Natural Treatment for Erectile Dysfunction

Mental Impotence Healer Program

Mike Millers Mental Impotence Healer is an eBook that utilizes guided imagery that can help you cure your psychological impotence. In guided imagery, you will be guided into imagining a scenario to guide you to overcome psychological and physical issues. It commonly uses descriptive language and instructions that have direct impact on the brain. Because the mind greatly influences your body, this system will help you have rock-hard erections whenever you need them most. Simply listen to The Mental Impotence Healer Program for 60 days and completely annihilate your sexual fears and in next to little time you will make yourself a brand new You! Recharged with sexual energy, bursting with self-confidence, rock solid on command, and conditioned to believe that your times of Psychological Impotence have dissapeared, for good! The Mental Impotence Healer Program provides you with your confidence back and will boost your self-esteem to amazing new heights. Listen to the beautiful, calm and relaxing Guided Imagery session and it definitely will totally transform your sex life. You will obtain control over your erections without taking any harmful medication or dangerous pills. Grab a set of headphones and the recordings will go to work while you relax. The carefully mastered binaural beats and subliminal messages will reprogram your subconscious mind to a radically altered state of heightened sexual awareness and desire! Continue reading...

Mental Impotence Healer Program Overview

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Author: Mike Miller
Official Website: www.mentalimpotencehealer.com
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My Mental Impotence Healer Program Review

Highly Recommended

I've really worked on the chapters in this book and can only say that if you put in the time you will never revert back to your old methods.

All the modules inside this ebook are very detailed and explanatory, there is nothing as comprehensive as this guide.

Etiology of erectile dysfunction after radical retropubic prostatectomy

Penile erection is a complex phenomenon that includes coordinated interaction of the nervous, arterial, venous and sinusoidal systems.13 While the neurogenic component to erectile dysfunction after radical prostatectomy is secondary to disruption of the cavernosal nerves,1 the arterial component is thought to arise from the disruption of accessory pudendal arteries or atherosclerosis.25 Breza etal. demonstrated that an accessory pudendal artery supplied additional blood to the penis in seven out of ten cadavers, and because of its close proximity to the prostate and bladder, could easily be compromised during radical pelvic surgery.26 Aboseif et al. showed a 40 incidence of erectile dysfunction after nerve-sparing radical prostatectomy. These patients had a minimal response after surgery to an intracavernosal vasoactive agent despite an adequate response preoperatively.13 This suggests a vascular etiology of postsurgical impotence, which was confirmed with reduced diameter and...

Etiology of erectile dysfunction after external beam radiotherapy

The causes of impotence are arteriogenic, neurogenic and pyschogenic in nature. After radiotherapy the most likely cause of erectile dysfunction is arteriogenic.65,69,70 Goldstein et al. postulated that postradiation impotence is secondary to damage to the internal pudendal and penile arteries.70 Radiation causes proliferation of the intima of vessels and is prothrombotic, favoring atherosclerotic plaque formation.71 The histologic changes after radiation therapy were initially demonstrated in animal studies, where damaged vessels became sites of fibroblastic proliferation and lipid depos-ition.72-74 These changes would certainly impede blood flow to the penis and cause erectile dysfunction. It is not surprising that a higher percentage of patients after radiotherapy present with erectile dysfunction, if they have a history of hypertension, atherosclerosis and tobacco use.70 In contrast to the factors affecting erectile dysfunction after radical prostatectomy, younger age did not seem...

Treatment of erectile dysfunction after radiotherapy

There are fewer data outlining the treatment of erectile dysfunction after radiotherapy as compared with surgery. Radiation treatment for prostate cancer used to be reserved for the elderly, who were not likely to care about postradiation impotence. This trend is changing as more and more younger patients are electing for radiotherapy as initial treatment for their prostate cancer - and, as a result, potency is a major Sildenafil, similar to retropubic prostatectomy patients, remains the first-line agent to treat erectile dysfunction after radiotherapy to the prostate. Zelefsky et al. reported significant improvement in the firmness of erection, durability of erection and increased frequency of sexual activity after silde-nafil use.77 Patients who had at least partial erections prior to radiation treatment were most likely to respond to sildenafil and at a significant rate of 90 . Patients with poor pretreat-ment erectile activity were not likely to respond to sildenafil after...

Sildenafil And Hypoxic Pulmonary Hypertension

Abstract We have previously demonstrated that sildenafil inhibits hypoxia-induced pulmonary vasoconstriction in healthy subjects. The aim of this study was to investigate the effects of the PDE5 inhibitor sildena-fil on pulmonary hemodynamics in patients with high altitude pulmonary hypertension (HAPH). Twenty-two patients with HAPH were randomized by age and level of mean pulmonary arterial pressure (PAP) in 3 groups a first group (n 9) treated with 25 mg of sildenafil 3 times a day a second group (n 5) - received 100 mg of sildenafil 3 times a day a third group (n 8) - treated with placebo. Pulmonary hemodynamics was measured by right heart catheterization at baseline and after 12 weeks of sildenafil therapy at, before and 1 hour after taking sildenafil or placebo. In the first group the mean PAP decreased after 12 weeks of sildenafil treatment from 36 8 to 30 8 mm Hg and to 25 7 mm Hg (p < 0.007) 1 hour after 25 mg of sildenafil, in the second group, mean PAP decreased after 12...

Clinical Presentation

Not significantly different than those symptoms associated with progressive benign prostatic hyperplasia, although they usually occur with a more rapid onset in the prostate cancer patients, with the duration of symptoms measured in months as opposed to years. As the tumor continues its local progression, patients may notice either hematospermia or decreased ejacu-latory volume secondary to ejaculatory duct obstruction. Erectile dysfunction as a consequence of extension beyond the capsule of the prostate by the malignant process and involvement of the neurovascular bundle(s) with local tumor progression may occur. In later stages of locally advanced prostate cancer, even the corpora cavernosa may be directly involved.

