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This ad-- of this chapter, several key pathways that regulate ditional mode of Ca2+-independent regulation can re-- smooth muscle tone will be highlighted. While an exhaustive these receptors not only activates the channel, but Comittee 13. Red arrows indicate association, binding and/or activation, whereas yellow arrows indicate inhibitory regulation. Yet, phosphoryla-- to affect caldesmon function, as previously outlined tion events are known to activate receptor-operated in the section on actin-associated proteins. Each channel consists of 4 subunits An important distinction to note is the source of and each subunit has 6 transmembrane segments. In with the type of contractile response exhibited by the intact tissues, these vasoactive compounds often smooth muscle (e. In penile they do exhibit greater permeability to extracellular cavernosal smooth muscle, C-type natriuretic pep-- Ca compared to other cations. These mechanisms have been demonstrat-- a mechanistic basis for signal cross-talk. Collectively, changes in membrane poten-- cells, such as the cavernosal smooth muscle cell. The regulation intracellular targets, which may play a role in the of Ca2+ sparks is not well understood, but ryano-- regulation of vascular smooth muscle contractility. In certain prostaglandins appear to be responsible for the cases, the same isoform (e. Isolated rabbit indicate that oxygen tensions change rapidly during 2 corpus cavernosum has been shown to synthesize the transition from the laccid to the erect state. It has been demonstrated that prostanoids a critical imperative in most tissues of the body but can induce both relaxation and contraction in penile the penis is the only organ which changes from ve-- corpus cavernosum. In certain disease states, nous to arterial oxygen tensions during the course of prostanoid imbalance may contribute to erectile its normal function. However, the clinical relevance of such synthase are two well-studied examples of a class indings remain controversial. At low oxygen endogenous prostaglandin that appears to elicit tensions, measured in the laccid state of the penis, relaxation of human trabecular smooth muscle; the the synthesis of nitric oxide are inhibited, preventing others causing constriction or having no effect on trabecular smooth muscle relaxation. The retina, brain, and small intestines, suggesting highly synthesis of prostanoids is similarly regulated in the localized sites of action. Therefore, oxygen tension may regulate the types of vasoac-- There are ive major groups of prostanoid receptors tive substances present in this vascular bed. Isolated corpus ity of endothelins to maintain long-lasting, sustained cavernosum tissue from various species, including contraction in corpus cavernosum smooth muscle. The extracellular matrix nisms underlying its action have yet to be completely itself is a dynamic structure that plays an important elucidated. This peptide has also introduction of this chapter, it is possible that smooth been shown to have growth factor activity, stimulat-- muscle cells may transform from primarily contractile ing mitogenesis in ibroblasts, smooth muscle, and to primarily synthetic cells (or vice versa) in response endothelial cells. In addition release from the intimal lining of blood vessels can to growth factors and cytokines, vasoactive factors be induced by shear stress. However, little is known have also been shown to have trophic effects in about the physiological or cellular mechanisms the vasculature, suggesting that many of the same which regulate its production in the penis. While the overall integration of various of corpus cavernosum smooth muscle [129,130]. They are distributed on both primarily characterized by a signiicantly decreased the endothelium and the smooth muscle and are expression of contractile proteins. This may account for the unique abil-- gene expression is an area of active study. In order to achieve a pronounced drug effect without signiicant adverse Many growth factors stimulate cell surface receptors events, especially on the cardiovascular system, with intrinsic tyrosine kinase activity in their a certain degree of tissue selectivity is mandatory. This tyrosine kinase activity Selective intervention in intracellular pathways is considered essential to regulating cell growth. While the reasons for this suppresses the induction of collagen synthesis by variability remain unclear, it must be stressed that transforming growth factor-beta 1 in human corpus cavernosum smooth muscle. Sonic hedgehog of these is nucleolin, a multi-functional protein located cascade is required for penile postnatal morphogenesis, primarily in the nucleolus. Sonic hedgehog: a common signal for ventral patterning along been accumulated