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Therapy for erectile dysfunction (ED) may be specific to the cause of ED or it may be nonspecific. There are only three causes of ED which have specific therapy: psychogenic, endocrine and certain types of reversible vasculogenic ED. In the era of oral therapy for ED, treatment is not cause-specific in the great majority of patients. For this great majority, only the basic evaluation of ED is needed. Only when there is a strong suspicion that the cause of a patient's ED is endocrine, psychogenic or reversible vascular disease are additional diagnostic tests indicated. In these three categories of patients, specific treatment of the cause of ED can produce a permanent and dramatic improvement in sexual function and satisfaction. [ABSTRACT FROM AUTHOR]

Focuses on the first international conference on the management of erectile dysfunction held in Chicago, Illinois as of March 2000. Participants at the conference; Topics discussed during the conference; Goals of the conference.

More than 50% of patients who have erectile dysfunction (ED) fit a standard medical and demographic profile: They are at least 50 years old, usually married or in a long-term, monogamous relationship, and they have been troubled by progressive erectile impairment for at least a year. Clinical evaluation of such patients is relatively straightforward: a 3-part history, physical examination, and basic laboratory tests. This article outlines a practical approach to such an evaluation, offers guidelines for evaluating patients who do not fit this profile, and delineates situations in which referral to a specialist may be indicated.

The addition of oral drugs to the armamentarium of therapies for erectile dysfunction promises to dramatically increase the number of men seeking treatment for this condition. It is important to have a rational approach to the diagnostic evaluation of erectile dysfunction and to tailor the evaluation to each patient's goals for his sexual function. It is important also to offer each patient the full array of therapeutic options for erectile dysfunction. This article reviews the outpatient diagnostic work-up and current treatment possibilities for erectile dysfunction. The article also discusses clinical research experience with new forms or oral and topical therapies now being developed for future treatment of erectile dysfunction.

Improvement in natural erections has been reported in approximately 9% of impotent men using intracavernous injections of vasoactive drugs for erection induction. The mechanisms which may account for this improvement are psychogenic, improved cavernous hemodynamics, prostaglandin-induced angiogenesis, improved cavernous oxygenation, cavernous smooth muscle hypertrophy and/or normal episodic fluctuations in erectile function. A review of the basic science literature on this subject reveals several theoretical explanations for this phenomenon but a review of the clinical literature reveals little convincing evidence that physiologic and/or pharmacologic factors are responsible for improvement in natural erections with intracavernous injection therapy. Furthermore, the prevalence of a placebo effect from impotence therapy exceeds the reported rate of improvement in natural or spontaneous erections. The most plausible explanations for spontaneous improvement in erections during or after intracavernous injection therapy are psychogenic and episodic variations in erectile function, rather than physiologic or pharmacologic factors. However, intracavernous injection therapy started soon after radical prostatectomy may have a protective effect in preserving normal cavernous physiology and erectile function in men being treated for prostate cancer.

Purpose: The American Urological Association convened the Clinical Guidelines Panel on Erectile Dysfunction to analyze the literature regarding available methods for treating organic erectile dysfunction and to make practice recommendations based on the treatment outcomes data., Materials and Methods: The panel searched the MEDLINE data base for all articles from 1979 through 1994 on treatment of organic erectile dysfunction and meta-analyzed outcomes data for oral drug therapy (yohimbine), vacuum constriction devices, vasoactive drug injection therapy, penile prosthesis implantation and venous and arterial surgery., Results: Estimated probabilities of desirable outcomes are relatively high for vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis therapy. However, patients must be aware of potential complications. The outcomes data for yohimbine clearly indicate a therapy with marginal efficacy. For venous and arterial surgery, based on reported outcomes, chances of success do not appear high enough to justify routine use of such surgery., Conclusions: For the standard patient, defined as a man with acquired organic erectile dysfunction and no evidence of hypogonadism or hyperprolactinemia, the panel recommends 3 treatment alternatives: vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis implantation. Based on the data to date, yohimbine does not appear to be effective for organic erectile dysfunction and, thus, it should not be recommended as treatment for the standard patient. Venous surgery and arterial surgery in men with arteriolosclerotic disease are considered investigational and should be performed only in a research setting with long-term followup available.

