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Impotence

Types, Causes and Treatment

By Dr. Wasim

Impotence or Erectile Dysfunction is the inability to achieve an erection, and/or dissatisfaction with the size, rigidity, and/or duration of erections. It affects 10-15 percent of all males and can be emotionally and psychologically disabling for men and their partners. In the past it was commonly believed to be due to psychological problems. It is now known that in 80% of erectile dysfunction cases, physical factors such as drugs, blood flow abnormalities, nerve impulse abnormalities or hormonal abnormalities are the major causes. Psychological factors account for the remaining cases and may be attributed to stress, performance anxiety and misinformation about sexuality. It can cause emotional strain between couples. Many times, men will avoid sexual situations due to their emotional pain associated with erectile dysfunction, causing their partner to feel rejected or inadequate. Some couples consider seeking treatment for this disease together, while other men prefer to seek treatment without their partner’s knowledge. A lack of communication is the primary barrier for seeking treatment, and can prolong the suffering. The loss of erectile capacity can have a profound effect on a man. The good news is that erectile dysfunction can usually be treated safely and effectively. According to the National Institutes of Health, erectile dysfunction is a symptom in many disorders and diseases

TYPES AND CAUSES

The following are some of the different types and possible causes of impotence:
1. Premature Ejaculation (PE)

Premature ejaculation is the inability to maintain an erection long enough for mutual satisfaction. Premature ejaculation is divided into primary and secondary forms:
   (i) Primary   premature       ejaculation
Primary premature ejaculation is a learned behavior that begins when a male first become sexually active. Like any learned behaviors, it can be unlearned. This form of Primary Ejaculation is psychogenic (as opposed to organic or physical) impotence.
   (ii) Secondary          premature       ejaculation
Secondary premature ejaculation occurs when, after years of normal ejaculation, the duration of intercourse grows progressively shorter. Secondary PE is due to physical causes, usually involving the penile arteries, veins, or both.

2. Performance Anxiety

Performance anxiety is a form of psychogenic impotence - usually caused by stress or anxiety.

3. Depression

Depression is another cause of psychogenic impotence. Some antidepressant medications cause erectile failure.

4. Organic Impotence

Organic impotence involves the penile arteries, veins, or both, and is the most common cause of impotence, especially in older men. When the problem is arterial, it is usually caused by arteriosclerosis, or hardening of the arteries, although trauma to the arteries may be the cause. The controllable risk factors for arteriosclerosis - being overweight, lack of exercise, high cholesterol, high blood pressure, and cigarette smoking - can cause erectile failure often before progressing to affect the heart. Many experts believe that when veins are the cause, a venous leak or "cavernosal failure" is the most common vascular problem.

5. Diabetes

Impotence is common in persons with diabetes. The process involves premature and unusually severe hardening of the arteries. Peripheral neuropathy, with involvement of the nerves controlling erections, is commonly seen in persons with diabetes.

6. Neurological Cause

There are many neurological (nerve problems) causes for impotence. Diabetes, chronic alcoholism, multiple sclerosis, heavy metal poisoning, spinal cord and nerve injuries, and nerve damage from pelvic operations can cause erectile dysfunction.

7. Drug Induced Impotence

A great variety of prescription drugs, such as blood pressure medications, anti-anxiety and antidepressant medications, glaucoma eye drops, and cancer chemotherapy agents are just some of the many medications associated with impotence.

8. Hormone Induced Impotence

Hormonal abnormalities such as increased prolactin (a hormone produced by the anterior pituitary gland), steroid abuse by body-builders, too much or too little thyroid hormone, and hormones administered for prostate cancer may cause impotence. Rarely is low testosterone responsible for impotence.

