Impotence

If you're suffering from impotence, you're not alone.

What Is Impotence?

Impotence (also known as male erectile dysfunction) is the inability to maintain an erection that is firm enough or that lasts long enough to have successful sexual intercourse. It is a frustrating condition that may have either physical or psychological causes. But there are many types of sexual dysfunction which may be confused with impotence.

For instance, premature ejaculation is not a sign of impotence. Nor is a low sex drive, or the fact that you may need manual or oral stimulation to get an erection. Impotence cannot be caused by too much sex or masturbation earlier in life. And there is no connection between impotence and infertility. Most importantly, impotence is not "normal" at any age. Impotence is common and experienced by many individuals.

Impotence is common.

Most men occasionally have difficulty getting an erection. However, about one in ten men are affected by continuing or chronic impotence.

Impotence can be devastating to those affected by it. Unfortunately, it can also be very difficult to talk about. But the first step is to seek professional help. If your doctor regularly treats impotence problems, you can be confident that he has heard all about impotence concerns from other patients.

Impotence is treatable.

In more than half of all impotence cases the cause is physical - the result of diabetes, a hormone problem, blocked arteries or other causes. In other cases, the cause could be psychological - the result of stress or depression. And in many cases, physical causes can produce psychological side effects.

Diagnosing the cause is the first step before recommending a treatment. Your urologist will require a thorough history, physical examination and laboratory tests to determine whether the impotence has a physical or psychological cause.

The good news is that there are treatments available. And there is usually more than one option to choose from, ranging from sex counseling or marriage counseling to medical and surgical treatments. Your urologist can determine which treatment alternative is appropriate for you. Most impotence problems can be treated successfully.

Psychological Causes

Depression can cause a lack of energy and a reduced sex drive, which may result in an occasional inability to get an erection, deeper depression and, ultimately, impotence. The first step is to treat the depression.

Stress, whether caused by your job, marital, financial or other situation, can lead to impotence. Like depression, it's a downward spiral as the impotence adds to the stress.

Performance anxiety, or fear of failure, happens to most men occasionally, but if it persists it can lead to impotence.

Misinformation about sexuality and about how men should or shouldn't be able to "perform" at a certain age can lead to anxiety and stress, which can lead to impotence.

To treat a psychological cause, your urologist may recommend that you seek treatment from a qualified psychologist, psychiatrist, sex therapist or marriage counselor. Couseling can often resolve the psychological problem causing impotence or be part of the recommended treatment. You and your partner may wish to go through counseling together.

Even if the problem is physical, there may be psychological side effects. Therefore, counseling may also be part of the recommended treatment for a physical problem.

Physical Causes

Diabetes can cause damage to the nerves or blood vessels that control the flow of blood to the penis. In some cases, keeping your diet and blood sugar under control may decrease the risk of impotence. But permanent damage to these nerves and vessels may result in chronic impotence.

Vascular problems, such as hardening of the arteries, can slow the blood flowing into the penis, making it difficult for you to get or keep an erection. In other cases, the veins that keep blood in the penis during an erection are damaged, and you cannot keep the erection long enough for sexual intercourse. Impotence can also occur if the nerves that control this flow of blood to the penis are damaged.

Pelvic surgery or trauma, including cancer surgery in the prostate, bladder, colon or rectal area, can cause impotence. In cancer surgery, the surgeon's most important goal is to remove all of the cancer. Nerves and blood vessels that control erections may be near the cancerous tissue; sometimes these are damaged in an effort to remove the cancer.

Neurological disorders such as spinal cord injuries can cause impotence. The spinal cord is the relay center for nerve impulses, brain messages and blood flow. When the spinal cord is damaged in certain locations, messages can't get through to the nerves of the penis, causing impotence.

Medications, including some prescriptions for high blood pressure, depression and a number of other conditions, may cause impotence by interfering with the nerve impulses or blood flow to the penis. Sometimes a change in the medications or the dosage will decrease the risk of impotence. However, medications should never be changed without the doctor's permission.

