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Does Viagra help with impotence in MS

The physical problem of erectile dysfunction is now openly discussed and is recognized commonly in otherwise healthy men. This change in the public attitude has helped men with MS accept this aspect of sexual function when it occurs and embrace the use of one of the approved drugs for erectile dysfunction. Viagra, Levitra, and Cialis appear to be at least as useful in men with MS as they are in otherwise normal men. Some studies have suggested that these drugs may also Orgasm be helpful in women having difficulty achieving an

ViagraA Treatment for Erectile Dysfunction

Viagra, a medication for erectile dysfunction, has received more attention than most newly developed drugs. Its development was one of the offshoots of the discovery of the cell-signaling function of nitric oxide (NO). When sexual stimulation triggers NO secretion, NO activates an enzyme called guanylate cyclase. This enzyme produces cyclic guano-sine monophosphate (cGMP). cGMP then relaxes the smooth muscle of the deep arteries and lacunae of the corpora cavernosa, increasing blood flow into these erectile tissues. Eventually, cGMP is broken down by an enzyme called phosphodiesterase type 5 (PDE5), and the erection subsides. Viagra helps to prolong erection by inhibiting PDE5, thus slowing the rate of cGMP breakdown (fig. 27.20). cGMP-Viagra Q J) Figure 27.20 The Mechanism by Which Viagra Prolongs Erection.

How does MS affect sexual function

Patients and physicians in the past rarely discussed sexual function and performance despite its central role in life. This was especially true when illness other than heart disease was at issue. Sexual relationships are a major bond between married couples, and the new frankness about these issues promises to benefit particularly MS patients greatly. There are a number of pertinent issues in this regard, many of which are equally important to healthy persons. The most common sexual problem affecting both men and women in good health is the lack of libido (sexual interest or sexual drive). Psychologic stress arising from interpersonal relationships and work is probably the most common single cause for this it is obviously much more of an issue in young adults affected by a major health problem. The resultant uncertainties that naturally arise in these situations contribute to this greatly. The actual diagnosis of illness may induce acute stress, which can precipitate sexual difficulty...

Udenafil Erectile Dysfunction [111115

Udenafil is the fourth in a class of drugs targeting the inhibition of the enzyme phosphodiesterase 5 (PDE5) for the treatment of erectile dysfunction. Inhibition of PDE5 results in the increase in endogenous cyclic guanosine monophosphate (cGMP) concentrations in the penile corpus cavernosum. cGMP induces smooth muscle cell relaxation and subsequent increased blood flow leading to a sustainable erection. Udenafil is a potent antagonist of human PDE5 with an IC50 of 8.25 nM and a comparable selectivity profile as sildenafil for the other PDEs. Unlike ta-dalafil, it does not inhibit PDE11, which has been implicated in myalgia and testicular toxicity. The key steps in the synthesis of udenafil involve the coupling of finally ring closure to build the pyri-midinone ring of the core. In Phase I studies to assess the safety, tolerability, and pharmacokinetics of udenafil, single doses of 12.5-400 mg and multiple doses of 100 and 200mg day were well-tolerated, and exposure increased in a...

Male Sexual Function

There are few data on male sexual function. It would seem that no unit has been able to follow up its own patients into mature adult life. It is recorded that no adult patients have normal faecal continence, which is certainly a bad start for any individual wishing to share his life and bed with another 34 . Nonetheless, in this study there was no difference in arrangements for family life between patients and the normal population in The Netherlands, and the same proportions were cohabiting. There was no specific reference to sexual function, but it was striking that 24 of patients never had a lasting relationship 34 . Pe a specifically records the sexual function of his older patients. All of 20 claimed to be potent, 14 enjoyed masturbation, 6 had had intercourse and one was married and has a child 7 . Iwai et al. give similar figures for all of their five male patients 35 . Rintala et al. have compared their own patients with low and high anomalies separately and compared them to...

Adaptation to Cancer

Surgery often requires a great amount of recuperation, sometimes causes new physical problems, and may cause substantial disfigurement. Radiation and chemotherapy often cause significant side effects, including hair loss, sterility, even nausea and vomiting, fatigue, and diarrhea. Anticipatory anxiety, classically conditioned by these treatments, may increase the severity of many of these symptoms. In the long term, cancer patients face problems with physical, psychological, and sexual functioning, as well as family and work difficulties. Many studies have demonstrated that cancer patients exhibit increased rates of depression, and some have demonstrated increased rates of anxiety. Behaviorists working in treatment settings have attempted to help individuals with cancer cope as well as possible with these difficulties.