RISK FACTORS

Direct risk factors for erectile dysfunction may include the following:

1. Type-II diabetes

2. Hypertension (high blood pressure)

3. Prostate Problems

4. Depression

5. Alcohol ingestion

6. Lack of sexual knowledge

7. Poor sexual techniques

8. Inadequate interpersonal  relationships

9. High levels of blood cholesterol

10. Smoking, which accentuates the effects of other risk factors such as vascular disease or hypertension?

11. Hypogonadism in association with a number of endocrinological conditions

12. Vascular disease and vascular surgery

13. Low levels of HDL (high-density lipoprotein)

14. Drugs

15. Neurogenic Disorders

16. Peyronie's Disease (distortion or curvature of the penis)

17. Priapism (inflammation of the penis)

18. Many   chronic diseases ,especially      renal     failure   and       dialysis

Age appears to be a strong indirect risk factor in which it is associated with increased likelihood of direct risk factors, some of which are listed above. It is estimated that nearly 5 percent of men become impotent by the age of 40, and 15 to 25 percent by the age of 65. Accurate risk factor identification and characterization are essential for prevention or treatment of erectile dysfunction.

DIAGNOSIS

1. Patient medical/sexual history

It may reveal conditions or diseases that lead to impotence and helps distinguish among problems with erection, ejaculation, orgasm, or sexual desire.

2. Physical examination

To look for evidence of systemic problems, such as the following:

(i) A problem in the nervous system may be involved if the penis does not respond as expected to certain touching.

(ii) Secondary sex characteristics, such as hair pattern, can point to hormonal problems, which involves the endocrine system.

(iii) Circulatory problems could be indicated by an aneurysm.

(iv) Unusual characteristics of the penis itself could suggest the basis of the impotence.

3. Laboratory tests

To help diagnose impotence include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. When low sexual desire is a symptom, measurement of testosterone in the blood can yield information about problems with the endocrine system.

4. Psychosocial examination

To help reveal psychological factors, the sexual partner also may be interviewed to determine expectations and perceptions encountered during sexual intercourse.

TREATMENT

Specific treatment for erectile dysfunction will be determined by the physician based on:

(i) Age, overall health, and medical history

(ii) Extent of the disease

(iii) Tolerance for specific medications, procedures, or therapies

(iv) Expectations for the course of the disease

(v) Individual opinion or preference

Some of the treatments available for erectile dysfunction include the following:

Nervine Tonic

Sildenafil citrate (ViagraTM) is the first approved non-surgical treatment for erectile dysfunction that does not have to be either injected or inserted directly into the penis to achieve and maintain erection. It was approved by the US Food and Drug Administration (FDA) for prescription sale at the end of March, 1998. Viagra does not directly cause penile erection, but affects the response to sexual stimulation.

Penile Injections

Prostaglandalins or Papaverine injections can be used to inject directly into the penis. There is also one pellet like  Prostaglandalins that can be inserted in the urethra and can result in erections.

Hormone Replacement Therapy

Testosterone replacement therapy may improve energy, mood, and bone density, increase muscle mass and weight, and heighten sexual interest in older men who may have deficient levels of testosterone. Testosterone supplementation is not recommended for men who have normal testosterone levels for their age group due to the risk of prostate enlargement and other side effects. Testosterone replacement therapy is available in an oral form and as a skin patch.

Penile Implants

There are three types of implants used to treat ED, including the following:

• Hydraulic pump - a pump and two cylinders are placed within the erection chambers of the penis which causes an erection by releasing a saline solution; it can also remove the solution to deflate the penis.

• Prosthesis - two semi-rigid but bendable rods are placed within the erection chambers of the penis which allows manipulation into an erect or non-erect position.

• Interlocking soft plastic blocks - these are placed within the erection chambers of the penis and can be inflated or deflated using a cable that passes through them. Infection is the most common cause of penile implant failure and is treatable with antibiotics. In some cases, the infected implant must be replaced by a new implant. Implants are usually not considered until other methods of treatment have been tried.

Dr. Wasim A.

Dept of Ilmul Advia, Mohammadia Tibbia College, Malegaon (MS) 

Dr. Khan N. A.

Dept of Ilmul Advia, Faculty of Unani Medicine, AMU, Aligarh (UP)

Dr. Azhar H.

Dept of Amraz-e-Niswan, Mohammadia Tibbia College, Malegaon (MS)

Dr. Intezar A.

Department of Hifzane Sehat, Mohammadia Tibbia College, Malegaon (MS)

Dr. Waseem can be reached at drwasim@gmail.com

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