Pregnancy rates after vasectomy reversal vary among different reporting surgeons. To study those patients who are most likely to achieve pregnancy after vasectomy reversal, and to eliminate the effect of variations in surgical technique and operative findings on surgical outcome, the pregnancy rate after vasectomy reversal was calculated in men who achieved completely and consistently normal postoperative semen analyses (sperm concentration 20 x 10(6)/ml. or more and sperm motility 50% or greater). Of 95 patients who met the study criteria 58 (61.1%) achieved pregnancy and 37 (30.9%) did not. Including an allowance for some patients who will achieve pregnancy beyond the study-followup, it is concluded that the maximum pregnancy probability for vasectomy reversal is approximately 67%. Failure to achieve pregnancy in approximately a third of the patients may be explained by partner infertility, epididymal dysfunction and sperm antibodies. Studies that report pregnancy chances in excess of two-thirds must have different patient demographics and/or different methods of statistical analysis.

During a 9-year period 1,469 men who underwent microsurgical vasectomy reversal procedures were studied at 5 institutions. Of 1,247 men who had first-time procedures sperm were present in the semen in 865 of 1,012 men (86%) who had postoperative semen analyses, and pregnancy occurred in 421 of 810 couples (52%) for whom information regarding conception was available. Rates of patency (return of sperm to the semen) and pregnancy varied depending on the interval from the vasectomy until its reversal. If the interval had been less than 3 years patency was 97% and pregnancy 76%, 3 to 8 years 88% and 53%, 9 to 14 years 79% and 44% and 15 years or more 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures and they were statistically the same for all patients regardless of the surgeon. When sperm were absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 of 83 patients (60%) and pregnancy in 20 of 65 couples (31%). Neither presence nor absence of a sperm granuloma at the vasectomy site nor type of anesthesia affected results. Repeat microsurgical reversal procedures were less successful. A total of 222 repeat operations produced patency in 150 of 199 patients (75%) who had semen analyses and pregnancy was reported in 52 of 120 couples (43%).

Currently, the only procedure that may be ready for clinical application in arteriogenic impotence is the retrograde revascularization operation for patients who have been shown to have localized obstruction of the internal pudendal artery. This applies almost exclusively to young healthy men with impotence due to pelvic trauma. The concept that perineal trauma causes localized obstruction of the penile artery is controversial. Because the best candidates for penile revascularization are young healthy men with localized, rather than diffuse, arterial pathology and with the absence of vascular risk factors, the overall role for treatment of arteriogenic or combined arteriogenic and venogenic impotence by penile revascularization is very limited. For patients with impotence following pelvic and possibly perineal trauma, as well as occasional patients with arteriosclerosis who wish to be considered for penile revascularization, evaluation should begin with screening intracavernous pharmacodiagnosis using papaverine with or without phentolamine, or prostaglandin E1. If a poor response occurs, identification of venous pathophysiology by cavernosometry and identification of arterial pathophysiology by dynamic infusion cavernosometry and/or duplex sonography of the corpus cavernosum should be undertaken. If there is no venous pathology, penile arteriography must be done to design an anatomically rational revascularization operation. In the future, improved results of penile vascular surgery may occur if we can develop a clearer understanding of the physiology and pathophysiology of erection, improved diagnostic techniques, and a better selection of surgical candidates.(ABSTRACT TRUNCATED AT 250 WORDS)