regarding smooth muscle biology the rostrocaudal axis of the neural tube. Int J Dev Biol and vascular physiology, it is important to keep in 1995;39:809-16. While a central and enduring hog gene therapy accelerates wound healing in diabetes question has been how Ca2+ can elicit different re-- by enhancing endothelial progenitor cell-mediated micro-- sponses within a given cell, it is becoming more ap-- vascular remodeling. In vitro and in 2+ vivo arterial differentiation of human multipotent adult in intracellular Ca lux play an important role in this progenitor cells. Peptidergic innervation of channels exhibit connexin-speciic permeability to cyclic the human male genital tract. Bidirectional electrical communication cyclase-activating polypeptide, helospectin, and vasoactive between smooth muscle and endothelial cells in the pig intestinal polypeptide in human corpus cavernosum. Cholinergic junctions in the proximal and distal mesenteric arteries nerves in human corpus cavernosum and spongiosum of the rat is suggestive of a role in endothelium-derived contain nitric oxide synthase and heme oxygenase. Regulation of adrenergic activity in penile corpus in smooth muscle, Nature 1994;372:231-6. Endothelial main and its complex with the essential light chain: visual-- dysfunction in diabetes. Myosin dysfunction with respect to nitric oxide, endothelium- phosphatase: structure, regulation and function. Mol Cell derived hyperpolarizing factor and cyclooxygenase Biochem 2004;259:197-209. Alteration of plasma-- of myosin light chain phosphatase in smooth muscle cell lemmalcaveolaemimicsendothelialdysfunctionobservedin relaxation. The shear stress of it all: the cell smooth muscle contraction and cytoskeletal reorganization membrane and mechanochemical transduction. Rho/Rho-kinase mediated [32] di Villa Bianca R, Sorrentino R, Sorrentino R, et al. J Mol Med gosine 1-phosphate induces endothelial nitric-oxide syn-- 2002;80: 629-38. Smooth muscle cell hetero-- Rho-kinase stimulates rat penile erection via a nitric oxide- geneity: patterns of gene expression in vascular smooth independent pathway. Br J intercellular communication in the modulation of vasomotor Pharmacol 2003;138:287-90. The endoplasmic reticulum: a multifunctional tial for relaxation of receptor-triggered smoothmuscle con-- signaling organelle. J Biol guanylate cyclase-coupled receptor in the penile corpus Chem 1994;268:12925-32. Biochem Biophys Res pathophysiology of vascular signaling controlled by cyclic Commun 1998;246: 570-7. Prostaglandins Leukot Essent potent, selective, non-emetic and orally active phosphodies-- Fatty Acids 2000;62:137-46. Am J Physiol Ca2+- and swelling-activated Cl- channels in alpha1-adre-- Heart Circ Physiol 2001;281:H552-8. Ca2+-acti-- impairment in a rabbit model of vasculogenic erectile dys-- vated Cl- channels in corpus cavernosum smooth muscle: function. Molecular dissection of nucle-- olin’s role in growth and cell proliferation: new insights. Various reviews type 2 diabetes mellitus, hypertension, and lipid of valuable reference include: Hidalgo-Tamola et abnormalities, all of which contribute to cardiovascular al. MetS, which is also called insulin re-- Diabetes mellitus is a common chronic disease, sistance syndrome or syndrome X includes glucose affecting 0. The MetS has been deined by remained at 20-25%, irrespective of whether the several expert groups including World Health Or-- clinic is endocrine-based or andrology-based[8;9]. This Since the presence of the MetS independently in-- wide variation of the prevalence may be attributed to dicates increased risk of cardiovascular disease, Comittee 13. In large cross-sectional domain in a cross-sectional survey of 3921 Cana-- analysis, Laaksonen et al. The presence of diabetes (odds ratio of declining T levels in MetS, suggesting an inverse 3.
Other adjuvant techniques added to the successful development of sex therapy as a multidisciplinary Many components of contemporary sex therapy started to appear practice (e. While all sex therapies espouse to improve sexual the emergence of various conceptualizations and psychotherapeutic functioning, their therapeutic goals may be narrow or broad, their treatments for sexual dysfunction. Beginning with traditional conceptualization of sexual dysfunction diferent, and their techniques psychoanalysis, which laid the foundation for sex therapy following diverse. Earlier understandings of sexual dysfunctions ofen included unconscious conficts that were perceived to be responsible for a broader issues relating to the maintenance of marital relationships and person’s sexual dysfunction. By the 1950s, however, common sexual the attribution of all types of neuroses to internal unresolved sexual disorders that claimed the attention of clinicians focused specifcally on conficts [2]. Other key disorders of focus were researching average people that did not exhibit sexual dysfunction. Tey labeled conceptualized based on the deviation from what was thought to be deviations from the response cycle as sexual dysfunctions (hypoarousal normal or typical sexual functioning. It has been stated of Masters and Johnson that “someday the world will recognize that these two people have made *Corresponding author: Lauren M. Reprod Sys extremes of psychoanalysis (which looked beyond the sexual symptom Sexual Disorders 1:109. