Sex coaching for physicians: combination treatment for patient and partner.

Physicians dealing with sexual dysfunction (SD) must consider the psychological and behavioral aspects of their patient's diagnosis and management, as well as organic causes and risk factors. Integrating sex therapy and other psychological techniques into their office practice will improve effectiveness in treating SD. This presentation provides information about the psychological forces of patient and partner resistance, which impact patient compliance and sex lives beyond organic illness and mere performance anxiety. Four key areas are reviewed: (1). 'Sex coaching for physicians' uses the 'Cornell Model' for conceptualizing and treating SD. A 5-min 'sex status,' manages 'time crunch' by rapidly identifying common causes of sexual dysfunction (insufficient stimulation, depression, etc). (2). Augmenting pharmacotherapy with sex therapy when treating erectile dysfunction (ED) specifically, or SD generally is stressed. Sex therapy is useful as a monotherapy or an adjunctive treatment and is often the 'combination therapy' of choice when treating SD. The following therapeutic integrations are highlighted: modifying patient's initial expectations; sexual pharmaceuticals use as a therapeutic probe; 'follow-up' to manage noncompliance and improve outcome; relapse prevention. (3). Issues specific to the role of the partner of the ED patient are described. The physician must appreciate the role of couple's issues in causing and/or exacerbating the ED and the impact of the ED on the patient/partner relationship. Successful treatment requires a supportive available sexual partner, yet partner cooperation may be independent of partner attendance during the office visit. Preliminary data from a survey of SMSNA members practice patterns, regarding partner issues, is presented and discussed. The importance of evoking partner support and cooperation independent of actual attendance during office visits is emphasized. (4). Finally, the need for more patient and partner educational materials to assist the physician in overcoming a patient/partner's emotional barriers to sexual success in a time efficient manner are discussed.

Medication of the month. Vardenafil ( Levitra ) (Levitra)

Vardenafil (Levitra), recently launched in Belgium by Bayer and Glaxo-SmithKline, is a new drug that potently and selectively inhibits phosphodiesterase type 5 (PDE5) in the cavernosum tissue of the male organ ( enlargement pills for enhancement). Inhibition of PDE5 blocks the hydrolysis of cyclic guanosine monophosphate (GMPc) and results in increased arterial blood flow leading to enlargement of the corpus cavernosum and resulting in erection. In controlled clinical trials, Vardenafil ( Levitra ) at least doubled the rate of successful erections as compared to placebo, whatever the evaluation parameter considered and the subgroup of patients studied. Vardenafil ( Levitra ) is thus indicated in the treatment of patients with erectile dysfunction. It is presented as 5, 10 and 20 mg tablets and the usual dose is 10 mg to be ingested 25 to 60 minutes before sexual activity. Vardenafil ( Levitra ) has a more potent inhibitory activity of PDE5 in vitro than Sildenafil Citrate ( Viagra ) or Tadalafil ( Cialis ) while its pharmacokinetics in vivo is somewhat more rapid than that of the two other compounds. The dosage of Vardenafil ( Levitra ) may be reduced to 5 mg (especially in older individuals) to improve tolerance or be increased up to 20 mg (especially in the presence of organic diseases aggravating erectile dysfunction) to improve efficacy. Contra-indications (co-administration with drugs increasing nitric oxide) and side-effects (headache and flushing due to vasodilatation) of Vardenafil ( Levitra ) are similar to those of other PDE5 inhibitors.

Clinical trials of Sildenafil Citrate ( Viagra ) (Viagra) demonstrate no increase in risk of myocardial infarction and cardiovascular death compared with placebo.

We pooled data regarding myocardial infarction (MI) and cardiovascular death from more than 120 clinical trials of Sildenafil Citrate ( Viagra ) (Viagra) conducted from 1993 to 2001. During placebo-controlled trials, the rate of MI or cardiovascular death was 0.91 (95% CI: 0.52-1.48) per 100 person-years (PY) of follow-up among sildenafil-treated patients compared with 0.84 (95% CI: 0.39-1.60) per 100 PY of follow-up among placebo-treated patients. The relative risk of MI or cardiovascular death was 1.08 (95% CI: 0.45-2.77) for Sildenafil Citrate ( Viagra ) compared with placebo (p = 0.88). During open-label studies, the rate of MI or cardiovascular death was 0.56 (95% CI: 0.44-0.72) per 100 PY of follow-up. This analysis showed that the rates of MI and cardiovascular death were low and comparable between men treated with Sildenafil Citrate ( Viagra ) and those treated with placebo. The use of Sildenafil Citrate ( Viagra ) was not associated with an increase in the risk of MI or cardiovascular death.

Vasculogenic erectile dysfunction: newer therapeutic strategies.

