Impotence : Causes and Treatment
Erection Problems Erectile Disfunction (Dysfunction)
Solutions
Viagra Drug Vacuum Pump and Surgery
Impotence
is a consistent inability to sustain an erection
sufficient for sexual intercourse. Medical
professionals often use the term "erectile
dysfunction" to describe this disorder and to
differentiate it from other problems that interfere
with sexual intercourse, such as lack of sexual
desire and problems with ejaculation and orgasm. This
fact sheet focuses on impotence defined as erectile
dysfunction.
Impotence can
be a total inability to achieve erection, an
inconsistent ability to do so, or a tendency to
sustain only brief erections. These variations make
defining impotence and estimating its incidence
difficult. Experts believe impotence affects between
10 and 15 million American men. In 1985, the National
Ambulatory Medical Care Survey counted 525,000
doctor-office visits for erectile dysfunction.
Impotence
usually has a physical cause, such as disease,
injury, or drug side-effects. Any disorder that
impairs blood flow in the penis has the potential to
cause impotence. Incidence rises with age: about 5
percent of men at the age of 40 and between 15 and 25
percent of men at the age of 65 experience impotence.
Yet, it is not an inevitable part of aging.
Impotence is
treatable in all age groups, and awareness of this
fact has been growing. More men have been seeking
help and returning to near-normal sexual activity
because of improved, successful treatments for
impotence. Urologists, who specialize in problems of
the urinary tract, have traditionally treated
impotence--especially complications of impotence.
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The penis contains two chambers,
called the corpora cavernosa, which run
the length of the organ . A spongy tissue fills
the chambers. The corpora cavernosa are
surrounded by a membrane, called the tunica
albuginea. The spongy tissue contains smooth
muscles, fibrous tissues, spaces, veins, and
arteries. The urethra, which is the channel for
urine and ejaculate, runs along the underside of
the corpora cavernosa. Erection begins with
sensory and mental stimulation. Impulses from the
brain and local nerves cause the muscles of the corpora
cavernosa to relax, allowing blood to flow in
and fill the open spaces. The blood creates
pressure in the corpora cavernosa, making
the penis expand. The tunica albuginea
helps to trap the blood in the corpora
cavernosa, thereby sustaining erection.
Erection is reversed when muscles in the penis
contract, stopping the inflow of blood and
opening outflow channels.
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Since an erection requires a
sequence of events, impotence can occur when any
of the events is disrupted. The sequence includes
nerve impulses in the brain, spinal column, and
area of the penis, and response in muscles,
fibrous tissues, veins, and arteries in and near
the corpora cavernosa. Damage to arteries,
smooth muscles, and fibrous tissues, often as a
result of disease, is the most common cause of
impotence. Diseases--including diabetes, kidney
disease, chronic alcoholism, multiple sclerosis,
atherosclerosis, and vascular disease--account
for about 70 percent of cases of impotence.
Between 35 and 50 percent of men with diabetes
experience impotence.
Surgery
(for example, prostate surgery) can injure nerves
and arteries near the penis, causing impotence.
Injury to the penis, spinal cord, prostate,
bladder, and pelvis can lead to impotence by
harming nerves, smooth muscles, arteries, and
fibrous tissues of the corpora cavernosa.
Also, many
common medicines produce impotence as a side
effect. These include high blood pressure drugs,
antihistamines, antidepressants, tranquilizers,
appetite suppressants, and cimetidine (an ulcer
drug).
Experts
believe that psychological factors cause 10 to 20
percent of cases of impotence. These factors
include stress, anxiety, guilt, depression, low
self-esteem, and fear of sexual failure. Such
factors are broadly associated with more than 80
percent of cases of impotence, usually as
secondary reactions to underlying physical
causes.
Other
possible causes of impotence are smoking, which
affects blood flow in veins and arteries, and
hormonal abnormalities, such as insufficient
testosterone.
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Patient History
Medical and
sexual histories help define the degree and
nature of impotence. A medical history can
disclose diseases that lead to impotence. A
simple recounting of sexual activity might
distinguish between problems with erection,
ejaculation, orgasm, or sexual desire.