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted the presenting sexual symptom). Kaplan’s development of the ‘new sex use, distribution, and reproduction in any medium, provided the original author and therapy’ is an example of a treatment that integrated both behavioral source are credited. Tese infuences may have included destructive as a moral phenomenon, stemming from Victorian principles, which attitudes exerted by parents or other power fgures, both in and outside asserted that sexual activity should be solely a means for procreation the family. Freud carried on the work of sexologists of his time, such as the clients’ lack of insight into their distorted assumptions. Te goal Kraf-Ebing, Hirschfeld and Ellis, by discussing the role of sexuality of psychoanalysis, then, was to rid the patient of their unformed or in health and by working to move sex from the moral domain to the unconscious irrational expectations. Freud theorized that sexuality played a signifcant part in the development of general mental illness. He, therefore, played both Under this theoretical orientation, sexual interest or desire can a direct and indirect role in the sexual reform movement by asserting be considered in two ways: 1) the physiological response of sexual that sexuality plays a large role in all individuals’ mental health [3]. According to Bieber, the object of psychoanalysis is the remediating sexual dysfunction, and some of his theories were largely person’s afective and interpersonal desire for intimacy. He divides discredited, Freud’s work was foundational in creating an atmosphere sexual disorders into two categories: (1) interpersonal disorders which amenable to the exploration of sexual disorder and for the subsequent arise from adverse parental reactions to the child (e. His work has permeated most aspects or competition), and (2) prohibitive disorders arising from parental of modern thought and consequently still has considerable infuence on prohibitions towards masturbation, sexual curiosity, exploratory sexual psychotherapy in general. Te most common sexual disorders included difculties falling in love, beginning and maintaining romantic or Freudian psychoanalysis sexual relationships, sustaining an efective marriage, opposition to Conceptualization of sexual disorder: Te theoretical foundation marriage, and fear or anxiety related to having children or becoming a of traditional psychoanalysis is based on the assumption that sexual parent [9]. Postpartum reactions are also included as sexual disorders disturbances arise from an individual’s history, specifcally their and can be experienced by males or females. Sexual symptoms include development through the psychosexual stages and the Oedipal spousal alienation, changes in sexual patterns such as increased Complex [7]. Freud himself attributed much of his patients’ neurosis frigidity and/or impotence, the occurrence of extramarital afairs and to the expression of sexually-based confict between the impulses of adverse reactions to children, such as rejection or competition [9]. Each id and superego, and feelings that emerged between child and parent of these disorders is to be remedied through long-term psychoanalysis, (e. Tus, sexual dysfunctions in which the individual’s historically founded maladaptive beliefs about (and neuroses in general) were considered to have originated sexuality and sexual expression are corrected. T erapeutic techniques: Specifc treatment goals include Furthermore, problematic attachment and tension with one’s parents identifying and resolving various irrational beliefs and moral judgments were viewed as perpetuating the development of unhealthy sexual surrounding an individual’s expectations of their sexual experiences. One example involves persons whose parents were unresponsive to their T erapeutic techniques: Psychoanalytic treatment of sexual needs as children, who went on to develop maladaptive assumptions disorders consisted of long-term psychotherapy that aimed to uncover about their relationships with others. Trough the development of a the hidden intrapsychic conficts that were believed to be responsible for long-term, stable and warm relationship with the therapist, the client the development of adult sexual dysfunction. Terapeutic goals