Male Impotence or Erectile Dysfunction
Erectile Dysfunction (ED), sometimes called impotence is a repeated inability to achieve or keep an erection firm enough for sexual intercourse. The word impotence may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as a lack of sexual desires and problems with ejaculation and orgasm but the term Erectile Dysfunction is more precise because it refers only to erection problems. Men with erection problems often retain other sexual functions. For example, they may have sexual desire and may still be able to have orgasms and ejaculate semen.
It is estimated that about thirty million men in the United States experience chronic erectile dysfunction. Studies show that about half of the men between the ages of 40 and 70 have ED to some degree. Until recently, there was only a little choice of treatment in cases of diminished erection or impotence. Fortunately, times have changed. Due to the fact that research has been successful over the years, men may now be treated for this problem. Possible therapies include medications, injections, sexual counseling and surgery. Most erection disorders are caused by a combination of physical and psychological problems. Urologists who have traditionally treated erectile dysfunction.
ANATOMY OF THE PENIS
The penis contains two chambers called the corpora cavernosa, which run the length of the organ. 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 tissue, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa.
HOW IS THE PENILE ERECTION ACHIEVED?
The physiological process of an erection begins in the brain and involves the nervous and vascular systems. The brain, for example, is where sensation of sexual arousal is experienced. The brain sends its arousal signal to the penile nerves. Nerves play and important role in achieving erections. Nerves are the pathways from the brain and spinal cord to the penis and are involved in releasing chemicals called neurotransmitters. The nerve impulses go to the two erection chambers, the corpora cavernosa. The corpora cavernosa are two cylinders side by side in the penis. Covering them is a dense, elastic fibrous envelope called the tunica albuginea. There, the nerve impulses cause relaxation of penile tissue and expanding of arterial blood supplies. As the penile tissue relaxes and penile arteries expand, the blood flow into the erection chambers increases. The penis then swells in size. Veins that drain the blood are compressed against the inner wall of the tunica albuginea. The blood is thus trapped, making the penis hard and erect. Continued stimulation keeps the process going and maintains an erection. When stimulation ends or following ejaculation, pressure in the penis decreases, blood is released, and the penis resumes its normal shape.
TYPES OF ERECTILE DYSFUNCTION
There are different levels of erectile dysfunction. One is when the penis does not harden enough or at all. The second type is when the penis does get somewhat erect, but not hard enough to allow intercourse. The third possibility is that the penis does not get erect normally,but then softens again too quickly.
WHAT CAUSES ERECTILE DYSFUNCTION?
Since an erection is caused by a precise sequence of events, erectile dysfunction can occur when any of the events is disrupted. Very often, an erectile problem will have more than one cause. The causes may be psychological or physical, or a combination of both. Distinguishing between psychological and physical causes is helpful because treatment may differ depending on the cause. Today, experts believe that 80-90% of all erectile dysfunction cases may be due to physical conditions with psychological factors accounting for the remaining 10-20%. In many cases, however, there are both psychological and physical reasons for the condition.
CAUSES OF ERECTILE DYSFUNCTION
There are many classification systems for the causes of ED. The easiest is to categorize the causes as physical, psychological, neurological, vascular and other. Reduced blood flow to the penis and nerve damage is the most common causes of erectile dysfunction. Underlying causes include the following: vascular disease, diabetes, drugs, hormone imbalance, neurological causes, pelvic trauma in surgery, Peyronie's disease, and venous leak.
Vascular Disease: Vascular disease is the predominant cause of erection problems. Low blood flow in and around the heart may cause a cardiac infarct, the same problem in the brain may cause a stroke, and in the penis it causes erection problems. Another cause of erection trouble may be the venous leak. If the veins that drain blood from the cavernous bodies in the penis do not sufficiently close during erection, it causes blood and pressure to leak out of the penis, which in turn will make it impossible to build up enough blood pressure in the cavernous bodies for sufficient erection.
Diabetes: Diabetes is a major cause of erection problem. Between 35 and 50% of men with diabetes experience erectile dysfunction and 50% of all diabetic men become impotent after age 50. The disease can damage blood vessels and nerve tissues. Both may have an effect on erection. High levels of blood sugar associated with diabetes often damage small blood vessels and nerves throughout the body, which can impair nerve impulses and blood flow necessary for erection.
Other: Drugs and vices, like drinking alcohol or smoking, may damage the nerves and blood supply needed for normal erection. There are over 200 prescription drugs that may cause or contribute to impotence, including drugs for high blood pressure, heart medication, antidepressants, tranquilizers and sedatives.
Hormonal Imbalance: Testosterone deficiency can result in a loss of libido (sexual desire) and a loss of erection. Low testosterone account for 1% of ED. High production of prolactin and high or low thyroid hormone levels (hyperthyroidism or hypothyroidism, may add to a low testosterone production and thus, cause a lower libido. Hormonal imbalances can also occur as a result of kidney or liver disease.
Neurological Causes: Multiple sclerosis, