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The evaluation and treatment of male sexual dysfunction has evolved into a more extensive evaluation. This new evaluation should now include evaluation of hypogonadism, ejaculatory function, lower urinary tract symptoms, and depression. The evaluation may be readily accomplished with the use of questionnaires. The management of these entities is discussed, including the novel phosphodiesterase-5 for male erectile dysfunction. Inclusion of the partner in the evaluation and management scheme will provide added benefit and may produce a better outcome.
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PMID:Erectile dysfunction: etiology, evaluation, and treatment options. 1504 84

Management of hypertension in the elderly should take into account, in particular, the possible negative impact of antihypertensive drugs on the patient's quality of life, the deterioration of which may result in a loss of independence and reduced treatment compliance. Quality of life is recognised as a multifactorial variable and can be subdivided into different domains (symptomatic well-being, emotional, physical, work-social, cognitive and life satisfaction), which are generally explored by means of specific questionnaires or scales. When evaluating elderly patients with hypertension, it is necessary to pay particular attention to specific domains such as symptomatic well-being, cognitive function, activity and sexual function, which have already been diminished by the age itself and the disease. The results of some large trials that specifically evaluated the quality of life effects of long-term therapy of hypertension in older people (Medical Research Council's [MRC] Trial of Hypertension in Older Adults, Systolic Hypertension in the Elderly Program [SHEP], Systolic Hypertension in Europe [Syst-Eur], Study on COgnition and Prognosis in the Elderly [SCOPE]) have shown that antihypertensive treatment as a whole either had no negative impact on quality of life, or even produced some improvement. The question whether some classes of antihypertensive agents are more beneficial or harmful than others in terms of quality-of-life effects remains largely unanswered. Results from long-term trials suggest that treatment with diuretics is not associated with adverse effects on quality of life. Nevertheless, chlortalidone and other diuretics have been more often associated with sexual dysfunction in men, including decreased libido, erectile dysfunction and difficult ejaculation, than other drug classes. Nonselective lipophilic beta-adrenoceptor antagonists, such as propranolol, have been reported to exert some negative effect on quality of life and have been associated with depression, impairment of memory function and adverse effects such as erectile problems. A less unfavourable impact has been described with beta(1)-adrenoceptor antagonists and those with vasodilating properties. Calcium channel antagonists have generally been associated with a positive effect on quality of life, although some trials have shown high rates of adverse effects and withdrawals, particularly with first-generation dihydropyridines. Concern has also been raised about the potential for adverse cognitive effects associated with the use of calcium channel antagonists, but studies on this topic are not univocal. ACE inhibitors have usually been reported to exert favourable effects on quality of life. These drugs seem to be effective in maintaining, or even improving, cognitive function through mechanisms other than blood pressure control. In addition, a number of studies reported favourable impact of ACE inhibitors on sexual function. Angiotensin II receptor antagonists have been associated with good tolerability and low withdrawal rate. They have been demonstrated not to interfere with or even improve cognitive function as well as sexual performance. Although no class of antihypertensive agents presents a clearly superior effect over the others in terms of quality of life, the current impression is that ACE inhibitors and angiotensin II receptor antagonists may offer some advantage, at least in regard to effects on cognitive function and sexual activity.
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PMID:Effect of antihypertensive agents on quality of life in the elderly. 1508 40

