Male Sexual Function: A Guide to Clinical Management

From The New England Journal of Medicine
"A man shall cleave unto his wife: and they shall be one flesh" (Genesis 2:24) is the unambiguous biblical directive to married men: participate in and enjoy sexual intercourse. Those who could not do so were considered to lack power -- to be "impotent" -- a distinctly undesirable trait and a sign of weakness in a man, particularly a man considered to be a leader. Our forefathers knew this. When King David, the singer of psalms and slayer of Goliath, was dying, they called upon Abishag, a young Shunammite virgin, to attempt to restore his health. "And the damsel was very fair, and cherished the king, and ministered to him: but the king knew her not" (1 Kings 1:4); once she confirmed his impotence, David was through as a leader, and he was replaced. Thousands of years later, the problem of impotence was approached in a different way by Freud, who blamed male sexual dysfunction on emotional problems -- psychogenic impotence -- but psychotherapeutic intervention proved to be largely ineffective. Urologists were next in line. They attributed impotence to inadequate penile stiffening, devised penile prostheses, and discovered that papaverine and, more recently, alprostadil caused the penis to become engorged with blood and created an erection when injected directly into the corpora cavernosa. But penile pain was a deterrent to widespread acceptance of this treatment.

The recent decision to expunge the word "impotence" from the medical lexicon and replace it with "erectile dysfunction," or "ED," was intended to make it easier for men to talk about their sexual problems. But solving the mystery of the biochemical mechanism of penile erection was the pivotal advance. We now know the fundamentals: first, during sexual stimulation, the nitric oxide cascade generates the high levels of intracavernosal cyclic GMP needed for blood to be shunted into the cavernosal sinusoids to initiate and maintain an erection (tumescence); second, a decline in cyclic GMP mediated by phosphodiesterase type 5 causes the normal postcoital loss of erection (detumescence). This breakthrough rearranged the landscape of erectile dysfunction, for it led to the discovery and development of the phosphodiesterase type 5 inhibitor sildenafil, which has dramatically alleviated the plight of men with erectile dysfunction.

In editing Male Sexual Function, Mulcahy has taken note of this important development, but almost as an afterthought. The brief, enlightening chapter by Padma-Nathan and Giuliano extensively reviews intracavernosal physiology and the role of inhibitors of phosphodiesterase type 5 in stabilizing erectile function by maintaining the level of intracavernosal cyclic GMP. The authors also review criteria for establishing the effectiveness of sildenafil and alert readers to the newer phosphodiesterase type 5 inhibitors, such as tadalafil and vardenafil, currently submitted for approval by the Food and Drug Administration (FDA). Padma-Nathan and Giuliano explain why the FDA rejected apomorphine, a centrally active agent that is effective in inducing erections. Unfortunately, apomorphine had an unacceptably high rate of adverse effects. Alas, only 22 pages of the nearly 400-page book are devoted to this important advance in our understanding of male sexual physiology.

The bulk of the book will be of interest primarily to urologists. There are chapters on penile implants and complications of penile-implant surgery, Peyronie's disease and its treatment, use of nerve-sparing surgical techniques to prevent erectile dysfunction after radical prostatectomy, and the management of priapism. The contributing authors are distinguished urologists at the forefront of research on the treatment of erectile dysfunction. But urologists may not remain at the forefront; on page 217, we learn that "the majority of [sildenafil] prescriptions have been written by primary care physicians (55-60%), non-urology specialists (21-25%), particularly cardiologists, and urologists (20-24%)." Only the chapter by Bancroft and Janssen, "Psychogenic Erectile Dysfunction in the Era of Effective Pharmacotherapy," acknowledges this change. Today, erectile dysfunction is a medically manageable problem. It is likely that the urologist's surgical skills will be needed only to help those men who have no response to medical treatment.

Richard F. Spark, M.D.
Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to the Hardcover edition.

Review
"The bulk of this book will be of interest primarily to urologists. There are chapters on penile implants and complications of penile-implants surgery, Peyronie's disease and its treatment, use of nerve-sparing surgical techniques to prevent erectile dysfunction after radical prostatectomy, and the management of priapism. The contributing authors are distinguished urologists at the forefront of research on the treatment of erectile dysfunction."... New England Journal of Medicine

Product Description
Male Sexual Function: A Guide to Clinical Management, Second Edition, completely updates and reviews newer developments, including linking erectile dysfunction (ED) with lower urinary tract systems, advances in erectile physiology, and the appreciation of ED as a form of endothelial dysfunction and a harbinger of other potentially lethal forms of vascular disease. Treatments of ED as well as the background, causes, associated conditions, and diagnostic tools are also provided. This new updated edition also presents the facts of sexual function and dysfunction so that the practitioner can properly treat basic problems with easily prescribed therapies. Also included is a new chapter on cardiovascular disease as well as chapters on pelvic surgeries, intracavernous injections with vasoactive agents, and vacuum erection devices.

Male Sexual Function: A Guide to Clinical Management, Second Edition provides a comprehensive overview of the field of male sexual function for urologists, primary care physicians, nurse practitioners, gynecologists, and psychologists and therapists who specialize in ED.


Book Info
A current, comprehensive review of the field of male sexual dysfunction, outlining the many changing concepts and trends. Features a section for primary care clinicians, outlining ways to approach sexual function and treatment. Also covers female sexual function, ejaculatory disorders, and priapism. DNLM: Impotence--therapy. --This text refers to the Hardcover edition.