Strategies of Androgen Deprivation

Surgical castration by bilateral orchiectomy is the most immediate method to reduce circulating testosterone by > 90 within 24 hours,11 and there is no risk of a paradoxical flare of the disease. Since the 1960s, the Veterans Administration Cooperative Urological Research Group (VACURG) trials, the earliest large-scale randomized studies of hormonal therapy, demonstrated the clinical effectiveness of surgical castration.12,13 Compared to placebo, orchiectomy retarded cancer progression in advanced cases, but no clear survival advantage for castration over placebo was seen. Recent clinical studies (i.e. surgical vs. chemical castration) are discussed later. Although surgical castration may be underused, some studies suggest that many patients prefer this approach for the reasons of convenience and cost.14 On the other hand, other studies suggest that this treatment approach is unacceptable to many patients, causing considerable psychological problems, with irreversible impairment in...

Benign prostatic hyperplasia

From TURP Retrograde ejaculation (common), haemorrhage (primary, reactionary or secondary 2-10 ), clot retention, more rarely incontinence, TUR syndrome (seizures or cardiovascular collapse caused by hypervolaemia and hyponatraemia due to absorption of glycine irrigation fluid), urinary infection, erectile dysfunction late urethral stricture.

Longterm complications

Impotence Examination of postoperative impotence after RRP is difficult for several reasons. Objective measure of potency, both before and after treatment, is difficult to assess. The definition of potency also varies widely in reported series, without a consensus definition. Definitions include the degree of tumescence

High Altitude Pulmonary Hypertension Study Design Of Study

Suitable patients were randomised to receive sildenafil, 25 mg or 100 mg, or matching placebo every 8 hours for 12 weeks. The study was double blind. The primary end point was the change in mean PAP from baseline (week 0) after 12 weeks of treatment. Other measures of efficacy were the change in PVR (mean PAP (mm Hg) - pulmonary capillary wedge pressure (mm Hg) cardiac output (CO, l min) x 80 dynes.s cm-5), cardiac output (l min), and 6-minute walk (6MW) distance from week 0 after 12 weeks of treatment. The physical limitation domain of the Kansas City Cardiomyopathy Questionnaire 16 was used to assess activity.

Response To Treatment Mean

There was a statistically significant difference among the three groups in changes from baseline to week 12 in mean PAP measured 8-10 hours postdose (trough) (p 0.039). Sildenafil 25 mg 8-hourly reduced mean PAP by -6.9 mm Hg (95 CI -12.4 to -1.3 p 0.018) compared with placebo. The treatment effect for the higher dose of sildenafil compared with placebo TABLE 2. Mean (SD) baseline characteristics of subjects randomised to receive sildenafil or placebo treatment TABLE 2. Mean (SD) baseline characteristics of subjects randomised to receive sildenafil or placebo treatment

Radical Prostatecomy Versus Cryosurgery

Compared to surgery, the complication rate of cryosurgery appears unacceptably high. Impotence is almost a universal complication of the procedure. Approximately 10 of cryosurgery-treated patients experience urethral sloughing. Incontinence rates up to 15 have been reported. Even worse, the complication of rectourethral fistula may occur in up to 3 of cases.43-44

Innervation Of The Prostate

The careful identification and mapping of the neurovascular bundles has provided a major advance in reducing the morbidity of radical prostatectomy.11 With the preservation of the nerve bundles according to appropriate anatomic guidelines, cancer control may be maintained without unnecessarily compromising erectile function.12'13 The relationship of the nerve bundles to the rectum has been described as fixed, while the size of the prostate can have a significant impact on the relative position of the nerves to the gland (lateral versus posteriolateral).

Rationale For Interposition Sural Nerve Graft

Given our current knowledge of the anatomy, function and regenerative ability of the pelvic autonomic nerves, it is not unreasonable to think that one could improve the functional outcome for patients with locally advanced prostate cancer who have undergone either unilateral or bilateral wide resection of the neurovascular bundle(s) (leaving the nerve intact on the prostatectomy specimen) by interposing a nerve graft to the free ends of the resected cavernous nerve(s). In patients with pathologic stage T3 disease, this approach would have the potential to improve cancer control by reducing the incidence of positive surgical margins as compared with nerve-sparing surgery and to reduce the incidence of impotence, and possibly incontinence, as compared with non-nerve-sparing surgery without nerve graft. Four key conditions determine whether patients can benefit from this approach. First, cavernous nerve function must be restored on the grafted side once the neuro-regenerative process is...

Preoperative Assessment

Patient-related factors are also important in decision making for radical prostatectomy. Advancing age and poor health status limit the indications of radical prostatectomy as a treatment option. Risk for incontinence and impotence, hospitalization and recovery period as well as fear of being under anesthesia should be discussed in detail before the surgery.

Risk Factors And Prevention

Surgical techniques for radical prostatectomy have evolved over the last several decades as a better understanding of the pertinent pelvic neurovascular anatomy has emerged.35 Modifications in surgical technique have allowed better preservation of erectile function' lower intraoperative blood loss and shorter hospital stays. However, whether any of these technical modifications have improved overall continence rates is unclear. In several instances, a number of other modifications to RP have been proposed with the goal of reducing or eliminating postoperative sphincteric incontinence. Careful preservation of the bladder neck fibers during dissection of the prostate has been suggested as providing a faster return to continence postoperatively36,37 and improving continence overall.13 Owing to concerns in preserving cancer-free surgical margins during RP, bladder neck preservation is not always possible. Lowe reported that preservation of the bladder neck did not result in improved...

Sexual Dysfunction Following Mesorectal Resection for Cancer

Surgery for rectal cancer may decrease the sexual function but the introduction of total mesorectal excision (TME) with autonomic nerve preservation has significantly increased the number of men with preserved post-operative sexual function 28 . In a prospective study of sexual function before and after rectal cancer surgery, TME significantly preserved the ability to achieve orgasm and to ejaculate when compared to standard rectal cancer surgery 29 . In a retrospective evaluation of sexual function following TME, 86 of patients less than 60 years of age and 67 of patients older than 60 years maintained their ability to engage in sexual intercourse, while 87 of all men maintained their ability to have an erection following TME. Retrograde ejaculation occurs rarely but does not diminish the patient's capacity for normal sexual activity 30 . The effects of TME for rectal cancer on female sexual function are less clear.

