Male Impotence

INTRODUCTION

Background: Sexual health and function are important determinants of quality of life. Disorders such as erectile dysfunction(ED) and female sexual dysfunction are becoming increasingly more important as a result of the aging US population and newer therapies. Because this subject is discussed widely in the media, men and women of all ages are seeking guidance in an effort to improve their relationships and experience satisfying sexual lives.

This review article discusses the physiology of the normal erection and the pathophysiology, etiology, and treatment of ED.

Successful treatment of sexual dysfunction has been demonstrated to improve sexual intimacy and satisfaction, improve sexual aspects of quality of life, improve overall quality of life, and relieve symptoms of depression.

Although this article focuses primarily on ED in males, one must remember that the sexual partner plays an integral role. If successful and effective management is to be achieved, the evaluation and discussion of any intervention should include both partners.

The Process of Care Model for the Evaluation and Treatment of Erectile Dysfunction has been developed to advance new guidelines for the diagnosis and management of ED in the primary care and multidisciplinary setting. The model was developed under the auspices of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. The chairman of the group of experts who prepared the guidelines was Raymond Rosen, MD.

The key components of this model are (1) a rational approach to diagnosis and treatment, (2) emphasis on clinical history taking and a focused examination, (3) specialized testing and referral in predefined situations, (4) a step-wise management approach with ranking of treatment options, and (5) incorporation of patient and partner needs and preferences in the decision-making process.

An alternative model is the patient goal-oriented approach as suggested by Tom Lue, MD, in which a minimum of testing is performed. The patient and his partner express a preference for reasonable and appropriate treatment options and work with the physician to implement this plan.

The availability of three phosphodiesterase-5 (PDE-5) inhibitors, ie, sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis), has permanently altered the medical management of ED. Many patients no longer expect or are willing to undergo a long evaluation and testing process to obtain a better understanding of their sexual problem, and they are less likely to involve their partner in a discussion of their sexual relationship with the physician.

Because of intense mass-media marketing efforts, the sexual expectations of men have risen to new highs and the attitude that something is wrong with a man if he does not achieve a perfect erection is prevalent. Men who have no difficulty obtaining erections are taking these PDE-5 inhibitor medications in the belief that their sexual performance will be enhanced and the opportunity for multiple orgasms will increase. Their medications are often obtained by a phone call to their doctor or even over the Internet with minimal or no physician contact at all. The misuse and overuse of these remarkable medications are likely to have a major impact on how sexual performance and sexual relationships are viewed.