Funny the things you never forget. It was 1968 and we were gathered in the lecture hall of the Rotunda Hospital - the world's oldest maternity hospital. The speaker was a then much loved character from the Dublin Obstetrical fraternity -- Dr Raymond Cross. He was then, by default as it were, Ireland's leading expert on Impotence as it was then called -- the more politically correct term of Erectile Dysfunction had yet to be invented. His task was indeed a thankless one for there were, if you will forgive the pun, no tools for his trade.

The lecture was hilarious and a light relief from the more serious topics of Placenta Previa and Persistent Occiput Posterior. The fact of the matter is that forty years ago there was no effective there treatment for ED and the subject was treated as a bit of a joke. I remember so well the lecturer holding up a kind of a wire splint that he had fashioned and into which the patient was supposed to place his penis before attempting intercourse. The thing had all the technological sophistication of a wire coat hanger except it was not as useful.

When this yoke failed to be effective, for one suspects it occasionally may have done, we were then quickly reduced to folk remedies. Chief among these of course were oysters. Oysters, Dr Raymond Cross told us were, according to the Dublin mythology of the day, capable of raising an erection on a dead Archbishop! More hilarity.

Now fast-forward ten years to the pioneering research of Masters and Johnson, with their classic work -- Human Sexual Response. This was rapidly establishing itself as the foundation of all sex therapy as it remains to this day. Perhaps their greatest contribution was the recognition of Performance Anxiety as a major singlecare contributing factor in all ED but most particular to that which affects younger men. Sexual dysfunction had at last come of age and the laughing had stopped.

Now fast-forward another ten years and we have the Penile Injections. Papaverine, injected directly into the corpus cavernosum, as an inducer of erections, was discovered by accident but quickly established itself as a highly effective, if somewhat uncomfortable, remedy for most ED of whatever etiology. Combined with Phentolamine its efficacy was further increased. Now however, both Papaverine and Phentolamine have largely fallen into disfavor due to their propensity for inducing priapism and penile fibrosis.

Today, both these chemical have been replaced by alprostadil or PGE1 presented, in the main, as Caverject 5 to 20mcg. Where higher doses of 50 or even 100 mcg of PGE1 are indicated, you may have your local compounding pharmacy make them up for you. Suffice here to know that today 95% of all ED of whatever etiology can be successfully and safely managed by this modality of treatment.

Now fast-forward another ten years, to 1998 and, at this site to a fanfare of global publicity that could hardly have escaped the attention of our neighbors on Jupiter, we get sildenafil or Viagra and the answer to a maiden's prayer at long last. Well, maybe not a maiden's prayer, but you know what I mean. For here finally was the ultimate aphrodisiac, the rhino horn and monkey gland all rolled into one little blue tablet, an oral preparation that could induce an erection in men. Utopia had indeed arrived.

Today its two first cousins Cialis and Levitra have joined Viagra and together these three oral preparations form the bulwark of pharmaceuticals in the management or treatment of erectile dysfunction. Unfortunately, with their easy and illegal availability on the Internet they are frequently abused as recreational drugs or pressed into service to treat ED when behavioural therapy might be more appropriate.

When it comes to diagnosing the cause and deciding on a treatment of any given case of ED it is worth remembering the results of the Massachusetts Longitudinal Aging Study. Here they found that about a third of men with moderate to severe erectile dysfunction recovered full sexual potency over time without any treatment. I also use this rule of thumb: Between the ages of 20 and 40 75% of ED will have a vitacost psychogenic factor underscoring it while over the age of 50 years 75% of ED will be. In all cases of ED performance anxiety must be address and explained even went it is often the last thing the patient wants to know about. Men often see performance anxiety as a weakness and as being somehow their own fault, hence the rejection.

A word about my old friend Testosterone Replacement Therapy or TRT. Recent peer-review published studies (Carruthers et al) have shown that when older men fail to respond adequately to the PDE-5 inhibitors alone the addition of testosterone, given as a transdermal gel (Testogel) or deep intramuscular injection (Nebido), will significantly improve their response to these medications. Do not give up on older men; they too disserve to be taken seriously.

The same researchers, Carruthers, Trinnick and Wheeler in a paper published in The Ageing Male Sep 2007 showed androgen blood assay to be a very poor marker for testosterone deficiency syndrome. And yet we still have practitioners adhering to this expensive and largely useless laboratory test.

Another consideration when dealing with older men with BPH and ED is the use of tadalafil 20mg taken daily. In an article published in last October's Journal of Urology it was unequivocally shown there that Cialis 20mg taken daily had equal efficacy to an alpha1 blocker also taken daily. And since we know that alpha1 blockers have no effect on erectile dysfunction and tadalafil has proven efficacy, then the latter as a treatment for BPH in the presence of coexisting ED might make sense.

Other pharmaceutical for ED are now in development. As to whether or not these will prove to be an advancement on our present repertoire of treatments remains to be seen. One thing is for certain though. In the space of a mere forty years, we have come an awfully long way from wire penile splints, oysters and dead Archbishops.

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