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IMPOTENCE
ERECTILE DYSFUNCTION (ED) or IMPOTENCE
Introduction
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
through he penis has the potential to cause impotence. Incidence rises
with age: about five 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.
How Does an Erection Occur?
The penis contains two chambers, called the corpora cavernosa, which
run the length of the organ.
A spongy tissue fills the chambers of the corpora cavernosa. 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.
An erection begins with sensory and mental stimulation.
Impulses from the brain and local nerves cause the muscles of the
penile arteries and the muscles of the spongy corpora cavernosa to
relax, allowing blood to flow in and fill the open spaces in the spongy
tissue. 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. The erection could
be compared to the action of air in a bicycle tire. Air is forced
into the inner tube under pressure. The inner tube (corpora cavernosa)
presses against the outer tube (tunica albuginea) creating firmness.
The blood is trapped in the corpora cavernosa sustaining the erection
similar to the air trapped in the tire's inner tube.
An erection is reversed when muscles in the penis
contract, stopping the inflow of blood and opening outflow channels
and allowing the blood to return to the body's circulatory system.
If you are interested in a very technical description
of the events, read the following.
With sexual stimulation, the parasympathetic nerves transmit impulses
through the pelvic plexus to the arterioles of the corpora cavernosa,
causing the release of nitric oxide. Nitric oxide activates an enzyme
called guanylate cyclase which results in increased levels of cyclic
guanosine monophosphate or cGMP. It is cGMP which causes the relaxation
of the smooth muscles of the blood vessels in the corpora cavernosa.
The increased arteriole inflow combined with an occlusion of the venous
outflow by dilation of the spongy tissue of the corpora results in
an erection. The erection is reversed when the cGMP is degraded or
broken down by another enzyme called phosphdiesterase type 5 (PDE5).
The smooth muscles contract, reducing the arterial inflow and allowed
better venous drainage.
What Causes Impotence?
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 medicactions 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.
How Is Impotence Diagnosed?
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 among problems
with erection, ejaculation, orgasm, or sexual desire.
A history of using certain 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. Careful
attention must be paid the the circulatory and neurological systems
(blood vessels and nerves) and, of course, the genitals (penis and
testicles). 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. For cases of
low sexual desire, measurement of testosterone in the blood and other
hormones made in the brain that control the levels of testosterone
can yield information about problems with the endocrine system. These
may include luetenizing hormone (LH), follicle stimulating hormone
(FSH) and prolactin. Tests for systemic diseases may include thyroid
hormone levels, blood counts, urinalysis, lipid profile, and measurements
of kidney and liver function.
Other Tests
Monitoring erections that occur during sleep (nocturnal penile tumescence
or NPT) 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.
Psychosocial Examination
In some cases, a psychosocial examination, using an interview and
questionnaire, reveals psychological factors. The man's sexual partner
may also be interviewed to determine expectations and perceptions
encountered during sexual intercourse. These interveiws may be performed
by a special sex therapist, psychologist, psychiatrist, or any health
provider with an interest in the psychological aspects of sexual problems.
What to Do?
Medical Treatment
Medical treatments for impotence include counseling when a psychological
problem is discovered. Working with couples and reducing tension,
improving communications, and trying to obtain realistic expectations
are areas where counseling can help. In some patients where psychologic
causes are not the originating problem, but have become a significant
factor, it may be necessary to go through counseling during the difficult
rehabilitation period.
Lifestyle modifications including changes in exercise,
stress levels, diet, alcohol, smoking, and illicit drug use may be
beneficial if felt to be a major contributing factor.
Viagra
The newest and most exciting development is in pill form. The drug
called sildenafil (or Viagra) has been studied in England and seems
to improve erections in men who have no known cause for difficulty
with erections. Studies on men with known causes, such as surgery
or diabetes, have not been completed, but early data are promising.
Viagra works by increasing blood flow to the penis. The drug is available
now. Early studies show very few side effects. The drug does not directly
cause erections, but enhance erections caused by sexual stimulation.
It works by partially blocking an enzyme in the penis that is responsible
for normally reversing erections. Some studies have shown 60-80% effectiveness
in selected patients with difficulty maintaining erections. About
1 in 25 men discontinued therapy from side effects, which included
headache, indigestion, visual disturbances, and flushing. Viagra,
which comes in three different dosages, and onset of action which
begins within 20-60 minutes. The effect lasts for four hours. Only
one dose per day is recommended. Diabetics and men who have had radical
prostate or bladder surgery have a lower success rate with Viagra.
