Treatment of erectile dysfunction.

The evaluation and treatment of Erectile Dysfunction has evolved dramatically over the last 10 years thanks to the improvement of our understanding of the physiology of erection and the development of effective drugs to be taken "on demand" before intercourse. In addition, Erectile Dysfunction is now clearly recognized as a medical disorder. It is beyond the scope of this article to go into details about the physiology and pathophysiology of the sexual cycle and the different diagnostic procedures for evaluating erectile disorders. Rather, we will concentrate on the therapeutic options for managing erectile disorders after a brief review of the most recent concepts of erection physiology and diagnosis.

Erectile function disorders. Epidemiology, physiology, etiology, diagnosis and therapy

Erectile dysfunction is a common, age-dependent functional disturbance of men associated to various comorbidities. Interdisciplinary cooperation with neurologists in ca-ses of a suspected neurological aetiology and with psychiatrists in cases with normalorganic diagnostic findings is necessary. Hormone replacement and psychotherapy can cure certain patients. Oral pharmacotherapy is the most effective therapy for erectile dysfunction with the highest patient preference. Oral PDE-5-inhibitors(sildenafil, Tadalafil ( Cialis ) , Vardenafil ( Levitra )) are superior in effectiveness to centrally acting drugs (apomorphin, yohimbine). Local pharmacotherapy (MUSE, ICI) is a second line therapy in cases of failure or contraindications for oral pharmacotherapy. Vacuum therapy and operative procedures(penile implants) complete the therapeutic options of erectile dysfunction.

Prostate cancer and sexuality: implications for nursing.

In the United States, men aged 65 and older are at particular risk for prostate cancer. Treatments for prostate cancer may result in erectile dysfunction, which can affect the older man's sense of self as well as his relationship with his intimate partner. Research has shown a range of factors associated with sexuality for men who have had prostate cancer and their partners. The PLISSIT model can be applied to nursing assessment and intervention of sexuality and prostate cancer. Nurses must acknowledge the sexuality of older men and their partners and the potential effect that prostate cancer can have on this multifaceted aspect of their lives.

Molecular pathophysiology and gene therapy of aging-related erectile dysfunction.

Erectile dysfunction (ED) is a major public health problem that seriously affects the quality of life of patients and their partners. ED is mainly associated with vascular disease, diabetes, smoking, and radical prostatectomy, and its prevalence increases significantly with aging. Vasculogenic ED, specifically corporal veno-occlusive dysfunction (CVOD), is caused by the impairment of the relaxation of the smooth muscle in the penile corpora cavernosa and occurs in 2/3 of cases, whereas the less common neurogenic ED is due to a defective nitrergic neurotransmission triggered by the sexual stimulus, either at the central hypothalamic and spinal levels or at the penile nerves. Based on animal and cell studies, neurogenic ED is assumed to be caused mainly by: (a) an insufficient synthesis of nitric oxide (NO) due to a decrease in the levels of the penile neuronal nitric oxide synthase (PnNOS) or the impairment of its regulation by protein effectors (NMDA receptor, protein inhibitor of nNOS: PIN), occurring in the neuronal bodies or nerve terminals, or (b) a loss of the cells themselves by apoptosis caused by the induction of inducible NOS (iNOS) and the production of peroxynitrite. In contrast vasculogenic ED, although may involve endothelial damage and down-regulation of endothelial NOS (eNOS), appears to be mainly caused by the relative loss of smooth muscle cells and replacement by collagen fibers (fibrosis) that impairs tissue compliance. In this case, iNOS induction may not be deleterious, but a defense mechanism preventing excessive collagen deposition. Gene therapy to the penile corpora cavernosa of cDNAs expressing PnNOS or eNOS, or counteracting PIN, has been effective in ameliorating ED in the aging rat model that exhibits both neurogenic ED and CVOD. cDNA constructs for other genes involved in the control of penile erection have also been successfully tested. Gene transfer into the penis may soon translate to the clinic as a therapy aimed to cure the underlying conditions in ED, including fibrosis, as opposed to the facilitation of erection on demand offered by the current oral therapies. erectile dysfunction Phosphodiesterase type 5 inhibitors: a biochemical and clinical correlation survey.

Phosphodiesterase type 5 (PDE 5) is the major cGMP hydrolyzing enzyme in penile corpus cavernosum and is an important regulator of nitric oxide-mediated smooth muscle relaxation. The critical role of PDE 5 in penile erection and the recent availability of specific and potent inhibitors of PDE 5 have enabled the development of effective oral treatment strategies that have been widely accepted by both health-care professionals and the lay public. This article examines the correlation between the available biochemical and clinical data for the PDE 5 inhibitors Sildenafil Citrate ( Viagra ) (Viagra), Tadalafil ( Cialis ) (Cialis) and Vardenafil ( Levitra ) (Levitra).

