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Editorial: Impotence--Defining the Role of Minimally Invasive Therapy
0022-5347/9#1551-0147$03.00/0
k JOURNAL OF U R O W Y Copyright 0 1996 by AMERICAN U R O ~ I CASS~CUTION, AL INC.
Vol. lM, 147, Jmuuy lSW Rlnttd in U.SA
EDITORIAL: IMPOTENCE-DEFINING THE ROLE OF MINIMALLY INVASrvE THERAPY During the early part of this century, impotence became a 9 patients. Although this approach may require multiple disease treated by the forerunner of the urologist, the vene- injections, the advantages are great compared to the more reologist, because the impression at the time was that impo- complicated irrigation and aspiration procedure. Most patence was caused by gonorrheal urethritis, excessive mastur- tients in this initial series had pharmacologically induced bation or coitus early in life.' Other myths became embedded priapism. in the mind of physicians and the lay public that the Freudian Every urologist has been asked a t some point by a patient theory of Oedipal conflict was the true cause of impotence in suffering from erectile dysfunction whether he could just get the absence of obvious conditions, such as paraplegia or pe- a "pill" to fix the problem. As Knoll et al (page 144) note nile deformity.' The widely held opinion often persists today "scientific studies to determinethe usefulness of these agenta that erectile dyshction is mostly psychogenic in origin. "he are scarce or in many cases are of questionable validity." Our reality is that of the estimated 10 to 20 million impotent men increased understanding of erectile neurophysiology and in the United States more than 50% have a clearly defined neuropharmacology has established a potential foundation organic cause, with that percentage being much greater in for these oral regimens. With yohimbine and isoxuprine or pentoxifylline in a randomized crossover study of patienta the older man.2 The management of organic impotence was revolutionized with mixed vasculogenic impotence, there was no effective by the development of prosthetic devices to achieve an ade- improvement in erection. Further investigations using their quate erection. The era of the modem penile prosthesis began study design with questionnaire and objective data, such as in the early 1970swith the introduction of the Small-Carrion duplex ultrasound scanning, are warranted before any oral prosthesi~.~ As the penile prosthesis has become more refined agent can be used reliably to help this patient population. Eskew et al reviewed the outcome of the initial and final and reliable, research into the physiology of normal erection and the pathophysiology of erectile dysfunction opened other treatment in more than 377 impotent men.' Not surprisingly, avenues to the treatment of impotence. These newer strate- patients initially chose the less invasive forma of thergies are designed not simply to create an erect penis suitable apy more than 90%of the time. The impotent man avoids the for vaginal penetration, as kith a prosthesis, but to restore more effective but more invasive options despite the m a t isfaetory results achieved with the less invasive therapies. As the normal physiological changes Been with tumescence. We are witnessing increased interest in the nonoperative an example, almost 80% of the men chose an oral medication approach to impotence. While penile prosthesis implanta- initially but the ultimate satisfactionrating was only 28%. In tion, revascularization, venous outflow surgery and other contrast, less than 2% of men initially chose the surgical operative interventions will enhance erectile function, mini- approach. However, the surgically treaw group had an ulmally invasive strategies, such as vacuum devices and intra- timate satisfaction rate of 94%, the highest of all therapies. With the desire for the m b h d l y invaaive management of cavernous injection therapy, are gaining in popularity. From impotence at a high level, mlagista must continue to develop the patient perspective the use of oral and topical agents is the ultimate in the minimally invasive approach. Several more effective strategies. The goal of our interventions ehould articles in this issue of the Journal highlight current issues be restoration "of both a healthy physical and emotional outlook to the patient and his partner and therefm to improve their in the management of erectile dysfunction. Intracavernous injection therapy has come to the forefront ultimate satisfaction with our treatment." Ongoing studies of with the recent Food and Drug Administration approval of topical and intraurethraltherapieshold promise with improve i t h the acientSc prostaglandin El. Prostaglandin E l is useful in the diagnosis ments in the design of the delivery vehicles. W urologists