Impairment of erectile function compromises quality of life in millions of men and their partners, many of whom prefer to suffer in silence. It is important to maintain an elevated index of clinical suspicion in patients with erectile dysfunction (ED) risk factors (e.g. hypertension, diabetes, coronary heart disease). There remains a high rate of voluntary discontinuation of therapy associated with most treatment modalities. Since the introduction of sildenafil, a greater awareness and openness regarding the epidemiology and treatment of male erectile dysfunction has emerged. The development of newer and potentially more efficacious phosphodiesterase type 5 (PDE5) inhibitors will serve to treat an even greater number of patients, allowing once daily and more convenient dosing. An increased understanding of the physiological principles of penile erection has allowed the development of novel oral pharmacological therapies. The new agents offer a potential benefit in a broader range of patients and clinical situations. They may provide a more acceptable alternative than other more invasive options (intracavernosal/urethral injection, implant surgery). The dopamine agonist apomorphine acts on the central control of penile erection to allow a sublingual preparation to produce a prompt response. It is not contraindicated in patients on nitrate medication for coronary artery disease, or in patients with depression or on antidepressants. As with any other treatment, the clinician's responsibility in the care of ED patients does not end with the writing of a prescription. Adequate education and follow-up are needed to optimize the efficacy and safety of oral ED therapy. Furthermore, patients and their partners need to be advised that the agents are not effective in the absence of sexual stimulation. Communicating with both the patient and his partner in a discreet, non-judgmental manner that fosters the physician-patient alliance can facilitate the recognition and treatment of ED.
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PMID:Update on oral treatments for male erectile dysfunction. 1509 34

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 or vardenafil and at least 48 h after a patient uses tadalafil.
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PMID:Role of the cardiologist: clinical aspects of managing erectile dysfunction. 1511 89

Erectile dysfunction (ED) is a common condition with a significant effect on the quality of life. The prevalence of ED rises with increasing age and other conditions (hypertension, diabetes, ischaemic heart disease, hypercholesterolaemia and depression). The MALES study is one of the largest epidemiological surveys to investigate the prevalence of ED. This study included 27839 patients spanning eight countries. In addition to the MALES study, we review the emerging link between lower urinary tract symptoms (LUTS), benign prostatic hypertrophy (BPH) and ED, including the effect of BPH treatment on sexual function. Preliminary data from the MALES II study shows a significant cascade effect in the treatment seeking behaviour and treatment adherence of patients taking sildenafil for ED. We explore the possible reasons behind the discontinuation of oral phosphodiesterase inhibitors prescribed for the long-term treatment of ED.
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PMID:Erectile dysfunction: an underdiagnosed condition associated with multiple risk factors. 1517 Dec 25

Following the landmark Massachusetts Male Aging Study (MMAS) that provided the first relatively unbiased study of the epidemiology of erectile dysfunction (ED), a number of additional studies were carried out in the U.S. and around the world. The studies vary in quality because they used different definitions of ED, different assessment instruments, different and sometimes biased sources of populations, inadequate response rates to questionnaires and interviews, cultural disparities in willingness to discuss sexual issues, and differing interpretations of the results. Nevertheless, the studies demonstrated similar levels of ED by age and an exponential rise with age. They also generally confirmed the conditions that correlated with ED in the MMAS, namely, diabetes, hypertension, coronary artery disease, prostate cancer therapy, and depression. These were exacerbated by cigarette smoking.
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PMID:Epidemiology of erectile dysfunction. 1514 84

A 25-year-old man with DSM-IV-TR Axis I social phobia and Axis II avoidant personality disorder and erectile dysfunction, presenting with depression, anxiety and insomnia, responded partially to extended release oral venlafaxine (75 mg/die for 6 weeks), but developed side effects and worsening symptoms when dose was increased to 150 mg/die; he responded to a combination of 75 mg/die venlafaxine and 4 mg/die reboxetine and improved on most of his symptoms.
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PMID:A case of social phobia and avoidant personality disorder with erectile dysfunction successfully treated with venlafaxine and add-on reboxetine. 1519 7