IMPORTANT NOTE: Patients who take
or need nitroglycerin or nitrates for heart disease cannot use this
drug. A number of heart attacks, some causing death, have been reported
since the introduction of Viagra. These appear to be due to the exertion
of sexual intercourse or to the use of nitroglycerin with Viagra against
doctor's orders. Patients with significant heart disease, whether
using nitroglycrin or not, should be counselled about the risk of
heart attack.
Hormone Therapy
Hormone treatments, namely testosterone, can be used in men whose
production of male hormones is low. Testosterone injections do not
really help men who have high levels, and these can be measured by
the physician at the initial evaluation. Testosterone injections are
not without their problems, however, as the use of the drug can stimulate
the growth of prostate tissue. Testosterone cannot be used in patients
with known or suspected prostate cancer as the cancer could grow more
rapidly. Other, less common side effects of testosterone use include
liver injury and increased blood pressure. Men who take testosterone
regularly usually stop sperm production, and permanent infertility
could result if testosterone is used long enough.
Yohimbine
Yohimbine is a medication made from the bark of a tree that grows
in India and Africa. Yohimbine acts on the nervous system and may
also have some affect on increasing the male libido. It is considered
homeopathic by medical doctors, that is, no definite uses are proven.
The drug is very safe with uncommon side effects such as mild dizziness,
nervousness, irritability, headaches and nausea rarely occuring. Some
studies have suggested 10-20% of men will respond to the treatment
with yohimbine, and it is necessary to take the medication for a full
two months before knowing whether it will work or not. However, a
task force of specialists sponsored by the American Urological Association
has recently determined that Yohimbine is no more effective than placebo.
Trazodone
Trazodone is an antidepressant drug that was found to induce prolonged
erections in some men. This side effect was unwanted and the prolonged
erections cause problems in many of the patients. However, in lower
dosages, (usually 100 mg at bedtime) it can promote normal erections.
Trazodone can cause drowsiness, nausea and difficulty urinating.
Self-Injection Therapy
What is self-injection therapy? This involves the patient or his partner
giving an injection of medication directly into the side of the penis
to create an erection. The erection created is a natural one and usually
begins 5 to 15 minutes after the injection. Not all patients respond
to this type of treatment, but those that do should develop an erection
that lasts anywhere from 30 to 120 minutes. About 70% of men find
that their erections are satisfactory with self-injection therapy.
The injections are given with a tiny needle and use very small amounts
of medicine. The injections are relatively painless and are easily
taught to the patient in one or two visits with the doctor.
The drugs used today include: prostaglandin (PGE-1
or Prostin or Alpoprostadil or Caverject), Papaverine hydrochloride
and phentolamine (Regitine). All of these drugs have been approved
by the FDA for uses other than impotence treatment. Only Prostaglandin
has been approved by the FDA for treating impotence. Papaverine and
phentolamine have not yet been approved by the FDA for this specific
purpose, although these two drugs were the initial ones used for self-injection
therapy. However, considerable experience has been obtained by urologists
over the past decade and all three drugs mentioned above are considered
safe for self-injection therapy.
Disadvantages of Self Injection Treatment
Self-injection treatment does require the patient or his partner to
learn to give injections directly into the penis. The patient does
need to return to the doctor for follow-up visits, particularly in
the early phases of treatment. The patient cannot use the injections
too often for fear of developing scarring and the self-injection treatment
should be limited to once every four to seven days (range depends
on medication type and initial response).
The injections are relatively costly and average
costs depend on what combinations of medications are used. An injection
may cost up to $8 to $10 per injection.
Not all patients are candidates for self- injection
therapy. A percentage of patients will not develop good erections,
and another set of patients might develop erections that do not go
away, making them poor candidates for continued use of this drug.
Advantages
The major advantage of self-injection therapy is the fact that the
erection created is similar to the body's own spontaneous erections.
The erection usually lasts 30 to 120 minutes, which is adequate duration
for successful and pleasing intercourse. Self- injection therapy does
not impede the development of an orgasm or ejaculation. Self- injection
therapy is less costly than surgical implantation. Self-injection
therapy can be used by the patient at his own discretion and at anytime
with a minimum amount of preparation. Treatment does not involve surgery
and is minimally painful in most patients.