and management of erectile dysfunction, and has generally basis for erectile dysfunction better unthe leademhip i n the basic Science investigashould continue replaced the earlier agents papaverine and phentolamine. Prostaglandin E l appears to be a safer drug, and may be less tion and management of this all too common disorder. While likely than papaverine and phentolamine to cause penile surgical intervention providea the highest degree of eatisscarring and priapism. In the study by Chen et al (page 1381, faction, we must strive to achieve the same result with the preexisting penile scar, and the duration and number of minimally invaeive approach. injections are risk factors for the phentolamindpapaverine Leonard G. Gomellcr regimen but not for the use of prostaglandin. Scarring is Department of Urology sporadic and can occur in approximately 15% of patients Thomns Jefferson University treated with prostaglandin. The authors make an important Philadelphia, Pennsylvania point that patients with Peyronie's disease or preexisting phentolamindpapaverine-inducedscar should not be denied REFERENCES intracorporeal prostaglandin therapy for fear of further scarring. 1. Zorgniotti, A W.and Lima, E.F.:Overview. In: JXagnsie and Priapism can induce corporeal body scarring and result in Management of Impotence. Philadelphk B. C. Decker, chapt. 1. pp. 1-12, 1991. impotence. Although medical and idiopathic conditions were 2. Cumming,J. and Pryor. J. P.:Treatment of organic impotence. formerly the most common cause of priapism, the use of Brit. J. Urol., 640, 1991. intracavernous injection therapy is probably the most com3. Small, M. P., Carrion,H.M. and Gordon, J. A: Small-Carion mon cause of priapism to date. Often, the nonoperative stratpenile proethesie. Urology, k 479,1975. egies to induce detumescence, such as aspiration and irriga4. E&w, A,Nana-SinlrhRm, P., Sebba#, M. and Jaronr, J. P.: tion, can be dif€icult for the patient. Muruve and Hodring Patient outcome analyak of goal-direeted therapy for impo(page 141)report on their experience with a reasonably simtence. J. Urol.. part 2,lm 367& abetract 656,2995. ple method to treat priapism. Using a small volume of phe5. Berger,R.E.,Berger,D.M.,Happe-IIartsall,C.A.andHeiman, J. R.: Couples: the 'art" of solving impobnca problems. AUA nylephrine (0.5 mg. in 2 ml. n o m d saline) isiected into the Update Series, I: 154, leeson 20,1988. corporeal body they were able to induce detumescence in 8 of 147
k JOURNAL OF U R O W Y Copyright 0 1996 by AMERICAN U R O ~ I CASS~CUTION, AL INC.
Vol. lM, 147, Jmuuy lSW Rlnttd in U.SA
EDITORIAL: IMPOTENCE-DEFINING THE ROLE OF MINIMALLY INVASrvE THERAPY During the early part of this century, impotence became a 9 patients. Although this approach may require multiple disease treated by the forerunner of the urologist, the vene- injections, the advantages are great compared to the more reologist, because the impression at the time was that impo- complicated irrigation and aspiration procedure. Most patence was caused by gonorrheal urethritis, excessive mastur- tients in this initial series had pharmacologically induced bation or coitus early in life.' Other myths became embedded priapism. in the mind of physicians and the lay public that the Freudian Every urologist has been asked a t some point by a patient theory of Oedipal conflict was the true cause of impotence in suffering from erectile dysfunction whether he could just get the absence of obvious conditions, such as paraplegia or pe- a "pill" to fix the problem. As Knoll et al (page 144) note nile deformity.' The widely held opinion often persists today "scientific studies to determinethe usefulness of these agenta that erectile dyshction is mostly psychogenic in origin. "he are scarce or in many cases are of questionable validity." Our reality is that of the estimated 10 to 20 million impotent men increased understanding of erectile neurophysiology and in the United States more than 50% have a clearly defined neuropharmacology has established a potential foundation organic cause, with that percentage being much greater in for these oral regimens. With yohimbine and isoxuprine or pentoxifylline in a randomized crossover study of patienta the older man.2 The management of organic impotence was revolutionized with mixed vasculogenic impotence, there was no effective by the development of prosthetic devices to achieve an ade- improvement in erection. Further investigations using their quate erection. The era of the modem penile prosthesis began study design with questionnaire and objective data, such as in the early 1970swith the introduction of the Small-Carrion duplex ultrasound scanning, are warranted before any oral prosthesi~.