A history
of using certain prescription drugs or illegal
drugs can suggest a chemical cause. Drug effects
account for 25 percent of cases of impotence.
Cutting back on or substituting certain
medications often can alleviate the problem.
Physical
Examination
A physical
examination can give clues for systemic problems.
For example, if the penis does not respond as
expected to certain touching, a problem in the
nervous system may be a cause. Abnormal secondary
sex characteristics, such as hair pattern, can
point to hormonal problems, which would mean the
endocrine system is involved. A circulatory
problem might be indicated by, for example, an
aneurysm in the abdomen. And unusual
characteristics of the penis itself could suggest
the root of the impotence--for example, bending
of the penis during erection could be the result
of Peyronie's disease.
Laboratory
Tests
Several
laboratory tests can help diagnose impotence.
Tests for systemic diseases include blood counts,
urinalysis, lipid profile, and measurements of
creatinine and liver enzymes. For cases of low
sexual desire, measurement of testosterone in the
blood can yield information about problems with
the endocrine system.
Other
Tests
Monitoring
erections that occur during sleep (nocturnal
penile tumescence) can help rule out certain
psychological causes of impotence. Healthy men
have involuntary erections during sleep. If
nocturnal erections do not occur, then the cause
of impotence is likely to be physical rather than
psychological. Tests of nocturnal erections are
not completely reliable, however. Scientists have
not standardized such tests and have not
determined when they should be applied for best
results.
Psychosocial
Examination
A
psychosocial examination, using an interview and
questionnaire, reveals psychological factors. The
man's sexual partner also may be interviewed to
determine expectations and perceptions
encountered during sexual intercourse.
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Most physicians suggest that
treatments for impotence proceed along a path
moving from least invasive to most invasive. This
means cutting back on any harmful drugs is
considered first. Psychotherapy and behavior
modifications are considered next, followed by
vacuum devices, oral drugs, locally injected
drugs, and surgically implanted devices (and, in
rare cases, surgery involving veins or arteries).
Psychotherapy
Experts
often treat psychologically based impotence using
techniques that decrease anxiety associated with
intercourse. The patient's partner can help apply
the techniques, which include gradual development
of intimacy and stimulation. Such techniques also
can help relieve anxiety when physical impotence
is being treated.
Drug
Therapy
Drugs for
treating impotence can be taken orally, injected
directly into the penis, or inserted into the
urethra at the tip of the penis. In March 1998,
the Food and Drug Administration approved
sildenafil citrate (marketed as Viagra), the
first oral pill to treat impotence. Taken 1 hour
before sexual activity, sildenafil works by
enhancing the effects of nitric oxide, a chemical
that relaxes smooth muscles in the penis during
sexual stimulation, allowing increased blood
flow. While sildenafil improves the response to
sexual stimulation, it does not trigger an
automatic erection as injection drugs do. The
recommended dose is 50 mg, and the physician may
adjust this dose to 100 mg or 25 mg, depending on
the needs of the patient. The drug should not be
used more than once a day.
Oral
testosterone can reduce impotence in some men
with low levels of natural testosterone. Patients
also have claimed effectiveness of other oral
drugs--including yohimbine hydrochloride,
dopamine and serotonin agonists, and
trazodone--but no scientific studies have proved
the effectiveness of these drugs in relieving
impotence. Some observed improvements following
their use may be examples of the placebo effect,
that is, a change that results simply from the
patient's believing that an improvement will
occur.
Many men
gain potency by injecting drugs into the penis,
causing it to become engorged with blood. Drugs
such as papaverine hydrochloride, phentolamine,
and alprostadil (marked as Caverject) widen blood
vessels. These drugs may create unwanted side
effects, however, including persistent erection
(known as priapism) and scarring. Nitroglycerin,
a muscle relaxant, sometimes can enhance erection
when rubbed on the surface of the penis.
