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WHAT ARE THE EFFICACIES AND RISKS OF BEHAVIORAL, PHARMACOLOGICAL, SURGICAL, AND OTHER TREATMENTS FOR IMPOTENCE

General Considerations
Psychotherapy and/or behavioral therapy may be useful for some patients with erectile dysfunction without obvious organic cause, and for their partners. These may also be used as an adjunct to other therapies directed at the treatment of organic erectile dysfunction. Outcome data from such therapy, however, have not been well-documented or quantified, and additional studies along these lines are indicated.

Efficacy of therapy may be best achieved by inclusion of both partners in treatment plans.
Treatment should be individualized to the patient's desires and expectations.
Even though there are several effective treatments currently available, long-term efficacy is in general relatively low. Moreover, there is a high rate of voluntary cessation of treatment for all currently popular forms of therapy for erectile dysfunction. Better understanding of the reasons for each of these phenomena is needed.

Psychotherapy and Behavioral Therapy
Psychosocial factors are important in all forms of erectile dysfunction. Careful attention to these issues and attempts to relieve sexual anxieties should be a part of the therapeutic intervention for all patients with erectile dysfunction.
Psychotherapy and/or behavioral therapy alone may be helpful for some patients in whom no organic cause of erectile dysfunction is detected. Patients who refuse medical and surgical interventions also may be helped by such counseling. After appropriate evaluation to detect and treat coexistent problems such as issues related to the loss of a partner, dysfunctional relationships, psychotic disorders, or alcohol and drug abuse, psychological treatment focuses on decreasing performance anxiety and distractions and on increasing a couple's intimacy and ability to communicate about sex.

Education concerning the factors that create normal sexual response and erectile dysfunction can help a couple cope with sexual difficulties. Working with the sexual partner is useful in improving the outcome of therapy. Psychotherapy and behavioral therapy have been reported to relieve depression and anxiety as well as to improve sexual function.
 However, outcome data of psychological and behavioral therapy have not been quantified, and evaluation of the success of specific techniques used in these treatments is poorly documented. Studies to validate their efficacy are therefore strongly indicated.

Medical Therapy
An initial approach to medical therapy should consider reversible medical problems that may contribute to erectile dysfunction. Included in this should be assessment of the possibility of medication-induced erectile dysfunction with consideration for reduction of polypharmacy and/or substitution of medications with lower probability of inducing erectile dysfunction.
For some patients with an established diagnosis of testicular failure (hypogonadism), androgen replacement therapy may sometimes be effective in improving erectile function. A trial of androgen replacement may be worthwhile in men with low serum testosterone levels if there are no other contraindications. In contrast, for men who have normal testosterone levels, androgen therapy is inappropriate and may carry significant health risks, especially in the situation of unrecognized prostate cancer. If androgen therapy is indicated, it should be given in the form of intramuscular injections of testosterone enanthate or cypionate. Oral androgens, as currently available, are not indicated.

Intracavernosal Injection Therapy 
Injection of vasodilator substances into the corpora of the penis has provided a new therapeutic technique for a variety of causes of erectile dysfunction. The most effective and well-studied agents are papaverine, phentolamine, and prostaglandin E[sub 1]. These have been used either singly or in combination. Use of these agents occasionally causes priapism (inappropriately persistent erections). This appears to have been seen most commonly with papaverine.  

Vacuum/Constrictive Devices
Vacuum constriction devices may be effective at generating and maintaining erections in many patients with erectile dysfunction and these appear to have a low incidence of side effects. As with intracavernosal injection therapy, there is a significant rate of patient dropout with these devices, and the reasons for this phenomenon are unclear.
The devices are difficult for some patients to use, and this is especially so in those with impaired manual dexterity. Also, these devices may impair ejaculation, which can then cause some discomfort. Patients and their partners sometimes are bothered by the lack of spontaneity in sexual relations that may occur with this procedure. The patient is sometimes also bothered by the general discomfort that can occur while using these devices. Partner involvement in training with these devices may be important for successful outcome, especially in regard to establishing a mutually satisfying level of sexual activity.