Erectile dysfunction (ED) and depression are highly prevalent and frequently comorbid. Sildenafil effectively treats ED in men with depression and in men taking antidepressants. We evaluated the efficacy of sildenafil in men with depression in remission and ED. Patients with a history of ED when major depressive disorder (MDD) was diagnosed, which persisted after MDD was treated to remission, were randomized to 12 weeks of treatment with sildenafil (50 mg, flexible) or placebo. Efficacy was assessed using intercourse success rates, a global efficacy question (Has treatment improved your erections?), the International Index of Erectile Function (IIEF) and Life Satisfaction Checklist (LSC). By week 12, intercourse success rates were significantly higher among sildenafil- (74%) compared to placebo-treated patients (29%; P=0.0001). About 83% and 34% of sildenafil- and placebo-treated patients, respectively, reported improved erections (odds ratio=9.4, P=0.0001). IIEF scores in the sildenafil group (n=83) were significantly improved compared to those in the placebo group (n=85; P <0.0001). LSC sexual life item improved significantly among sildenafil- versus placebo-treated patients. The most frequently reported adverse events were transient and mild-to-moderate. Sildenafil is an effective and well-tolerated treatment for ED in patients with a history of ED at the time of MDD diagnosis, and which persisted after the MDD was treated to remission.
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PMID:Efficacy of sildenafil citrate (Viagra) for the treatment of erectile dysfunction in men in remission from depression. 1520 65

Regarding the aetiology of erectile dysfunction, beside numerous organic causes in many cases psychological factors play an important role. The pathophysiological mechanisms underlying the so-called psychogenic erectile dysfunction are not yet understood. Based on a neurobiological approach to psychogenic erectile dysfunction, polysomnographic investigations were carried out with the aim of identifying possible alterations of the sleep EEG. 24 male patients with psychogenic erectile dysfunction without detectable organic factors or other mental disorders were studied in the sleep laboratory, as well as an age-matched control group without sexual dysfunctions. Beside a reduction of sleep efficacy, the most prominent finding was a shortening of REM latency in the patients compared to the controls. Moreover, spectral analysis revealed a reduced theta power for all sleep stages and a reduced delta power for stage II and slow wave sleep in the patients. The findings support the point of view that psychogenic erectile dysfunction is an organic disorder of the brain. The sleep EEG abnormalities may reflect dysregulations in limbic structures which are suggested to be involved in the pathophysiology of sexual dysfunctions. As these alterations had also been reported for other mental disorders, particularly depression, they appear to be non-specific biological abnormalities for different psychiatric syndromes, including psychogenic erectile dysfunction.
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PMID:Sleep investigations in erectile dysfunction. 1550 27

Our objective was to determine factors associated with sexual problems in a sample of HIV-seropositive gay male clinic patients. Using a cross-sectional survey design a volunteer sample of 78 outpatient HIV-seropositive gay male service users completed a self-report questionnaire. This examined sexual problems, their perceived causes and associated factors including demographics, health status, sexual behaviour, self-justifications for sexual risk-taking and mood state (Hospital Anxiety and Depression Scale). Fifty (69%) of 78 HIV-positive gay men reported one or more sexual problems. Erectile dysfunction (ED) was reported by 38% rising to 51% in the context of trying to use condoms. Loss of interest in sex was reported by 41% and 24% experienced delayed ejaculation. The presence of sexual problems affected condom use in that 33 (90%) of the 37 gay men who had ED associated with condom use were inconsistent condom users in insertive sex compared to 28% of those not having this type of ED (P < 0.001). The presence of ED did not reduce the frequency of anal intercourse but those with ED associated with condoms were significantly more likely to have had receptive anal sex in the past three months (62%) compared to men without ED with condoms (38%) (P = 0.05). Risk cognitions such as wanting to lose oneself in sex, leaving responsibility for condom use to the active partner and perceptions that condoms interfere with pleasure were significantly more likely to be endorsed by those who report ED with condoms. Other factors associated with sexual problems included low T-cell counts (i.e. < 200). Psychological explanations were the most frequently cited causes of sexual problems, whether alone or in interaction with HIV disease itself, and combination therapy. A high incidence of sexual problems was found amongst this sample of HIV-positive gay men. Untreated sexual dysfunctions may contribute to sexual risk-taking and therefore HIV clinics need to address both issues. Further research is required to better understand the role of psychological factors, HIV disease itself and combination therapy in the incidence and treatment of sexual problems.
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PMID:Factors associated with sexual problems in HIV-positive gay men. 1553 58


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