focused gains insight into healthy relationships, and thus is able to have a not on the symptoms of sexual dysfunction, but on the understanding corrective emotional and interpersonal experience. Symptom relief was thought to come is thought to help eradicate irrational beliefs about others. A second naturally with the resolution of underlying conficts, as it was assumed example involves a clients’ belief that it is morally wrong to practice that individuals who were able to confront their repressed conficts masturbation. However, if damage supposition was largely unsupported and that Freudian psychoanalysis occurs to the rapport between therapist and client, all therapeutic resulted in little improvement in patients’ sexual functioning [6]. In contrast, Ellis [6] argued that assumptions such as Freud’s, only Important considerations for the psychodynamic therapist include served to intensify client’s pathological beliefs about sexuality rather identifying his or her own irrational beliefs and biases. Furthermore, all topics brought forth by the sexual information to clients, 2) supervising activity/homework client need to be adequately addressed in order to prevent the client’s assignments, and 3) showing clients active ways to challenge their assumption that unaddressed topics are taboo or inappropriate to talk negative assumptions about sexuality. One approach allowed patients to participate in sexual activity as Post-freudian psychoanalysis soon as they felt capable, while requiring monitoring and altering of Conceptualization of sexual disorder: According to Bieber [9], sexual behavior based on experience of success or failure. Considering that psychoanalysis interact with each other in successful sexually intimate ways, and that can traditionally take many years, refraining from any sexual activities most sexual problems result from a lack of education or misconceptions while undergoing treatment may be particularly difcult for clients to about sexuality. Social psychology research that was being conducted in the 1970s Post-psychoanalytic contributions to sex therapy had demonstrated that attitude, emotions, and behavior are all closely linked and that a change in any one of these is likely to initiate a change Kinsey exposed the diverse sexual activities of ‘normal’ men in the others [16]. Terefore, by changing the behavior associated with (1948) and women (1953), in a time where there was no biological typical sexual encounters, individuals may also develop more positive understanding of sexual urges or physiological processes involved in attitudes towards sexual experiences. Te laboratory-based research of Masters efort to change a client’s attitude or “sexual value system”; a change and Johnson that burgeoned in the late 1960’s, complimented Kinsey’s in attitude is seen as a by-product of the change in behavior [16]. Researchers such as Kinsey, and Masters and combination of these brief and solution-focused methods was most Johnson set out to examine the sexual behavior of typical people, but efective [5,19]. Additionally, Schover and Leiblum [13] have suggested “any study exploring what is normal, is by defnition defning what is that behavioral techniques for sexual dysfunction were perhaps the not” [8]. Terefore, it soon became clear that there was a need to defne most efective psychotherapy of this time. One of the most commonly used behavioral techniques in sex By the 1970’s the Sexual Revolution was in full swing, bringing with therapy is that of systematic desensitization. In this technique, the it a surge of clientele who were eager to improve and even perfect their sexual relationships [13]. Many believed that sexual gratifcation was therapist and client work together, creating a list of anxiety provoking available to all individuals if only they sought direction to attain the sexual experiences. Te research of Masters and Johnson [14] Te list is to only include experiences in which the client engages in, or was so well publicized that self-help books and magazines articles soon hopes to be able to engage in (irrelevant or unrealistic scenarios do not provided the education necessary for clients to start asking questions need to be included) [16]. Te client is led into a relaxed state using deep about how to enrich their sexual lives [1]. Te 1970’s became a time for muscle relaxation or pharmaceutical treatment, and the stimuli are then the development and fourishing of many types of sex therapy. Te active component behind systematic desensitization is pairing “a response antagonistic to anxiety…in the Behavioral and directive therapies presence of anxiety-evoking stimuli so that it is accompanied by a complete or partial suppression of the anxiety response [20]. Te bond Conceptualization of sexual disorder: Afer establishing the between