous consultations and on the evidence coming from the scientiic literature published from 2003 to 2009. Expert opinion was based on systematic grading of the medical literature in addition to cultural and ethical considerations. Algorithms, recommendations and guidelines for sexual dysfunction in men are presented. These guidelines were developed in an evidence-based, patient-centered, multidisciplinary manner. It was felt that all sexual dysfunctions should be evaluated and managed following a uniform strategy. Speciic evaluation and treatment guidelines and algorithms were developed for every sexual dysfunction in men, including erectile dysfunction; disorders of libido, orgasm, and ejaculation; Peyronie’s disease; and priapism. Sexual dysfunction in men represents a group of common medical conditions that need to be managed from a multidisciplinary perspective. It or procedures should not be recommended identiied the following fundamental concepts as the without controlled clinical data or research- basis for the management of sexual dysfunctions in based evidence supporting their use. Misinformation or myths may lead to uninformed • the three principles for clinical evaluation and sexual decisions with serious consequences. Evaluation of the patient with differ according to the absence or presence erectile dysfunction of signiicant mental (cognitive) or emotional (affect) distress. Initiating the discussion • Physical examination and laboratory tests In some circumstances, a single question (eg, are strongly recommended but not always “Do you have questions or concerns about your necessary. Diagnostic procedures with the often conducted in a face-to-face interview with the highest level of evidence should be used, when patient, although paper-and-pencil questionnaires or appropriate. The style or manner in which sexual inquiry is conducted is • Improved management of sexual dysfunction important: It should relect a high level of sensitivity depends on physicians’ inclination and ability and regard for each individual’s unique ethnic, to educate patients about their sexual function cultural, and personal background. The aim of taking a sexual history should be These principles represent the evolution of scientiic ascertaining the severity, onset, and duration of the thinking in the management of sexual dysfunction in problem as well as the presence of concomitant both sexes. Similarly, references the medical and sexual history is essential are not included in this manuscript but are accessible and frequently the most revealing aspect of the in the articles discussing each topic. A comprehensive sexual history is essential in conirming the patient’s diagnosis as well as in the evaluation of the patient’s overall 2. Questions apply speciically to the evaluation of male arousal, desire, and orgasm/ ejaculation dificulties. Deinition of erectile dysfunct- can be addressed to all patients presenting with sexual dificulties. Second, the physician associated with sexual dysfunction, such as body must actively investigate the possible association habitus (secondary sexual characteristics) and with cardiovascular conditions to differentiate assessment of the cardiovascular, neurologic, and among potential organic and psychogenic causes genital systems, with particular focus on the genitalia in the etiology of a patient’s sexual problem. Some of these medications of the medical history and can sometimes reveal can either cause or contribute to the patient’s sexual unsuspected physical indings (eg, decreased dificulties, and a change in medication may result peripheral pulses, atrophic testes, penile plaque). Additionally, In addition to identifying speciic etiologies or the use of certain medications may be important comorbidities, the physical examination may provide contraindications for speciic treatments. Medical an opportunity to inform the patient about aspects of history may include all medical conditions that could his sexual anatomy or physiology as well as to provide interfere with sexual function. Psychosocial history should be recognized that the physical examination can also be a source of shame, embarrassment, or Potential etiologies for sexual dysfunction include discomfort for many patients. Every effort should be a wide range of organic and medical factors, but made to ensure the patient’s privacy, conidentiality, multiple psychological or interpersonal factors (eg, and personal comfort during the examination. A detailed psychosocial assessment the physician should always review the major is essential in every case of sexual dysfunction. Laboratory testing the physician should not assume that every Recommended laboratory tests for men with patient is involved in a monogamous, heterosexual sexual problems typically include fasting glucose, relationship. For this reason, it is advisable to begin cholesterol, lipids, and a hormone proile. As with the history with broad questions: “Are you sexually the physical examination, these tests are performed active at the moment? Additional laboratory are often of crucial signiicance to assessment and tests (eg, thyroid function) may be performed at the treatment. Were there particular times of change in physician’s discretion based on the patient’s medical the sexual relationship? Specialized testing for erectile physician should ask questions about other relevant aspects of the patient’s life, including interpersonal dysfunction relationships, occupational status, inancial security, the classical specialized tests—with the exception family life, and social support. Physical examination or sleep-related erections—are not equipped to the etiology or causal factors for sexual dysfunction speciically and accurately assess cavernosal may or may not be apparent from the patient’s history neuro-endothelial function. At best, they examination will not identify the speciic etiology or typically conirm an expected diagnosis. Moreover, cause of sexual dysfunction; however, a focused these tests are expensive, time-consuming, invasive, physical examination is strongly recommended. This prone to complications (prolonged erections), and examination should include a general screening rarely conclusive except in experienced hands. A for medical risk factors or comorbidities that are thorough description of the available specialized test 1270 Chapter 26. Treatment of erectile dysfunct- tion • Identify and reduce resistance to premature discontinuation of pharmacotherapy. Medical treatment for erectile dysfunction dysfunction Psycho-sexologic literature has made an important 2. It is easily understood by considering their effect on the not clear which of these interventions in combination physiology of smooth muscle relaxation. The increased accumulation of blood in the dawn of the age of pharmacologic treatment the corpus cavernosum caused by this relaxation is began 25 years ago with the recognition that the underlying basis for penile erection. Alprostadil penetrating into smooth muscle cells and inhibiting is also available as an intraurethral suppository. This decreased degradation increases relaxation route of administration is less effective than the of the smooth muscle, which dilates the corporeal intracavernosal route. Local therapies are considered sinusoids, resulting in increased blood low and second-line therapy and should be considered in allowing an erection to occur. Patients who improves outcome results, as conirmed by the eventually opt for an implant are usually highly experience of a number of authors. This because of unnatural erections and cumbersome decision is usually based on the physician’s comfort application. Patients with a larger penis will be best served by a three-piece inlatable device, as these devices erectile dysfunction deliver the best rigidity. Arterial revascularization shorter penises often choose the three-piece device because semirigid rods and two-piece implants are Many retrospective studies report outcome data for more dificult to conceal. Surgery for cavernous venot erection and that girth, not length, is responsible for occlusive dysfunction penile rigidity. They do not restore does not conform to the desiderata of good clinical any special sensitivity or sexual drive that may have practice or evidence-based medicine. If the cylinders are diagnostic values for available tests, universal removed at a later date, the capsule remains, and diagnostic criteria for case selection for surgery, the empty space will partially ill with proliferating and consensus on choice of operation in a given scar tissue. This may make it dificult for the patient patient have not been unequivocally established. Penile prosthetic surgery for its consequences, pain, mechanical failure, penile shortening, and autoinlation.