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the fray can we begin to see the interlocking, overlapping, and colliding aspects of globalization as a whole and begin to formulate national and international policies that take account of these rapid changes and interconnections That s what this book is about It is nearly impossible to talk about basic concerns like mortgages, retirement plans, and gas prices, for example, without examining global intersections in trade, nance, energy, immigration, the environment and defense But we, as US citizens, seem blind to how twenty- rst century civilization is connecting more nations and peoples than ever before Our elected of cials, too, are fumbling with major policy decisions amid the world s changing power structure Without recognizing, admitting, and understanding these connections, we can t even begin to discuss how the United States and other countries can craft and harness effective policies amid this breathtaking progress

18 ing the corpus cavernosum by a direct effect in the case of local perfusion [236]

Reports on nocturnal erections for HPRL men are inconsistent Following recordings for three consecutive nights, De Rosa et al considered that nocturnal erections were abnormal in every one of 41 patients with macroadenoma, and in 8/10 patients with microadenoma, with respect to a control group of normal men [231] Conversely, in six men with PRL >300 ng/mL, Carani et al found no difference with respect to their normal control group as concerns both the nocturnal erections and the erections induced by audiovisual stimulation [232]

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It is somewhat understandable that we Americans can t get our heads into the chaos of globalization For most of the twentieth century, we lived in an easy-to-understand world The US economy was the largest and most competitive but fairly insular and domestic; trade was less than 10 percent of our total economic activity Our comparative advantages in technology coupled with a strong dollar and cheap oil helped propel a living standard that surpassed much of the world After World War II, we dominated the global scene and lived large literally Automobiles grew longer and heavier, people grew taller and fatter, homes grew bigger, and the nation s political and economic in uence grew ever grander Because of the vast US marketplace, many outward looking countries naturally wanted to do business with us and emulate our rich lifestyle wearing designer and logo-bearing clothes, driving big ashy cars, listening to popular music, watching TV and movies, and eating too much We were seen as leaders of the free capitalist world, a bit gauche but with our heads and hearts essentially in the right places

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Routine determinations of serum PRL found HPRL in 1 5% of ED patients Compiling the 10 largest series of literature leads to a prevalence of marked HPRL (serum PRL >35 ng/mL) at 062% and of pituitary adenomas at 038% of 8707 ED patients [238] Though low, these gures are higher than the corresponding prevalences found in two studies of unselected Asiatic populations totaling over 13 000 men (HPRL in respectively 017 and 029%, and pituitary tumors in 0036 and 006%) [239,240] In addition some ED patients were found to have mild HPRL (serum PRL 20 35 ng/mL), for a 15% prevalence [238]

HPRL impairs the pulsatile release of LH, which results in a decrease of T secretion It is often believed that this is the main cause of ED [233] In fact it may not explain every case Serum T is in the (low) normal range in nearly half of the ED patients with marked HPRL (for example in 17 of the 41 patients with prolactinoma of De Rosa et al [231], who observed a highly signi cant inverse relationship between nocturnal erections and PRL, but not T) Moreover, during treatment of men with HPRL with the PRL-lowering agent bromocriptine, sexual improvement correlates better with the PRL decrease than with the T increase [229,231] Erections can return prior to any increase in T The other mechanisms may include a decrease in the 5 -reduction of T into DHT observed in HPRL men DHT seems the main metabolite accountable for the effects of T upon the primate brain centers However the main T-independent mechanisms probably depend on PRL interactions with neurotransmitter systems: possibly downregulation of the brain receptors to dopamine, a neurotransmitter that stimulates sexual behavior of most animal species, because PRL increases the synthesis, turnover and release of central dopamine; interaction of PRL with the opioid and serotoninergic systems, both involved in the adjustment of sexual behavior Studies in rats con rm a central inhibition of the penile re exes by experimental HPRL [234] However two experimental studies in dogs also suggest the possibility of a peripheral effect, with prolactin locally inhibiting the capacity to relax of the cavernous smooth muscle cells [235] and contract-

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