Summary of Self Injection Therapy
If you decide to start the self-injection program, we will have you
back to the office for test doses to see which drug and dosage is
most appropriate and effective for you. After we have established
the drug dose, we will then teach you how to draw medication from
a vial, and also how to inject it safely into the penis. You may want
to bring a partner to watch, although a partner is not absolutely
necessary if you have good dexterity and eyesight. We will have you
read, understand and sign a consent form. The form will mention the
various risks of the medications and injections. We will go over all
of these risks and conditions for you in detail at the time of the
educational program. If you have any questions about self-injection
therapy, please don't hesitate to ask us.
Risks
As mentioned, these medications have not been approved by the FDA
and so technically need to be considered experimental. All medications
have some potential risks and side effects and risks do exist with
all of these drugs and the injections. These may include the possibility
of bleeding or bruising from the injection, and a small chance of
infection. One of the more common risks include the development of
a prolonged erection or priapism (more than four hours). An episode
of priapism might require a trip back to the physician or to the emergency
room to receive other medications to counteract the self-injection
medications and relieve the prolonged erection. Priapism happens in
only a few percent of the patients. The patient does need to be aware
that any erection lasting more than four hours need to be dealt with
by a physician. Another complication is the development of permanent
scarring within the penis. The medications can be irritating to the
penile tissues, and scarring is most often seen in patients who abuse
the drug by using it too often. Scarring could create difficulty obtaining
erections even with additional medication. If the scarring were severe,
placement of a penile prosthesis, if that other option was chosen
at a later time, might be difficult. Even rarer is the development
of other medical problems. Papervine has been known to cause changes
in liver function tests which go away if the drug is stopped. Some
men complain of dizziness, heart palpitations and/or a flushed feeling
with these medications.
Uretheral Suppositories
MUSE is the name of a drug treatment and represents a unique approach
for the treatment of erectile dysfunction. It is based on the discovery
that the urethra (the tube in the penis for urine to pass from the
bladder to the outside of the body) can absorb certain medications
into the surrounding erectile tissues thereby creating an erection.
The MUSE system uses prostaglandin E1, the same medication used in
the self injection therapy, and has been approved by the FDA for the
treatment of impotence.
An erection should begin within 5-10 minutes after
administering MUSE. The duration of effect is approximately 30-60
minutes. However, the actual duration will vary from patient to patient.
The most common side effects that have been reported
using MUSE are aching in the penis, testicles, legs and in the area
between the scrotum and the rectum, warmth or burning sensation in
the urethra, redness of the penis due to increased blood flow, and
minor urethral bleeding or spotting due to improper administration
MUSE was released in early 1997 and more experience
will be gained over the first few years that it is available to the
public through their physicians. It is likely that MUSE will not be
as effective as the self-injection therapy because of the variability
of absorption of the medication and will most definitely be more expensive.
The absence of needles however makes this form of therapy very attractive
for those men in whom the treatment works.
Vacuum Devices
The vacuum erection device is a simple mechanical tool, which allows
the man to develop an erection which is suitable for sexual intercourse.
Why do Vacuum Erection Devices Work?
Erections are created when blood in trapped in the penis much like
air is trapped in an inflated tire. The more air that is placed into
the tire, the firmer the tire becomes. Likewise, the more blood trapped
temporarily in the penis, the firmer the erection. The vacuum erection
device works by bringing more blood into the penis and then trapping
it.
How Does Vacuum Erection Devices Work?
The penis is inserted into a hollow plastic tube, which is pressed
against the body creating a seal. A vacuum is then created in the
tube by use of a small hand pump. This in turn draws blood into the
penis causing engorgement, enlargement and rigidity. After one to
three minutes of vacuum, an adequate erection is created and a soft
rubber O-ring is then placed around the base of the penis in order
to trap the blood and maintain the erection. The vacuum tube is removed
and sexual intercourse is then possible. The rubber O-ring will maintain
the erection until removed, and in most circumstances this can be
left in place for 25 to 30 minutes.
Who are the Best Candidates for Vacuum Erection
Devices?
Vacuum erection devices work best in patients who are able to achieve
a partial erection on their own. After having adequate foreplay, which
creates a mild erection, the partner can be of help in applying and
using the vacuum device. In any type of sex therapy, the partner's
full acceptance of whatever technique used is always helpful.
Advantages
One of the major advantages of vacuum erection devices is safety.
There is no surgery, internal injections or significant side effects.