Effect of Laparoscopic Technique on Genitourinary Function

A recent study 32 investigated the frequency of bladder and sexual dysfunction, secondary to pelvic nerve injury, following laparoscopically assisted and conventional open mesorectal resection for cancer in a randomised trial of laparoscopic vs. open resection. A retrospective analysis of bladder and sexual function before and after operation was performed by means of postal questionnaires and telephone interviews. Of the responders, 40 patients had undergone laparoscopically assisted resection and 40 had had an open operation. No significant deterioration in bladder function following an operation was observed, although two patients in the laparoscopic group required long-term intermittent self-catheterisation. A significant difference in male, but not female, sexual function was noted, with seven of 15 sexually active men in the laparoscopic group reporting impotence or impaired ejaculation, compared with only one of 22 patients having an open operation. All patients with bladder or...

Attempts To Decrease Positive Surgical Margins

The role of nerve-sparing surgery remains controversial with regard to its association with positive surgical margins. Although postoperative erectile dysfunction is multifactorial, bilateral excision of neurovascular bundles to reduce postoperative positive surgical margins compromises postoperative potency. Several reports have suggested nerve-sparing techniques do not significantly increase the rate of positive surgical

Advantages Of The Laparoscopic Approach

Decreased blood loss and possibly shorter duration of catheterization seem to be the obvious advantages. Blood loss is less partly due to the tamponading effect of the pneumoperitoneum. In most laparoscopic series the estimated blood loss was less than 500 ml compared to an about 1000 ml blood loss after open surgery.10 The urinary continence following surgery appears satisfactory. Erectile function may not completely recover for 1-2 years following surgery. The efficacy of the nerve-sparing technique in the LRP has, therefore, not been adequately studied. Magnification and the better visualization that is provided during laparoscopy can theoretically result in more accurate dissection. This can result in a superior nervesparing technique. The positive margin rate of 13.75-27.9 is comparable to the series by Weider and Soloway,11 who

An outpatient Sexual dysfunction

Impotence is reported in 20-50 of men following EBRT, depending upon the definition of potency and the time frame of assessment.47 More contemporary series have revealed that 60-70 of men who are potent prior to radiation retain potency following treatment.50'51 However, deterioration of potency with age, intercurrent diseases, such as hypertension, cardiovascular disease and diabetes, and the use of medications all compromise erectile function in this population of older men with prostate cancer.

Recent Studies on the Effects of Hypoxia on CBF Autoregulation

Subjects had been randomized to tadalafil, dexamethasone or placebo as part of a study on the pharmacological prevention of high-altitude pulmonary edema 18 . Altitude was associated with an increase in a cerebral sensible AMS (AMS-C) score (p< 0.001), without change in average CBF, ARI, or CCP. However, the AMS-C score was negatively correlated to ARI (r - 0.47, p< 0.01). The ARI and CCP were positively correlated to arterial oxygenation. The AMS-C score was lower in dexamethasone-treated subjects compared to high-altitude pulmonary edema-sensible controls. A stepwise multiple linear regression analysis on arterial PCO2, SaO2, and baseline or altitude ARI, identified altitude ARI as the only significant predictor of the AMS-C score (p 0.01). These results supported the notion that impaired dynamic autoregulation of CBF could play a role in AMS symptomatology 28 .

Who best determines quality of life

Nearly universally available, and any reported series of radical prostatectomy or radiation therapy will include an estimate of urinary incontinence, erectile dysfunction, bowel toxicity, etc. However, as the science of survey research began to be applied to cancer patients, it became clear that physician estimates and patient estimates of QOL often disagree.38 Litwin etal.39 utilized the CAPSURE database to assess differences in physician and prostate cancer patients' estimates of QOL using the SF-36 and UCLA PCI. Substantial differences were seen in assessment of physical, urinary, bowel, sexual function, fatigue and pain, with urologists generally underestimating quality of life. This trend has been noted by other studies,40-42 and explains why most modern QOL studies distribute questionnaires with return envelopes addressed to research coordinators, so as to remove the physician from the process as much as possible.

Radical prostatectomy

Radical prostatectomy is historically associated with significant urinary incontinence and impotence. Recent improvements in the anatomic approach to the procedure and nerve preservation have improved but not eliminated these side effects. During the first year after surgery, continence and potency (with nerve sparing) improves, but the degree of improvement and final outcome varies widely in the literature. Talcott etal.49 reported a prospective cohort study and found that, at 12 months, impotence was 75 and incontinence was 35 . In another study,50 they noted high impotency rates among bilateral nerve-sparing patients, and essentially no benefit for unilateral nerve sparing. In a study of Medicare outcomes, In the PCOS report on radical prostatectomy,51 the findings at 18 months included incontinence in 8.4 and impotence in 59.9 . Age, nerve sparing and race affected sexual function and, beyond 18 months, 41.9 reported their sexual function was a moderate to large problem. Litwin et...

Brachytherapy with or without XRT

Quality of life data from brachytherapy is just beginning to emerge. Cross-sectional data from Davis etal.34 showed that brachytherapy is associated with erectile dysfunction and irritation obstruction urinary side effects that improve in the first 12 months after treatment, and a decrease in erectile function. Scores from the SF-36 were no different than age-matched controls. Sanchez-Ortiz etal.60 also used the SF-36 UCLA PCI and found that among pretreatment potent men, 51 developed erectile dysfunction however, this finding did not correlate with androgen deprivation, SF-36 scores or satisfaction rates. Brandeis etal.31 also performed a cross-sectional study and found the same pattern of SF-36, sexual function and urinary function changes, but also found that patients who had combination brachytherapy XRT had even lower sexual and urinary function scores. Krupski etal.61 also performed a cross-sectional study using the FACT G, AUASI and a separate sexual function inventory....

Salvage local therapy

Salvage radical prostatectomy is well known to be a morbid procedure, with high incontinence and impotence rates. Salvage radiation therapy may also add morbidity to radical prostatectomy. Impotence is generally the rule, but continence is often preserved if XRT is delivered after enough time has passed for the patient to regain postoperative continence. However, rigorous study of salvage treatments using validated instruments is extremely limited. Tefilli etal.69 used the FACT-G and FACT-P instruments to study their series of patients with locally recurrent prostate cancer who underwent salvage prostatectomy versus salvage XRT. As one would expect, salvage prostatectomy was associated with significantly lower scores for physical well-being, and urinary continence compared to salvage XRT. Perrotte et al.70 studied the MD Anderson series of salvage cryotherapy using a modified UCLA PCI and SF36, and AUASI. They were able to demonstrate significantly better incontinence and pain scores...