Alcoholism disrupts hormone levels and can lead to permanent nerve damage, causing impotence. This type of impotence may be reversible depending on the severity of the nerve damage.

Hormone problems are rarely the cause of impotence, but certain diseases can disrupt the balance of hormones which control erections. Kidney failure and liver disease are among these conditions.

If it is determined that you are impotent, and that your impotence is caused by a physical problem, your doctor can offer several options for treatment. These may include hormone therapy, injections, vacuum devices, penile implants or vascular surgery.

How does an erection occur?

For an erection to occur, several parts of the body must work together. The brain sends messages to control the nerves, hormone levels, blood flow and muscles that cause an erection. If anything interferes with these messages, or if any part of the system doesn't function correctly, an erection will not occur.

The brain controls all sexual function, from perceiving arousal to initiating and controlling the psychological, hormonal, nerve, and blood flow changes that lead to an erection.

Arteries deliver the extra blood to the penis that causes it to stiffen. Veins then drain the blood out of the penis after intercourse.

Nerve impulses relay signals of arousal and sensation to and from the penis.

Hormones, including testosterone, control the male sex drive. Testosterone is secreted by the testicles.

THE FLACCID PENIS

The shaft of the penis contains the corpora cavernosa which run the full length of the penis and into the pelvis. These spongy tissues are rich in smooth-muscle blood vessels which, in the flaccid state, contain relatively little blood. Without sexual stimulation, the penis remains flaccid.

THE TUMESCENT PENIS

When the brain perceives sexual arousal, it stimulates the nervous system to dilate the blood vessels in the corpora, making room for extra blood. The corpora absorb arterial blood flow like a sponge. At this point the penis is swollen, but not yet rigid enough for intercourse.

THE ERECT PENIS

As the corpora continue to absorb blood, they constrict the veins, restricting the outflow of blood. Blood is trapped in the blood vessels of the corpora which become engorged, making the penis rigid and erect.

WHAT TO EXPECT AT YOUR EXAMINATION

Your urologist will ask you several questions in order to understand when and under what circumstances you experience signs of impotence. Then your urologist will give you a complete physical exam. This exam is to determine if the blood vessels, nerves, and tissues of your penis are working normally.

Your doctor may begin by feeling for the pulse in your penis and surrounding pelvic area. This will provide an indication of whether the blood supply to your erectile tissues is adequate.

Your doctor must also perform a rectal examination to check for prostatitis, or an inflamed prostate gland. Problems with your prostate can cause problems with the blood flow and nerve sensations in the penis. It can also make intercourse uncomfortable.

Your doctor will also check for physical abnormalities such as Peyronie's disease (a curved and painful erection caused by scar tissue in the penis). He will also check your history for previous injuries or surgery in the pelvic area which may have caused nerve damage.

TESTS YOU MAY BE ASKED TO TAKE

To confirm your diagnosis, other tests can detect hormonal abnormalities, determine blood flow problems, and may help to rule out psychological problems.

Blood tests and urine analysis

These tests are used to measure your hormone levels, cholesterol, and triglycerides (to detect hardening of the arteries), and liver and kidney function. To detect diabetes mellitus a blood glucose test may also be requested.

Penile blood flow studies

Additional tests may be conducted to determine how effectively blood flows into the penis. Another test involves an injection with a drug that increases penile flow, bypassing your penile nerves. If the blood vessels of your penis are healthy, this injection will produce an erection.

Sleep monitoring

During the dream portion of sleep, most men experience at least 3 to 4 erections. An absence of nighttime erections may indicate that the nerve or blood supply to your penis is inadequate for erections. Your doctor may ask you to monitor nocturnal erections at home with a simple test.

PHYSICAL CAUSES CAN BE TREATED

Depending on your diagnosis, your recommended treatment may be medical or surgical. Medical treatments range from simply changing your prescription drugs to hormone replacement therapy, antidepressant therapy, and devices or self-injection therapy to produce erections. Surgical treatments include vascular surgery or implants. Your urologist will discuss options that may be appropriate in treating your impotence, as well as the risks and benefits of each option.

