Medical Aspects
of Male / Female

Medical Aspects of Male/Female Sexual Dysfunction in the Next Millennium

Our title, "The Medical Aspects of Male/Female Sexual Dysfunction in the Next Millennium" sounds rather formal and serious. And , in fact, it is.

Statistically 50 percent of the women and more than 35 percent of the men have some type of sexual problem. In the course of one year, one out of eight couples have simultaneous sexual difficulties. If one analyzes the combined statistics of the Massachusetts Aging Study and a February, 1999 article in the Journal of the American Medical Association by Dr. Edward Laumann, Chairman of the Sociology Department at the University of Chicago on sexual health in the United States, 30 million men age 18 and over have erectile dysfunction and 50 million women have a dysfunction ranging from a decrease in desire, arousal and lubrication and orgasmic and pain disorders. Sometimes it helps to use natural supplements, such as profemin. But what if they do not help?

Sexual dysfunction is a serious problem and I can not think of another health issue affecting as many people, their relationships and lives. Is this issue important enough for society to invest time, energy and money?

What are the social implications of treating sexual dysfunction? Should I treat a 65-year-old man for erectile dysfunction whose 60-year-old wife or partner is not interested in or capable of sexual activity? Modern Maturity devoted its September-October, 1999 issue, to sexual issues in what it called on the cover "Great Sex, the post Viagra Survey." Then we ask. Who should pay for treatment? Insurance companies will pay in full for radical prostatectomy surgery to cure a 55-year-old with cancer of the prostate, but will put up a fight when billed for treating the surgically induced sexual dysfunction in that patient. Who should pay for sexual enhancement drugs and procedures? Why don't insurance companies pay for birth control.

Intuitively, we all know that sexual problems can effect self image, interpersonal relationships, and workplace production, causing divorce, marital discord, dysfunctional families, depression and severe psycho social problems. There have been few medical or sociological studies proving this. Yet I have seen this repeatedly in my practice of 25 years and you may have experienced this in your own life.

You may not have been aware of this in the lives of your friends, associates and relatives because sexual problems often are unmentionable. Your best friend would be more willing to reveal a prostate cancer or a breast cancer than erectile dysfunction, premature ejaculation, anorgasmia, lubrication difficulties, low arousal and poor sexual desire. How will we treat men, and women, for sexual problems now, in the near future and throughout the next millennium?

My estimate of the future is based on scientific and pharmacological facts available to us today, though many of which are demonstrated only in animal and scientific models. Some of what I say will be controversial. Other statements will be hard to believe, but no harder to believe then the fact that we now have a pill (Viagra) that can produce an erection in 75 percent of men with erectile dysfunction. Who would have thought this in 1973 when we only had surgery and the implantation of the inflatable penile prosthesis available to us as the major treatment modality? What we find in the next millennium will be even more unbelievable. Previously we could not think about the effective control of weight, and now appear like It is wonderful!

The new century is virtually upon us. First let us briefly examine how society views sexual dysfunction. In the late the late 1800s, if a woman enjoyed sexual relations and received pleasure she was considered psychotic and labeled a nymphomaniac, and everything was done to prevent sexual gratification.

Now in the 1990s oral sex and self manipulation are accepted by physicians, clinicians and therapists as acceptable, normal behavior for both men and women: We must be careful in deciding what is abnormal without examining social mores, and even more importantly, understanding the social situation and the relationships that may occur.

For example, take a marriage or relationship stressed by physical, psychological or sexual abuse. In many cases this leads to decreased desire, almost always on the part of the woman. This is really a normal reaction to a pathological relationship. This is not a pathological or dysfunctional sexual disorder, even though the problem of decreased desire is found in one third of women with sexual problems. As you may suspect, decreased desire even in stressed men is infrequent, only affecting five to 10 percent of men.

In order to understand the future, we need to understand where the treatment for sexual dysfunction began. Prior to 1973 none existed. In 1973, Dr. Brantly Scott and Dr. Gerald Timms invented the inflatable penile prosthesis. Erectile dysfunction therapy was born, giving men a significant new treatment for their sexual dysfunction.

