Not many people are aware that in most cases physical rather than psychological causes are responsible for impotence (ED), and that ED is usually eminently curable.
exual impotence is perhaps the most poorly understood and mismanaged of all medical disorders. Two factors are responsible for this unfortunate state of affairs.
- Ignorance, myths, superstition, guilt and the stigma and taboo attached to anything sexual in the minds of the people.
- Abysmal sexual ignorance : on account of which people continue to believe that impotence is something that is largely psychological in origin.
These two factors explain why most cases of impotence do not come to light and why the few that do are grossly mismanaged. It is not surprising, therefore, that the general impression is that impotence is something largely incurable.
This is unfortunate because not only are most cases of impotence NOT psychological in origin but most are EMINENTLY CURABLE as well.
Impotence, or erectile dysfunction (ED, E.D.), as andrologists prefer to call it, has always been and continues to remain an extremely common disorder. It is said to afflict as much as 10 percent of the male population. Above the age of 40, nearly 52 % of men are affected. Despite this staggering incidence, few cases come to light.
Contrary to popular belief, impotence is almost never an 'all or none' phenomenon. Most laymen (and several doctors) believe that a man can either have an erection of very good quality or none at all. Nothing can be farther from the truth. Most men with erectile dysfunction have normal desire and can obtain an erection, only the erection is not hard enough or doesn't last long enough, Hence the term erectile dysfunction (which suggests partial loss) is preferred to impotence (which suggests a total loss). Not many are aware that in most cases organic rather than psychological causes are responsible.
|In as many as 80-90 percent of cases of chronic impotence, the cause is NOT in the mind but IN THE BODY.|
However, the trend is slowly but definitely changing. This is largely due to tremendous advances in andrological research over the past few years which have conclusively established that in as many as 80-90 percent of cases of chronic impotence, the cause is not in the mind but in the body. These causes can be identified using modern andrological investigative modalities, quantified and often successfully treated using totally non-psychological methods.
In an era where so many advances have been made in nearly all other branches of medicine, it is surprising that male reproductive system research has remained so woefully neglected and backward. For instance, the branch of obstetrics and gynecology (the female analogue of andrology) which deals with disorders of the female reproductive system has been with us for several decades now and is a well recognised specialty. In fact, so advanced is the understanding of the subject that today, in most countries, gynecologists restrict themselves to sub-specialty areas within their subject such as gynecological oncology, high-risk pregnancies, female infertility etc. because it is so difficult to keep pace with all the developments in the subject.
|A man's ego often does not permit him to admit that there is something wrong with his 'manhood'|
It may be of interest to our readers to deliberate in passing the reasons for this delayed understanding of the subject.
Clinical States associated with impotence
Impotent since birth
Impotence sets in after years of normal sex
Causes of Secondary Impotence
- Diabetes mellitus
- Hypertension (high blood pressure)
- Renal (kidney) failure
- Heart disease
- Neurological disorders - multiple sclerosis, stroke, paraplegia, spinal cord lesions, Parkinsonism, etc.
- Injuries - sudden - e.g. pelvic and perineal
- Injuries - gradual - as in bicycle-riders etc.
- Surgery-operations on bowel, rectum, bladder, rectroperitoneum, spine, urethra, prostate etc.
- Local e.g. Peyronie's disease
- Medication e.g. drugs administered for duodenal ulcer, hypertension, mental disease etc.
Two factors are predominant. The first of these is male chauvinism. Throughout human history, most of our societies have been patriarchal and male-dominated. Men's egos would not let them admit that there could be something wrong with their 'jewels of manhood'. Ironically, it is these very men who researched the female reproductive system and helped develop the branch of gynecology and obstetrics. But they refused to look into themselves.
The second reason is a misinterpretation of the teachings of Sigmund Freud. This led to the erroneous conclusion that most male sexual problems had their roots in the mind.
Whereas most branches of medicine have taken their roots from biology - the study beginning with an understanding of the anatomy(structure) and physiology(function) of that part, and proceeding to then figure out what happens when anatomy or physiology goes wrong thus causing disease (pathology), the male reproductive system alone took its roots from psychology rather than biology, thus causing tremendous damage.
This explains why most people know that it takes a complex concatenation of neuromuscular phenomena to lift a finger but fail to realize that equally complex phenomena are needed to lift the penis!! Most think that all that is needed for the latter event to occur is a naughty thought.
What then causes impotence(ED) ? Although ED (impotence) can afflict anyone from 13 to 90 and is associated with a wide variety of clinical conditions and disease states (see box above), the basic mechanisms causing impotence are only a few. All of these can be accurately identified using modern andrological investigative techniques.