Vascular Surgery  
Surgery of the penile venous system, generally involving venous ligation, has been reported to be effective in patients who have been demonstrated to have venous leakage. However, the tests necessary to establish this diagnosis have been incompletely validated; therefore, it is difficult to select patients who will have a predictably good outcome.
 Moreover, decreased effectiveness of this approach has been reported as longer term followups have been obtained. This has tempered enthusiasm for these procedures, which are probably therefore best done in an investigational setting in medical centers by surgeons experienced in these procedures and their evaluation.

Penile Prostheses
Three forms of penile prostheses are available for patients who fail with or refuse other forms of therapy: semirigid, malleable, and inflatable.
The effectiveness, complications, and acceptability vary among the three types of prostheses, with the main problems being mechanical failure, infection, and erosions. Silicone particle shedding has been reported, including migration to regional lymph nodes; however, no clinically identifiable problems have been reported as a result of the silicone particles.  

Staging of Treatment
The patient and partner must be well informed about all therapeutic options including their effectiveness, possible complications, and costs. As a general rule, the least invasive or dangerous procedures should be tried first.
Psychotherapy and behavioral treatments and sexual counseling alone or in conjunction with other treatments may be used in all patients with erectile dysfunction who are willing to use this form of treatment.
In patients in whom psychogenic erectile dysfunction is suspected, sexual counseling should be offered first. Invasive therapy should not be the primary treatment of choice.
If history, physical, and screening endocrine evaluations are normal and nonpsychogenic erectile dysfunction is suspected, either vacuum devices or intracavernosal injection therapy can be offered after discussion with the patient and his partner.
These latter two therapies may also be useful when combined with psychotherapy in those with psychogenic erectile dysfunction in whom psychotherapy alone has failed.
The motivation and expectations of the patient and his partner and education of both are critical in determining which therapy is chosen and in optimizing its outcome.
If single therapy is ineffective, combining two or more forms of therapy may be useful. Penile prostheses should be placed only after patients have been carefully screened and informed.
Followup should include continued patient education and support in therapy, careful determination of reasons for cessation of therapy if this occurs, and provision of other options if earlier therapies are unsuccessful.

HOW TO OVER COME PAIN DURING INTER COURSE..  
It's true that when important emotional needs, such as sexual fulfillment, are unmet, there is a risk for an affair. But having sex at all costs is not the solution. In fact, if you follow my Policy of Joint Agreement (never do anything without an enthusiastic agreement between you and your spouse) you would never have sex in a way that's painful to you. Instead, you would pursue painless sexual options until you have resolved the problem.
Most women throughout most of their lives experience no pain whatsoever when they have intercourse.
 The vagina is designed for intercourse, and works very well for that purpose under most conditions. But, once in a while, most women do experience pain during intercourse. And when they do, they should identify and treat the problem before having intercourse again.
There are primary and secondary causes of vaginal pain during intercourse.
The primary causes are those that are responsible for the initial pain or discomfort.
Secondary causes are those that are created by the pain itself if intercourse continues, and they can trigger vaginal pain long after the primary causes have been overcome.

