Male Erectile Disorder Introduction

The treatment of male erectile disorder has received a great deal of attention and publicity over the last several years. The arrival of sildenafil (Viagra), a new oral treatment for male erectile disorder, has sparked renewed interest in all aspects of this serious and frequently occurring condition. The new oral treatments for male erectile disorder have also changed the scope of practice of treatment for this disorder. As McCullough noted,

For the past 25 years, treatment of ED [erectile dysfunction] has fallen within the urological specialty. The only nonpsychotherapeutic intervention before sildenafil that could be prescribed by any physician was the vacuum erection device. The penile implant increased the awareness of the organic etiologies of erectile dysfunction and made available a surgical cure for ED. In 1983, penile injection therapy was introduced and became the mainstay within the American urological community, until 1997, when the FDA [U.S. Food and Drug Administration] approved the intraurethral prostaglandin pellet. Urologists, who had the most experience with the treatment of ED, administered all these therapies. The availability of oral medication has changed the treatment of ED. A total of 75% of sildenafil prescriptions are written by physicians with little to no residency training in the diagnosis and management of the condition. As many as 55% of the prescriptions are written by primary care physicians, 23% are written by nonurological specialists and 22% are written by urologists (Pfizer, data on file).”

For the past 25 years, treatment of ED [erectile dysfunction] has fallen within the urological specialty. The only nonpsychotherapeutic intervention before sildenafil that could be prescribed by any physician was the vacuum erection device. The penile implant increased the awareness of the organic etiologies of erectile dysfunction and made available a surgical cure for ED. In 1983, penile injection therapy was introduced and became the mainstay within the American urological community, until 1997, when the FDA [U.S. Food and Drug Administration] approved the intraurethral prostaglandin pellet. Urologists, who had the most experience with the treatment of ED, administered all these therapies. The availability of oral medication has changed the treatment of ED. A total of 75% of sildenafil prescriptions are written by physicians with little to no residency training in the diagnosis and management of the condition. As many as 55% of the prescriptions are written by primary care physicians, 23% are written by nonurological specialists and 22% are written by urologists (Pfizer, data on file).”

These are interesting and staggering numbers. Presumably and hopefully, psychiatrists will also include the prescribing of sildenafil as a part of their practice of management of male erectile disorder. Psychiatrists have traditionally ignored sexual dysfunction, because they did not know how to ask about it and what to do about it when it was identified and because they have not been properly trained to manage it. It is also well known that patients often do not spontaneously tell their physicians about sexual problems, and physicians (including psychiatrists) do not ask about such problems.

Some experts have been understandably alarmed by the public’s focus on a quick fix of a complex problem. It would seem that the management of male erectile disorder has turned totally to biology and pharmacology and away from psychological treatment modalities. Nevertheless, the management of male erectile disorder requires complex diagnostic and therapeutic skills, an integrated approach, and an understanding of erectile dysfunction in the broader psychosocial context.

In this chapter I review the newest information on all aspects of the management of male erectile disorder. It would not be possible to begin without some background discussion, including a brief overview of male erectile disorder and its prevalence and a review of the basic physiology and pharmacology of erection. This background information will allow the reader to better understand the complex process of managing this disorder.