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Impotence Causes and Treatment
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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 (see figure 1). 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 HistoryMedical 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 ExaminationA 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 TestsSeveral 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 TestsMonitoring 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 ExaminationA 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).
PsychotherapyExperts 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 TherapyDrugs 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 DevicesMechanical 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
(see figure 2).
 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.
SurgerySurgery 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 (see
figure 3). 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 causes are usually physical.
- Impotence treatment is not age specific.
- Impotence treatment includes psychotherapy, drug therapy, vacuum devices, and
surgery.
Keeping on Top of Your Condition
Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.
A new service available to patients provides a convenient means of staying informed, and ensures that the information is both reliable and accurate. If you wish to find out more about HealthNewsflash's innovative service, take the tour.
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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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