Not until 1983, however, was the first effective medical treatment for erectile dysfunction introduced and introduced in a dramatic fashion by an English neurophysiologist at the American Urological Association meeting in Las Vegas, Nevada. In the course of presenting his three minute paper on the use of the vasoactive drug papaverine injected into the penis to produce an effective erection, he stepped away from the podium and in front of approximately 6,000 people dropped his pants, injected his penis, presented his three minute talk behind the podium and then came out from behind the podium and demonstrated to the audience his erect penis. The urologists had just witnessed the beginning of the modern medical treatment of sexual dysfunction.

The development of the auto administration of a vasoactive drug for erectile dysfunction led to the first FDA approval (in 1995) of a drug to treat erectile dysfunction. Caverject (prostaglandin E-1), by Pharmacia-Upjohn. At this point, development of erectile pharmacology exploded. Muse, a prostaglandin E-1pellet that can be placed in the urethra, not injected, effectively produced an erection in approximately 50 percent of men. This set the stage for the drug that changed the world for men and women.

On March 27, 1998, Viagra (sildenafil), the first FDA-approved oral drug effective for the treatment of male erectile dysfunction was introduced. This is such an important drugs that I must explain how it works. Viagra inhibits the inhibitor of cyclic GMP, the enzyme produced at the neurovascular junction and lining of the blood vessels, stimulating nitric oxide, a poison that paralyzes the muscles of the blood vessels causing increased blood flow, tumescence and engorgement of the penis. This type-5 phosphodiesterase inhibitor is safe and effective in approximately 75 percent of men with erectile dysfunction.

But we still haven't talked about medical treatment for women. In fact, in 1998 we had not even medically defined female sexual dysfunction. On July 13, 1999, The Wall Street Journal reported under this headline, "Now Drug Companies Turn to Women's Sex Problems" noting there is indeed a market for their products. The story told about drugs that will be available to the medical community to treat women with sexual problems. Strangely enough, though, as supplements for weight loss on the contrary began with women's proposals, for example,

Viagra took erectile dysfunction out of the realm of its "all in your head" and even Bob Dole appeared in a public service announcement discussing erectile dysfunction as a treatable medical problem. The public is now being educated (it is interesting to note there are more than 536,000 web pages on Viagra alone) that erectile dysfunction is not always psychological.

Approximately 85 percent of the cases have a true physical cause. Sexual dysfunction in both men and women is a symptom, possibly the first, of another medical problem. The physical cause should be diagnosed in order to treat a problem that may in fact be more serious than the dysfunction itself.

In what direction are we going in the next century? What about women? I have personally prescribed Viagra to women, as have other urologists, even though there is no FDA approval for use by women yet. This may be the start of providing medication for woman. We are treating women based on the fact that although the physical characteristics are different, male and female genitalia are biochemically and physiologically similar.

The penis is analogous to the clitoris and the entrance of the vagina is analogous to the spongy tissue surrounding the male urethra. Tissue evaluation of the walls of the vagina and erectile tissue of the penis look identical under the microscope. More importantly medications that effect the male genitals also effect the vagina and clitoris. All the drugs that we are now using or want to use for men to promote erectile function will produce engorgement of the vagina, tumescence of the clitoris and increased lubrication. We refer to this as sexual arousal in women.

What are the drugs that are expected to soon win FDA approval? Let me tell you what is in the pipeline. The drug, apomorphine, which will be called Uprima by its producer, TAP Pharmaceutical, is the first drug to work centrally on the paraventricular nuclei of the brain to stimulate pelvic congestion - erection in men and arousal in women. It also may have the added benefit of improving sexual desire. That could be beneficial to the 33 percent of women with that sexual dysfunction.

Vasomax is a rapid release oral phentolamine tablet and can facilitate an erection within 10-15 minutes. Vasomax does not have the nitro glycerin/nitrate contraindication that phosophodiesterase inhibitors (such as Viagra) have, though it works in less than 60 percent of men. Nine million men taking nitrates, many having erectile dysfunction, will have an effective oral treatment using Vasomax and Uprima. I believe many millions of women can benefit from taking these drugs as well.

