Impotence
New treatments offer hope for millions
Impotence was never exactly a topic for cocktail party chatter. That is, until Bob Dole began publicly extolling the virtues of the newly announced impotency drug, Viagra. Whether Viagra proves medicinal boom or bust pales besides Dole's accomplishment in getting impotence out of the closet and into the doctor's office -- where it is treatable.
Also called erectile dysfunction, impotence is the consistent inability to achieve or sustain an erection that will allow for sexual intercourse. The erection may be too weak, too brief, or too painful. Impotence affects 10 to 20 million men in the United States. In fact, it is responsible for more than half a million doctors' visits each year.
Contrary to popular myth, psychological factors alone cause only 10%-20% of cases of impotence. The vast majority of causes are physical and treatable. In fact, 95% of men who receive treatment are eventually able to achieve satisfactory sexual function.
Pronunciation
IM-po-tense
Synonyms
- Erectile dysfunction
Detailed Description
Doctors now use the term "erectile dysfunction" rather than "impotence" to define problems with erections. It better describes the problem physically and helps to distinguish erection problems from other sexual dysfunctions, such as:
- Loss of libido: lack of interest in sexual relations
- Loss of emission: lack of urethral secretions, prostatic, or seminal fluid
- Retrograde ejaculation: ejaculate is not emitted but instead is refluxed (backs up) into the urinary bladder
- Loss of orgasm: loss of the pleasurable sensations and rhythmic contractions that culminate sexual response
- Premature ejaculation: ejaculation before sexual arousal is complete
To better understand impotence, it's helpful to fully understand the anatomy of the penis and male sexual response. Two chambers filled with spongy tissue, called the corpora cavernosa, run the length of the penis. A membrane called the tunica albuginea surrounds them both. The urethra, which emits urine and semen from the body, runs beneath the corpora cavernosa.
An erection can result from either thinking or dreaming of sex, or direct stimulation of the genitals, although most of the time both sources of stimulation come into play. In a man without impotence, such stimulation prompts brain impulses that tell the muscles of the corpora cavernosa to relax. Blood then begins to fill the spongy tissue, causing the penis to expand. The tunica albuginea then contracts, trapping the blood inside the penis and sustaining erection. In healthy sexual response, the process usually doesn't reverse until just after ejaculation, when the corpora cavernosa muscles contract, stopping the inflow of blood, and the tunica albuginea create resistance, allowing the blood to flow back into the body.
As you can see, attaining and maintaining an erection is a complex series of events, involving nerve impulses in the brain, genitals, and spinal column and requiring response from the muscles, veins, arteries, and fibrous tissues in or near the corpora cavernosa. A disruption of any one of these events can cause impotence.
Impotence has many causes, most of them physical, such as diabetes; alcoholism; drug side effects or illicit drug use; vascular, thyroid, or nerve disorders; prostate surgery or disease; spinal cord or genital trauma; and hormonal abnormalities. Psychological causes include depression, anxiety, stress, low self-esteem, lack of sexual information, poor relationship with sexual partner, and psychosis.
Untreated, impotence may only worsen, since inability to achieve an erection can cause performance anxiety -- which, in itself, can cause impotence. Nonetheless, even if left untreated, impotence will stop in about 15% of those men affected.
How Common Is Erectile Dysfunction?
About one in 10 men report having impotence, but more have it and do not report it. Teenage boys and younger adults report impotence, but it is most common in men over age 45. Between 15%-25% of 65-year-old men may have impotence. Even though it becomes more common with age, aging itself does not cause impotence; instead, underlying problems -- such as arteriosclerotic vascular disease -- which often occur in older men, can cause impotence.
Established Causes
In the past, medical experts thought that emotional issues largely caused impotence. But experts now think that the majority of cases involve organic issues, not just psychological or emotional problems. The many causes of impotence include:
Physical
- Diabetes mellitus
- Excessive alcoholism
- Drug abuse
- Decreased penile circulation
- Neurologic processes, such as spinal cord injuries and diseases
- Atherosclerosis
- Structural abnormalities (perhaps due to surgery)
- Medications such as antihypertensives, sedatives, antihistamines, and antipsychotics
- Penile diseases such as Peyronie's disease
- Endocrine disorders such as testicular failure and hyperprolactinemia (rare)
Psychological
- Depression
- Anxiety
- Schizophrenia
- Poor relationship with sexual partner
- Fear of sexual incompetence
- Stress
Environmental
- Smoking
- Rushed lovemaking
- Exposure to toxic chemicals
Risk Factors
Risk factors include:
- Use of certain medications
- Prior surgery, especially cardiovascular, pelvic, or prostate surgery
Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.
Symptoms
The most common signs and symptoms for impotence include:
- Inability to achieve an erection
- Inability to maintain erection throughout intercourse
- Decrease in erection size and rigidity
How Erectile Dysfunction Is Diagnosed
You tell your doctor about your erection problems, and your doctor tries to identify the underlying cause. Since many organic conditions can contribute to impotence, your doctor should note factors in your medical history such as:
- High blood pressure
- Diabetes mellitus
- Hyperlipidemia
- Neurologic disease
- Pelvic surgery or trauma
- Alcohol use
- Tobacco use
- Recreational drug use
Laboratory Work
Your doctor may order one or more of these tests:
- Complete blood count (CBC)
- Urinalysis
- Serum electrolytes and glucose
- Lipid profile
- Hormone analysis (testosterone, prolactin)
- Measurement of penile blood pressure (Doppler technique)
- Measurement of penile/brachial blood pressure
- Dynamic cavernosography and cavernosometry
- Monitor of erections during sleep: nocturnal penile tumescence (NPT)
- Psychosocial examination
- Electrodiagnesis (bulbocavernosus reflex)
Imaging
Diagnosis through imaging techniques, including:
- Angiogram
- Doppler
- Cavernosogram
Goals of Treatment
If you seek treatment, you have a very good chance of enhancing your ability to have and sustain an erection that will allow you to have sexual intercourse. Several treatments for impotence address the underlying causes.
Treatment Overview
Treatment for impotence follows a course that rules out many potential causes for the condition. Most treatment moves from the least invasive (reducing doses on drugs causing impotence) to the most invasive (surgery). Depending on the cause of the dysfunction and on your lifestyle, your doctor may suggest more than one type of treatment.
Several drugs can treat impotence. Some, like Viagra, you take orally; others you inject into your penis, insert into the end of your penis, or rub on your penis. Doctors can usually treat impotence without surgery, which involves implanting penile prostheses to help you achieve erection or repairing the arteries or veins of your penis.
Depending on the type of therapy and medication prescribed, you should meet regularly with a doctor to assess the treatment and your response to it.
Reducing Doses on Drugs Causing Impotence
Your doctor may first suggest that you cut back on certain medications or substitute others in their place. Since recreational drugs, including alcohol, can greatly limit sexual response, you should use them less. Also, most urologists are adamant that a patient should stop smoking, as it constricts the blood vessels, including those in the penis.
Psychotherapy and Behavioral Therapy
Counseling focuses on decreasing your performance anxiety. Also, counseling can help you and your partner to discuss sex and foster intimacy with each other.
Drug Therapy
Drugs Most Commonly Prescribed
The most famous impotence drug right now is Viagra (sildenafil). Approved by the FDA in 1998, it is an oral drug that relaxes smooth muscles in the penis during sexual stimulation, allowing increased blood flow to the penis and making an erection possible. Though popular, Viagra is relatively new, so researchers have not carried out long-term tests on its effects. Other new oral drug formulations are also being developed.
Second choices
Other drugs include:
- Alprostadil (Muse: a urethral suppository, Caverject: an injection into the penis)
- Testosterone cypionate: for abnormally decreased gonad activity (hypogonadism)
- Bromocriptine: for hyperprolactinemia
- Injections of papaverine and phentolamine
- Nitroglycerin: this muscle relaxant can induce erection when rubbed on the penis
- Yohimbine (Yocon)
Hormone replacement
If you have abnormally low levels of a male hormone called testosterone, your doctor may prescribe testosterone injections or skin patches for replacement therapy.
Binding/Vacuum Constriction Devices
You can buy an inexpensive binding device, called a cock ring, at stores that sell sex toys. Once you achieve an erection, you place the binding device around the base of your penis, helping to sustain the erection by preventing blood from flowing back into your body. Vacuum constriction devices are composed of a plastic cylinder to sheath the penis, a hand-operated vacuum pump, and a binding device. The pump draws air out of the cylinder, creating a partial vacuum around your penis and drawing blood into it. You place a binding device on your penis, and then withdraw the cylinder.
Surgery
Surgery to substitute for erectile function or improve vascular function is the last treatment considered for impotence. It consists of three separate procedures:
- Implants. The doctor inserts penile prostheses or penile implants in each of the two corpora cavernosa. These implants may be rigid, malleable, hinged, or inflatable. The inflatable types are associated with more mechanical failures and complications than the others.
- Arterial reconstruction. If the arteries that carry blood into the penis are blocked or damaged (usually from injury), your doctor might surgically reconstruct the arteries.
- Venous surgery. Your doctor may surgically block penile veins that impair erection by allowing blood to flow back into the body prematurely.
Appropriate Healthcare Setting
Unless you are undergoing surgery, you won't need to stay in the hospital in almost all cases of impotence. Surgery will require that you stay in the hospital for one or two days and recover outside the hospital over six weeks.
Healthcare Professionals Who May Be Involved in Treatment
- Urologists
- Sex therapists
- Geriatricians
- Family medicine doctors
- Internists
- Psychologists
- Psychiatrists
- Behavioral therapists
Diet Recommendations
A high-fat diet can lead to atherosclerosis, a condition that restricts blood flow-- including blood flow into the penis. Studies have linked obesity and high cholesterol levels, both resulting from high-fat diets, with increased risk of impotence.
Quality of Life
Intimate relationships are an important aspect of life. While intercourse is not the only kind of intimacy, performance problems can affect self-esteem. Medical attention can address physical issues and underlying medical causes of impotence. In dealing with psychological and social issues, you may need the help of an understanding partner or professional counselor.
Considerations for Older Men
Impotence is not an inevitable consequence of aging. In fact, it is not unreasonable for healthy men to expect they'll have normal erections into their 90s. However, men over 50 may consider these facts in assessing their own sexual function:
- It takes more time to feel arousal, achieve an erection, and respond to stimulation
- The level of a male sex hormone called testosterone is diminished
- The circulatory system, which makes erections possible, changes with age
- Stress of any type may affect sexual function
Supplements
Antioxidants: Antioxidant nutrients, notably vitamin E, may help prevent the build-up of fatty, cholesterol-rich arterial deposits that can contribute to impotence.
Herbs
- Ginkgo: Best known for improving blood flow through the brain, ginkgo also improves blood flow into the penis. In one study, urologists gave ginkgo extract (80 mg three times a day) to 50 men whose impotence was caused by narrowing of the arteries that carry blood into the penis. After nine months, 31 of the men could achieve erections, while the remaining 19 could achieve erections when ginkgo was combined with a forerunner of Viagra. [1]
Ginkgo also helps treat impotence caused by antidepressant medications -- an all-too-common side effect. At the University of California at San Francisco Medical Center, researchers gave ginkgo extract (100 mg twice a day) to 63 men and women who reported sexual side effects from the Prozac family of antidepressants -- the selective serotonin reuptake inhibitors (SSRIs). Herbal treatment improved sexual response in 84% of the participants. This study had no placebo group, but the response rate was much higher than the 30% response placebos typically produce. [2] - Yohimbine: Found in the bark of a West African tree, it has an age-old reputation as an erection booster and is the active ingredient in several prescription drugs used to treat impotence. A recent study found that yohimbine is much more effective than a placebo in treating impotence. [3] If you'd rather not use the prescription drug, yohimbine products might help.
1 Sohn. M. and R. Sikora. "Ginkgo Biloba Extract in the Therapy of Erectile Dysfunction," Journal of Sex Education and Therapy (1991) 17:53.
2 Cohen, A.J. and B. Bartlik. "Ginkgo Biloba for Antidepressant-Induced Sexual Dysfunction," Journal of Sex and Marital Therapy (1998) 24:139.
3 Ernst, E. and MH Pittler. "Yohimbine for Erectile Dysfunction: A Systematic Review and Meta-Analysis of Randomized Clinical Trials," Journal of Urology (1998) 159:433.uvy{9(R)|}
Websites & Organizations
American Foundation for Urologic Disease
Toll Free Info-Line about Erectile Dysfunction: 800-835-9021
The Geddings Osbon, Sr. Foundation
P.O. Drawer 1593
Augusta, GA 30903-1593
Phone: 800-433-4215
Impotence Information Center
P.O. Box 9
Minneapolis, MN 55440
Phone: 800-843-4315
Impotence Institute of America
8201 Corporate Drive, Suite 320
Landover, MD 20785
Phone: 301-577-0650
The Mayo Clinic
Medic Drug's Impotence Resource Center
Phone: 800-686-8886 or 440-449-7727
Email: info@medicdrug.com
Medical Center of Las Colinas
6750 N. MacArthur Blvd., Ste. 211
Irving TX 75039
Phone: 972-501 - 0112
FAX: 972-501-0431
National Kidney and Urologic Diseases Information Clearinghouse
3 Information Way
Bethesda, MD 20892-3580
Email: nkudic@info.niddk.nih.gov
Sexual Function Health Council
American Foundation for Urologic Disease
300 West Pratt Street, Suite 401
Baltimore, MD 21201
Phone: 800-242-2383
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