Complications and Management

Aside from the complications inherent to abdominal procedures in general, several complications are relatively specific to this operation including sexual dysfunction, nonhealing of the perineal wound, and complications related to the ileostomy stoma itself. Sexual dysfunction (erectile dysfunction or retrograde ejaculation in men and dyspareunia in women) has been reported in up to 11 of men undergoing proctectomy for inflammatory bowel disease (9) and up to 50 of women (10). Even with the use of intersphincteric proctectomy, nonhealing of the perineal wound remains a significant problem, occurring in 11 of patients operated on for ulcerative colitis and 33 of those operated on for Crohn's disease (11). Complications related to the ileostomy are reviewed earlier.

Classification Of Sexual Dysfunction

Erectile dysfunction Female sexual dysfunction includes sexual desire disorders along with impaired arousal, orgasmic disorder, and vaginismus. Females may perceive their sexuality differently, and their sexual activity is, in part, culturally defined. This definition impacts upon the way in which women understand their own sexuality and whether they can adjust their expectations of their sexual functioning. Female sexual dysfunction may be due to early childhood experiences, or to later trauma, including sexual abuse, childbirth, and infertility, among others. Myths about sexual activity and sexual functioning may well affect both males and females. In males, while orgasm and emission are normally linked, they can be separated, because in the latter phase organic muscle contraction and emission are responsible for ejaculation. Male sexual dysfunction includes premature ejaculation, retarded ejaculation,

Gene therapy applications in the lower urinary tract

The lower urinary tract is ideally suited for minimally invasive therapy. All of the lower urinary tract can be reached either percutaneously or through endoscopy. Using MDSCs to deliver growth factor genes, an ex viv approach, could treat such disabling and prevalent conditions as urinary incontinence, interstitial cystitis (IC), and erectile dysfunction (ED) and limit the risk of systemic side effects. Figure 2 depicts MDSC-based tissue engineering in the lower urinary tract. This section focuses on gene therapy strategies that use both viral and nonviral approaches in the lower urinary tract. 5.3. Erectile Dysfunction Several studies of nitric oxide synthase (NOS) gene therapy for erectile dysfunction have been reported. Champion et al. demonstrated the feasibility of gene transfer of endothelial NOS (eNOS) augmenting erectile responses in the aged rat (50). They administered a recombinant adenovirus containing the eNOS gene into the corpora cavernosa of the aged rat. An increase...

Brain Imaging Studies Show Stimulants in Action

In other words, increased dopamine in the synapse can act almost as a kind of Viagra to encourage the brain's response to the task. Thus MPH may counter the chronic problem with motivating oneself to do necessary, but not intrinsically interesting, tasks. In this way stimulant medication may help to alleviate the problems described in Chapter 1 as impotence of the mind.

Family Medical History

'In your family - that is, your parents, brothers and sisters - are there any health problems that seem to run through the family ' You may prompt with suggestion such as diabetes, hypertension, and skin problems. This gives you information about predisposition, especially with diabetes and skin problems, and helps with differential diagnosis and may be a contributing factor in the reason for the visit, as for example with impotence or recurrent vaginal candidiasis.

Core Characteristics Of The Disease

The extrapyramidal features appear similar to those in PD, including bradykinesia with rigidity, postural instability, hypokinetic speech, and occasionally tremor, usually with a poor or unsustained response to chronic levodopa therapy. The signs of cerebellar dysfunction include disorders of extraocular movements, ataxic speech, and ataxia of limb movements and gait resulting in postural instability and frequent falls. Autonomic insufficiency results in orthostatic hypotension, urinary retention or incontinence, and impotence, often accompanied by constipation and decreased sweating. Parkinsonian, cerebellar, and autonomic features often occur in combination in MSA, but one or, in some patients, two features may predominate.

Why Has The Person Come For A Checkup

Your initial questions should identify why the person has come for a check-up. Be aware that there may be a subtext to their visit careful listening will help you identify if there are other concerns (Law & McCoriston, 1996 Presswell & Barton, 2000). These may include sexual dysfunction therefore follow up throwaway lines or ambiguity - 'So does this cause impotence ' Your response may be 'Is impotence or problems with having sex worrying you '

Preoperative abnormalities

A review of 31 patients with Cushing's disease showed that the commonest clinical features, in order of frequency, were weakness, thin skin, obesity, easy bruising, hypertension, menstrual disorders, hirsutism, impotence, striae, proximal muscle weakness, oedema, osteoporosis, mental disorders, diabetic GTT, backache, acne, hypokalaemia and fasting hyperglycaemia (Urbanic & George 1981). Fractures occur, and wound healing is poor.