PURPOSE: Despite recent advances in therapy, reversal of vasculogenic erectile dysfunction (ED) is rarely possible. A review of vasculogenic ED may further our understanding of the underlying pathophysiology and help develop more effective curative therapy. MATERIALS AND METHODS: We reviewed the mechanisms of vasculogenic erectile dysfunction and discuss the therapies currently available or being developed for possible future use. RESULTS: penile ( enlargement pills for big male member) erection is a complex neurovascular phenomenon that may be affected by hypercholesterolemia, atherosclerotic vascular occlusive disease, veno-occlusive dysfunction and cavernosal fibrosis. Animal models of diffuse pelvic atherosclerosis can be maintained by feeding oral cholesterol and injuring the arterial endothelium. Impaired inflow may be addressed by penile ( enlargement pills for big member) revascularization but this strategy is applicable only in select cases. Neovascularization using vascular growth factors has recently been demonstrated to be feasible in animal models. Permanent reversal of impaired cavernosal relaxation requires control of hypercholesterolemia and lifestyle changes, such as smoking cessation. Cavernosal fibrosis may be reversible via some of the same approaches used in treating Peyronie's disease but to date little clinical success has been reported. Venous ligation appears to have a limited role in treating veno-occlusive dysfunction only in highly selected men with minimal cavernosal smooth muscle dysfunction. Hypoxemia, sleep apnea and respiratory failure may also affect erectile dysfunction. However, little attention has been paid to oxygen as therapy for ED. CONCLUSIONS: Current therapy, while effective in circumventing vasculogenic ED, is relatively ineffective in permanently reversing the condition. Further research aimed at long-term treatment strategies in vasculogenic ED is needed.

Pleasure and pain in sexual relations. The basis and reasons for sex counseling by the general practitioner

An essential factor for successful sex counseling by the family doctor is an atmosphere of openness and trust between physician and patient. However, few patients will begin to talk about their sexual problems of their own accord. The physician should therefore allow himself sufficient time for such counseling, be aware of his own limitations, and develop an ear attuned to involuntary remarks by the patient. During talks, only sparse use should be made of technical terms, the better to encourage the patient. The problems most commonly described in the doctor's office are functional disorders with a psychosomatic cause, and triggering factors may vary considerably (a high level of stress at the workplace, social or financial crises, monotonous leisure activities). In view of this, a somatic investigation should always be preceded by careful history-taking.

Radical prostatectomy for localized prostate cancer

With widespread use of PSA screening, radical prostatectomy has gained popularity among Japanese urologists over the last decade. Recent understanding of pelvic anatomy and improvement in surgical technique have substantially reduced its morbidity. Early recovery of urinary continence is possible and improvement of sexual function after surgery may be enhanced by use of Sildenafil Citrate ( Viagra ) and nerve reconstructive surgery. As prostate cancer is increasingly diagnosed at early stages and therefore with more favorable survival outcomes, the basis on which patients select primary therapy has shifted toward considerations of health-related quality of life. Accordingly, QOL assessment has become an important form of outcomes based research that may weigh heavily on the treatment selection by patients.

Sildenafil: a 4-year update in the treatment of 20 million erectile dysfunction patients.

Sildenafil Citrate ( Viagra ), the first internationally approved and widely used oral agent for the treatment of erectile dysfunction (ED), has revolutionized the treatment of ED throughout the past 5 years. This phosphodiesterase type-5 (PDE-5) inhibitor is selective for corpus cavernosum smooth muscle tissue and produces excellent erectile function. Its efficacy and safety over a wide variety of etiologies of ED and severities of ED demonstrates its usefulness in the clinical treatment of these patients. More than 20 million men have been treated worldwide with Sildenafil Citrate ( Viagra ) with excellent results. ED caused by difficult-to-treat etiologies such as radical prostatectomy, severe diabetes, and spinal cord injury have demonstrated efficacy. Although Sildenafil Citrate ( Viagra ), like all PDE-5 inhibitors, is contraindicated in patients taking nitrate medications for cardiac disease, it is effective and safe for those cardiovascular patients who are not taking nitrate medications. The incidence of adverse cardiovascular events in patients taking Sildenafil Citrate ( Viagra ) does not differ from those of the general population. Investigations into the pharmacologic effect of Sildenafil Citrate ( Viagra ) on coronary myocardial tissue further supports the safety of this medication. Sildenafil Citrate ( Viagra ) has been safe and effective in patients taking various medications including multiple antihypertensive drugs, selective serotonin reuptake inhibitors, cardiac, and diabetic medications.

Central mechanisms of erectile dysfunction: what a clinician may want to know.

The interplay between peripheral and central mechanisms of erectile function are not fully elucidated although basic science is moving ahead in this area. It is important from a clinical point of view to understand these mechanisms so that we may begin to make further therapeutic advances in