A system
for inserting a pellet of alprostadil into the
urethra is marketed as MUSE. The system uses a
pre-filled applicator to deliver the pellet about
an inch deep into the urethra at the tip of the
penis. An erection will begin within 8 to 10
minutes and may last 30 to 60 minutes. The most
common side effects of the preparation are aching
in the penis, testicles, and area between the
penis and rectum; warmth or burning sensation in
the urethra; redness of the penis due to
increased blood flow; and minor urethral bleeding
or spotting.
Research on
drugs for treating impotence is expanding
rapidly. Patients should ask their doctors about
the latest advances.
Vacuum
Devices
Mechanical
vacuum devices cause erection by creating a
partial vacuum around the penis, which draws
blood into the penis, engorging it and expanding
it. The devices have three components: a plastic
cylinder, in which the penis is placed; a pump,
which draws air out of the cylinder; and an
elastic band, which is placed around the base of
the penis, to maintain the erection after the
cylinder is removed and during intercourse by
preventing blood from flowing back into the body
One
variation of the vacuum device involves a
semirigid rubber sheath that is placed on the
penis and remains there after attaining erection
and during intercourse.
Surgery
Surgery
usually has one of three goals:
- to
implant a device that can cause the penis
to become erect;
- to
reconstruct arteries to increase flow of
blood to the penis;
- to
block off veins that allow blood to leak
from the penile tissues.
Implanted
devices, known as prostheses, can restore
erection in many men with impotence. Possible
problems with implants include mechanical
breakdown and infection. Mechanical problems have
diminished in recent years because of
technological advances.
Malleable
implants usually consist of paired rods, which
are inserted surgically into the corpora
cavernosa, the twin chambers running the
length of the penis. The user manually adjusts
the position of the penis and, therefore, the
rods. Adjustment does not affect the width or
length of the penis.
Inflatable
implants consist of paired cylinders, which are
surgically inserted inside the penis and can be
expanded using pressurized fluid . Tubes connect
the cylinders to a fluid reservoir and pump,
which also are surgically implanted. The patient
inflates the cylinders by pressing on the small
pump, located under the skin in the scrotum.
Inflatable implants can expand the length and
width of the penis somewhat. They also leave the
penis in a more natural state when not inflated.
Surgery to
repair arteries can reduce impotence caused by
obstructions that block the flow of blood to the
penis. The best candidates for such surgery are
young men with discrete blockage of an artery
because of an injury to the crotch area or
fracture of the pelvis. The procedure is less
successful in older men with widespread blockage.
Surgery to
veins that allow blood to leave the penis usually
involves an opposite procedure--
intentional blockage. Blocking off veins
(ligation) can reduce the leakage of blood that
diminishes rigidity of the penis during erection.
However, experts have raised questions about this
procedure's long-term effectiveness.
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Advances in suppositories,
injectable medications, implants, and vacuum
devices have expanded the options for men seeking
treatment for impotence. These advances also have
helped increase the number of men seeking
treatment. An oral form of the drug
phentolamine may soon join sildenafil in the
armamentarium of noninvasive treatments for
impotence. Other treatments in the experimental
stages include reconstruction surgery for damaged
veins and arteries in the penis. Whether or not
this method proves to be safe and effective,
ongoing improvements in traditional methods
should continue to create more successful and
widespread treatment of impotence.
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- Impotence
is a consistent inability to sustain an
erection sufficient for sexual
intercourse.
- Impotence
affects 10 to 15 million American men.
- Impotence
usually has a physical cause.
- Impotence
is treatable in all age groups.
- Treatments
include psychotherapy, drug therapy,
vacuum devices, and surgery.
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Impotence Information Center
P.O. Box 9
Minneapolis, MN 55440
1-800-843-4315 Sexual Function Health Council
American Foundation for Urologic Disease
300 West Pratt Street
Suite 401
Baltimore, MD 21201
1-800-242-2383
The
Geddings Osbon, Sr. Foundation
P.O. Drawer 1593
Augusta, GA 30903-1593
1-800-433-4215
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FOR
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