John D Pirsch Jon S Odorico Hans W Sollinger

In the United States, diabetes mellitus is the third most common disease and fourth leading cause of death from disease. Diabetes is the leading cause of blindness, the number one cause of amputations and impotence, and one of the most frequently occurring chronic childhood diseases. Diabetes is also the leading cause of end-stage renal disease in the United States, with a prevalence rate of 31 compared with other renal diseases. Diabetes is also the most frequent indication for kidney transplantation, accounting for 22 of all transplantation operations.

Diabetic autonomic neuropathy

Atic DPN can vary from mild to severe. Cardiac symptoms include fixed tachycardia, orthostatic postprandial hypotension, arrhythmias, and in severe cases, sudden cardiac death. Gastrointestinal symptoms include constipation, nightime diarrhea and gastroparesis with early satiety, nausea and vomiting. Genitourinary symptoms are common in men, with impotence present in nearly all males after 25 years of diabetes. Urinary retention occurs in men and women. Abnormal pupillary responses and abnormal sweating occurs, with anhydrosis of the feet and hands, and gustatory sweating in more severe cases. Abnormal neuroendocrine responses likely contribute to hypoglycemic un-awareness in type 1 patients.

Ethical Concerns in Performance Measurement

The enhanced ability to collect and handle data electronically has greatly expanded the potential for the use of these data to make improvements in the quality of care. The use of such databases, however, raises a spectre of misuse that could harm patients, health care providers, and the public at large (Donaldson 1994). Disclosure of inaccurate data about quality of care has the potential to cause direct economic harm to providers and health care organizations, and it may mislead the public. Disclosure of information about medical conditions in the course of measuring quality has the potential to embarrass, distress, or directly harm individuals. For example, disclosure of treatment for HIV, mental illness, or pelvic inflammatory disease a diagnosis of epilepsy or impotence and the performance of an abortion or an examination for rape all have the potential to stigmatize an individual. Disclosure of the existence of a genetic disease may make a person as well as his her offspring...

Regulation of other receptors

It has an inhibitory effect on the cardiovascular system. Ergometrine also has a high affinity to uterine a2 receptors, and it therefore influences uterine muscle activity. Ergometrine is used in the treatment of postpartum or postbortal haemorrhaging. Yohimbine blocks presynaptic a2 adrenoreceptors and increases the release of noradrenaline at sympathetic nerve endings. It may be used to increase heart rate and blood pressure and even in the treatment of severe cases of male impotency.

Long Term Bowel Function in Adults

There are only a few reports concerning the functional results of low ARM, with a follow-up extending beyond childhood. Karkowski et al. 61 reported good continence in 12 (80 ) of his 15 patients with low malformations. Nixon and Puri 32 found normal control under all circumstances in 23 (74 ) of their 31 adult or adolescent patients. The remaining patients had occasional or frequent soiling. These results reflects the traditional view of the long-term outcome in these patients. More recently, the large series of Ong and Beasley 58 and Rintala et al. 62 have demonstrated that a significant percentage of patients have abnormal anorectal function at adult age. Ong and Beasley had 35 patients with a follow-up of more than 15 years. Although the majority had good continence according to commonly used clinical scoring methods, only 13 (37 ) of the patients were clean at all times. Seventeen patients (49 ) had smearing and 5 (14 ) intermittent soiling. Rintala et al., using a quantitative...

The Impact Of Parkinsonism On Healthrelated Quality Of Life

The only parkinsonian disorder that has been assessed in detail with regard to Hr-Qol is PD. Studies on Hr-QoL of patients with PD have improved our understanding of subjectively experienced difficulties associated with this disease, and we now have a clearer understanding of what aspects of Hr-QoL are most important to patients with PD. A full review of the expanding Hr-QoL literature in PD is beyond the scope of this chapter. However, it has consistently been found that all areas of Hr-QoL are affected by PD, not merely the physical impairment or functioning (23,25,26). The main areas of impairment in PD are in physical functioning, emotional reactions, social isolation, and energy. Other domains of impairment of Hr-QoL in PD, include bodily discomfort pain, self-image, cognitive function, communication, sleep, role function, and sexual function (23,25-27). It has also become clear that in PD, it is not primarily disease severity and presence of the symptoms of PD that determine...

