Making Love Again

The authors undertake the difficult task of attempting to put into lay terms the current understanding of erectile function and dysfunction as well as discussing in great depth one of the current forms of therapy-penile injection therapy. Dr. Eid relates with painstaking detail his personal approach to patients who present with erectile difficulties and how he persuades them to receive office injection. He also discusses his personal approach to office testing and the other modalities that are currently available for diagnostic evaluation of erectile dysfunction. Intermingled throughout the text are various case vignettes that are extremely helpful. Although “the news is good” that injections restore sexual functioning, the authors’ introductory chapters overemphasize men’s sexual performance and subscribe to the conventional myths regarding male sexuality. For example, they promise that with injections sex will be as it was at age 18 and better than what it was at 30, with longer-lasting erections to make their partners multiply orgasmic. These “superlover” expectations can be appealing but are misleading. To the authors’ credit, they address the importance of psychological intimacy, although they minimize the impact of divorce, death of spouse, and marital conflict on erectile functioning. Although we agree with the majority of the authors’ comments, we strongly disagree with many of the biased attitudes towards the evaluation and treatment of erectile dysfunction in men. We believe most urologists cannot adequately distinguish psychogenic from organic erectile dysfunction as readily as Dr. Eid. In addition, because erectile dysfunction is a n area that abounds with litigation, we strongly believe in objective diagnostic testing in an effort to rule out oyert psychopathology as the main cause of erectile dysfunction. In our practice, we have also moved away from routine office injections on the initial visit, as we feel that the first encounter should be an exploratory one for both the patient and the physician. Inasmuch a s all of our patients see Dr. Seftel (the urologist) as well as Dr. Althof or Dr. Terezis (the psychologists), we aim to understand the underlying problem with the patient and his partner. Thus, we take painstaking effort to understand the present interpersonal relationships that exist as well as any socioeconomic and environmental influences that may be playing a role. We also make a strong effort to evaluate organic disease with simple, noninvasive, objective office testing. At the end of the first session, we believe it is important t o understand the patient, his spouse, and the milieu in which he and his partner are operating prior to initiating any therapy. Once we have established a diagnosis, we again spend a great deal of effort evaluating and discussing the treatment options. Thus, our patients hear from a t least two or three individuals about the various treatment options, side effects, and costs, and are able to make a n intelligent, informed decision over the course of time. Furthermore, the authors state as fact that more than 80% of erectile disorders have an organic etiology. Such a statistic depends upon one’s field or perspective-that is, a urologist is likely to see more organic cases whereas a psychologist is likely to see more psychogenic cases. The authors acknowledge that it is generally more acceptable for men to believe or hope that their erectile dysfunction is organically based, but encourage this belief by stating how easy it is to fix an organic problem by injection. Although they make an effort to decrease the shame associated with this sensitive problem, they do not address how such feelings contribute to the search for a quick, emotionally pain-free fix and how they can interfere with optimal treatment, particularly if psychotherapy is indicated. Also, the authors do not adequately address the management of mixed organidpsychogenic cases or the controversy over giving injections to a man with psychogenic erectile dysfunction. Nor do they adequately address the value of psychotherapeutic support as an adjunct to injections, especially in those cases in which feelings of inadequacy and anxiety are pervasive. Instead, they promise that men can achieve erections whenever they want without worry, regardless of the situation. Such promises do not acknowledge cases in which psychogenic distress overrides erectile functioning, even with the use of injections. In sum, the authors are to be congratulated for tackling a very sensitive and difficult issue in a very sensitive and practical way and for presenting the information concisely, with clarity, and in lay language that is easily understood. The down side of this text resides in Dr. Eid’s biases in his approach to evaluation of patients with erectile dysfunction and in the diagnostic testing that is currently available. Despite these shortcomings, this text is a welcome addition to the lay and urologic literature, and is a publication we encourage physicians and their patients with erectile dysfunction to become familiar with either prior to or during the course of their evaluation or treatment for erectile dysfunction.