Clinical Applications

Knowledge of sleep stages may be especially valuable in diagnosing and treating sleep disorders, because the frequency, patterns, and symptoms of these disorders may be associated with specific stages of sleep. For example, knowledge of the muscular paralysis that accompanies REM sleep has been instrumental in diagnosing the cause of male impotence. Partial or total erections are present in about 95 percent of REM periods. Therefore, men who complain of impotence yet demonstrate normal REM erections can be diagnosed as suffering from psychologically based impotence. These patients may benefit from psychotherapy or sexual counseling. In contrast, men who do not achieve REM erections are diagnosed as suffering from organically based impotence and require hormone therapy or surgical implantations.

Nerve sparing versus nonnerve sparing

Most men presenting with prostate cancer will have localized disease and, therefore, a long disease-free survival after treatment for their cancer.19 Successful treatment of prostate cancer not only depends on the length of time patients are cancer free, but also a patient's sexual function, which comprises a major component of their quality of life.19 It is recognized that nerve-sparing procedures provide the patient with a better quality of life and quicker return of erections.2,16 Quinlan etal. reported that there was a twofold increase in the risk of impotence when one neurovascular bundle was widely excised.2 This implies a neurogenic component to the physiologic mechanism of erection. Similarly, Geary etal. found that the potency rates increased with the number of neurovas-cular bundles spared.16 The number of intact neurovascular bundles was the most significant factor affecting postoperative potency.

Quality of life after radiotherapy

Patients who choose external beam radiation treatment for their prostate cancer seek cure above all else. The goal of any cancer treatment is to eradicate the tumor cells, with quality of life issues taking a close second. Physicians must help patients weigh the benefits of cancer treatment with the consequences, like erectile dysfunction. In addition to not being able to achieve an erection sufficient for intercourse, patients complained about decreased orgasmic pleasure and reduced ejaculate volume in one series by Helgason etal.80 Erectile dysfunction closely parallels the quality of life patients experience and all factors that comprise erectile dysfunction need to be properly addressed to patients beforehand, like orgasmic pleasure and the ability to ejaculate.

Decision And Choice Of Treatment

His first choice was surgery, performing a radical prostatectomy to remove the entire prostate gland and adjacent glands. He assured me that he could perform and leave the nerves intact that are responsible for penile erections (nerve-sparing technique). He recommended that I make an appointment to see a radiation oncologist for consultation about their choice of treatments. The radiation oncologist talked to me about several specialized treatments external beam radiation to destroy the cancer cells in the affected areas radioactive seed implants, placing little rice-size 'pellets' in the prostrate gland to destroy the cancer cells and cryosurgery, controlled freezing of the prostate gland to destroy cancer cells.

Vascular Supply And Innervation Of The Corpora Cavernosa

The arterial supply to the corpora cavernosa is usually from the internal pudendal artery via the common penile artery. The three branches of the common penile artery are the cavernosal artery, the dorsal penile artery and the bulbourethral artery. The cavernosal artery, during its course within the corpus cavernosum, gives off helicine arteries that feed the trabecular erectile tissue and sinusoids. The dorsal artery of the penis is responsible for engorgement of the glans penis. Accessory arteries arising form the obturator, vesical, femoral or external iliac arteries may exist. Only on rare occasions are branches of the obturator or vesical arteries the predominant supply to the corpora cavernosa, making vasculogenic erectile dysfunction after RRP uncommon.5,10

Neurostimulationcaver Map

Kim et al. reported that a positive CaverMap response poorly predicted recovery of potency after radical prostatec-tomy.23 A positive CaverMap response was noted in 77 of men but only 18 reported regaining sufficient potency for sexual intercourse.23 None of the patients who had both neurovascular bundles excised could achieve erections post-operatively. This group of patients also had a negative Caver-Map response, which validates the neurogenic component to erectile dysfunction. Because the high CaverMap response rate did not correlate with the low potency rate postopera-tively, it is hypothesized that erectile function is most likely a multifactorial process.

New Issues In The Radical Retropubic Prostatectomy

Without a doubt, experienced prostate surgeons will identify numerous points of our technique that they perform differently. The point to emphasize for surgeons in training is that there are many ways to perform this operation that will be successful, so long as the principles of oncologic surgery are followed, while trying to minimize the side effects of incontinence and, when indicated, impotency. Again, we emphasize that careful ongoing review of one's personal pathologic and quality of life results is needed. Walsh has even recently described keeping video coverage of each case so that outcomes can be correlated with the original surgical technique. While Cavermap in this trial showed improved results, Klotz36 has postulated that the Cavermap may improve the results in the control group, as the same surgeons were performing Cavermap versus non-Cavermap dissections by random assignment. Thus, Cavermap may not be an ongoing necessity for optimized outcomes, but may assist surgeons...

Prognostic Implication Of Positive Apical Margin

The importance of prostatic apex dissection in anatomical radical prostatectomy, as it relates to potency and urinary continence, is well established. The proximity of the rhabdo-sphincter must be preserved to minimize incontinence after prostatectomy. The anatomical location of the apex of the prostate deep in the pelvis, and the proximity with critical structures responsible for preservation of continence and sexual potency make the proper dissection of this area challenging. Before the anatomic approach, the high incidence of incontinence after radical prostatectomy had led patients and physicians to consider seriously alternatives to surgery even for the most appropriate candidates. Attempts to preserve the neurovascular bundles or maximal urethral length may compromise the extent of cancer excision, resulting in positive surgical margins at the apex.

Preoperative Counseling

A common issue for many men is the appropriateness of nerve preservation, while also controlling cancer. Positive surgical margins increase the risk of PSA recurrence and need for additional treatments,10 and the neurovascular bundle is a common site of spread of disease. Many factors affect return of potency following radical prostatectomy including age, number of bundles preserved and presurgical potency.11 In addition, preservation of both nerves (and for some patients under 55 years of age unilateral nerve sparing) is required for response to Sildenafil.12'13 It has been suggested that nerves may be preserved in the majority of men with potentially curable disease, and that intraoperative findings can guide the decision based upon induration in the lateral pelvic fascia, adherence of the neurovascular bundle to the prostate while it is being released, and inadequate tissue covering the postero-lateral surface of the prostate once the prostate had been removed, leading to secondary...

