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Editorial: Impotence
0022-534719511536-184 1$03.00/0 Vol. 153, 1841-1842, June 1995 Printed in U.S.A.
T H E JOUKNAI. OF UR0l.OCY
Copyright 0 1995 by AMERICAN UROLOCICAL ASSOCIATION,
INC.
EDITORIAL: IMPOTENCE The use of intracorporeal injections of drugs that are direct The majority of men suffering from erectile dysfunction smooth muscle relaxants or a-antagonists has become the who present to the urologist are older, have vascular risk hallmark of treatment of erectile dysfunction. Because of the factors and suffer from an underlying organic disease assohigh dropout rate of men who have successfully benefited ciated with the vasculature. A small percentage (3% as refrom this treatment, as well as the reluctance of many men to ported by Munaniz et al, page 1831) will have traumatically perform self-injection, alternative routes of administration of induced erectile dysfunction. Because the criterion for entry these agents have been sought. To date, 3 such routes are into this study was a definite history of trauma associated under investigation: oral, topical and intraurethral. It is with the development of erectile dysfunction, I would expect probable that all of these techniques will be successful in that the percentage of those with traumatic impotence would various subsets of the population. Intracorporeal injection be higher since many patients will either not remember the will remain the gold standard, since it is the best technique trauma or not associate it with the development of impofor delivering vasoactive agents to the corporeal smooth mus- tence. This exhaustive study documents, with m d e r n diagculature as well as fine tuning the dosage required to create nostic techniques and objective data, the association of an erection while controlling for the development of pria- trauma (pelvic and perineal) with the development of either pism, However, for obvious reasons (as implied previously) arterial insufficiency and/or Corporeal VenO-OCClUSiVe dysalternative routes of administration would clearly become function resulting in changes in erectile activity. It is impormore widely accepted by the general population. In the series tant to note that the majority of these Patients were Young ~ (page v 1828) ~ a small ~ number of men who and did not suffer from associated vascular risk factors. Beby K~ and M are relatively young and suffer from neurogenic impotence fore our understanding of arterial and venous pathophysiol(and would also be expected to have normal pudenddpenile Om related to erection, and our ability to diagnose these blood vessels and a normal veno-occlusive mechanism) were Parameters, most of these Patients would have been treated studied for hernodynamic responses to topical prostaglandin for psychogenic erectile dysfunction. The long duration beEl. & the authors note subset of impotent patients tween their seeking medical attention and the development years and greater dysfunction (an average Of would be most likely to respond to topical therapy. For pro- Of penned trauma) may ponents of topical therapy, this study has good news and bad than years in the group who Of inadequacy and shame, more news. The good news is that the topical application of pros- reflect not Only their commonly associated with impotence in the younger age taglandin E l does result in direct corporeal smooth muscle relaxation. If I read this article correctly, the grades 4 and 5 group, but also the lack of understanding and knowledge by them and possibly their physicians of the association beerections that resulted were present for a long period, since tween trauma and the development of impotence. duplex ultrasound studies were done 45 minutes after applidynamic infusion All patients in this study cation. If true, then the resultant erections were clearly phar- cavernosometry and cavernosography, with a smaller group macological rather than reflex in nature. The bad news is undergoing pudendal arteriography. The site-specific nature that the peak systolic flow velocities, although increased, of the is important in largely did not increase to the range where erectile rigidity trauma with the pathophysiology~The majority of would be accomplished. This finding would lead one to be- patients with abnormal cavernosometry and cavernosogralieve that the use of topical prostaglandin E l in patients with leakage from the proximal or fixed more severe arterial inflow problems or corporeal veno-occlu- phy area ofthe corpora. men found, arterial abnormalities were sive dysfunction would not result in appreciable changes in relatively and confined to the pudendaupenile arterpeak systolic flow velocity. ies in patients with normal larger inflow vessels. The absence As a phase I study, this article has certainly Proved the o f g e n e r h e d atherosclerosis on arteriogaphy and the absence safety and efficacy of this agent. As the authors note, further ofpan-cavernom l e d on cavernosography denote this l o c ~ studies are required and will probably be performed in a double-blind fashion prospectively randomizing patients to The importanceof this study lies not only in its objectively active drug 01 Placebo VOUPS. Further studies with d k r n a - defining the syndrome of traumatically induced erectile dystive dosages would also be necessary. When studying Pa- function but also in its wide social implications. The authors tients who do not have spinal cord