MEDICATION

Changing prescription medications or their dosages may change the side effects which may be causing your impotence. Hormone replacement therapy may be recommended if you have a hormone deficiency. Antidepressant drugs may be the first course of treatment if you've been diagnosed with severe clinical depression. Do not change medications without your doctor's permission.

VACUUM ERECTION DEVICES

These devices, applied to the penis externally, draw blood into the penis and keep it there by using a constriction band (rubber band) that his placed around the base of the penis.

INJECTIONS

Injecting medications directly into the penis prior to intercourse can also produce an erection. If you and your doctor choose this option, you will be taught how to administer the injections yourself.

VASCULAR SURGERY

For a few men, vascular surgery may be indicated to improve penile blood flow. Leaking veins may be surgically repaired. In cases where arterial blockage is reducing blood flow to the penis, an arterial bypass may be recommended.

SURGICAL IMPLANTS

Penile implants, or prostheses, may be a longer term option for a significant number of impotent men, especially those who've tried psychological and other medical treatments without success. Implants have helped over 250,000 men return to an active sex life, and many studies show high satisfaction with the results among most patients and their partners.

All implants are concealed entirely within the body and require manipulation before intercourse to make the penis erect, and afterwards to place it in a relaxed position or to make it flaccid.

There are several types of implants to choose from. Differences include manner of operation, naturalness of the erection, and the number of components implanted. In choosing a penile prosthesis you should consider the manual dexterity that is needed to operate the device.

Before deciding on a penile prosthesis, you should consult with your urologist about the physical, psychological, cosmetic, and functional outcome of the implantation surgery. You should be sure that you understand the risks and benefits of the surgery.

There are certain instances when your physician may decide that a surgical implant is not an appropriate choice for you: risks associated with surgery; your medical history; satisfaction with a less invasive treatment option; if you choose not to be implanted with a silicone elastomer device; or if you want to preserve the possibility of latent erectile capability.

In addition to discussions with your doctor, you may want to discuss the options available with your partner.

WHAT TO EXPECT DURING IMPLANT SURGERY

Implantation of a penile prosthesis involves a surgical procedure usually lasting from 30 minutes to 2 hours. The length of your hospital stay depends on your physical condition and the type of prosthesis chosen. In some cases you may be able to return home the same day, and return to work in just a few days.

Your doctor should be able to give you a thorough explanation of what will happen during your hospital stay and, specifically, during the surgical procedure. In general, the procedure begins with some preoperative tests, which may include blood tests, urine alysis, and delivery of antibiotics. If you receive a general anesthetic, you will be asked to abstain from food or drink for 12 hours before surgery. There are three types of incisions: infrapubic (in the abdomen above the penis), penile (in the shaft of the penis), or scrotal (in the scrotum below the penis).

You will experience pain at the operative sites during the post-implantation period and during periods of initial use. In most cases the pain subsides within a few weeks of surgery; however, cases of chronic pain have been reported.

Recovery times vary from patient to patient. Most men will probably be able to resume everyday activities six weeks after surgery. Your urologist will talk to you about when you will be able to use your device. You will also have several post operative visits, and annual or semi-annual follow-up visits with your urologist thereafter. During this recovery time and after, take care to avoid trauma to the pelvic or abdominal area. Trauma may damage the prosthesis or surrounding tissues.

Implant surgery carries the same types of risks that every surgical procedure involves, including that of infection and those associated with anesthesia. In addition, the outcome of your implant surgery may be unsuccessful. For example, the device may fail to function as intended, which may lead to additional surgery to remove or replace the prosthesis. If the prosthesis must be removed, reimplantation of a new prosthesis may be complicated by the amount of time between the two surgeries. Discuss these possibilities with your urologist.