We examined 11 patients with acquired obstructive azoospermia resulting from irreparable obstruction of 1 vas deferens and severe damage to the contralateral testis. All of the patients underwent transseptal crossed vasovasostomy with no morbidity. Of 8 patients evaluated with postoperative semen analyses 4 (50 per cent) demonstrated total sperm counts of 29 to 205 million and 2 pregnancies (25 per cent) have been reported, with followup ranging from 5 months to 2 years. The etiologies of the vasal obstruction included previous inguinal surgery in 7 patients, vasectomy in 1, ejaculatory duct obstruction in 1, ectopic ureter in 1 and vasal agenesis in 1. Factors leading to loss of the contralateral testis were torsion in 5 patients, mumps orchitis in 2, varicocele in 1, pediatric inguinal herniorrhaphy in 1, epididymal blow out in 1 and unknown in 1. A representative case involving a unilateral ectopic ureter emptying into the seminal vesicle and subsequent contralateral testicular torsion is presented. The results indicate that a transseptal crossed vasovasostomy should be done in patients satisfying the criteria presented.

Deep pelvic midline (Müllerian duct) cysts may cause obstruction of the ejaculatory duct. Two previously fertile patients with adult-onset azoospermia and one patient with severe oligozoospermia were each found to have a Müllerian duct cyst. Semen characteristics included low volume and pH, and absent semen coagulation, odor, and fructose. Vasography showed a retroprostatic and/or retrovesical cyst that communicated with the ipsilateral ejaculatory duct, reflux from the cyst into the contralateral ejaculatory duct, and absent communication of the cyst with the urethra. Transurethral incision of the cyst was successful in one patient and unsuccessful in another. Pregnancy was established by the successfully treated patient. Müllerian duct cyst may cause obstructive azoospermia or oligozoospermia, which may be progressive in adult life, and which is compatible with previous fertility.

New clinical developments in the diagnosis and treatment of male sexual dysfunction have occurred in the past several years. Much of this information has not been disseminated to the general medical public. Of particular note, a series of reliable penile prosthetic devices for the treatment of advanced erectile dysfunction is now considered to be established and valid surgical therapy. The new diagnostic techniques of nocturnal penile tumescence monitoring, penile plethysmography, penile sphygmomanometry and phalloarteriography are beginning to show that some patients with erectile impotence have arteriosclerosis of the penile arteries. These patients were formerly considered to have psychogenic or idiopathic impotence. Some of these patients with vasculogenic impotence may benefit from the new surgical technique of penile revascularization, thus obviating the need for penile prosthetic implants.A preliminary report of a small series of cases of corpus cavernosum revascularization using the microsurgical implantation of the inferior epigastric artery directly into the corpus cavernosum with prolonged systemic anticoagulation gives a cure/improvement rate of 40 percent. Better selection of patients for operation and perfection of surgical technique offer the chance for improvement in this rate of success. The proper role of corpus cavernosum revascularization in the treatment of impotence remains to be clearly defined. However, these preliminary results, coupled with several reports from Europe, are sufficiently encouraging to justify continued clinical investigation and surgical experience with penile revascularization for vasculogenic impotence.

This initial report from the Vasovasostomy Study Group concerns intraoperative data obtained during vasovasostomy from 639 vasa in 334 patients. These data are related to the obstructive interval (time from vasectomy to vasovasostomy) and to the presence or absence of histologically proved sperm granuloma at the old transected testicular end of the vas (vasectomy site). Rates of sperm absence from vas fluid at the testicular end increased with longer obstructive intervals and with absence of a sperm granuloma. If sperm were present in fluid at the testicular end of the vas, the quality was poorer when the obstructive interval lengthened and when sperm granuloma was absent. Vas luminal diameters at the testicular end were smaller when a sperm granuloma was present. These observations support the theory that a sperm granuloma at the vasectomy site may have a beneficial, pressure-releasing effect that could be favorable prognostically for fertility after vasovasostomy.

