This is a very provocative manuscript with a number of significant implications in the understanding of the causes and the development of treatment plans for erectile dysfunction (ED). It presents, in a convincing way, the conundrum of what comes first: the hypogonadism or the ED. Orthodox postulates have established that hypogonadism leads to sexual dysfunction (disorders of libido and inappropriate NOS production). The results of this and previous research by the same authors provides some food for thought. They challenge that view and imply that the reverse may also occur: sexual inactivity leads to effects in the hypothalamus resulting in a decrease production of pituitary gonadotropins (LH in particular) eventually resulting in hypogonadism. Resumption of sexual activity spontaneously corrects the hormonal abnormality. These findings need confirmation. At present they should only be viewed preliminary.

Radical departures of traditional thinking like this are always received with a great deal of skepticism. Questions like, why not to give androgens (in the absence of contraindications) to all impotent men in conjunction with other therapies (since measurement of B-LH is not readily available to most clinicians)? Should one just use testosterone measurements? What is meant by sexual inactivity? Does it include only genital manipulation or does it extend to other forms of sexual activity including exposure to erotic material or even sexual thoughts? Is, therefore, a range of ‘sexual inactivity with variable degrees of effect on hormonal production?’ Why patients ‘inactive’ for long periods maintain sexual desire? How long does it take for sexual inactivity to result in hormonal changes? These and others are legitimate questions that require in-depth study and unambiguous answers.

The authors are to be congratulated for their persistence on this line of inquiry. It opens an important field for further study. The correctness of their findings, again, requires additional independent investigation.