HisandHerHealth: Information About Sexuality, Prostate, Incontinence

Urologists are leading the march as sexual medicine moves into the next century. After all, few physicians are as adept at carrying the flag for our most intimate issues as those already treating our most private conditions.

But, despite the vast inroads made in the field of sexual dysfunction in recent years, it took the better part of a century before doctors of any stripe stepped up to deal with the condition—in either gender. Today, urologists are behind a scientific explosion in the field as it relates to both male and female sexual dysfunction.

Long left to believe sexual problems were psychological, women have seen a rapid turn of events in recent years as doctors investigate the issue: There's now proof that the arousal-to-orgasm miscues some women experience can originate in their bodies, not just in their heads. Not since William Masters and Virginia Johnson described vaginal changes during sexual arousal in 1966 has so much attention been paid to female physiology as it relates to sexual function, or the lack thereof.

In 1997, more than 30 years after Masters and Johnson published their groundbreaking book, Human Sexual Response, Boston University's Kwangsung Park suggested that diminished blood flow reduced arousal in the clitoris and vagina, just as it did in the penis. With animal models, he was the first to show that a woman's problems could be physiological.

The lack of consensus on definitions of what female sexual dysfunction was clinically and the fact that psychologists and physicians had been working independently up to that point laid the ground for a 1998 international meeting that delivered a roadmap for female sexual dysfunction. For the first time, a multi-disciplinary panel sponsored by the American Foundation for Urologic Disease standardized existing disorders of sexual arousal, desire, orgasm and pain for women, confirming that they could be triggered by physiological and psychological causes—the need for additional research in the area.

Yet, despite the accelerated pace in recent years, research on female sexual dysfunction still lags behind that of men, who, for centuries have taken desperate measures to recapture their sexual vigor. While "lost manhood" charlatans of the early 1900s hawked bogus testicular rejuvenation extracts, physicians attempted to "renew" patients by grafting human cadaver testicles into them.

Though these treatments failed, they did succeed in energizing Texas surgeon J.S. Wooten (1902) and Illinois professor G.F. Lydston (1908) who conducted the first penile surgeries by tying off blood vessels to cause engorgement. Later, N.A. Bogoras (1936) and R. T. Bergman (1948) inserted rib cartilage for rigidity.

Yet the heroes were urologists who fashioned the first successful inflatable penile prosthesis. By 1973, F. Brantley Scott and his Houston colleagues had succeeded in implanting a device into the penis that could be pumped with saline to achieve erection. Shortly thereafter, urologists Michael Small and Harnan Carrion introduced an implantable, malleable rod as a prosthesis. While others added silver wire and hinges, these models were the prototypes of today's prostheses.

But the introduction of the penile prosthesis paled in comparison to British physiologist Gile Brindley's dramatic demonstration at the 1983 Annual Meeting of the AUA. Brindley closed his lecture by dropping his pants to reveal a perfectly erect phenoxybenzamine-induced erection. Following Brindley's demonstration, Adrian Zorgniotti began teaching patients self-injections with injectable phentolamine and papaverine, a drug touted in 1982 by French vascular surgeon Ronald Virag. In the meantime, two functional tests for penile circulation were developed: one was a duplex ultrasound test by Tom F. Lue at the University of California, San Francisco and the other was dynamic cavernosometry and cavernosography by Irwin Goldstein at Boston University.

By 1996, patients would have their first self-injectable impotence drug, with FDA-approved alprostadil (prostaglandin-E1). Thereafter, physicians often prescribed a "triple-mix" of vasoactive drugs—papaverine prostaglandin, and phentolamine. By 1997, an innovative applicator—MUSE (Medicated Urethral System for Erection)—was approved by the FDA to facilitate prostaglandin absorption by the urethral mucosa.

But, while these prostheses and pharmaceutical aids were helpful for men suffering from erectile dysfunction, they did not compare to the ease of orally administered sildenafil citrate, a cardiovascular dilating agent used for patients with angina. British scientists noted its penis-enhancing capabilities when study participants reported erections. Sildenafil citrate, with the proprietary name of Viagra, caught on like wildfire in the late 1990s, even before Senator Bob Dole became a spokesperson for the drug. But Viagra's benefits may not be limited solely to males: evidence has suggested that it could also increase genital blood flow in females. In 2000, the FDA approved the first female prosthesis, the EROS clitoral device.

And research continues as physicians work to unravel the secrets to sexuality. Lue, along with Goldstein, already has confirmed the role of arterial flow and relaxed penile smooth muscle in achieving erections. Moreover, at the University of California, Los Angeles, Jacob Rajfer and Louis Ignarro (a Nobel laureate) identified nitric oxide as the principal neurotransmitter for penile erection. On the female side, UCLA's Jennifer Berman, along with her sister, sex therapist Laura Berman, are investigating the hormones that promote female sexual function and response—and the medical conditions that prevent it.

These developments are an inkling of things to come as urology's most prolific thinkers carry sexual medicine's flag into the next century.