~ As the penile prosthesis has become more refined agent can be used reliably to help this patient population. Eskew et al reviewed the outcome of the initial and final and reliable, research into the physiology of normal erection and the pathophysiology of erectile dysfunction opened other treatment in more than 377 impotent men.' Not surprisingly, avenues to the treatment of impotence. These newer strate- patients initially chose the less invasive forma of thergies are designed not simply to create an erect penis suitable apy more than 90%of the time. The impotent man avoids the for vaginal penetration, as kith a prosthesis, but to restore more effective but more invasive options despite the m a t isfaetory results achieved with the less invasive therapies. As the normal physiological changes Been with tumescence. We are witnessing increased interest in the nonoperative an example, almost 80% of the men chose an oral medication approach to impotence. While penile prosthesis implanta- initially but the ultimate satisfactionrating was only 28%. In tion, revascularization, venous outflow surgery and other contrast, less than 2% of men initially chose the surgical operative interventions will enhance erectile function, mini- approach. However, the surgically treaw group had an ulmally invasive strategies, such as vacuum devices and intra- timate satisfaction rate of 94%, the highest of all therapies. With the desire for the m b h d l y invaaive management of cavernous injection therapy, are gaining in popularity. From impotence at a high level, mlagista must continue to develop the patient perspective the use of oral and topical agents is the ultimate in the minimally invasive approach. Several more effective strategies. The goal of our interventions ehould articles in this issue of the Journal highlight current issues be restoration "of both a healthy physical and emotional outlook to the patient and his partner and therefm to improve their in the management of erectile dysfunction. Intracavernous injection therapy has come to the forefront ultimate satisfaction with our treatment." Ongoing studies of with the recent Food and Drug Administration approval of topical and intraurethraltherapieshold promise with improve i t h the acientSc prostaglandin El. Prostaglandin E l is useful in the diagnosis ments in the design of the delivery vehicles. W urologists and management of erectile dysfunction, and has generally basis for erectile dysfunction better unthe leademhip i n the basic Science investigashould continue replaced the earlier agents papaverine and phentolamine. Prostaglandin E l appears to be a safer drug, and may be less tion and management of this all too common disorder. While likely than papaverine and phentolamine to cause penile surgical intervention providea the highest degree of eatisscarring and priapism. In the study by Chen et al (page 1381, faction, we must strive to achieve the same result with the preexisting penile scar, and the duration and number of minimally invaeive approach. injections are risk factors for the phentolamindpapaverine Leonard G. Gomellcr regimen but not for the use of prostaglandin. Scarring is Department of Urology sporadic and can occur in approximately 15% of patients Thomns Jefferson University treated with prostaglandin. The authors make an important Philadelphia, Pennsylvania point that patients with Peyronie's disease or preexisting phentolamindpapaverine-inducedscar should not be denied REFERENCES intracorporeal prostaglandin therapy for fear of further scarring. 1. Zorgniotti, A W.and Lima, E.F.:Overview. In: JXagnsie and Priapism can induce corporeal body scarring and result in Management of Impotence. Philadelphk B. C. Decker, chapt. 1. pp. 1-12, 1991. impotence. Although medical and idiopathic conditions were 2. Cumming,J. and Pryor. J. P.:Treatment of organic impotence. formerly the most common cause of priapism, the use of Brit. J. Urol., 640, 1991. intracavernous injection therapy is probably the most com3. Small, M. P., Carrion,H.M. and Gordon, J. A: Small-Carion mon cause of priapism to date. Often, the nonoperative stratpenile proethesie. Urology, k 479,1975. egies to induce detumescence, such as aspiration and irriga4. E&w, A,Nana-SinlrhRm, P., Sebba#, M. and Jaronr, J. P.: tion, can be dif€icult for the patient. Muruve and Hodring Patient outcome analyak of goal-direeted therapy for impo(page 141)report on their experience with a reasonably simtence. J. Urol.. part 2,lm 367& abetract 656,2995. ple method to treat priapism. Using a small volume of phe5. Berger,R.E.,Berger,D.M.,Happe-IIartsall,C.A.andHeiman, J. R.: Couples: the 'art" of solving impobnca problems. AUA nylephrine (0.5 mg. in 2 ml. n o m d saline) isiected into the Update Series, I: 154, leeson 20,1988. corporeal body they were able to induce detumescence in 8 of 147