Book Review

The New Injection Treatment for Impotence: Medical and Psychological Aspects

N Engl J Med 1993; 329:439-440August 5, 1993

Article

The New Injection Treatment for Impotence: Medical and Psychological Aspects
By Gorm Wagner and Helen Singer Kaplan. 210 pp., illustrated. New York, Brunner/Mazel, 1993. $29.95. ISBN: 0-87630-689-X

Impotence is more common than most clinicians realize. Recent reports estimate that more than 20 million American men between the ages of 40 and 70 years have some degree of erectile dysfunction. Wagner and Kaplan believe that antisexual, Victorian codes of social behavior have inhibited the study of human sexuality. The landmark work of Masters and Johnson has, however, introduced new ideas about genital function and a classification of male sexuality into three phases: libido or desire, erection, and ejaculation.

Medically, it is the erection phase that is amenable to pharmacologic treatment by intracavernosal injection. Actually, this form of therapy has been embraced worldwide for over 10 years, so from a purist's standpoint, it is not a new treatment, as the title of this book suggests.

What is new is the combination of organic and psychogenic perspectives the authors bring to a subject so emotionally charged that it causes many patients to feel vulnerable and exposed. Because most physicians also feel uncomfortable dealing with sexual matters, the authors aim to ease the critical doctor-patient relationship by demystifying the subject.

The first half of the book, by Dr. Wagner, deals with the biologic basis and medical management of impotence. He carefully covers the history of therapy for erectile dysfunction, from the first report of penile-revascularization surgery in 1973 to the serendipitous observation of erections in cats after intravenous injections of alpha-blockers by Domer in 1978, and the treatment of impotence by the injection of vasoactive agents into the corpus cavernosum in the early 1980s. Wagner briefly discusses the anatomy of the penis and relates our present understanding of the physiology of cavernosal smooth muscle to new theories of gap-junction cellular communication and the role of nitric oxide in the erectile response. He discusses the method of intracavernosal-injection treatment and other therapeutic options. He warns that patients should never make a hasty decision, that spouses should be involved, and that there is still merit in obtaining a history that incorporates a broad-minded and neutral view of sexuality.

In the second half of the book, Dr. Kaplan discusses the psychiatric aspects of intracavernosal-injection therapy, illustrating her ideas with 12 case reports. Her main caveat is that despite the availability of mechanical solutions, many patients receive no long-term benefit because of hidden emotional and marital difficulties. She suggests that impotence can serve as a subtle defense against the emergence of deeper, unconscious conflicts and that for this reason each patient entering an intracavernosal-injection program should undergo brief psychiatric screening to exclude anyone prone to adverse psychological reactions.

For the most part, Kaplan downplays the organic basis of impotence and suggests that it is in the patient's best interest to restore sexual function through psychiatric therapies, regardless of cost and time, before undergoing intracavernosal-injection therapy. However, she does concede the value of the injection treatment -- for example, in single, impotent men who have performance anxiety, and are caught in the Catch-22 of avoiding the sexual encounters that could alleviate those anxieties.

Kaplan compellingly dispels the myth that older patients must eventually lose their sexuality. She points out that for them the restoration of sexual functioning -- like the restorative value of hearing aids, glasses, and pacemakers -- can be a tremendous gift and a source of pleasure and well-being.

Because of rapid scientific progress, this is a field in which it is difficult to remain current. For example, there is no mention of the intraurethral delivery of vasoactive substances, a treatment that may soon replace intracavernosal-injection therapy. Because of its balanced but opposing contributions, however, this book has something for everyone who deals with the treatment of sexual dysfunction. It is ideal for ancillary office personnel and for patients who want to know more about erectile dysfunction and its treatment.

Wayne G. Hellstrom, M.D.
Tulane University, New Orleans, LA 70112