Medication Side Effects

Side effects of psychotropic medication are particularly important. They can be very severe and harmful to the individual. Some common side effects are increased appetite, hormonal difficulties (e.g., failing to menstruate), motor difficulties (e.g., shuffling gate), muscular problems (e.g., stiffness), dryness of mouth, blurred vision, impotence, low blood pressure, seizures, and immune system reactions.

PDE Inhibitors and Cardiovascular Disorders

With the discovery of the second messenger nitric oxide and its link to activation of guanylyl cyclase, there has been a renewed interest in inhibition of cGMP-selective PDEs as a means to produce vascular smooth muscle relaxation. While testing several compounds that inhibit the cGMP-specific PDE5, it was discovered that the corpus cavernous of the penis was particularly sensitive to these drugs. This observation has lead to the development of drugs useful in the treatment of penile erectile dysfunction (Licht, 1999). Sildenafil citrate (Viagra) is one of the most widely publicized drugs produced at the end of this century. Another area of potential use of PDE5 inhibitors is for the treatment of pulmonary hypertension (Beavo, 1995).

Jack H Mydlo and Matthew Karlovsky

Cannon etal. reported on the increased occurrence of primary cancers in association with multiple myeloma and Kaposi's sarcoma.23 With the advent of effective pharmacotherapy for erectile dysfunction in the elderly, there is speculation that there may be a corresponding increase in the incidence of sexually transmitted diseases among this age group, including the human immunodeficiency virus, or HIV.24 This may have many ramifications in the future in the treatment of patients with prostate cancer.

Radical Prostatectomy Versus Brachytherapy

Again, there is a widespread perception that there is no impairment in sexual function with brachytherapy. After reviewing 66 references published over the last 10 years, Peneau observed an impotence rate of 25 associated with brachytherapy and progressive decrease in sexual potency with time.38 In a study comparing general and disease-specific health-related quality of life in men undergoing brachytherapy to those undergoing radical prostatectomy and age-matched healthy controls, sexual function and bother were equivalent in RP and brachytherapy groups, and both were worse than in healthy controls.39 The same study has shown that general health-related quality of life did not differ greatly among the three groups. Urinary leakage was better in the brachytherapy group than in the prostatectomy group however, both were worse than controls. The brachytherapy group had significantly worse AUA symptom index scores and worse bowel function than RP group. Patients who underwent combined...

Recovery Of Potency And Continence After Sural Nerve Graft

A recent analysis of 93 patients who underwent unilateral nerve-sparing RRP (between November 1994 and November 1999) with (n 51) or without (n 42) contralateral SNG showed that 32 of the 51 men who had unilateral SNG recovered erectile function compared with 7 of the 41 men who did not have SNG. The average time to recovery of erectile function was significantly shorter in the SNG group mean time to potency recovery 13.7 months, 95 confidence interval (CI) 11.4-15.9 months than in the non-SNG group (mean time to potency recovery 65.9 months, 95 CI 57.7-74.1 months). Even after adjustment for age, the Kaplan-Meier probability of recovery of erectile function remained significantly higher in the SNG group than in the non-SNG group at 6, 12, 18 and 24 months (P < 0.05). The age-adjusted hazard rate when the SNG group was compared with the non-SNG group was 4.04 (P 0.003), indicating the Kaplan-Meier probability of erectile function recovery in the grafted patients was four-fold higher...

Lateral Pelvic Lymph Node Dissection LPLD Technical Notes Indications Results and Complications

Eighty per cent of patients complain of post-surgery bladder disorders, 40 complain of lack of a bladder kick sensation and 76 complain of impotency these percentages are twice as high as those of patients who underwent ordinary surgery 16 . This is the consequence of sacrificing pelvic autonomic nerve structures 30 .

Evaluating treatment options

Examination of the treatment options for prostate cancer requires an analysis of the specific advantages and disadvantages of each modality. As shown in Table 24.4, each modality has specific issues which may make the modality more or less advantageous. RRP has an advantage in that it offers accurate pathologic prognostic information, which is lacking with both radiotherapy modalities, and offers the most data on long-term (> 10 year) cancer control. Conversely, XRT and brachytherapy carry much less risk of peritreatment morbidity or mortality, with quicker recovery and return to work. The issues of incontinence and erectile dysfunction, as mentioned previously, differ between modalities, with acute occurrence and delayed recovery for RRP, and delayed occurrence in either radiotherapy modality.

Personal Objectives

In the vignette that opens this chapter, Mr. Diehl is concerned about his ability to enjoy life. He does not experience symptoms from his hypertension. In fact, he doubts that he has hypertension, while he attributes symptoms that he does experience, e.g., impotence, to his medication. Trying to trump his quality-of-life concerns with clinical objectives may not succeed, especially if this is attempted by means of professional authority. He admits that he is not cooperating in his care as well as he could. His cooperation may well be necessary to obtain the professional objective of disease control.

Future Directions

To preserve normal vision it may be necessary to prevent plasticity in diseases and after retinal injury. Knowing the intrinsic and external stimuli for synaptic change will make it possible to develop strategies to preserve stability. There has already been some interest in calcium channel blockers as a preventive of rod cell degeneration. Although these blockers have had mixed results regarding the delay of degeneration (Frasson et al., 1999 Pearce-Kelling et al., 2001), it would be of interest to know if they prevent synaptic plasticity since both rod and cone plasticity depends on calcium influx. Drugs which affect the NO-cGMP pathway may also, unintentionally, affect photoreceptor synapses. Viagra, for instance, which blocks PDE 5 and possibly also PDE 6 activity, increases cGMP levels and has been shown to have some effects on postreceptoral elements in the outer retina (Jagle et al., 2004). Are these drugs inducing synaptic plasticity in retinal cells Thus both to protect...