The vacuum erection device will work for almost any type of erectile
problem. The cost of the vacuum erection device is less than surgery
or the continued use of self-injection treatments. The vacuum device
can be used at the patient's convenience and at any time. Most of
the major companies that manufacture vacuum erection devices provide
a refund policy if the vacuum erection device is not successful. The
vacuum erection devices range in cost from $300 to $500 and require
a prescription. Some insurance companies will reimburse all or part
of the costs.
Disadvantages
One of the disadvantages of the vacuum erection device is the mechanical
aspect of obtaining an adequate erection. This might have a negative
influence on the patient and his partner. The device takes 5 to 10
minutes to set up, which technically interferes with foreplay. Some
patient's body build makes it difficult to apply the vacuum erection
device. Once the rubber O-ring is applied, there is not an erection
between the rubber band and the body, making the penis somewhat floppy.
The O-ring inhibits the normal flow or ejaculation
after orgasm in some patients. This is not harmful and the semen will
pass once the rubber band is removed. Some patients complain of a
sense of coldness and/or numbness of the penis after the O-ring has
been placed. The O-ring should be removed after 25 to 30 minutes because
of restricted blood flow. The erection will soften when the O-ring
is removed. Vacuum erection devices might be harmful to patients who
have blood clotting problems or use blood thinners because of bleeding
into the tissue.
Summary
If you have any questions about vacuum erection devices, please don't
hesitate to ask us. We have videotapes available for further information
about vacuum erection devices, and you need only to borrow a tape
or come into the office to view it.
Penile Prostheses
Implantation of a penile prosthesis is one of several options available
for the treatment of impotence. The penis consists of three hollow
tubes running along the length of the shaft. One of these, the urethra,
runs along the bottom of the penis and brings urine from the bladder
out through the end of the penis. The other two matched tubes running
side by side on the top of the penis are constructed much like an
automobile tire with an outer tube and an inner tube. The erection
is created by the two inner tubes filling and pushing against the
outer tubes much like a tire that is inflated with air.
One of the treatment options for erectile dysfunction
is the placement of prosthetic inner tubes within the penis to mimic
the inflation process and create an erection. Penile implants were
first used in the 1950s, and as time went on further advances occurred.
Different types of prostheses were developed and hundreds of thousands
of men throughout the world have been successfully treated with a
penile implant.
Today there are three types of penile prostheses.
These include the semirigid implant, the inflatable implant and a
self-contained inflatable implant.
Semi-Rigid Prostheses
Semirigid implants are paired silicone-covered malleable or bendable
metal rods. The semirigid prosthesis allows the penis to be rigid
enough for penetration, but the malleable rods allow it to be flexible
enough to allow concealment in a curved position. It is the simplest
of all prostheses and has the least chance of mechanical failure.
It is also the simplest to place.
The major limitations include the fact that the penis
is always semi-erect. Even with the bendability, concealment is a
potential problem when wearing some types of clothing. Another disadvantage
is that the prosthesis does not inflate so the erection achieved is
only from the size and rigidity of the prosthesis.
Inflatable Penile Prostheses
Inflatable prostheses are the most natural of the implants. These
are soft paired inner tubes made of silicone or bioflex, which are
inert plastics. The inner tubes are literally filled with a solution
that comes from a small reservoir placed under the muscles of the
abdomen. A pump is used to transfer the fluid from the reservoir to
the penile cylinders or inner tubes. The more fluid that is pumped
into the inner tubes, the firmer and larger the erection. When the
erection is no longer desired, the fluid returns to the reservoir
leaving the penis soft and pliable.
The major advantages of inflatable penile implant
are a more natural erection with total patient control, both in the
amount of fluid that is put into the penis, as well as the time the
erection is desired. The erection will last indefinitely until the
patient transfers the fluid back into the reservoir. One major disadvantage
is that the surgical implantation is a little more complicated than
a simple semirigid implant. Also, with the multiple parts there is
a higher chance of mechanical failure which might require revision
or repair. 9Many of the companies do have insurance policies to cover
part or all of the costs of the prosthesis replacement but not the
surgical or hospital fees.)
Self Contained Inflatable Prostheses
Self-contained inflatable implants are paired silicone cylinders which
have a pump at the very tip of the prosthesis, along with a reservoir
within the shaft that transfers fluid in such a way that the cylinder
becomes firm.
The advantage of this type of prosthesis is that
the surgery is somewhat simpler than the multi-component prosthesis.
The major disadvantage is that the inflatable portion
of it does not really increase the girth of the penis significantly.