Sexual Reproductive Issues

Even in today's postsexual revolution society there is uneasiness in talking about sexual concerns. Whereas many patients feel comfortable in bringing up the subject of sex, others do not. In the interview process the nurse can simply ask if there are sexual concerns, questions, or dysfunction. This allows the patient to express such issues if they exist. It also further assesses the overall quality of life that the patient experiences in living with the complications of IBD. Alterations in body image (from steroids, surgical scars, fistulas, or ostomies), pain, and fatigue can alter sexual functioning. Optimizing medical therapy to gain remission and steroid-sparing are the primary goals with this issue. Surgical intervention may be necessary support groups, ostomy nurses, gynecologists, and urologists may be appropriate referrals. Often patients need an ear to talk openly to about this delicate topic in a nonthreatening environment.

Radical vulvar surgery

Groin Labia Majora

Radical vulvectomy and groin node dissection have been the standard treatment for cancer of the vulva since 1912 when this procedure was first described by Basset. Because carcinoma of the vulva is rare, accounting for only 0.4 of all cancers in women, scientific comparisons of variations on this operation have often been limited by studies with small or heterogeneous samples. Traditionally, an en bloc radical resection of the entire vulva and bilateral inguinal nodes through the trapezoid or 'butterfly' incision was the treatment of choice for all vulvar carcinomas. Currently, unilateral radical vulvectomy and ipsilateral inguinal node dissection are considered to be adequate treatment of a lateral lesion which does not approach the clitoris or perineal body. Bilateral inguinal node dissection is indicated in cases of midline lesions or if positive lymph nodes are encountered during the ipsilateral groin node dissection associated with a lateral lesion. The current trend is toward...

Vacterl Syndrome Life Expectancy

Vacterl Syndrome Life Expectancy

With improved surgical techniques and paediatric intensive care facilities, many patients with ARM now live relatively normal lives, with a near-normal life expectancy. Therefore, sexual function and fertility are of increasing importance. Sexual function may be impaired for several reasons Patients who have normal sexual function may also experience difficulties with fertility. In male patients these two aspects may be inextricably linked, as men with erectile difficulties also may fail to ejaculate and will require sperm extraction techniques. The extent of these problems in the adult ARM population is difficult to assess as many of the long-term outcome studies are carried out to include a paediatric population, where questioning about sexual activity and fertility would be inappropriate. Therefore, cohorts for late follow up have to be recruited from a variety of sources, including patient support groups, which may give an overestimate of late problems. Furthermore, research tends...

Male Genital Anomalies

Newly Born Girl Vagina Abnormality

The incidence of male genital anomalies is lower than for female genital anomalies. However, an exact level is difficult to define because of limited and contradictory literature. Hoekstra et al. recorded all of the genitourinary anomalies associated with ARM in 150 children 30 . The genital anomalies in boys were relatively uncommon and mainly of little significance, especially when considering sexual function in later life (Table 36.3). Although spinal cord anomalies have a major impact on sexual function in both genders, it tends to be more severe in males, at least in those born with my-elodysplasia. There is a high incidence of neurovesical dysfunction in children with ARM. The main cause is

Anatomical Foundations

Ejaculation Nerves Spine

To understand male sexual function, we must give closer attention to the blood circulation and nerve supply to the penis. Figure 27.19 Neural Control of Male Sexual Response. Figure 27.19 Neural Control of Male Sexual Response. Figure 27.19 Neural Control of Male Sexual Response (continued). Figure 27.19 Neural Control of Male Sexual Response (continued).

Surgery Anatomy And Dissection

Perhaps the most striking aspect of ancient Indian medicine was the range of surgical interventions and the level of success claimed by the disciples of Susruta and Caraka. Vedic myths speak of remarkable operations on men and gods, such as a cure for impotence achieved by transplanting the testes of a ram to the afflicted god Indra. Ayurvedic texts describe more prosaic but still formidable operations such as cesarean section, lithotomy (removal of bladder stones), couching the cataract, tonsillectomy, amputations, and plastic surgery. Thus, the Ayurvedic surgical tradition offers an interesting challenge to Western assumptions that systematic human dissection, animal vivisection, and the rejection of humoral pathology are essential for progress in surgery. In ancient India, surgeons mastered many major operations without these supposed prerequisites.