Description

Radical prostatectomy is the gold standard for surgical treatment of prostate cancer, having been revived and popularized by Walsh in the late 1970s and early 1980s.3 Since Walsh's landmark description of the local anatomy of the prostate gland in relation to the adjacent vasculature and neurovascular bundles, the surgical complication rate has dramatically decreased.4 With the introduction of the nerve-sparing radical retropubic approach, markedly reduced rates of postoperative incontinence and impotence have been achieved, making radical prostatectomy the most common treatment of localized prostate cancer offered to men younger than 70.5'6

Statistical Analysis

Changes from baseline to week 12 in the primary end point (mean PAP) and the secondary end points (PVR, CO, physical symptom score, and 6MW) were compared between the sildenafil and placebo groups using analysis of variance (ANOVA). The differences among all three treatment groups were compared using ANOVA. If a significant difference was observed among the three treatment groups, comparisons of each treatment group with placebo were conducted. In addition, the combined sildenafil dose groups (sildenafil 25 mg 8 hourly and 100 mg 8 hourly) were compared with placebo by ANOVA.

Cardiac Output

There was no statistically significant difference among the three groups in changes from baseline to week 12 in cardiac output measured at trough levels (p 0.051), so no further statistical comparisons were carried out. The treatment effects at trough levels were -1.0 l min (95 CI -2.1 to 0.1) and 0.5 l min (95 CI -0.8 to 1.9) for the lower and higher doses of sildenafil compared with placebo. When patients receiving sildenafil were combined into a single treatment group, cardiac output at trough levels was reduced by was -0.4 l min (95 CI -1.6 to 0.7) but was not significantly different from placebo. No statistically significant difference was observed among the three groups in changes from baseline to week 12 in cardiac output measured at 1 hour post-dose. The respective treatment effects for the lower and higher doses of sildenafil compared with placebo at 1 hour post-dose were -0.6 l min (95 CI -1.8 to 0.6) and -0.2 l min (95 CI -1.2 to 1.6). For the combined sildenafil treatments...

Mw Distance

There was a statistically significant difference among the three groups in changes from baseline to week 12 in 6MW distance (p 0.028). The increase on sildenafil 25 mg 8-hourly was 45.4 m (95 CI 11.5 to 79.4 p 0.011) and on sildenafil 100 mg 8-hourly it was 40.0 m (95 CI 0.2 to 79.8 p 0.049) compared with placebo. For the combined sildenafil treatment groups there was a statistically significant treatment effect size (p 0.007) of 43.5 m, compared with placebo (95 CI 13.4 to 72.6).

Other Parameters

There was a statistically significant difference among the three groups in changes from baseline to week 12 in physical symptom score (p 0.024). The treatment effect for the lower and higher doses of sildenafil compared with placebo were 8.4 (95 CI 20.2 to 17.0) and 14.0 (95 CI 4.0 to 24.1 p 0.009), respectively. For the combined sildenafil treatments the statistically significant treatment effect size (p 0.012) was 10.4 compared with placebo (95 CI 2.5 to 18.3). There was no significant treatment effect on systemic blood pressure. Sildenafil was well tolerated. All subjects reported some improvement in wellbeing and no adverse effects were reported.

Discussion

Other operative modifications, including sparing of the puboprostatic ligaments, passage of a suture ligature rather than a right angle for securing the dorsal venous complex and sharp resection at the apex allows for more precise dissection. These maneuvers act to preserve the external sphincter with its fixation intact, contributing to improved continence rates. Preservation of the external sphincter has been shown in several series to be significant in preservation of continence.11'12 It was rare for patients to note full continence initially more than 5 years ago, but it occurs more frequently now.13 Although the role bladder neck preservation plays in continence remains controversial, many believe it provides a speedier return of continence14 and reduces the incidence of bladder neck contracture.15 Dissection of the bladder neck is performed more carefully now, aided by palpating the catheter and defining the natural plane of dissection between the prostate and bladder. Some may...

Potency

All forms of treatment for prostate cancer affect erectile function. Appropriately selected RPP candidates (PSA 10ng ml and Gleason score 6) may be offered a nerve-sparing approach. Nerve-sparing RPP is equally effective in preserving potency as the retropubic approach and may be performed unilaterally or bilaterally.6 It has been our practice to offer bilateral nerve-sparing only to those patients with a single positive biopsy core. Most patients undergo a unilateral nerve-sparing RPP with deliberate sacrifice of the neurovascular bundle on that side on which side biopsies were positive, suggesting the location of the bulk of the tumor. Frazier et al. found 77 of patients to be potent 1 year after nerve-sparing RPP.5 Weldon et al. analyzed the time course to recovery of potency and found that potency returned in 50 of patients after 1 year and in 70 after 2 years. A further important observation was the strong inverse correlation of the rate of successful potency sparing and...

Patient Selection

Patients that should be avoided during the learning curve include those with the following obesity history of radiotherapy to the prostate transurethral resection of the prostate and previous bladder and prostate surgery, and laparoscopic inguinal hernia repair. Neoadjuvant hormonal treatment can make surgery difficult due to periprostatic adhesions and fibrosis. The nerve-sparing technique is difficult during a surgeon's early experience. We would, therefore, recommend that patients with preoperative erectile dysfunction be chosen and that the nerve-sparing technique should not be attempted initially. Patients with prostates that are larger than 80 g and less than 20 g would also be relatively difficult initially. As experience is gained, indications for laparoscopic prostatectomy should include all patients who are candidates for radical prostatectomy. A large median lobe can make bladder neck preservation difficult and would necessitate bladder neck reconstruction.

Sexual Dysfunction

Male sexual dysfunction is regulated by the auto-nomic nervous system via the pelvic plexus which lies posterolateral to the bladder. Sympathetic nerves are responsible for ejaculation, while parasympathet-ic nerves govern erection. Sexual dysfunction after APR defined by partial or total impotence, loss of emission or retrograde ejaculation was observed in 6 40 (15 ) who had normal sexual function prior to operation.