Primary Causes of Vaginal Pain
One of the most common primary causes of vaginal pain during intercourse is a dry vagina. Usually, when a woman is sexually aroused, fluids are secreted in the vagina that keep the lining well lubricated.
But if a woman is not sexually aroused, or if fluids are not secreted for some other reason, intercourse can cause very painful damage to the vaginal lining. And in some cases, the lining of the vagina can actually tear, resulting in post-intercourse bleeding.
There are two ways to avoid a dry vagina during intercourse
The first is to avoid intercourse until you are sexually aroused. The second way is to use an artificial water-based vaginal lubericant, such as K-Y jelly, Vagisil Intimate Moisturizer, or Replens Vaginal Mosturizer, as a substitute or backup for natural luberacant.
Since vaginal secretion is usually an indication of a woman's sexual interest,Usually recommend that intercourse wait until she experiences sexual arousal and natural lubrication.
We want couples to avoid getting into the habit of sex that's passionless for her. But if natural secretion is an unreliable indicator of your sexual arousal, WE would certainly recommend an artificial lubricant.
If you're not sure if a dry vagina is the cause of your pain, use an artificial lubricant once. If there is no pain under those conditions, then you have proof that it's the cause of your distress.
Another common cause of vaginal discomfort during intercourse is bacterial infection. This occurs frequently in women, and an antibiotic will generally cure the problem within a week or so.
A related problem is bladder infections. While the problem may be in the bladder or urethra, not in the vagina, it often causes discomfort during intercourse.
A visit to your doctor will identify and treat a bacterial infection so that you will have minimal interruption in your sexual fulfillment. But be sure to make the appointment as soon as intercourse is uncomfortable. Otherwise it can develop into a secondary cause of vaginal pain that I will explain later.
There are other diseases that can cause pain or discomfort during intercourse.
Vaginal endometriosis is one of them. When your doctor examines you for possible bacterial infection, be sure to ask him or her about endometriosis, because it is often overlooked during an examination. Your doctor examination will also be able to check for any vaginal tumors or venereal diseases that may be causing your discomfort.
If you have experienced vaginal bleeding after intercourse, your doctor should also be able to identify its source, and treat it for you. Sometimes a scratch or tear in the lining caused by something other than intercourse can be the cause of your problem.
It is very important for you to be comfortable with regular pelvic examinations. Otherwise you may let a medical problem become so far advanced that it causes you permanent injury. If you are embarrassed to see a male doctor, find a female doctor. But whatever you do, don't let your inhibitions prevent you from experiencing painless intercourse.
If your doctor can identify the source of your vaginal discomfort, don't have intercourse until the problem is treated and overcome to his or her satisfaction. Some problems can be treated in a week or less, while others, like endometriosis may take months to overcome.
If you are unable to have intercourse during treatment for a vaginal disease, that doesn't mean you'll be forcing your husband to rush off to have sex with someone else. I suggest that your husband be informed by your doctor of what it is you are going through, and how you will be treated.
A major problem you may face is your husband's failure to see your sexual reluctance for what it is: vaginal pain brought on by a physical cause. If he doesn't believe you when you explain that it's the pain that makes you reluctant, his ignorance puts your sexual relationship, and probably your marriage as well, at risk. But once he understands the nature of the problem, and knows that it isn't an affair or some other emotional cause, he will be happier with alternatives to intercourse while you wait for your treatment to take effect.
In some cases, a husband's thoughtlessness is remembered long after the painful symptoms are gone.
If your husband tries to force you to have painful intercourse with him and threatens you if you do not cooperate, your memories of his insensitivity will be a far greater barrier to your future sexual relationship than your disease ever could have been. Don't let him create those barriers to your future together.
 Insist that there be no sex unless you enjoy the experience with him. It's not only in your best interest, but in his best interest too. If you go ahead and try to make love when it's painful to you, you may have a very difficult time making love to him in the future.  

A Secondary Cause of Vaginal Pain  
This reflex responds to stimulation of the vaginal opening. If you suffer from vaginismus, you will notice it most whenever you first try to insert something into your vagina. The opening involuntarily contracts and pain is immediately felt. In extreme cases, the contraction is so tight that nothing can penetrate it.  
The way to eliminate this reflex is to set aside a few minutes each day, preferably several times a day, to expose the opening of your vagina to penetration without triggering the reflex. If you can associate vaginal penetration with no pain or discomfort, the reflex will be extinguished. But remember, even an occasional triggering of the reflex can strengthen it.  
Begin each session by covering your finger with water-based lubrication (such as K-Y jelly, Vagisil Intimate Moisturizer, or Replens Vaginal Mosturizer). Very slowly, lubricate the opening of the vagina with your finger, then slowly insert your finger about an inch. Even in the worst cases of vaginismus, a finger can be inserted so slowly into a lubricated vaginal opening that the reflex is not triggered. In a slow circular motion, gently rub the vaginal opening with your finger in ever-increasing circles.
 Remember to go slowly enough not to trigger the reflex or experience any discomfort. After you have rubbed the opening for about a minute without any pain or discomfort, slowly insert your finger into the vagina, and in a circular motion gently rub the inside of the vagina as far as your finger will go. Then remove your finger, and do the same thing all over again. Do it about five times before you end the session.
You will notice that after the first insertion of your finger, the opening is much less sensitive, and you will be able to penetrate much more quickly without triggering a reflex. Move your finger slowly enough so that you avoid any discomfort. But after a while, you will find that you can move it very freely without pain.
You may end the first session thinking that you have overcome the reflex, only to discover at the beginning of the next session that it is back. So start the next session very slowly and carefully, doing again what you did during the first session. When you think you are ready, use a larger object than your finger, such as a candle, and increase the diameter of the object until it is about the size of a penis. Be sure to re-lubricate whatever you chose to insert, and go slowly to avoid the reflex.
The number of sessions to completely eliminate the reflex will depend on the severity of the vaginismus. But when it is eliminated, you should be able to insert an object the size of a penis, with lubrication, fairly rapidly without any pain or discomfort.
There are some women who are not comfortable touching themselves, and would prefer having their husbands carry out these exercises. While it can work, the problem with anyone else doing it is that no one but you knows precisely how much pressure to use, and your husband would inadvertently trigger the reflex far more often than you would. That means that it would take much longer for you to overcome vaginismus with his help.
His turn should come after you are convinced that the reflex is extinguished. Up to this point, obviously, you should have avoided intercourse, because it would have brought the reflex back. But when you think the reflex is gone, it's time to start having intercourse again. Unfortunately, you will find that after you have learned to insert a penis-sized object into your vagina without incident, the reflex may suddenly reappear the first time your husband tries to insert his penis.
To prepare for that common outcome, the first time you have intercourse you should insert his penis yourself. Use plenty of lubricating fluid, and lay on top of him when you do it so you can control the penetration.
 He should lay motionless so that the penetration and thrusting is done only by you so you can stop whenever you experience the least amount of discomfort.
Eventually, you will be able to insert his penis without any pain, thrust as fast and deep as you want, and experience no discomfort whatsoever. The vaginismus reflex will have been eliminated.
If it ever comes back, it will be in a much milder form, and you will be able to eliminate it in a day or so by going back to inserting his penis yourself and controlling the thrusting motion during intercourse.
Whenever you experience any pain during intercourse, stop immediately. And then solve the problem before resuming intercourse.
 