injury, Some method of estimate that 600,000 American men currently suffer from sexual stimulation in conjunction with topical application traumatic vasculogenic impotence, with 250,000 of these would be appropriate. cases being secondary to sports-related injuries. Although I believe that topical agents will only be able to treat a this number is obviously an approximation, it appears clear s ~ ~ - ~number all of patients with organic impotence. On the that a large number of men suffer from this entity. As stated, other hand, patients with purely psychogenic impotence most of them are young and healthy. The urologist, therefore, whose physiological mechanisms are intact may prove to be a when faced with a young male patient presenting with erecmore realistic group for this type of therapy. In these patients tile dysfunction without any underlying vascular risk factors only a short course of topical agents may be required. should closely question the patient in a n attempt to elucidate Alternative routes of administration of vasoactive agents a history of perineal or pelvic trauma. In addition, most of will usher in a new era of erectile enhancement rather than these cases could have been avoided. A large number of the just the treatment of erectile dysfunction. Many men after pelvic trauma cases would have been obviated by the use of age 60 years note a decrease in penile rigidity despite the fact seat belts. Sports-related injuries largely involve blunt that they can still have adequate sexual intercourse. These trauma to the perineum. The use of a cross bar in bicycles men would not be oriented toward self-injection but most designed for men should now not only be viewed as sexist but assuredly would be oriented to oral or topical routes to en- also as potentially dangerous. Most boys and men engaged in potentially traumatic sports activities are accustomed to hance rigidity and potentially prolong erections. 1841
~
1842
IMPOTENCE
wearing protection for the external genitalia. It would be reasonable for the development of a perineal device to protect the underlying perineal structures. As noted in the Appendix to this study, the average force applied to the perineum from a straddle injury due to a bicycle cross bar may be equivalent to the force applied to the perineum from falling off a 10-foot roof and landing with direct contact to the perineal area. Finally, the knowledge of this entity of traumatic induced erectile dysfunction should be widely disseminated to
coaches, parents and athletes. This might not only increase their interest in protecting the perineal region but also decrease the time during which these young men suffer in silence without seeking proper urological consultation. Robert J. Krane Urology Department Boston University Medical Center Boston, Massachusetts
T H E JOUKNAI. OF UR0l.OCY
Copyright 0 1995 by AMERICAN UROLOCICAL ASSOCIATION,
INC.
EDITORIAL: IMPOTENCE The use of intracorporeal injections of drugs that are direct The majority of men suffering from erectile dysfunction smooth muscle relaxants or a-antagonists has become the who present to the urologist are older, have vascular risk hallmark of treatment of erectile dysfunction. Because of the factors and suffer from an underlying organic disease assohigh dropout rate of men who have successfully benefited ciated with the vasculature. A small percentage (3% as refrom this treatment, as well as the reluctance of many men to ported by Munaniz et al, page 1831) will have traumatically perform self-injection, alternative routes of administration of induced erectile dysfunction. Because the criterion for entry these agents have been sought. To date, 3 such routes are into this study was a definite history of trauma associated under investigation: oral, topical and intraurethral. It is with the development of erectile dysfunction, I would expect probable that all of these techniques will be successful in that the percentage of those with traumatic impotence would various subsets of the population. Intracorporeal injection be higher since many patients will either not remember the will remain the gold standard, since it is the best technique trauma or not associate it with the development of impofor delivering vasoactive agents to the corporeal smooth mus- tence. This exhaustive study documents, with m d e r n diagculature as well as fine tuning the dosage required to create nostic techniques and objective data, the association of an erection while controlling for the development of pria- trauma (pelvic and perineal) with the development of either pism, However, for obvious reasons (as implied previously) arterial insufficiency and/or Corporeal VenO-OCClUSiVe dysalternative routes of administration would clearly become function resulting in changes in erectile activity. It is impormore widely accepted by the general population. In the series tant to note that the majority of these Patients were Young ~ (page v 1828) ~ a small ~ number of men who and did not suffer from associated vascular risk factors. Beby K~ and M are relatively young and suffer from neurogenic impotence fore our understanding of arterial and venous pathophysiol(and would also be expected to have normal pudenddpenile Om related to erection, and our ability to diagnose these blood vessels and a normal veno-occlusive mechanism) were Parameters, most of these Patients would have been treated studied for hernodynamic responses to topical prostaglandin for psychogenic