Prolactinomas

Reported in the literature however, prolactinomas can be locally destructive, especially the macroadenomas. In addition to affecting pituitary function by a local mass effect, they can invade the optic chiasm as well as the adjacent cavernous sinus causing cranial nerve neuropathies (CN III, IV, V1, V2, VI). In women, the slightest elevation in prolactin can cause menstrual disturbances. Men, on the other hand, tend to present with symptoms of local mass effect. Physiologic effects of hyperprolactinemia in men (low libido, impotence, and infertility) are less sensitive to the hyperprolactinemia than symptoms in females (oligomenor-rhea or amenorrhea). Any male patient with erectile dysfunction

Sexual function

Three-dimensional conformal radiation therapy is able to cause sexual impotence by disruption of the arteriolar system supplying the corporal muscles.12 The mechanism of sexual dysfunction after transperineal brachytherapy (TPB) has been less well evaluated. Secondly, overall satisfaction with sex life and sexual function may change at different rates over time depending on the radiotherapeutic modality. It may well be that men receiving IGTPB recover at slower rates than those treated with 3D-CRT, since the mechanism of impotency may be neurovascular injury rather than solely microvascular angiopathy. In addition, the radiotherapeutic doses delivered over several months in palladium or iodine brachytherapy as opposed to 8 weeks in external beam potentially prolongs the tissue effect. Another factor is whether the selection of isotope and the actual delivered dose by postimplant dosimetry had any bearing on the rates of potency cited. This is particularly important since data indicate...

Late complications

Compared to 3D-CRT, PB is associated with both more acute and chronic urinary morbidity. This was illustrated in one series that compared outcomes in men with favorable risk prostate cancer who received either 3D-CRT (n 137) or transperineal 125I implantation (n 145).7 In the PB group, 31 had grade 2 urinary symptoms persisting after 1 year, and the median duration of grade 2 urinary symptoms was 23 months (range 12-70 months). In contrast, acute grade 2 urinary symptoms resolved within 4-6 weeks after completion of 3D-CRT, and at 5 years, only 8 still had grade 2 urinary toxicity. The 5-year likelihood of post-treatment erectile dysfunction among patients who were initially potent before therapy was similar between the two groups, as was the 5-year likelihood of grade 2 late rectal toxicity (6 and 11 , respectively, for 3D-CRT and PB). The impact of brachytherapy on potency was evaluated in In a third report surveying patient-reported symptoms at an average of 5.2 years following...

Peyronies disease

Medical Oral vitamin E supplements and para-aminobenzoate are used. Local injections of collagenase, steroids and calcium channel blockers into the plaque have all been attempted with inconclusive effectiveness. Low-dose radiation therapy can reduce pain but has no effect on the plaque. Surgical Excision of the plaque and skin graft or the removal of tissue on the opposite side to the plaque to counteract the abnormal curvature (Nesbit procedure). Penile implants may be combined with the above procedures or may even be corrective alone. C In severe cases, erectile dysfunction may develop. Tissue atrophy may occur with some of the medical treatments. Excision of the plaque may result in partial loss of erectile function and rigidity, whereas Nesbitt procedure causes a shortening of the erect penis.

Surgical Options

The rate of genito-urinary dysfunction in males after anterior resection for cancer is 0-49 25 this is an acceptable rate in the presence of a certain cancer but for a prophylactic surgery it should be carefully evaluated. The rate of impotence after rectal excision for inflammatory bowel disease is lower than after excision for rectal cancer ranging from 0-25 25-30 . The incidence of sexual dysfunction increases with age and when a mesorectal plane is preferred to close rectal plane of dissection 25 .

Radiation therapy

Radiation therapy is traditionally associated with bowel side effects and erectile dysfunction. As noted previously, the technique has evolved tremendously with conformal beam planning, dose escalation and frequent use of neoadjuvant adjuvant androgen deprivation. Thus, the era studied and technique used will significantly affect QOL results. In the PCOS study,52 bowel function decreased at 6 months but improved to baseline by 24 months. Urinary function and bother were essentially not affected by treatment. Sexual function declined over time, such that by 24 months, 43 of all men with pretreatment potency were no longer potent. Bother assessment also declined over time. Other studies have also documented this pattern of sexual function decline.49'53-55 However, reports of impotence after conformal beam radiation therapy have been lower (13-29 )56-58 and etal. reported decreased bowel complications (34 to 10 , P < 0.04) for moderate to major changes in bowel function. The importance...

Potency rates

Potency rates following external beam radiation therapy vary widely, from 23 to 73 depending on the type of radiation delivered and length of follow-up.53-59 Some authors have noted that potency was retained in a greater percentage of patients who had a higher level of sexual functioning prior to radiation treatment.53'60-62 This observation correlates with the findings from the radical prostatectomy data, which also show that preoperative sexual functioning is a significant predictor of postoperative impotence. Three-dimensional conformal radiotherapy (3D-CRT) differs from conventional external beam radiotherapy in its treatment planning and delivery technique. The former obtains images of the patient's internal anatomy by computed tomography scans in the treatment position, and then delivers a more precise radiation dose to spare more normal tissue. The goal is to irradiate at higher doses with less morbidity. Studies have been contradictory concerning the ability of 3D-CRT to offer...

Brachytherapy

Brachytherapy, another treatment option for patients with prostate cancer, is the implantation of radioactive isotopes into a body cavity or tissue.83 This mode of therapy is improved today with better isotopes (palladium-103), computed tomography and transrectal ultrasound. Potency rates after interstitial brachytherapy have generally been better than those for either radical prostatectomy or external beam radiation therapy. Brachytherapy potency rates have been reported between 47 and 97 in several studies.63'84-90 Factors that had negative impacts on postbrachytherapy potency were pretreatment erectile dysfunction, high implant dose (D90 160 Gy for I-125 and 100 Gy for Pd-103), and short duration hormonal therapy of 5-6 months.89 No difference in postbrachyther-apy erectile dysfunction was noted between iodine-125 or palladium-103.91 The etiology of impotence after brachytherapy is thought to arise from either excessive radiation exposure to the neuro-vascular bundles92,93 or...