PENILE PROSTHESES AND HOW THEY WORK

Because each type of prostheses offers unique feature, you will want to discuss the choices with your urologist. The best choice of penile prosthesis for you will depend upon your medical condition, your lifestyle and, possibly, the cost of each prosthesis.

Your urologist can help you and your partner learn to use the prosthesis correctly.

MALLEABLE PROSTHESIS

A malleable prosthesis consists of two rods that are inserted into the shaft, or corpora cavernosa, of the penis. The rods may either be positioned up for intercourse or down for everyday activities.

To prepare for intercourse, you must lift the penis, making the rods as straight as possible.

To better conceal the erection during everyday activities, the prosthesis must be bent down. It can be bent in more than one place to fit more comfortabley around the scrotum.

Advantages:

• Easy for you and your partner to use.
• Generally, the simplest operative procedure.
• May be the best option for men with limited dexterity.
• Fewer mechanical parts.
• Same-day surgery usually possible.
• It is the least expensive type of prosthesis.

Disadvantages:

• Your penis will always be rigid, though it is generally not noticeable under most types of clothing.
• Penis may not feel as natural when erect or flaccid as with other implants.

SELF-CONTAINED INFLATABLE PROSTHESIS

Two cylinders are implanted within the corpora cavernosa of the penis. The cylinders contain sterile saline fluid which moves within them to make the penis stiffer and softer and allows you to control your erection.

To get an erection you must squeeze and release the front of each cylinder (which will be in the glans of the penis) in a pumping action. This forces the fluid out of the reservoir (located on the opposite end of the cylinder) and into the shaft of the cylinder, making the penis erect.

To make the penis softer again, simply bend the penis down, hold for several seconds, and release. This forces the fluid back into the reservoir.

Advantages:

• Fewer components than two-piece or three-piece inflatable devices.
• Erection feels more natural than that of a malleable rod prosthesis.
• Easier to conceal when flaccid than a malleable rod prosthesis.

Disadvantages:

• Erection may not feel as natural as two-piece or three-piece inflatable prosthetic erection.
• Possibility of mechanical malfunction, including fluid leaks or clogs.
• Not as flaccid as a two-piece or three-piece inflatable prosthetic erection.
• Possibility of inadvertent erections exists.

TWO-PIECE INFLATABLE PROSTHESIS

This prosthesis consists of two components connected by tubing: a pair of cylinders and a single pump bulb. The pump is implanted in the scrotum and the cylinders are implanted in the corpora cavernosa. The device is filled with saline solution.

To get an erection you squeeze and release the pump several times. This transfers fluid from the reservoir (located at the end of each cylinder) to the cylinder shaft, making the penis stiffer.

To relax the penis, you bend the cylinders down and hold them in this position for six to twelve seconds. This transfers the fluid back into the reservoir.

Advantages:

• Small inflation pump provides comfort and ease of use.
• Easier to conceal than a malleable or self contained device.
• Fast and easy one-step deflation procedure.
• Fewer components than a three-piece inflatable device may allow for same-day surgery.

Disadvantages:

• Requires some manual dexterity to inflate
• Possibility of leakage, clogs, or device malfunction exists.
• Contains more mechanical components than a malleable or a self-contained prosthesis.

THREE-PIECE INFLATABLE PROSTHESIS

This prosthesis consists of three components which are connected by tubing: a reservoir, two cylinders, and a pump. The reservoir is implanted under the abdominal muscles and is filled with sterile saline solution. The cylinders are inserted into the corpora cavernosa. The pump is placed in the scrotum.

To get an erection you must squeeze the soft bulb portion of the pump several times. This forces fluid out of the reservoir and into the cylinders, making the penis stiffer.

To relax the penis, press the "deflation site" on the pump, which moves the fluid back into the reservoir.

Advantages:

• Most closely approximates the process and feel of a natural erection.
• Cylinders expand in girth.
• When inflated, it feels more firm and more full than other prosthetic erections.
• When deflated, it feels softer and more flaccid, and is more easily concealed than other prosthetic erections.