these responses is then weakened and the anxious response components of the “normal” sexual response cycle, Masters and Johnson associated with sexual stimuli is eventually extinguished [20]. Typically laid the foundation for modern sex therapy with the publication of their book Human Sexual Inadequacy [15]. Te use of imaginal emphasis on cognitive and behavioral approaches to psychotherapy exposure rather than in vivo exposure can actually be more efective, that proved to be of much shorter therapeutic duration than traditional because imaginal exposure is conducted in the therapist’s ofce under analytic approaches [8,13]. Emphasis was placed on the non-biological his or her supervision, while in vivo exposure occurs in the home, in factors present in the development of sexual dysfunction. As anxiety was entirely on the sexual symptoms, rather than the broad and past- decreases in these sessions, it is assumed that sexual desire is reciprocal oriented relational issues that were the focus of psychoanalysis. Furthermore, the act of receiving instructions from the Common sexual dysfunctions were classifed based on deviations therapist frees the client from any negative thoughts or moral judgments from the ‘normal’ sexual response cycle [14] and included erectile that they may have toward themselves [22]. Instead, the individual is dysfunction, premature ejaculation, pain associated with intercourse viewed as being a ‘good’ and compliant patient. Te development of sexual disorders was purported to intercourse, he may be instructed to engage only in sensual activities occur because sexual encounters are regarded as anxiety provoking that don’t require an erection. While anxiety addressed in psychoanalysis originated instructions, his anxiety is alleviated. Masters and practice, which is ofen employed in conjunction with other behavioral Johnson considered the underlying cause of one’s anxiety as largely techniques. Couples are encouraged to T erapeutic techniques: While it is accurate to categorize the participate in sensual activities such as being naked with one another, Masters and Johnson method as behavioral, it was actually the frst or exploring acts of foreplay, but are instructed not to engage in anxiety method to integrate both educative and directive components into provoking acts until the completion of the desensitization process. Tis was a fundamental change from Terefore, the patient is able to learn that sensual experiences can be the traditional psychoanalytic orientations which viewed humans enjoyable without the constant pressure to ‘perform’.
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Priapism associated with concurrent of verapamil gel to smoking weed causes erectile dysfunction cheap cialis with dapoxetine 30 mg with visa the penile shaft fails to statistics for erectile dysfunction order cialis with dapoxetine infiltrate the tunica use of phosphodiesterase inhibitor drugs and albuginea erectile dysfunction medication patents cheap 60mg cialis with dapoxetine amex. Visual erotic stimulation test for initial screening of psychogenic erectile dysfunction: a reliable McMahon C G erectile dysfunction needle injection video buy line cialis with dapoxetine, Stuckey B G A, Andersen M et al. Sexual 2004;29(6):640 dysfunction after radical prostatectomy: Prevalence, treatments, restricted use of treatments and distress. Relapse prevention strategies and 2004;29(6):631 techniques with erectile dysfunction. Clinical trials of sildenafil citrate (Viagra) demonstrate no increase Melman A, Bar-Chama N, McCullough A et al. The first human in risk of myocardial infarction and cardiovascular trial for gene transfer therapy for the treatment of erectile death compared with placebo. Ann Clin design results and analysis of drug treatments for Psychiatry 1990;2(2):93-101. Intracavernous sulfate, and growth hormone levels in ambulatory papaverine/phentolamine-induced priapism can be accurately men. The effect of changes in adiposity on testosterone levels in older Meyhoff H H, Rosenkilde P, Bodker A. Non-invasive men: longitudinal results from the Massachusetts Male management of impotence with transcutaneous nitroglycerin. Effect of Casodex on sleep- of sexual dysfunction associated with antidepressant related erections in patients with advanced prostate cancer. Current and Future Strategies for Preventing and Managing Erectile Dysfunction Mulhall J P, bdel-Moneim A, Abobakr R et al. Improving the accuracy of vascular testing in impotent men: correcting hemodynamic alterations using a Montorsi F, Briganti A, Salonia A et al. Improved Intracavernosal forskolin: Role in management of minimally-invasive assessment of penile haemodynamics: the vasculogenic impotence resistant to standard 3-agent combination of colour Doppler sonography and injection- pharmacotherapy. Brain