Almost every scrotal operation may be done with local anesthesia. Occasionally general anesthesia may be elected, but the basic orientation to scrotal surgery should be with local anesthesia as long as the operation can be completed within 3 hours. The only scrotal operation for which I routinely elect general anesthesia is bilateral vasoepididymostomy because this is the only scrotal procedure that takes over 3 hours. Very rarely a scrotal hernia or a huge hydrocele obscures the cord, preventing administration of local anesthesia. Aside from these rare exceptions, I perform all scrotal surgery with local anesthesia. The use of preoperative sedation makes it possible for all patients to tolerate the small amount of discomfort associated with injection of a local anesthesic. Once the anesthetic is injected, scrotal surgery is painless. Regardless of the choice of local or general anesthesia, virtually all patients are discharged to home on the day of surgery. All scrotal surgery should be considered to be ambulatory surgery.

A patient who was impotent following pelvic trauma was evaluated by penile artheriography. The study revealed bilateral disruption of the internal pudendal artery at the level of the urogenital diaphragm. It is concluded that impotence in this case is vasculogenic, although it is not possible to eliminate conclusively the possibility of neurogenic factors. Evaluation of more patients with this new technique of penile arteriography is necessary to establish the frequency of vasculogenic impotence in pelvic trauma. A review of the current literature revealed that impotence is approximately 10 times more common after conventional retropubic urethral realignment for acute prostatomembranous disruption compared to treatment by cystostomy tube alone. Analysis of the pertinent neurovascular anatomy suggests that when impotence is caused by surgical dissection of the periprostatic region the pathogenesis probably is neurogenic because of injury to the prostatic plexus and/or cavernous nerves, and it may be irreversible.

An eleven-year-old boy with bilateral intraperitoneal cryptorchism underwent transabdominal orchiopexy. The right internal spermatic vessels had to be divided to allow for scrotal transposition. Because of previous inguinal exploration, only the right inferior epigastric artery was found. The accompanying veins could not be identified. Therefore, the testicle was revascularized by an arterial without venous anastomosis. Perivasal collaterals were relied on to carry the venous return. The postoperative result was excellent, providing a testicle of growing size in the inferior scrotum nine months after surgery. Testicular revascularization in the management of intraperitoneal cryptorchism currently provides 85 to 90 per cent chance for a successful scrotal transposition when the testicular blood supply must be divided. This case suggests that only the arterial micro-anastomosis is necessary for the management of this difficult surgical problem. Further experience is needed to validate this concept.

To study its intraoperative significance the gross appearance of the vas fluid found during vasovasostomy was compared to the quality of sperm in the fluid, obstructive interval and presence or absence of a histologically proved sperm granuloma. Data were obtained from 648 vasa in 340 patients. As the gross appearance increased in opacity, there was a small decrease in the proportion of morphologically normal, motile sperm (23 to 7 per cent) and a corresponding small increase in the proportion of sperm without tails (2 to 12 per cent). These minor trends had statistical but no intraoperative surgical significance. There was no variation in the proportion of vas fluid azoospermia with gross appearance. There was no significant difference in the gross appearance of the vas fluid with increasing obstructive interval. Finally, the presence or absence of a sperm granuloma had no effect on the gross appearance of the vas fluid, and the appearance had no predictive value relative to sperm granuloma. We conclude that the gross appearance of the vas fluid should not be used as a basis for operative decision-making during vasovasostomy.

An easier technique of microsurgical vasovasostomy, a modified one-layer anastomosis, is compared to double-layer anastomosis. In this preliminary report there is no difference between the modified one-layer and double-layer techniques in per cent of patients postoperatively obtaining normal sperm count and pregnancy. Since the modified one-layer technique is easier, faster, and less expensive, this technique deserves further clinical experience and evaluation.

We report on the low incidence of transient fertility in 892 patients who underwent microsurgical vasovasostomy. Of the 892 patients in whom fertile sperm concentrations (as defined by us) developed 2 to 8 months postoperatively 28 later suffered azoospermia or severe oligospermia. The wives of 5 of the 28 patients with such transient postoperative fertility became pregnant before the patients became azoospermic or severely oligospermic again.