Executive Functions and the Brains Signaling System

Those who care about persons with ADD and witness their poor performance in important tasks routinely prod them to deal with their impotence in the face of those tasks by insisting Just make yourself do it We can all see that you have the ability. It's just a matter of realizing what is really important and exercising willpower Alternatively, they may impose punishments on the person with ADD or shame them for their failure to make themselves do consistently what they ought to do. These critics seem to assume that the person with ADD needs only to speak emphatically to the conductor of their own mental operations to get the desired results.

Fertility and Disease Activity

In male patients with IBD, impotence from procto-colectomy may be an unspoken issue regarding fertility. Compassionate inquiry may be helpful some patients respond to Viagra therapy. It is known that sulfasalazine may cause reversible oligospermia and impair sperm morphology and motility (Narendranathan et al, 1989).

Cirsium setosum Willd MB Fam Asteraceae

Cirsium Setosum

For impotence due to Deficiency of Kidney Yang, it is used with Radix Rehmanniae Preparata (Shu Di Huang), Semen Cuscutae (Tu Si Zi), and Fructus Schisandrae (Wu Wei Zi). For infertility due to depletion of the Vital Essence and Blood, it is used with Colla Cornus Cervi (Lu Jiao Jiao), Radix Rehmanniae Preparata (Shu Di Huang), Radix Angelicae Sinensis (Dang Gui), and Placenta Hominis (Zi He Che). For coldness and pain in the lower back and knee, it is used with Radix Morindae Officinalis (Ba Ji Tian), Rhizoma Dioscoreae (Bi Xie), and Cortex Eucommiae Ulmoidis (Du Zhong).

Multiple System Atrophy

The predominant loci of nerve cell loss vary across the MSA subtypes, but with overlap, and they are associated with the prominent but overlapping clinical features, including speech and language findings. Thus, in striatonigral degeneration (MSA-P) nerve cell loss and gliosis predominate in the neostriatum and substantia nigra parkinsonian features, including hypokinetic dysarthria, are prominent and beneficial response to levodopa is limited because striatal neurons containing dopamine receptors are lost. In OPCA (MSA-C), there may be prominent involvement of the cerebellum, explaining clinical cerebellar features, including ataxic dysarthria. In Shy-Drager syndrome, early and prominent dy-sautonomia (including orthostatic hypotension, incontinence, reduced respiration, and impotence) stems from loss of preganglionic sympathetic neurons in the intermediolateral horns because the sub-stantia nigra, striatum, cerebellum, and corticospinal tracts are also affected, parkinsonism...

Psychological Therapies

Hence, in therapy the reduction of anxiety becomes a major priority. Early behavior therapists like Joseph Wolpe used this approach in the treatment of sexual problems. He used a method that he called systematic desensiti-zation,'' in which the sexual problem was dealt with in graded, nonthreatening stages. As a first step, the couple were asked to refrain from intercourse, but to engage in other intimate behaviors, mainly touching and caressing, in a gentle, step-by-step way. In this fashion, anxiety could be overcome gradually, and full sexual functioning restored. This basic behavioral approach was followed by a more formal, essentially behavioral, treatment package developed by William Masters and Virginia Johnson universally known as the Masters and Johnson approach.'' In this, after the assessment, the couple are asked to agree to a ban on intercourse, and they are then given detailed instructions in graded sexual exercises. The first stage is...

Are there treatments for loss of genital sensation

A loss of sensation in the genital area can pose problems for both men and women with MS. Fortunately, such a loss of sensation in most patients is usually temporary. In men, the use of Viagra and the other drugs in this group can, in part, overcome erectile dysfunction related to decreased sensation in some cases. Temporary or not, for many women, the use of vibrators can overcome the inability to achieve orgasm. Eros is a specially designed commercially available device to enhance clitoral engorgement and provide stimulation for women who require it. It is important that women consult physicians who are knowledgeable in this area. Generally, gynecologists and sex therapists are better informed than most physicians.

Screening at the Population Level Trends in Incidence and Mortality

The morbidities of prostate cancer treatment are better defined than the efficacy of the treatment itself. All forms of localized prostate cancer therapy have side effects but those for radical prostatectomy and external beam radiation are best described. Both are known to cause impotence, rectal injury, urinary incontinence, and urethral stricture. Literature reviews from physicians at major medical centers give impotence rates of 25 to 40 , rectal injury rates of 1 to 3 , urinary incontinence rates of 3 to 6 , and urethral stricture rates of 8 to 18 , with radiation therapy at the lower range compared to surgery.37 higher than physician-reported morbidity rates. In a survey of Medicare patients38 undergoing radical prostatectomy from 1988 to 1992, 30 reported the chronic need for pads and urinary clamps. More than 60 reported a problem with wetting, 60 reported having no erections since surgery, and 90 reported no erections sufficient for intercourse in the month prior to answering...

Qualities

Sural Nerve Conduction Study

Tachyarrhythmias, ileus, urinary retention, impotence, incontinence and pupillary abnormalities. In some polyneuropathies and mononeuropathies the autonomic changes are revealed by skin changes at examination. The dry, anhidrot-ic skin in diabetic neuropathy is a good example. Skin changes in peripheral nerve lesions can include pale, dry, and glossy skin, and changes of the nailbeds. The methods suggested for testing include RR variation testing, the sympathetic skin response, and the Ewing battery.

The penis

Penile Blood Pressure Measurement

The body of the penis is the major section running from the glans penis, externally, to the roots, internally. The major erectile tissue of the penis is situated in this body section, the main area of which is the corpus carvenosus penis, which runs along the dorsal aspect of the penis above the urethra and is enclosed by the tunica albuginea. This tough, fibrous sheath confers some rigidity to the penis, giving it support at full erection but, due to its elastic properties, also allowing for expansion of the penis, by up to twofold (Figs 3.7 and 3.8).

Ethical Issues

If the couple perceives the male erectile dysfunction as the only problem and the focus is on obtaining erections without looking at underlying problems, ethical dilemmas are raised for the therapist. Equally, if a child molester presents for therapy for sexual dysfunction, there is a clear and serious dilemma for the therapist. It is possible that under these circumstances the patient may not divulge his complete history. The forensic aspects of the underlying problems will need to be taken into account as part of the assessment. When couples are about to break up and the underlying sexual dysfunction tends to take on a greater importance, the couple's energies may be focused on the sexual problem rather than on the relationship itself. Often the patients, their partners, and some therapists may see psychological treatments as time consuming and prolonged, painful experiences, whereas physical treatments may be more appealing. Physical treatments should be offered only after a...

Evolving Therapies

Some reports have shown that diabetic patients with gas-troparesis have abnormally high pyloric sphincter pressures. This has lead to the concept of pyloric spasm and the idea that therapies aimed at relaxing the pyloric sphincter could improve gastric emptying. The use of sildenafil and local botulinum toxin A injections have been proposed to address this particular pathophysiology. Preliminary reports suggest that 100 to 200 Units of botulinum toxin injected directly into the pylorus endoscopically is effective in temporarily relieving symptoms in idiopathic and diabetic gastroparesis, although further study is needed (Ezzeddine et al, 2002). It would seem best suited to the setting of an accidental vagal nerve injury accompanying fundoplication or esophageal surgery. Here it would simulate the effects of a pyloroplasty without the necessity for surgery. Since repeated administration will be required, formulation and administration issues may preclude its use as a first line...

Treatment

The necessity of a specific treatment of sexual dysfunction must be evaluated individually in each MSA patient. Male impotence can be partially circumvented by the use of intracavernosal papaverine, prostaglandin E1, or penile implants (Colosimo and Pezzella, 2002). Preliminary evidence in PD patients (Zesiewicz et al., 2000) had suggested that sildenafil may also be successful in treating erectile failure in MSA A recent trial confirmed the efficacy of this compound in MSA, but also suggested caution because of the frequent cardiovascular side-effects (Hussain et al., 2001).

Decision Analyses

The first such analysis was performed by Fleming et al.30 The authors developed a series of outcomes for men 60 to 75 years of age, using estimates of the disutility of complications of treatment and of the disease and concluded that only with the most optimistic assumptions regarding treatment efficacy would treatment for prostate cancer affect patient outcomes. Unfortunately, for reasons that are inexplicable, of the five natural history studies of prostate cancer that the authors used to estimate what would happen to patients if tumors were left untreated, four studies reported on results of T1a disease. (As stated above, T1a disease unquestionably behaves in an indolent fashion and is undeniably different from T1b-T2 disease in all respects.) Additionally, the disutility of a variety of complications is very much at odds with the experience of any clinician who manages prostate cancer. For example, treatment-related impotence and incontinence were given disutility factors of 95...

Greco Roman Medicine

The magical and shamanistic practices that once flourished in Greece left their traces in myths, poems, and rituals, such as the annual festival held in honor of Melampus, founder of a long line of seers, who had acquired knowledge of divination from Egypt. Combining elements of purification and ''psychotherapy'' with strong purgative drugs, Melampus was able to cure disorders ranging from impotence to insanity. Melampus is also said to have taught Orpheus how to use healing drugs.

Elimination

Drug metabolism occurs primarily in the liver, by the cytochrome P450 (CYP450) enzyme system. When a drug is absorbed through the GI tract, it often undergoes first-pass metabolism. This is where the absorbed drug passes through the liver before being distributed throughout the rest of the body and whilst in the liver, it is metabolised. This process can either activate a drug, as is the case with valaciclovir, or form an inactive metabolite, as with the opioid analgesics. Some metabolites may be toxic and lead to adverse effects. If a drug is heavily metabolised in the liver, it can lead to poor oral bioavailablity, resulting in higher doses being required. Some drugs can inhibit or induce CYP450 enzymes, leading to drug-drug interactions. For example, ritonavir is a potent inhibitor of cytochrome isoenzyme 3A4 thus it can greatly affect the bioavail-ability of other drugs, such as sildenafil.

Artificial Devices

Base of the penis, the patient and his partner often find it very difficult to deal with, when compared to papaverine injections. Furthermore, in this method, skin temperature of the penis falls and the erection is often not very strong. The commonest device in use is a rigid tube made of plastic, which is connected to a hand pump at one end and an opening at the other through which the flaccid penis is inserted. Prior to this, the penis and the tube are well lubricated and a rubber constriction band is placed around the open end of the tube. When the pump is used, air is pumped out and the resulting negative pressure draws blood into the corpora, producing an erection. Following this, the constricting rubber band can be slipped off to place it at the base of the penis to limit venous outflow. This band can be left in situ for half an hour. Another appliance Correctaid works on the same principle but the condom-shaped device is made of transparent silicon rubber. A tube is passed...

The Cerebral Cortex

Even if we usually cannot consciously control the ANS, it is clear that the mind does influence it. Anger raises the blood pressure, fear makes the heart race, thoughts of good food make the stomach rumble, sexual thoughts or images increase blood flow to the genitals, and anxiety inhibits sexual function. The limbic system (p. 534), an ancient part of the cerebral cortex, is involved in many emotional responses and has extensive connections with the hypothalamus, a site of several nuclei of autonomic control. Thus, the limbic system provides a pathway connecting sensory and mental experiences with the autonomic nervous system.

Pathology

A supraspinal contribution to the autonomic failure of MSA is now well established. Cell loss is reported in dorsal motor nucleus of the vagus (121) and involves catecholaminergic neurons of ventrolateral medulla (122). It has also been described for the Edinger-Westphal nucleus and posterior hypothalamus (123) including the tuberomamillary nucleus (124). Papp and Lantos (125) have shown marked involvement of brainstem pontomedullary reticular formation with glial cytoplasmic inclusions (GCIs), providing a supraspinal histological counterpart for impaired visceral function. Autonomic neuronal degeneration affects the locus ceruleus, too (20). Disordered bladder, rectal, and sexual function in MSA-P and MSA-C have also been associated with cell loss in parasympathetic preganglionic nuclei of the spinal cord. These neurons are localized rostrally in the Onuf's nucleus between the sacral segments S2 and S3 and more caudally in the inferior intermediolateral nucleus chiefly in the S3 to...

Colovaginoplasty

Reconstruction of the vagina for congenital or acquired absence can be accomplished by several different procedures, which are summarized in Table 35.2. The goals of therapy should include fertility, if at all possible, adequate sexual function without the need for continual dilatations or lubrication, and elimination of the risk of malignant change in the intraabdominal gonads. Historically, the Frank procedure, the McIndoe procedure, and the laparoscopic traction approach described by Vecchietti have been used. The Frank procedure involves progressive non-surgical dilatation with graduated dilators used for 20 min per day 4 . A 43 success rate was reported and failures were attributed to a lack of compliance. McIndoe described dissection of the space between the rectum and bladder with placement of a mold covered with a split-thickness skin graft 12 . Dilators are then used during epithelialization of the neovagina. Complications rates are small (10 ) and include

Paraphiliacs

Those with paraphilias, or variant sexual desires and practices, sometimes present with sexual dysfunction. Paraphiliacs seeking treatment in this way are almost always male, reflecting the vast preponderance of males over females among paraphiliacs. In their presentation, they often complain of difficulties in non-paraphiliac sexual relationships. For example, a man with a strong shoe fetish might seek help for an inability to obtain or maintain an erection in sex without contact with a woman's shoe. These patients need to be assessed carefully, and individually tailored treatment needs to be considered. The aim should be, as far as possible, to incorporate the paraphilia in a limited, controlled way into the person's sexual repertoire. Needless to say, criminal paraphilias such a pedophilia or zoophilia, or any paraphilia that the patient's

Amyloidosis primary

Initial neuropathic symptoms are most commonly burning pain and loss of sensation in the feet. These symptoms may precede development of multiorgan involvement by 1 year. With disease progression, patients experience distal muscle weakness and in advance cases autonomic symptoms of postural hypotension, syncope and impotence.

Investigations

Sexual Function Sexual dysfunction is a frequent and early symptom of MSA, particularly in male patients. Since male MSA patients frequently develop erectile failure in their forties, and therefore experience substantial impairment of their sexual performance, expert uroneurological advice should be sought for further investigation and implementation of appropriate therapeutic intervention. The pathophysiology of impotence in MSA is unclear however, it is likely to include central autonomic disturbance and, more rarely, peripheral factors such as venous leakage.

Dysautonomia

Urinary disturbances often appear early in the course of the disease, or are a presenting symptom (impotence common in men). Urinary incontinence (70 of MSA) or retention (30 ) may be detected by medical history, leading to more refined explorations. MSA, PSP, as well as PD patients complain of urgency, frequent voiding, or dysuria. Some describe difficulties voiding but are not aware of chronic urinary retention. Incontinence is never observed in patients with PD and rarely in late stages in PSP. In all cases, additional laboratory tests such as urodynamic tests and sphincter electromyogram (EMG) may make the association between urinary symptoms and urinary tract denervation (13). Patients with PD have less severe urinary dysfunction, by contrast with these common findings in MSA. However, sphincter EMG does not distinguish MSA from PSP.

Evaluation

A careful history and physical examination will frequently provide the clinician with considerable information. In general, risk factors for aortoiliac occlusive disease parallel those seen for other atherosclerotic lesions (elderly, male, diabetes, hypertension, tobacco abuse). In contrast, however, nearly half of all patients with limited, localized aortoiliac disease are women. Women patients tend to have more focal disease, are active smokers and present at a younger age than their male counterparts. Male patients are somewhat older and tend to have diffuse atherosclerotic disease. Patients with localized, segmental disease typically present with varying degrees of claudication. Frequently, this may involve the proximal thigh, buttock or hip. The classic Leriche syndrome describes the patient with thigh or buttock claudication associated with impotence, wasting of the thigh musculature and diminution of the femoral pulses. However, as mentioned previously, many of these patients...

Conclusions

The modern effort to demarcate a taxonomy of distinct clinical conditions is often traced to Kraepelin (1917). Kraepelin, however, had himself acknowledged that wherever we try to mark out the frontier between mental health and disease, we find a neutral territory, in which the imperceptible change from the realm of normal life to that of obvious derangement takes place (p. 295). The DSM-IV diagnostic categories do provide valid and useful information (as indicated in the chapters included within this text). However, undermining their validity and clinical utility is the false assumption that they are qualitatively distinct conditions. An adequate understanding of the diagnosis, etiology, pathology, comorbidity, and treatment of all mental disorders may require an acknowledgment that they are not conditions qualitatively distinct from one another nor from the anxiety, depression, sexual functioning, sleep, cognitive aberrations, drug and alcohol usage, and personality traits evident...

Prosthesis

The use of plastic splints for the penis was first described in 1952. Semi-rigid silastic rods result in an almost permanently erect penis which can be bent to different angles. Acceptability of these processes has been improved by using modified appliances. An inflatable penile implant has been used to provide improvements in both girth and rigidity. Such a device works on a fluid-filled system that allows the flaccid and erect penis to appear normal. The choice between semirigid or inflatable devices depends very much on the patient's and his partner's preferences.

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