Cryosurgery

Potency after cryosurgery has been poor. Rates of erectile dysfunction after this procedure have ranged from 100 to 10 depending on the length of follow-up.91'95-99 Immediately after cryosurgery, impotence is almost universal as the neurovascular bundles thaw. As time progresses after surgery, there is evidence that erectile function returns in some patients. Bahn et al. reported impotence rates of 90 after 6 months, but only 41 after 1 year.100 Other studies confirmed that the impotence is usually transient with 86 of patients recovering erectile function to some degree.95'97'99 Immediate postoperative impotence is caused by the iceball extending into the lateral periprostatic tissue, which shelters the neurovascular bundles.98 The neurovascular bundles are, therefore, destroyed by the extreme cold temperature. In addition, patients have noted decreased sensitivity and parasthesia of the glans penis and general penile numbness 3 months after cryosurgery.91,98 This may be secondary to...

Hormonal Therapy

LHRH agonists, like leuprolide and goserelin, decrease gonadotropin release, which suppresses testicular androgen production. LHRH agonists decrease sexual desire, sexual intercourse, and frequency, duration and rigidity of nocturnal erections when serum testosterone levels fall to castration levels.107 These agents are potent inhibitors of the male sexual response and must be used judiciously in younger patients who wish to preserve sexual function. When bicalutamide was compared with flutamide plus goserelin in prostate cancer patients, fewer patients in the bicalutamide group had erectile dysfunction, which ensured a better quality of life.102 The bicalutamide group of patients enjoyed a higher emotional well-being, vitality and social functioning. Finasteride and flutamide combined as androgen ablative therapy for advanced prostate adenocarcinoma have been studied. Finasteride inhibits 5a-reductase, decreases the conversion of testosterone to 5a-dihydrotestosterone and provides a...

Oxytocin Agonists

Intravenously administered oxytocin for the induction of labour and may also have a role in the treatment of male erectile dysfunction, presumably based on the part oxytocin is believed to play in the regulation of male and female sexual activity. Selectivity for oxytocin over vasopressin V2 has been a problem with this series, but success was obtained with compound (59), which has an oxytocin agonist EC50 of 33 nM and a 25-fold selectivity versus vasopressin V2 118, 119 . Related compounds from this series have been claimed in a recent patent and are reported to be oxytocin agonists and vasopressin V1a antagonists 120, 121 .

Complications

Impotence In a large prospective study examining 482 men receiving prostate brachytherapy who were potent prior to treatment, the 5-year actuarial impotency rate was 47 .90 When stratified for implant monotherapy, implant plus adjuvant XRT, implant plus NHT or implant plus adjuvant XRT and NHT, the 5-year actuarial impotency rates were 76 , 56 , 52 and 29 , respectively. Multivariate analysis identified pretreatment NHT use and patient age as independent predictors of post-treatment impotence in this study. In a subset analysis of 84 men who tried sildenafil for erectile dysfunction after treatment, patients who did not receive NHT had a significantly better response then those treated with NHT. These results are similar to a comparative study examining 3D conformal XRT and 125I prostate brachytherapy in the favorable risk patient by Zelesky.91 This study noted a 5-year likelihood of erectile dysfunction of 53 after implantation in men who were potent before treatment, and was...

Male Infertility

Physiologically, male fertility requires good erectile function spermatogenesis normal endocrine function (specifically testosterone and FSH) and ejaculation. In addition, sexual intercourse timed appropriately to ovulation is an important key to conception. Because of the anxiety and stress that is often associated with couple infertility, male patients often describe difficulty with erections. Obviously, if sexual intercourse is not occurring then conception is impossible This information must be addressed specifically with the patient as he may not volunteer it. Erectile dysfunction secondary to various disease states including diabetes and atherosclerosis must also be elucidated. Any previous history of genitourinary cancers or pelvic surgeries that may have impaired erectile function should also be addressed. the patient is unwilling, financially or psychologically, to undergo ART, other options such as donor sperm insemination or adoption should be discussed. Testosterone,...

Methods

The effects of sildenafil 100 mg and placebo on the pulmonary vascular response to an acute hypoxic challenge were compared in 10 male volunteers aged 18 to 27 years in a randomized, double blind study. The volunteers attended the catheterization laboratory at the National Center of Cardiology in Bishkek (760 meters above sea level), Kyrgyz Republic, on 2 occasions, 1 week apart. All gave written, informed consent and were judged to be healthy on the basis of medical examination and routine hematology and biochemistry. The study was approved by the local hospital ethics committee in Bishkek and followed international guidelines for medical research on human subjects. On each occasion, a Swan-Ganz thermodilution catheter (Baxter Healthcare Ltd) was sited in the pulmonary artery via a jugular vein. Baseline measurements were made after 30 minutes rest, and then sildenafil or placebo (lactose) was given orally in a gelatin capsule with 100 mL of water. One hour later, the volunteers...

Specific Hormones

EXCESS May occur in prolactin-producing tumors, or with excess thyroid releasing hormone (TRI1) production, which stimulates prolactin secretion in addition to TSH secretion. Galactorrhea (excess milk secretion) results, as well as amenorrhea and anovulation secondary to disturbances of the menstrual cycle. Nursing also stimulates prolactin production and hence is associated with decreased fertility during the phase of nursing. Excess prolactin in males results in testosterone deficiency and impotence.

Vascular Supply

The principal arterial supply to the prostate is provided by branches of the inferior vesical artery, which is in turn supplied by the hypogastric artery. The capsular artery and its branches run posteriolateral to the prostate in parallel with the cavernosal nerves. The branches of the capsular artery enter the prostate at a right angle and can be sources of bleeding during dissection, while the artery itself terminates in the pelvic diaphragm. Occasionally an aberrant pudendal artery can be seen coursing lateral to the prostate. The effort to preserve this during surgery may aid in preserving erectile function postoperatively.6

Priapism

Priapism occurs in two-thirds of males with SCD, with a peak incidence in the second and third decades. It is caused by vaso-occlusion leading to obstruction of venous drainage from the penis. It typically affects the corpora cavernosa alone, resulting in a hard penis with a soft glans. Episodes can be brief (stuttering) or prolonged, when they last for longer than 3 h. Recurrent priapism leads to fibrosis and eventual impotence. Young boys require explanation of symptoms and the need to seek early help for priapism. At the onset of priapism, patients should drink extra fluids and attempt to urinate. Persistent priapism

Dealing With Erectile Dysfunction

Dealing With Erectile Dysfunction

Whether you call it erectile dysfunction, ED, impotence, or any number of slang terms, erection problems are something many men have to face during the course of their lifetimes.

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