Disadvantages:

• Requires some manual dexterity to operate.
• Contains more mechanical components than other prostheses.
• Possibility of leakage, clogs, or device malfunction exists.
• Possibility of inadvertent erections exists.
• It is the most expensive type of prosthesis.

How safe are silicone elastomer prostheses?

Some penile prostheses are made of solid silicone elastomers (a type of rubber) but do not contain silicone gels. Silicone elastomers have been commonly used in a variety of biomedical devices for over 40 years. They are used as a biocompatability reference which new materials are tested against. Flourosilicone, a silicone fluid is used as a lubricant between internal silicone and fabric layers in the cylinder to reduce abrasion. Silicone fluids have an extensive history of use in medical devices, such as syringe lubrication.

Scientific literature has included reports of adverse events in patients with implantable silicone devices. These adverse events, as reported, indicate allergic-like reactions or autoimmune-like symptoms. No casual relationship has been established between these events and silicone elastomer.

Will my prosthesis have to be replaced?

It is not feasible to predict how long an implanted penile prosthesis will function in a particular patient. As with any biomedical prosthesis, penile prostheses are subject to wear and eventual failure over time. Other causes can lead to malfunctions of the prosthesis which occur more quickly. Discuss any changes you notice in the function of the prosthesis with your doctor.

Product wear or other mechanical problems, such as unintended inflation or deflation, or difficulty or inability to inflate or deflate may lead to additional surgery to remove or replace the device.

Am I Impotent?

If, after reading this information, you are still questioning whether or not you are impotent and what the cause may be, the following questions may indicate whether you should consult a urologist. In general, if you answer "yes" to any of the first six questions, you should see a urologist who specializes in the treatment of impotence.

If your current doctor does not regularly treat impotence problems, you might ask for a referral to a urologist who specializes in the diagnosis and treatment of impotence.

When you see the urologist, share the answers from the self-test. The information will be valuable to the doctor as he or she determines diagnosis.

Most importantly, you should know that persistent impotence is not a problem that you should have to live with, or that will just go away. It's important to make a medical appointment as soon as the problem becomes apparent, in order to avoid the psychological problems which may make it worse. Remember, impotence can be treated in almost every case.

TAKE AN IMPOTENCE SELF-TEST

Current Sexual Performance

1. Have you had any difficulty recently in achieving erections?
2. Does this problem occur at least three out of every four times that you attempt intercourse?

Sexual Performance Trends

1. Have you been having difficulty for longer than one month in achieving erections regularly?
2. Are morning and spontaneous erections becoming less common?
3. Does it take much longer to achieve an erection than in the past?
4. Has it become more difficult to have intercourse in certain sexual positions?

Medical History

1. Have you ever been told you have any form of heart disease, especially hardening of the arteries, peripheral arterial disease (PAD) or hypertension?
2. Have you ever had an operation for heart disease or some other cardiovascular problem?
3. Have you ever been told you have an elevated cholesterol level?
4. Do you ever experience serious pain in the legs when walking?
5. Are you taking any form of drug for a cardiovascular problem, especially hypertension?
6. Are you taking drugs on a prescription basis for any other problem?
7. Do you have any known glandular disorder, especially diabetes?
8. Do you have any neurological disorder, such as multiple sclerosis or epilepsy?
9. Have you every had major surgery in the pelvic area, especially surgery involving the prostate gland or colon?
10. Have you ever had an injury involving the pelvic area, back, spinal cord, or head?
11. Have you ever been treated with radiation therapy for a problem in the pelvic area?
12. Have you ever had an episode of priapism (persistent and painful erection)?

Lifestyle

1. Do you now smoke or did you once smoke for a long period of time?
2. Are you a heavy drinker or a diagnosed alcoholic?
3. Have you used illegal drugs, especially cocaine?
4. Are you a frequent user of non-prescription drugs?
5. Are you excessively overweight?

If you would like more information on this topic, please contact us.

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