                                 Diagnosis and Management of Prolonged Penile Erection

Priapism, a spontaneous, prolonged, usually painful penile erection, results from abnormal regulation of penile flaccidity. Harmon and Nehra review the diagnosis and management of different types of priapism.
High-flow or arterial priapism results from increased arterial inflow into the cavernosal sinusoids, overwhelming venous outflow. This may cause a painless semirigid to rigid erection. Damage to cells is rare because of high oxygenation. Causes of high-flow priapism include idiopathic etiologies and groin or saddle trauma resulting in pudendal artery damage. Management of high-flow priapism is elective.
In the flaccid state, vascular inflow is limited because of resistance caused by contracted cavernous arterial branches and sinuses. Neurotransmitters or vasoactive substances relax smooth muscles, with decreased compliance resulting in minimal resistance to incoming blood flow. Expansion of the sinusoidal walls inhibits venous outflow, and an erection occurs.
Assessment of priapism includes a detailed history and a physical examination, observing the penile shaft for rigidity and pain.
A complete blood count and a sickle cell preparation may be indicated.  
 
ABOUT IMPOTENCE?
WHAT STRATEGIES ARE EFFECTIVE IN IMPROVING PUBLIC AND PROFESSIONAL KNOWLEDGE:::
Despite the accumulation of a substantial body of scientific information about erectile dysfunction, large segments of the public -- as well as the health professions -- remain relatively uninformed, or -- even worse -- misinformed, about much of what is known.  
This lack of information, added to a pervasive reluctance of physicians to deal candidly with sexual matters, has resulted in patients being denied the benefits of treatment for their sexual concerns. Although they might wish doctors would ask them questions about their sexual lives, patients, for their part, are too often inhibited from initiating such discussions themselves.
Improving both public and professional knowledge about erectile dysfunction will serve to remove those barriers and will foster more open communication and more effective treatment of this condition.
Strategies for Improving Public Knowledge
To a significant degree, the public, particularly older men, is conditioned to accept erectile dysfunction as a condition of progressive aging for which little can be done. In addition, there is considerable inaccurate public information regarding sexual function and dysfunction.
Often, this is in the form of advertisements in which enticing promises are made, and patients then become even more demoralized when promised benefits fail to materialize
 Accurate information on sexual function and the management of dysfunction must be provided to affected men and their partners.
They also must be encouraged to seek professional help, and providers must be aware of the embarrassment and/or discouragement that may often be reasons why men with erectile dysfunction avoid seeking appropriate treatment.
To reach the largest audience, communications strategies should include informative and accurate newspaper and magazine articles, radio and television programs, as well as special educational programs in senior centers. Resources for accurate information regarding diagnosis and treatment options also should include doctors' offices, unions, fraternal and service groups, voluntary health organizations,
State and local health departments, and appropriate advocacy groups. Additionally, since sex education courses in schools uniformly address erectile function, the concept of erectile dysfunction can easily be communicated in these forums as well.  