New treatment options for erectile dysfunction. Pharmacologic and nonpharmacologic options

Erectile dysfunction is a medical condition that influences the sexual life of millions of men and women worldwide. Due to a large number of currently available drugs, the therapy of erectile dysfunction has changed profoundly during the last decades. The pharmacologic options are divided into initiators versus conditioners and central- or peripheral-acting drugs. Besides intraurethral and intracavernous application of prostaglandin E(1) (PGE(1), peripheral initiator)--a transdermal application is still in clinical testing--there are drugs for oral application. PGE(1), the vasoactive drug mainly used, was replaced by Sildenafil Citrate ( Viagra ) in first-line-therapy. PGE(1), administered intracavernosally or intraurethrally, is highly effective with success rates up to 90%, but the attrition rate due to personal inconvenience remains significant. Yohimbine is known as a central amplifier of erection and is useful in psychogenic and mild organic erectile dysfunction. Apomorphine, a central initiator of erection, amplifies erectile response as a central dopamine agonist in mild and moderate erectile dysfunction and starts acting 15-20 min after sublingual application. The phosphodiesterase type 5 (PDE-5) inhibitors sildenafil, Vardenafil ( Levitra ), and taldalafil are peripheral conditioners. Sildenafil, the most distributed oral agent worldwide, should be taken orally 60 min before sexual intercourse in combination with sexual stimulation. Sildenafil Citrate ( Viagra ) shows a high efficacy-safety profile with success rates for all etiologies between 50-80%. Paralleling nitrate-containing medication is an absolute contraindication. Vardenafil, another selective PDE-5 inhibitor with potentially higher selectivity and efficacy compared to Sildenafil Citrate ( Viagra ) was just approved. The data from the clinical trials show the same adverse events and success rates as sildenafil. Tadalafil ( Cialis ) , just launched as well, amplifies erectile function for up to 24 h, allowing the patient to engage in sexual activity for this period. Adverse events and success rates resemble those of the other two substances. If medical treatment fails, there are nonpharmacologic options such as the vacuum constriction device and penile implants. The vacuum device is a safe and effective option for well-selected patients. Penile implants, especially the inflatable ones, completely imitate the physiologic erection. Due to recent research, infection rates and mechanical failures were minimized. Therefore penile implant surgery is well accepted by the patients and their partners. Despite this wide variety of options, therapy of erectile dysfunction should be performed in an individually adapted way. The patient's exact history, physical examination, collaboration of medical disciplines and choice of therapy will offer all patients the possibility to achieve or regain a satisfying sexual life.

Advances in radical prostatectomy

In the western world, adenocarcinoma of the prostate is the most common malignant neoplasm of human males. In recent years, the incidence of the disease has increased dramatically in China. Surgery is an important treatment for prostate cancer. This article reviews the progress in radical retropubic and perineal prostatectomy, standard laparoscopic and robot-assisted laparoscopic radical prostatectomy. It covers the necessity, techniques and experience of surgery, nerve preserving techniques and erectile dysfunction, complications and outcomes, advantages and disadvantages of and comparison between various surgical approaches.

Hypogonadism and erectile dysfunction: the role for testosterone therapy.

The role of low testosterone levels in erectile dysfunction (ED) remains unclear. Both organic and psychogenic factors contribute to ED, with vasculogenic causes being the most common etiology. Approximately 10-20% of patients with ED are diagnosed with hormonal abnormalities. At the physiologic level, two second messenger systems are involved in mediating erections, one involving cyclic adenosine monophosphate (cAMP) and the other involving cyclic guanosine monophosphate (cGMP). PDE5 inhibitors such as Sildenafil Citrate ( Viagra ) promote the cGMP pathway, while alprostadil affects the cAMP pathway. Evidence is strong that, in animal systems, testosterone has direct effects on erectile tissue. However, although testosterone clearly has an impact on libido in humans, its effect on penile function is less clear. Evaluation of ED includes medical, sexual, and psychosocial history assessments, as well as laboratory tests to check for diabetes and hormonal abnormalities. Initial interventions should involve correction of potentially reversible causes of ED, such as hypogonadism. First-line therapy for other patients is typically oral PDE5 inhibitors, such as sildenafil, Tadalafil ( Cialis ) , or Vardenafil ( Levitra ). For patients who fail treatment with PDE5 inhibitors, local therapies such as intracavernous alprostadil are highly successful. Recent data also support the success of combination therapy with Sildenafil Citrate ( Viagra ) and testosterone. This opens the possibility of other combinations of testosterone and other treatments of ED. The ability to exploit multiple pathways in the physiologic processes leading to erection may help improve therapy for ED.