It is also not as soft or concealable as the multicomponent implant
when deflated.
Advantages of Implants
Implants are effective in treating impotence due to almost every cause.
There is a 90%+ success rate when both partners are informed of the
nature and limitations of the prosthesis. Prostheses require no further
treatment after implantation, and there is no external equipment which
might have negative connotations to the partner. No medications or
injections are needed and once the prosthesis is placed and functioning,
there are no further costs. The newer prostheses are very reliable
and the chance of mechanical failure is very low, in the range of
two to four percent per year.
Disadvantages of Implants
Once an implant has been placed, natural erections usually no longer
occur. If the prostheses were then removed the normal erections are
unlikely to return. There is a small chance of infection which would
require removal of the prosthesis. Some patients can develop surgical
complications or anesthetic complications. Occasionally patients will
notice numbness at the head of their penis and intercourse can be
uncomfortable. Because the erection is not caused by increased blood
flow to the penis, the head of the penis is not part of the erection,
and this softness may be bothersome to some patients.
Recently the safety of silicone and silicone products
such as silastic have been questioned. Breast prostheses using liquid
or gel forms of silicone were removed from the market by the FDA.
Concerns raised were the inflammatory responses to this type of silicone
which included pain, scarring and disfigurement. In addition, possible
associations were raised among silicone and the development of immune
disorders like rheumatoid arthritis and a possible association to
an increased development of cancer. It is noteworthy that the solid
silicone breast implants that are filled with water were not removed
from usage. In May, 1994, a class action suit was filed against the
major manufacturer of penile prostheses claiming many of these same
issues. The penile prostheses are all of the solid variety and use
water as a filling. Most observers feel the suit to be without basis,
but of course, only time will tell and more research and follow-up
needs to be done. Solid silicone products are used extensively in
medicine and include cardiac pacemakers and brain shunts. Thousands
and thousands of implants of all types have been used for years with
very little and predictable risks and side effects.
Costs
Some insurance policies will cover the cost of prostheses and this
can be established through our business office. Patients who are considering
a prosthesis should be aware that other types of therapy might be
available, including vacuum devices and self-injection therapy.
VASCULAR RECONTRUCTIVE SURGERY
A small percentage of patients may be candidates for some form of
reconstruction of the penile blood flow. This includes patients with
poor arterial blood supply and those also with venous leaking. The
long-term results from this type of surgery have been generally disappointing
with even the best of results showing only 1 out of 20 men being helped.
Surgery is technically difficult, relatively expensive, and includes
complications of nerve damage and scar tissue formation. Given the
relatively low success rate, along with the technical difficulty and
expense of this type of procedure, vascular reconstructive surgery
has not been generally accepted widely.
SEX THERAPY
For many years physicians believed almost all of the sexual dysfunctions
to be caused by psychologic reasons. As we have gotten a better understanding
of the physiology of erections, it has become known that many of the
problems with impotence are caused, in fact, by physiologic reasons
that are uncontrollable by the patient. However, a significant number
of men still develop erectile problems purely on the basis of psychologic
causes. In addition, men with an underlying physical disorder often
develop psychologic problems as well because of their lack of performance.
Even if the physiologic or as physicians often say "organic"
problem is corrected, the man's self-image and confidence may be affected
significantly enough that return to normal functioning is difficult.
Among the problems in dealing with psychologic problems
is the fact that the topic is difficult to talk about or even bring
up in front of a physician. Once the lack of confidence is deeply
imbedded in the man's psyche, the subsequent lack of confidence becomes
very difficult to remove from the man's thinking. Other emotions that
may be felt include deep frustration, anger, depression and a sense
of inadequacy.
Whether the cause of the difficulty with maintaining
or achieving erections is purely psychologic or secondary to another
physiologic cause, the end result creates a lack of confidence which
results in a "self-fulfilling prophecy". The patient is
so fearful of not obtaining an erection that the worry becomes so
overwhelming that fears are born out -- no erection or loss of erection.
Sex therapists are trained professionals who deal
with sex problems uniquely, and are very goal oriented to provide
techniques, advice and counseling on dealing with the sexual problem
only. They may provide reading and videos for help in their training.
Usually only a few visits will provide definite improvement, and it
is usual not to require more than a few months of treatments before
seeing some definite results. Other causes of stress, obtaining adequate
expectations from your partner and looking at relationships are also
essential to effective sexual counseling. Some of the more specific
treatments include exercises or treatment plans that are carried out
in the privacy of one's home and does not require in-hospital or in-office
treatments. The patient's partner is definitely brought into the technique
training.