erectile dysfunction. The long duration beEl. & the authors note subset of impotent patients tween their seeking medical attention and the development years and greater dysfunction (an average Of would be most likely to respond to topical therapy. For pro- Of penned trauma) may ponents of topical therapy, this study has good news and bad than years in the group who Of inadequacy and shame, more news. The good news is that the topical application of pros- reflect not Only their commonly associated with impotence in the younger age taglandin E l does result in direct corporeal smooth muscle relaxation. If I read this article correctly, the grades 4 and 5 group, but also the lack of understanding and knowledge by them and possibly their physicians of the association beerections that resulted were present for a long period, since tween trauma and the development of impotence. duplex ultrasound studies were done 45 minutes after applidynamic infusion All patients in this study cation. If true, then the resultant erections were clearly phar- cavernosometry and cavernosography, with a smaller group macological rather than reflex in nature. The bad news is undergoing pudendal arteriography. The site-specific nature that the peak systolic flow velocities, although increased, of the is important in largely did not increase to the range where erectile rigidity trauma with the pathophysiology~The majority of would be accomplished. This finding would lead one to be- patients with abnormal cavernosometry and cavernosogralieve that the use of topical prostaglandin E l in patients with leakage from the proximal or fixed more severe arterial inflow problems or corporeal veno-occlu- phy area ofthe corpora. men found, arterial abnormalities were sive dysfunction would not result in appreciable changes in relatively and confined to the pudendaupenile arterpeak systolic flow velocity. ies in patients with normal larger inflow vessels. The absence As a phase I study, this article has certainly Proved the o f g e n e r h e d atherosclerosis on arteriogaphy and the absence safety and efficacy of this agent. As the authors note, further ofpan-cavernom l e d on cavernosography denote this l o c ~ studies are required and will probably be performed in a double-blind fashion prospectively randomizing patients to The importanceof this study lies not only in its objectively active drug 01 Placebo VOUPS. Further studies with d k r n a - defining the syndrome of traumatically induced erectile dystive dosages would also be necessary. When studying Pa- function but also in its wide social implications. The authors tients who do not have spinal cord injury, Some method of estimate that 600,000 American men currently suffer from sexual stimulation in conjunction with topical application traumatic vasculogenic impotence, with 250,000 of these would be appropriate. cases being secondary to sports-related injuries. Although I believe that topical agents will only be able to treat a this number is obviously an approximation, it appears clear s ~ ~ - ~number all of patients with organic impotence. On the that a large number of men suffer from this entity. As stated, other hand, patients with purely psychogenic impotence most of them are young and healthy. The urologist, therefore, whose physiological mechanisms are intact may prove to be a when faced with a young male patient presenting with erecmore realistic group for this type of therapy. In these patients tile dysfunction without any underlying vascular risk factors only a short course of topical agents may be required. should closely question the patient in a n attempt to elucidate Alternative routes of administration of vasoactive agents a history of perineal or pelvic trauma. In addition, most of will usher in a new era of erectile enhancement rather than these cases could have been avoided. A large number of the just the treatment of erectile dysfunction. Many men after pelvic trauma cases would have been obviated by the use of age 60 years note a decrease in penile rigidity despite the fact seat belts. Sports-related injuries largely involve blunt that they can still have adequate sexual intercourse. These trauma to the perineum. The use of a cross bar in bicycles men would not be oriented toward self-injection but most designed for men should now not only be viewed as sexist but assuredly would be oriented to oral or topical routes to en- also as potentially dangerous. Most boys and men engaged in potentially traumatic sports activities are accustomed to hance rigidity and potentially prolong erections. 1841
~
1842
IMPOTENCE
wearing protection for the external genitalia. It would be reasonable for the development of a perineal device to protect the underlying perineal structures. As noted in the Appendix to this study, the average force applied to the perineum from a straddle injury due to a bicycle cross bar may be equivalent to the force applied to the perineum from falling off a 10-foot roof and landing with direct contact to the perineal area. Finally, the knowledge of this entity of traumatic induced erectile dysfunction should be widely disseminated to
coaches, parents and athletes. This might not only increase their interest in protecting the perineal region but also decrease the time during which these young men suffer in silence without seeking proper urological consultation. Robert J. Krane Urology Department Boston University Medical Center Boston, Massachusetts