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Modern Trends In The Management of Erectile Dysfunction by Hussein Ghanem, MD
For centuries, men suffered in silence. Erectile dysfunction (ED or impotence) has been present since creation of man and there was never a satisfactory treatment. The prevalence of this devastating disorder increases gradually with age and is much higher than expected.
Worldwide, more than 100 million men are estimated to have some degree of ED. ED is estimated to affect as many as 30 million men in the US. Surveys in the United Kingdom and France have estimated the overall prevalence of moderate-to-complete ED to range from 30% to 40%.
Given such shocking statistics one can only wonder how come the public awareness is so limited in this area. Not only are the patients uninformed about the availability of treatment to almost every case of impotence, but also physicians are unaware of such modern diagnostics & therapeutics for this problem. Viagra (Sildenafil) and more recently Vardinafil (in clinical trials) are excellent medications but are certainly not the only tool.
Management of erectile dysfunction requires a thorough understanding of the various causative factors whether psychogenic or organic, knowledge and experience in requesting investigations -as needed- as well as interpreting results wisely. Empathy and respecting the couple's preferences in treatment are basic qualities of any effective Andrologist or sex therapist.
The patient's needs are best served through what is known as a goal-directed
approach. A proper sexual & medical history as well as a focused physical examination will allow us to reach a diagnosis in most cases. Investigations are ordered if deemed necessary to confirm a certain condition or direct future treatment. Patients should not be subjected to multiple, expensive & invasive diagnostic procedures if this was not expected to alter the treatment plan. This doesn't only save patients unnecessary expenses but also saves them from additional trauma resulting from what is referred to as 'false positive results'.
A vivid example of idiopathic (doctor induced) problems is Adam's story. Adam is just a nickname I chose to refer to numerous patients with this condition. Adam has always been a real stud who would get full rigid erections on watching any sexually provocative scene. His erections have always been easily maintained and long lasting. He loved his fiancé and has been dreaming about their wedding night. He was not involved in premarital sex because of his culture & religious upbringing. However, he always
developed a full erection whenever they touched hands.
At last they married and Adam approached his wife. Both were tired from a week of preparation and a night of celebration. The lust gradually turned into anxiety about how to complete the job. Disaster, the strong erection gradually softened then was lost completely.
Adam overreacted, filled with shame he didn't accept his wife's reassurance that everything would be OK. Next morning he woke up with a strong morning erection but still decided to visit a doctor to get to the bottom of this unexpected incident.
Such a case is clearly psychogenic and would have resolved easily with counseling, reassurance and empathy. Unfortunately, Adam stepped into a busy clinic where he waited for an hour then an authoritative physician ordered some tests. The results: Penile venous leak, an organic vascular disorder. Treatment plan: Penile venous ligation surgery. A very clear yet common example of unnecessary prescription of investigations, false positive results, dogmatic interpretation of results, insensitivity to the patient's
concerns and faulty medical advice.
At this stage some patients have the insight to get a second opinion but unfortunately many would believe that they do have a physical problem and go ahead with needless surgery or frequently divorce.
Many organic factors could be also involved in the development of impotence. Organic impotence could be related to vascular risk factors, neurological factors, hormonal factors, medical illnesses or drug induced. The general advice to preserve potency and health is to avoid smoking, drugs & alcohol, and to control general medical disorders mainly high blood pressure, diabetes and high cholesterol. Exercise and healthy living (avoiding excess fatty foods & dairy products) are also advisable.
Therapy for erectile dysfunction is generally classified into first line, second line, and third line treatments.
Treatment decision-making
. 1st line therapy
Oral erectogenic agents e.g. Viagra and new medications in clinical trials
Vardenafil & Cialis
Vacuum devices
Couples/sexual therapy
. 2nd line therapy (Local treatments)
Intraurethral alprostadil
Intracavernosal self injections
. 3rd line therapy (Surgery)
Penile prosthesis
Finally, the general public as well as physicians must be made aware that at the beginning of the third millennium, Impotence might be the first disorder that could almost always be reversed by proper treatment. There is certainly room for improvement. Research is going on in several areas to produce more specific & effective drugs, simpler delivery systems for local medication, and even gene therapy to improve a person's responsiveness to sexual stimulation. This article appears in the following topics:
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