Evaluation and treatment of autonomic disorders of the urogenital system.

Autonomic pathways are important in the regulation of both lower urinary tract and sexual function, and their interruption in neurological pathologies predictably results in variable urogenital dysfunction, depending mainly on the level of the lesion. A normal neurological examination of a patient with urogenital complaints should exclude an underlying neurological pathology, and the neurologist should become involved in the management of symptoms. Electromyography can be of value in the diagnosis and management of cauda equina lesions and multiple system atrophy, but neurophysiological investigations are of no importance in the diagnosis of neurogenic sexual dysfunction. Urodynamic studies have proven helpful in determining the type and management of lower urinary tract dysfunction. Oral anticholinergics usually combined with clean intermittent catheterizations are the first-line treatment options for neurogenic lower urinary tract dysfunction, with intravesical treatments emerging as the main alternative in intractable incontinence. The availability of effective oral phosphodiesterase inhibitors has revolutionized the management of erectile dysfunction, but treatment of ejaculatory and orgasmic disorders as well as of female sexual dysfunction still remains problematic.

Critical analysis of surgery for Peyronie's disease.

PURPOSE OF REVIEW: This review focuses on the surgical management of Peyronie's disease in the light of recent published reports from 2003 and 2004. RECENT FINDINGS: Although there have been a number of non-surgical innovations in this field, the surgical treatment of Peyronie's disease still remains the only alternative for patients not responding to other therapies. Various surgical modalities have recently been promulgated, however the ideal surgical procedure is still not perfected, particularly in cases of severe and complex penile curvature. The recent results of various surgical approaches have engendered concern about their long term benefits. SUMMARY: The initial management of the acute presentation of Peyronie's disease is conservative and non-surgical. Surgery for Peyronie's disease is contemplated only after stabilization of the fibrotic process, and is generally reserved for men with severe penile deformities that impede satisfactory sexual intercourse. If there is ample penile length and the deformity is mild to moderate in severity, a variety of plication techniques may be considered to provide a straight and functional penis. In patients with larger plaques, severe curvature, complete or hourglass deformities, then incision or excision of the plaque and the placement of a graft are recommended. Most authorities currently favor non-synthetic graft materials whose properties resemble the anatomy and functionality of the tunica albuginea. The implantation of a penile prosthesis, with or without excision/incision of the diseased tunica albuginea, is reserved for patients with erectile dysfunction who have not responded to medical therapies. Manual modeling of the deformed penis over a penile prosthesis may prevent some patients from needing more complex surgical grafting procedures.

Prevention and treatment of erectile dysfunction using lifestyle changes and dietary supplements: what works and what is worthless, part II.

It seems naive to believe that some plants or herbs do not contain specific compounds that could benefit patients with ED. Many supplements have not been investigated in a laboratory or clinical research setting before commercial sale, however,which creates a complex situation. If efficacy is or is not demonstrated through adequate research, then the benefit or lack thereof cannot be mentioned on the label. Furthermore, clinicians and the public cannot be made aware of which compounds or supplements are effective because no general standards for sale exist under the current guidelines. Dietary supplements have received a tremendous amount of publicity. The large and growing market for ED treatment seems to have contributed partly to the promotion of numerous supplements and their apparent benefits. Whether these dietary supplements have merit is questionable. Some supplements may produce results opposite to those advertised. Other supplements may be enjoying the benefits of the placebo effect. Because a placebo response of 25% to 50% has been recorded in clinical trials with effective agents, it is understandable that some supplements enjoy financial success despite the limited research espousing their use. If one to two of four individuals or one of three individuals who try a dietary supplement gain some benefit for their ED, the market for these supplements will remain extraordinary. On a larger scale, of 100,000 men who try a supplement, approximately 25,000 to 50,000 will claim some success. The challenge for clinicians is to discuss the placebo response properly and the need for good research before any intervention, especially supplements, can be advocated for general use. Table 2 summarizes some popular ED supplements and general conclusions that can be drawn from clinical investigations. Some dietary supplements may have an active ingredient that benefits patients with certain types of ED. An exciting area of future dietary supplement research is the ability of certain agents to have a synergistic effect with prescription agents for ED, thereby improving response rates in men that have failed approved ED therapy initially, especially with oral agents. Randomized clinical trials are the best method of determining which dietary supplements will become a part of conventional medicine. Therefore, more randomized trials for dietary supplements are needed so that they may have the opportunity to become a part of the mainstream milieu, which means that more funding needs to be made available for ED research. The coming years of research should bring enormous excitement and objectivity to this area of medicine.

Erectile dysfunction: why drug therapy isn't always enough.

We increasingly recognize that erectile dysfunction (ED) usually arises from a mix of organic and psychogenic causes, yet management of this condition too often neglects the complexity of most cases of ED. While therapy with Sildenafil Citrate ( Viagra ) and similar investigational drugs can play an important role in many cases of ED, physicians should recognize and try to address the psychological and interpersonal context in which ED exists in their patients.