activation patterns hardness: a unifying factor for defining response in the during video sexual stimulation following the administration of treatment of erectile dysfunction. Effect of yohimbine trazodone on psychogenic impotence: a randomized, double- Muneer A, Ralph D J, Minhas S. Sildenafil (Viagra) for male erectile dysfunction: a meta-analysis of clinical trial Munoz M, Bancroft J, Beard M. Rev Endocr Metab Disord relation to age and in comparison with normal 2005;6(2):85-92. Int J Impot Res dysfunction in men 40 to 69 years old: results from a 2005;17(3):291-292. Flutamide administration at 500 mg daily has similar effects on Moreira E D, Lisboa Lobo C F, Villa M et al. J Androl correlates of erectile dysfunction in Salvador, northeastern 2004;25(4):630-634. Intracavernous injection of prostaglandin E1 is effective in patients Morley John E, Kaiser Fran E. Vellas, with erectile dysfunction not responding to Bruno (Ed); Albarede, J 1992;-L(Ed):1992-165. Journal of Vascular & in the treatment of sexual dysfunction induced by Interventional Radiology 2000;11(8):1053-1057. Lancet 1999;353(9155):840 testosterone after 3-month luteinizing hormone- releasing hormone agonist administered in the Narayan P, Trachtenberg J, Lepor H et al. A dose-response neoadjuvant setting: implications for dosing schedule study of the effect of flutamide on benign prostatic hyperplasia: and neoadjuvant study consideration. Transdermal and topical help for sexual problems after prostate cancer treatment: A pharmacotherapy for male sexual dysfunction. Epidemiology of external vacuum device in the management of erectile erectile dysfunction in four countries: cross-national study of the dysfunction. Drugs Aging treatment and monitoring of late-onset hypogonadism in males: 2002;19(3):217-227. Depression, antidepressant therapies, and erectile dysfunction: clinical trials Ozbek E, Yurekli M, Soylu A et al. The role of of sildenafil citrate (Viagra) in treated and untreated patients adrenomedullin in varicocele and impotence. Erectile Dysfunction and Comorbid Depression: Prevalence, Treatment Strategies, and Associated Medical Conditions. J Indian Med Assoc study of male sexual disorders: The neurophysiological 2000;98(12): assessments, anxiety-depression levels, and response to fluoxetine treatment [10]. The role of endothelial dysfunction in the pathophysiology of Pagani E, Glina S, Puech-Leao P et al. Anxiety and high plasma erectile dysfunction in diabetes and in determining catecholamines do not impair pharmaco-induced erection of response to treatment. Altered sexual treatment in 52 patients with chronic function and decreased testosterone in patients receiving myeloproliferative diseases. General quality dysfunction in married impotent patients: interrelationship with of life 2 years following treatment for prostate cancer: anthropometry, hormones, metabolic profiles and lifestyle. The role of prolactin levels in the sexual activity of married men with erectile dysfunction. Sexuality and intimacy following radical prostatectomy: Patient and partner perspectives. Comparison of effect on erection between vacuum constriction devices and intra- Pescatori E S, Silingardi V, Galeazzi G M et al. Asian J Surg Audiovisual sexual stimulation by virtual glasses is 1997;20(2):162-166. The PsychoedPlusMed approach to erectile dysfunction treatment: the impact Parazzini F, Menchini Fabris F, Bortolotti A et al. Frequency of combining a psychoeducational intervention with and determinants of erectile dysfunction in Italy. Sildenafil increases of moclobemide and doxepin in major depression with ocular perfusion. The Scandinavian Prostate Cancer Group Study: The case for conservative management. Comparison of moclobemide with selective serotonin reuptake Parsons J K, Marschke P, Maples P et al. Eur Neuropsychopharmacol 2000;10(5):305 sparing radical retropubic prostatectomy. The efficacy Aldosterone antagonism: An emerging strategy for and complications of salvage cryotherapy of the prostate. The management on retinal blood flow and flicker-induced retinal vasodilatation of impotence in diabetic men by vacuum tumescence in healthy subjects. Oral terbutaline in the management of A, Briganti A, Barbieri L, Zanni G, Surdi N, Cestari A, pharmacologically induced prolonged erection. Evaluation of Efficacy and Safety of Oral Mesylate Phentolamine for the Treatment of Erectile Pommerville P J. Re-dosing of prostaglandin-E1 versus prostaglandin Radomski S B, Herschorn S, Rangaswamy S. Topical E1 plus phentolamine in male erectile dysfunction: a dynamic minoxidil in the treatment of male erectile color power Doppler study. Switching to moclobemide to reverse and Safety of Once-a-Day Dosing of Tadalafil 5 mg and 10 mg fluoxetine-induced sexual dysfunction in patients with in the Treatment