In development are more specific type-5 phosphodiesterase inhibitors like Viagra, which because they are more specific, cause fewer side effects such as facial flushing, headaches, dyspepsia and vision disturbances. Some of these newer, more specific Viagra-like drugs will work faster, and may last up to 24 hours, making sexual relations more spontaneous.

Newer delivery systems will be used to assist drug action. Creams, patches (including a batter- operated electrophoretic patches, decreases the resistance of the skin allowing better penetration and absorption of a drug), and slow-release tablets are already on the verge of FDA approval. Prostaglandin E-1 creams or dissolvable vaginal inserts will find a place in female sexual dysfunction. Prostaglandin E-1 is vasoactive, increasing vaginal and clitoral blood flow as well as improving lubrication, and it may also decrease fibrosis and atrophy associated with the aging of the vagina. Prostaglandin E-1 is found in large quantities in semen. It is possible that vaginal atrophy is the result of decreased sexual activity and infrequent coating of the vagina with prostaglandin E-1 from the semen.

But let's come back to today for a moment. This morning I prescribed for a patient a totally new delivery system for the world's most famous sexual dysfunction drug - Viagra. The sublingual Viagra I prescribed is a tablet that is placed under the tongue and is absorbed directly through the lining of the mouth and tongue and therefore works within 15 minutes instead of an hour and is not affected by stomach contents. The active ingredient, sildenafil is manufactured by Pfizer, but the delivery system involves compounding Viagra into the sublingual proprietary tablet.

Testosterone injections and patches has been used in men to treat erectile dysfunction in those patients who are androgen deficient. Testosterone simulates sexual desire and aggressiveness in men as well as women. Low non-masculinizing doses have been used in women with decreased desire. A testosterone cream would allow the smaller doses necessary in women to be more easily administered. Patches, specifically for post-menopausal women with sexual dysfunction, may include estrogen and low-dose testosterone.

For men who do not benefit from medical treatment or do not desire drugs, implantation of an inflatable penile prosthesis may be the only alternative, even though it requires a surgical procedure. Over the years mechanical and technical modifications have improved the reliability of these devices. In fact, many studies have revealed that patient and partner satisfaction with penile implants is close to 98 percent.

In the near future continued improvement will occur, including special coatings to the plastic materials that will be so slippery that bacterial adhesion to these devices will be reduced and subsequent infection should be decreased to what is already a low infection rate of 0.5 to 1.5 percent. Decreasing infections will reduce the morbidity for many couples who need and desire these procedures, especially in the diabetic population who run a higher than normal risk of infection, and who have the most difficult and advanced form of vasculargenic erectile dysfunction, most commonly requiring surgical prosthetics.

We have discussed treatment modalities during the present and into the near future. What is in store for those men and women who have a sexual dysfunction farther out into the next millennium.

Genetic research involving the transfer of DNA material, either inoculated or by a viral vector, will enable cells in the genital region to once again produce adequate nitric oxide. The blood improves and leads to erections or arousal and lubrication. Imagine inhaling a benign virus that has been impregnated with DNA and contains the genetic coding for the enzyme systems, that when transferred into cells. allows cells that can not produce nitric oxide to once again produce nitric oxide. Now that the cells can produce nitric oxide sufficient vasodilatation and pelvic congestion will resolve pathology in the female and male genital area.

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As unbelievable as this may be, the process of tissue engineering and the ex vivo (outside the body), production of functioning human organs such as the penis and vagina exist today in the laboratory.

In the next millennium, physiologically and biochemically active male and female genitalia will be constructed from human cells cultured and grown over an appropriately shaped lattice or mold. In the process of these cells growing, differentiation into the various layers of the vagina and penis will occur. This brave new world is no braver than penile prosthesis was in 1973.

Male and female genital organs which are absent, nonfunctional or inadequate, if not correctable by future medical or genetic treatments, may be constructed by tissue engineering techniques and surgically installed to produce functioning erogenous organs.

I have discussed medical treatments of male and female dysfunctions - now and in the future. All that I have talked about may be able to make the organs function properly. However, because sexual relationships are so complex, it is extremely important to remember that medical treatments alone may not be the total answer and behavioral and psychological therapy still may be a necessary adjunct.

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