Treatment modes

Relationship between Erectile Dysfunction and Lower Urinary Tract Symptoms
Sexual dysfunction and LUTS are significant contributors to overall quality of life. Male sexual dysfunction may reveal problems such as ejaculation, decreased libido, erectile function or combinations of all three.

New data has appeared to indicate potential links in epidemiological, physiologic, pathophysiologic and treatment aspects of these two entities. There may be relevant clinical management questions and guideline implications related to the association, if BPH/LUTS and sexual dysfunction are more than coincidental. For example, treatment of one condition (e.g., BPH) might have influence on the other (e.g. sexual dysfunction). There are specific drug cooperation issues (e.g., alpha-blockers and PDE-5 inhibitors) that need attention. Why should urologists worry about SD in men with LUTS in the first place, even if such an association were present?

Surgical Aspects of Correcting Premature Ejaculation
Ejaculatory dysfunction is the most common male sexual disorder. Up to 30% of men are affected by premature ejaculation (PE) - the most common presentation of ejaculatory dysfunction. However, this problem remains not to be easily treated. Sex therapists know numerous cases in which PE is not so easily treated with behavioral therapy in spite of the fact that there is often an optimistic opinion about successful treatment of PE.

Psychological elements (performance anxiety), endocrine abnormality (hypogonadism, abnormal leptin level), infection of genitourinary organ (prostatitis), automonic and peripheral nerve disturbance (hyperexcitability/hypersensitivity of the penis) – all these can induce PE. In order to promote treatment efficacy and avoid recurrence after treatment, treatment of PE should be established according to the underlying etiologies of the disease. Incipient treatment should begin with appropriate treatment options established on underlying organic diseases for PE. Penis desenstization was suggested in patients with hypersensitivity of the penis, as a similar principl. Surgical procedure, for example - selective dorsal neurectomy, is being introduced to reduce penile hypersensitivity.

The primary source of afferent somatic input from the penis is the dorsal nerve of the penis and is critical in the male sexual function of erection and ejaculation. Briefly, a 1 to 2 cm incision is deepened to the level of Buck's fascia and made at the coronary sulcus. Several peripherally running nerve are then identified and only nerve’s peripheral branches are severed, remaining main trunk of the nerve intact. It is understood that this variant of surgery should be limited to patients who have penile hypersensitivity. Reducing sensation in the penis may induce erectile failure with total neurectomy of the dorsal nerve. This why, main trunk of the dorsal nerve should remain intact.

The lives of thousands of men across Europe and is the most frequent non-skin male malignancy in Western countries are affected by prostate cancer (PC). PC is diagnosed around every 3 minutes with 190,000 new cases detected every year in the USA . Because of the worldwide trend for increased longevity in the general population, and the improved level of detection due to routine prostate-specific antigen tests PC incidence is greatly increasing. Both external-beam radiotherapy (EBRT) and brachytherapy (BT) can be offered as curative options. Decrease in libido and ejaculation problems occur in 90% and 6080%, respectively. Although, most of these studies are retrospective, the explanation of ED is not clear and often only one question about sexual functioning is asked.

ED
The only treatment modality for post-radiation ED was the use of intracavernosal injections that were effective in most of the patients before sildenafil citrate (Viagra®) was introduced. The efficacy of sildenafil in open-label studies was reported in 80% of the patients after BT and in up to 90% of patients after EBRT. Sildenafil improved erections significantly as compared to placebo in the only double-blind study recently performed; 90% of the patients needed the 100 mg-dose. Side effects were moderate or mild.

Sexual dysfunction after radiation for PC has been frequently undervalued. Patients should be informed about effective treatments for ED and offered sexual counseling.

Pharmacological Treatment of Ejaculatory Disorders
One of the most common male sexual disorders and extends from premature ejaculation, through inhibited ejaculation to a complete inability to ejaculate, anejaculation, and includes retrograde ejaculation is ejaculatory dysfunction. The final phase of the sexual response cycle is constituted by orgasm and ejaculation. In normal ante-grade ejaculationemission, ejection and orgasm are 3 basic mechanisms involved. In this cascade of events ejaculatory dysfunction can result from disruption at any point.

A reflex comprising sensory receptors and areas, afferent pathways, cerebral sensory areas, cerebral motor centres, spinal motor centres and efferent pathways is ejaculation. A complex interplay between central serotonergic and dopaminergic neurons with secondary involvement of cholinergic, adrenergic, nitrergic, oxytocinergic and GABAergic neurons predominantly controls the ejaculatory reflex. Seminal emission and ejection are integrated by several forebrain structures including the medial preoptic area (MPOA) and the nucleus paragigantocellularis (nPGi) into the complex pattern of copulatory behaviour.

Male rat studies demonstrate that serotonin 5-HT2C and 5-HT1A receptors determine the speed of ejaculation and they are involved in the ejaculatory process. Ejaculation in male rats whereas stimulation of postsynaptic 5-HT1A receptors resulted in shorter ejaculation latency agonists delayed by stimulation of 5-HT2C receptors with non-selective 5-HT2C. Selective serotonin re-uptake inhibitors (SSRIs) administration results in active presynaptic membrane 5-HT transporters blockade and delay ejaculation and the resultant higher synaptic cleft levels of 5-HT activate post-synaptic 5-HT2C and 5-HT1A receptors.