Impotence can be of several types :
Where the arteries supplying blood to the penis do not bring in enough blood to cause an erection. This can occur because of a narrowing of the arteries such as occurs in the elderly, diabetics and those with high blood pressure or because of injury to the genital region which causes a block in the artery to the penis. The last is very common in the young. The injury can be major and sudden as after a vehicular accident causing a fracture of the pelvis or pubic bones, or low grade and gradual, as in bicycle and other riders, and occurs because sustained friction in that region causes a clot-like substance (thrombus) to develop in the artery to the penis. This clot gradually grows and ultimately blocks the blood supply to the penis completely.
|Today, it has been established that erectile dysfunction (ED) is a marker, a warning sign, for future cardiovascular diseases like heart attacks and strokes. Diseases of arteries affect the smaller arteries (penis) before they affect the larger ones (coronaries of the heart and carotids of the brain).
This makes a very strong case for the early diagnosis and management of ED, and this, in turn, will allow the early detection of diseases like diabetes, high blood pressure, high cholesterol, high lipids, etc..
|College student S.V.S., 23, became totally impotent following a vehicular accident in which he sustained a fracture of the pelvis and a rupture of the urethra. This involved hospitalisation for nearly a month and an operation.
Before the accident, he had had a normal sex life with his fiance. When he went back to the doctors who treated the primary problem, he was told that his was a purely psychological problem and that everything would be all right in a couple of months. A year later, there was still no improvement and he wanted to break his engagement. An article in a magazine brought him to an andrologist. A phalloarteriogram study showed that the main artery to the penis was blocked. The patient was finally cured with a microsurgical bypass operation - a penile revascularization procedure.
Arteriogenic impotence resulting from injuries is very common but often unsuspected because of ignorance of the causative conditions. Many such patients are to be found in orthopedic and urology wards. The impotence is often discovered much later, after the more obvious wounds and fractures have healed. Ironically, it is most often discovered by the patient himself and not by the doctor.
Where the veins of the penis leak blood and prevent the development of a rigid erection. In a normal man during full erection the veins close down almost completely and practically no blood flows out from the penis. This allows blood to accumulate in the sinusoids of the penis, thus raising pressure and allowing for the development of rigidity or hardness.
Venogenic impotence is extremely common. It is said to account for as much as 30-70 percent of all impotence. Some men have venogenic impotence from birth (primary). Such men have never had a rigid erection all their lives. Others develop venogenic impotence suddenly after years of normal sexuality (secondary).
The nerve supply to the penis is very complex. A proper conduction of impulses along these is basic for the initiation and maintenance of an erection. It is these nerves that activate the arteries and the veins and alter the dynamics of blood flow within them.
Many things can go wrong with the nerve supply to the penis. Injuries to the back, especially if they involve the vertebral column and the spinal cord can cause impotence. So also can injury to other nerves supplying the penis such as occurs after pelvic or perineal trauma. A wide variety of operations performed for other conditions can cause incidental injury to the nerves of the penis and cause impotence. These include operations on the rectum, prostate, urethra, spine, retroperitoneum, urinary bladder etc..
Of course, disorders of the nervous system such as multiple sclerosis, myelitis, tumour etc. are wont to cause impotence if they involve the nerve supply to the penis.
Another disease affecting the nerves to the penis is diabetes mellitus. Impotence is extremely common among diabetics. In fact, as many as 50 per cent of all diabetics are impotent. Impotence in diabetics is almost always organic in origin. Appropriate therapy for diabetes can never restore erectile function because the basic diabetic process can never be reversed. Only the blood sugar levels and the complications of diabetes are controlled. Modern andrology, however, can offer a cure to nearly all patients with diabetes-related impotence. This is another fact that is, unfortunately, not known to most people. Few diabetologists address erectile dysfunction (ED, impotence) in their patients.
|R.K., 47, a senior corporate executive married happily for 20 years with three children, complained of declining erections. Over the preceding six months, his erections had become so weak that he could not penetrate. He stopped trying three months ago.
He thought that this was due to his highly stressful lifestyle and pressures at the workplace. He even took a vacation with his wife hoping that this would improve matters. It only made them worse. His wife, at first very co-operative, eventually began to feel rejected and there was a palpable friction in their marriage.
When first seen at the Andromeda Andrology Center, R.K. was defensive. "How can this happen to a guy like me doc ? I could do it all night, several times a night, night after night. My family doctor says that this kind of thing is quite common these days and it's probably the stress".
It turned out that R.K. was a diabetic of 8 years' standing. He also had high blood pressure for which he was on beta blockers. He was obese (209 lbs - 175 cm) and smoked 40 cigarettes a day. He partied 7 days a week and drank quite heavily. He had never exercised in his life. Sadly, his family doctor had never connected any of these to his sexual problem.
Andrologic tests at Andromeda Andrology Center revealed that his overall rigidity levels were well below normal and that he had problems both with his arteries and his veins. He was eventually cured with an inflatable penile prosthesis implantation operation.
Many drugs also cause neurogenic impotence by affecting the neurotransmitters at the nerve endings. Notable among these are anti-hypertensives (BP lowering) and psychotropics. The list is very large. Often, it is not known that the medicine (which is prescribed for some unrelated disease, such as duodenal ulcer) is the culprit.