Strategies for Improving Professional Knowledge :  
Provide wide distribution of this statement to physicians and other health professionals whose work involves patient contact.  
Define a balance between what specific information is needed by the medical and general public and what is available, and identify what treatments are available.  
Promote the introduction of courses in human sexuality into the curricula of graduate schools for all health care professionals. Because sexual well-being is an integral part of general health, emphasis should be placed on the importance of obtaining a detailed sexual history as part of every medical history.
Encourage the inclusion of sessions on diagnosis and management of erectile dysfunction in continuing medical education courses.
Emphasize the desirability for an interdisciplinary approach to the diagnosis and treatment of erectile dysfunction. An integrated medical and psychosocial effort with continuing contact with the patient and partner may enhance their motivation and compliance with treatment during the period of sexual rehabilitation.  
Encourage the inclusion of presentations on erectile dysfunction at scientific meetings of appropriate medical specialty associations, State and local medical societies, and similar organizations of other health professions.  
Distribute scientific information on erectile dysfunction to the news media (print, radio, and television) to support their efforts to disseminate accurate information on this subject and to counteract misleading news reports and false advertising claims.
Promote public service announcements, lectures, and panel discussions on both commercial and public radio and television on the subject of erectile dysfunction.  

WHAT ARE THE NEEDS FOR FUTURE RESEARCH?  
This consensus development conference on male erectile dysfunction has provided an overview of current knowledge on the prevalence, etiology, pathophysiology, diagnosis, and management of this condition.  
The growing individual and societal awareness and open acknowledgment of the problem have led to increased interest and resultant explosion of knowledge in each of these areas.  
 Research on this condition has produced many controversies, which also were expressed at this conference. Numerous questions were identified that may serve as foci for future research directions.  
 These will depend on the development of precise agreement among investigators and clinicians in this field on the definition of what constitutes erectile dysfunction, and what factors in its multifaceted nature contribute to its expression.
 In addition, further investigation of these issues will require collaborative efforts of basic science investigators and clinicians from the spectrum of relevant disciplines and the rigorous application of appropriate research principles in designing studies to obtain further knowledge and to promote understanding of the various aspects of this condition.

CONCLUSIONS  
· The term "erectile dysfunction" should replace the term "impotence" to characterize the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance
· The likelihood of erectile dysfunction increases progressively with age but is not an inevitable consequence of aging. Other age-related conditions increase the likelihood of its occurrence.
· Erectile dysfunction may be a consequence of medications taken for other problems or a result of drug abuse
· Embarrassment of patients and the reluctance of both patients and health care providers to discuss sexual matters candidly contribute to underdiagnosis of erectile dysfunction.
· Contrary to present public and professional opinion, many cases of erectile dysfunction can be successfully managed with appropriately selected therapy.
· Men with erectile dysfunction require diagnostic evaluations and treatments specific to their circumstances. Patient compliance as well as patient and partner desires and expectations are important considerations in the choice of a particular treatment approach. A multidisciplinary approach may be of great benefit in defining the problem and arriving at a solution.
· The development of methods to quantify the degree of erectile dysfunction objectively would be extremely useful in the assessment both of the problem and of treatment outcomes.
· Education of physicians and other health professionals in aspects of human sexuality is currently inadequate, and curriculum development is urgently needed.
Education of the public on aspects of sexual dysfunction and the availability of successful treatments is essential; media involvement in this effort is an important component.  
This should be combined with information designed to expose "quack remedies" and protect men and A good sexual rule of thumb is, Don't have intercourse if it's painful.  
If you ever experience pain during intercourse, stop. Then, see a doctor to help you determine the cause of the pain and help you overcome the problem. When the physical cause of the pain is eliminated, go back to having intercourse painlessly and enjoyably. To do otherwise invites disaster.  

REFERENCES:   
Kaplan : A concise text book of psychiatry
Dr.Harley's Q & A column
NIH consensus development - conference statement
Prof.Michael gonzales
American family physician
Internet mental health

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