of Erectile Dysfunction: Results of a depression. Switching to moclobemide to reverse fluoxetine-induced sexual dysfunction in Pouaha J, Martin S, Reichert-Penetrat S et al. Sildenafil in the treatment of erectile fluoxetine-induced sexual dysfunction in patients with dysfunction. The efficacy of tadalafil in improving sexual satisfaction and Rhoden E L, Estrada C, Levine L et al. The value of pituitary overall satisfaction in men with mild, moderate, and magnetic resonance imaging in men with hypogonadism. Clin Psychol Rev still the gold standard for treatment of erectile dysfunction in 1996;16(6):497-519. Rosen, Raymond C (Ed); Leiblum, Sandra Risa (Ed) 1992;(1992):378 Roach M, Winter K, Michalski J M et al. Penile bulb dose and impotence after three-dimensional conformal radiotherapy for Rosenthal B D, May N R, Metro M J et al.
A large series (3 erectile dysfunction age group order cialis with dapoxetine 20/60 mg fast delivery,000 patients) from Iran describes an exceedingly low transfusion rate (3 erectile dysfunction webmd cheap cialis with dapoxetine 30 mg line. Reading the peer-reviewed literature erectile dysfunction treatment vitamins best cialis with dapoxetine, case series tend to erectile dysfunction treatment aids order cialis with dapoxetine with mastercard mirror daily practice, while randomized trials may differ substantially. Urodynamic outcome is usually excellent, with an observed increase in Qmax from 8. Pressure-flow studies, performed before and after surgery, confirm complete relief of outlet resistance following surgery and a significant decrease in detrusor hypertrophy (62). Some new evidence has been recently produced, but it hardly changes what we already know about the procedure. We have enough new series on simple prostatectomy to test such a hypothesis, but the way complications are considered varies so much that comparison is difficult. A recent series from the Bavaria region of Germany provides data from 868 patients in 55 different institutions (64). The development of the Clavien classification system, introduced in 1992, helped to standardize the evaluation of complications in surgical clinical trials (65). Data on complications of simple pros- tatectomy according to the Clavien classification have been only recently available. Oranusi and co-workers report data from a retrospective analysis of a patient series operated on in Southeast Nigeria, with an overall complication rate of 40. Complication rates for the different Clavien grades are summarized in Table 7 (66). Complication rates of open transvesical prostatectomy according to the Clavien- Dindo classifcation system. Whether such an outstanding improvement is really needed in our daily practice is an open question that goes beyond the scope of this discussion. A similar study from Iran showed a mean prostate volume of <50 g, showing the limitations inherent in the randomized design of the study (69). Recent cases series of open prostatectomy may offer a more reliable perspective of its clinical outcome in the current medical environment. A recent single- centre series from Turkey shows that open prostatectomy is now performed in larger prostates (mean prostate volume 73. Open prostatectomy can still be considered a standard procedure for glands greater than 100 g (70). Consistent data were published from Japan where Takeuchi and co-workers compared the prostate volume of patients undergoing open prostatectomy in the period 1987–1990 and 1991–1994, showing an increase in the average prostate volume. In their opinion, subcapsular prostatectomy could be indicated in 18% of patients in contemporary series (71). Some of the new less-invasive modifications proved to be as effective as open surgery, but simple prostatectomy itself cannot be ignored and remains a part of the urologist’s armamentarium (70,73). Laparoscopic and robot-assisted laparoscopic surgery has recently challenged open prostatectomy, and the feasibility of these approaches has been confirmed. This is clearly a preliminary series, and it is difficult to compare these data with those from other series, as operative time may decrease with increasing experience, although the long catheterization time remains diffi- cult to explain. Another series from Italy confirms the feasibility of the procedure but also the long operative time (median, 180 min), the short hospital stay, and the long catheterization time (7. Single-port procedures have also been described, showing that the technical challenges have been solved, although no patient series is available–only case reports (75). The first task when a new procedure is proposed is its feasibility–that is, the possibility to complete the operation (without conversion to open surgery for laparoscopic procedures) with reasonable rates of peri-operative complications