This occurs when there is an imbalance or insufficiency of sex hormones in the blood stream. It accounts for about 5 to 10 per cent of all organic impotence. Generally, hormonal changes affect the libido (or sex drive) rather than the quality of the erection per se. A variety of disease conditions can cause these changes.
|Endocrinologic (or hormonal) |
Sometimes, more than one factor can be operative in the same patient. Such patients generally have systemic disease. Notable examples are diabetes, kidney failure and liver failure.
|In recent years, a condition known as the andropause has been identified in men. Men in their middle age and beyond, are known to develop drops in their bioavailable levels of testosterone, resulting in a condition quite analogous to the menopause in women. The andropause is frequently associated with ED. More information about this condition is available on our andropause |
Another group where mixed factors operate is where long standing impotence has led to secondary psychiatric disorders such as depression etc.. Here, the basic causative factor is organic but being unrecognised and untreated (or maltreated) it eventually takes its toll on the mind, often because the patient thinks or has been led to believe that the condition is incurable and that it's all in his mind.
When there is no organic factor and the problem lies purely in the mind, it is labeled a case of psychogenic impotence. But before such hasty labeling it is necessary to prove by andrological investigation that no organic or bodily cause exists.
Only then can treatment proceed in a scientific and systematic manner.
| CURRENT TREATMENT OPTIONS FOR IMPOTENCE|
There are several treatment options for impotence. This is a very brief discussion on some of the options.
Counseling and sex therapy are sometimes effective in helping patients with minor sexual problems, especially when these are caused by sexual ignorance and psychological factors.
The introduction of Viagra by Pfizer in March, 1998,, marked the beginning of a revolution in the oral medical management of erectile dysfunction (ED, E.D., impotence). The launch of Viagra was soon followed by that of Levitra and Cialis. Other (even better) drugs are in the pipeline.
Effective oral medication has re-written the management of ED and is effective in nearly 70 - 75 % of cases. Several internet resources are available for more detailed information about these drugs and these will not be discussed in detail here.
Testosterone is the major male hormone that gives men their sexual characteristics (deep voice, beard, chest hair). As men age, their level of testosterone decreases (andropause) and this may have an adverse effect on sexual performance. In proven cases of andropause, testosterone preparations may enhance potency and improve sex drive. However, this therapy must be only offered under expert medical supervision because many side effects can occur. Other endocrine disorders causing low testosterone, elevated prolactin, and other abnormal hormonal states, will require specialist endocrinologist attention.
Vacuum therapy involves the use of an external vacuum device, and one or more tension rings. This therapy is purported to be effective for over 90% of the men who use it. In fact, most can technically master its use in one day, and can use it to maintain erections for up to 30 minutes, even after ejaculation and/or orgasm.
Hormone Replacement Therapy|
|K.M., 65, decided to remarry 8 years after his wife's death. He married a lady considerably younger and though he was not totally impotent, there was a major libido mismatch and he felt that he was not being fair to his wife. A vacuum device solved his problem. He has been using it satisfactorily for more than 2 years.|
Side effects, include petechiae (reddish, pinpoint-size dots) and ecchymoses (bruising). These conditions are not painful or serious and generally occur only during an initial learning period. Penile temperature may decrease 1-2 degrees during use. Vacuum devices are generally favoured by elderly patients with erectile dysfunction.
The need for the use of injections has declined enormously since the advent of orally effective drugs like Viagra for ED. Papaverine, phentolamine, prostaglandin E1, and combinations of these drugs may be self-injected into the penis with a fine, small gauge hypodermic needle. Men must first be taught the procedure in the physician's office. These drugs produce erections of good quality for about 75-85% of patients who select this option. Some patients combine this method with the use of an external vacuum device. Not too many injections are used nowadays.
|A Self-Injection Kit|
Erections obtained by injection usually last 30-60 minutes and may not subside when a man has an orgasm or ejaculates, and may interfere with the patient's social/business agenda. An overdose can cause a prolonged and painful erection that may require medical or surgical intervention. Frequent use may lead to the build-up of scar tissue in the penis, further complicating the process of erection.
A penile prosthesis (implant) is a fixed or mechanical device surgically implanted within the two corpora cavernosa of the penis, allowing erection as often as desired. Penile prosthetic implantation surgery gives good results and high satisfaction ratios with low complication rates when performed at centers of excellence. The incidence of side effects is low. Penile prostheses are available in semi-rigid, self-contained 2-piece inflatable, and 3-piece inflatable models. Newer advances in implant design have reduced the complication rates and increased satisfaction rates further.
Penile revascularisation and venous ligation are microsurgical procedures similar in technical complexity to a heart by-pass operation although they clearly do not carry anywhere near the same risk to the life of the patient. ! With the advent of oral drugs, the need for microsurgical intervention nowadays is not frequent. Some patients, however, will request a microsurgical cure rather than have silastic devices inserted into their penises. They would prefer that implantable penile prostheses be tried only as a last resort.
|How the Inflatable Penile Prosthesis works|
|The Chief Medical Consultant of Andromeda Andrology Center, Hyderabad, India, Dr.Sudhakar Krishnamurti, performing microsurgery on a patient||