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Impotence and Erectile Dysfunction - The Safe And Easy Treatment
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Impotence
Overview
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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
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
(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.
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 (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
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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National
Kidney and Urologic Diseases Information Clearinghouse
3
Information Way
Bethesda, MD 20892-3580
E-mail: National Kidney
and Urologic Diseases Information Clearinghouse
The
National Kidney and Urologic Diseases Information
Clearinghouse (NKUDIC) is a service of the National
Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK). The NIDDK is part of the National
Institutes of Health under the U.S. Public Health
Service. Established in 1987, the clearinghouse
provides information about diseases of the kidneys
and urologic system to people with kidney and
urologic disorders and to their families, health
care professionals, and the public. NKUDIC answers
inquiries; develops, reviews, and distributes
publications; and works closely with professional
and patient organizations and Government agencies
to coordinate resources about kidney and urologic
diseases.
Publications
produced by the clearinghouse are carefully reviewed
for scientific accuracy, content, and readability.
This
e-text is not copyrighted. The clearinghouse encourages
users of this e-pub to duplicate and distribute
as many copies as desired.
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NIH
Publication No. 95-3923
September 1995 e-text
last updated: August 2000 |
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