and good short- and mid-term clinical outcomes. Once feasibility is proven, other issues become important, such as operative time, hospital stay, and catheterization time (for simple prostatectomy). Well, the technique is feasible, although operative time remains, on average, long. But the question remains, should surgeons be trained in open suprapubic or retropubic prostatectomy to be able to perform it laparoscopically, or can residents be trained directly with the robot? Complete removal of the hyperplastic tissue seems to guarantee the best long-term clinical outcome in patients with large prostates. Training of our residents in the management of large prostates remains a priority and a challenge independent of surgical technique. The presence of coexisting conditions such as large bladder stones, inguinal hernias, and large blad- der diverticula may dictate an open surgical approach. Although most of us would never consider such a complication, the Chinese paper implies this is a possibility. The 532-nm wavelength is selectively absorbed by Hb, which acts as an intracellular chromophore. The short optical penetration that is associated with this wavelength confines its high-power laser energy to a superficial layer of prostatic tissue that is vaporized rapidly and hemostatically with only a 1 to 2 mm rim of coagulation. The thin coagulation zone arises as a result of the quasi-continuous emission characteristics of the 532-nm laser. Typically, continual irradiation of a single point causes heat to diffuse in to deeper tissue layers, creating coagulation wherever there is enough convection thermal energy for protein denaturation but insufficient energy for vaporization. Patients experienced a significant improvement in Qmax (142%) by 24 hours post-operatively. More than 30% of patients were sent home without a catheter; those with post-operative catheters had them removed in a mean of 14 hours. Reported morbidities were generally minor: 8% of patients experienced mild-to- moderate dysuria lasting more than 10 days, 8% had transient hematuria, and 3% had post-operative retention. Among the 56 men who were potent prior to the procedure, 27% experienced retrograde ejaculation, but none of them experienced impotence. The mean pre-operative prostate volume was 101 mL, with a mean operative time of 123 minutes. No transfusions were required, nor was there evidence of post-operative hyponatremia. Of these patients, 29 were being treated with ongoing oral anti-coagulation or had a severe bleeding disorder. No major compli- cations occurred during or following the procedure and no blood transfusions were required. Two patients required re-operation within 12 months due to recurrent urinary retention. Eight (33%) of these patients had a previous myocardial infarc- tion, seven (29%) cerebrovascular disease, and seven (29%) peripheral vascular disease. No patients developed clinically significant hematuria post-operatively and none developed clot retention. Significantly more energy and time was used for lasing per gland size in these patients (104). Of the patients, 31 (19%) were on warfarin, 101 (62%) were on acetylsalicylic acid, 19 (12%) were on clopidogrel, and 11 (7%) were on two or more anticoagulants. Three of these patients (50%) required blood transfusion and one (17%) required re-operation. Interim 24-month follow-up data found that the rate of intra-oper- ative bleeding (3% vs. Length of hospitalization, length of catheterization, and adverse events were lower in the laser group. Peri-operative morbidity and symptom improve- ment was equivalent in the groups at 6 months (107). Hospitalization stay and catheterization time were significantly shorter in the laser group. Photoselective vaporization of the prostate was performed in antegrade fashion through a suprapubic cystotomy at 40, 80, and 120 W settings for 3 distinct firing periods (5,10, and 20 seconds) at unique locations in the prostate. Moreover, the higher power provided more efficient vaporization with less hemostasis, and, as a result, utilization of a lower-power coagulation setting is important in achieving hemostasis. The increased efficacy of the 120-W laser device was accompanied by a higher bleeding rate and a slightly deeper coagulation zone. Outcomes reviewed included peri-opera- tive data, complications, and functional outcomes. Another modifi- cation is an added coagulation power mode due to the intermittent pulsing and continuous flow of a room temperature irrigant over the tip. Early level 4 evidence with the 180-W laser with the actively cooled fibre demonstrates it to be extremely efficient, and, in the hands of experienced users, it appears to have equal efficacy and safety (116). With the new aqueous cooled fibres and the 180-W laser system, power to 180 W can be utilized.