Erectile Dysfunction Treatment - Viagra
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Herbert W. Riemenschneider, MD
The problem of sexual dysfunction is a sensitive issue and difficult to talk about. (Fig. 1) However, once people begin to discuss their sexual problems it is difficult to confine the discussion to the relatively limited time available in a standard office appointment. Therefore, it is necessary to be able to communicate in a sensitive, direct manner and listen carefully.To be able to understand the nature of the problem of erectile dysfunction it is
important to know the pertinent anatomy. The prostate, a part of the reproductive system,
is the most troublesome organ in human kind. Diseases of the prostate and treatments can
have a major influence on a man’s ability to perform sexually. The unique
characteristics of the penis relate to the ability of smooth muscle that makes up the
erectile tissue to either be in a state of contraction or relaxation. When the smooth
muscle of the erectile tissue and penile arteries are relaxed there is a higher blood flow
into the penile arteries and a higher resistance to blood flowing through the penis. This
results in an erection.
The physiology of erection is related to vascular events that are dependent upon the interaction of nerves and blood vessels. (Fig. 2) Nitric oxide is released from nerve endings in erectile tissue at the time of sexual stimulation. This reaction results in the production of cyclic GMP (c-GMP). This causes smooth muscles of the erectile body to relax and the sponge-like tissues within it to begin to swell. The swelling of this spongy vascular tissue pinches off the veins that drain the erectile body against the side walls of this chamber. As this occurs blood accumulates in the erectile body. When the c-GMP is broken down by the enzyme, 5-phosphodiesterase (PDE-5), the process is reversed and the erection goes down.
Sexual dysfunction can be defined as a persistent pattern of human response not viewed as pleasurable. Evaluation of this problem includes a history, physical examination, psychological testing and blood testing. The most valuable part of this evaluation is the medical history. From it we can learn when the problem began, how it occurred and what other circumstances were associated with it. These insights form the basis of understanding the problem. Masters and Johnson made a major contribution to understanding the problem when they introduced the phases of the male cycle : excitement, plateau, orgasm/ejaculation and then resolution. They demonstrated how this cycle can be affected by day to day events and how understanding it can allow the events to be altered so that the male sexual response returns toward normal.
Erectile dysfunction (Fig. 3) is the persistent inability to achieve or maintain an erection sufficient for satisfactory intercourse. It can be associated with serious and chronic medical conditions, and these can clearly affect the quality of life. The Massachusetts Male Aging study (Fig. 4) demonstrates that 52 % of men between the ages of 40 - 70 experience a significant degree of erectile dysfunction.
Urologists believe that most patients do not need a lengthy, costly work-up, but there are many circumstances that need to be considered in the process. (Fig. 5). The basic assessment includes a medical history, physical examination, hormone assessment, special attention to whether morning erections are present and the assessment of the firmness of the erection. Frequently these problems are caused by medications that can include antidepressants, antihypertensives, alcohol, cigarettes, recreational drugs and hard narcotics.
Mother nature turns down the level of available testosterone as a safety mechanism as the male ages. This can cause the capacity to perform sexually to diminish. Although consistent with nature’s plan, this event clashes with the social standard that has incorporated sexual activity into the fabric of living. It is because of these standards it is important to understand and, at times, alter the biologic time table to improve the quality of life.
In the early 1980s it was recognized that medications could be injected into the penis to promote erection. Some of those agents were already available for other medical uses. Dr. Brindley, a very proper Englishman, demonstrated this in an unforgettable manner at the American Urological Association meeting in Las Vegas in 1982. He addressed an after-dinner audience and, while doing so, had on classic English attire with the exception of sweatpants as part of his three-piece ensemble. During the after-dinner lecture he reached the main point of his discussion stating that medications were available that when injected into the penis can cause an erection. He demonstrated the point by stepping out from behind the podium, pulled his sweatpants to his knees and demonstrated a very substantial erection he’d produced by injecting Papaverine into his penis in the men’s room prior to beginning the lecture. He not only stood beside the podium but walked into the audience with his sweatpants at half mast and asked members in the audience of approximately 3,000 to physically assess the quality of his erection. I was there and later concluded that this was the shot that was heard around the world.
Penile injection was the primary option used to treat erectile dysfunction for 15 years after the Brindley demonstration. However, on November 17, 1997, attention was refocused on a pill that worked for treatment of ED. This development was the subject of Newsweek’s cover on that date. (Fig. 6) The pill was seen as the answer for a non-invasive treatment of erectile dysfunction. Suddenly all of the men who’d experienced this problem but said nothing began to ask for help. It became very clear that the market was huge and an attractive option for the 52 % of men over the age of 40 who are believed to have this problem.
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