Working together to reduce anxiety and increase confidence, both partners
can help each other to relieve some of the anxieties and reestablish
normal sexual relationships.
Sex therapy is also helpful in patients who have
premature ejaculation or difficulty in obtaining an ejaculation.
In some patients the problems are so deep-seated
that the pure psychologic techniques are not effective. In these cases
the sex therapist might work with the physician in concert using a
technique such as a vacuum erection device or self-injection therapy
to aid in the early achievement of erections. As the patient's self-confidence
improves, these therapies might be discarded, although they can be
used in the future as well. On occasion, medications or injections
of hormones can be used to also help initiate or stimulate early sexual
functioning. Sex therapy is usually not covered by insurance policies,
but it is unlikely that the counseling will need to continue past
six months or so, which should keep the costs within most people's
budgets.
EXTERNAL SUPPORTS
Some men have had success using external support devices. The most
popular of these is called Rejoyn. These devices are essentially a
semi-rigid condom. They are placed over the penis and provide the
necessary rigidity without the need of an erection. These can be purchased
without a prescription at many pharmacies or by calling 1-800-297-9329
for more information.
WHAT DOES NOT WORK
At this point there is no evidence that nutritional supplements or
vitamins have any significant bearing on sexual performance. The Food
and Drug Administration has currently banned the sale or advertising
of all nonprescription products for the treatment of male impotence
because none had been scientifically shown to be effective. Nitroglycerin
patches and minoxidil (the drug for baldness) have not been shown
to be effective for impotence when used as penile patches.
WHAT'S NEW
Another new oral (taken by mouth) drug is apomorphine. This drug also
seems to promote erections in men with psychogenic problems Apomorphine
may also work in men having difficulty maintaining erections. Large
studies are currently underway in the US to determine the safety and
effectiveness of these drugs. We do not expect release of this drug
until late1998.
Yet another oral drug is Vasomax (phentolamine).
This medicine is still being tested and does not seem to have the
effectiveness of Viagra with a 40% response in men tested. At higher
doses, a lowering of blood pressure may be problematic.
All of the oral drugs have different modes of action
and if one does not work, the others may. Combinations of drugs, (e.g.
Viagra and ?) and other techniques may also be possible.
In recent European studies, a new injectable drug
called VIP is being tested. VIP stands for vasoactive intestinal peptide.
When mixed with phentolomine (Regitine), an older injectable drug,
80% of men had successful erections, even if they had failed other
injectables. Studies are just beginning in the US.
Two other injectables being researched abroad are
called moxislyte and forskolin Initial success rates of 80% are being
reported. No US studies are yet completed.
North American studies of creams containing nitroglycerin
that are applied to the penis have shown modest success in mild to
moderate erectile dysfunction. Plans to study this drug in the US
are planned. South American studies of creams containing prostaglandin
(Alprox-TD) that are applied to the penis have shown modest success
in mild to moderate erectile dysfunction. No plans to study this drug
are planned in the US for now.
SUMMARY
Impotence is a treatable problem, and is not the inevitable consequence
of aging. Almost all patients with impotence can be treated. A thorough
evaluation looking for the causes of impotence can be followed by
the appropriate diagnostic testing, and then a multitude of treatment
choices become available to assure that each patient has a successful
outcome. In terms of determining which therapy is best for each individual,
one must be informed of all the various possibilities, both about
the cause of the impotence and the type of treatments that are available.
None of the treatments will significantly affect the ability to have
an orgasm. About 35-50% of men that start with self-injection therapy
or vacuum devices will not be satisfied and will seek other treatments.
Some men will, unfortunately, give up and not seek additional help
from their urologist. Penile prostheses have an acceptance rate of
90% or more but requires a procedure. MUSE suppositories are too new
to give long term follow-up.
If needed, psychologic support and counseling by
a professional sexual counselor should be considered in many patients
regardless of the cause of the impotence to help with any adjustments.
Sex therapy is often helpful and can be done by a qualified psychiatrist,
psychologist, physician, or sex therapist with training and experience
in this specialty area. In addition to counseling, exercises and reading
to help increase sexual skills and reduce anxiety and improve communications
can be very helpful.
Points to Remember
•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.
Copyright 1999 Dialog Medical, Inc. All rights reserved
www.dialogmedical.com
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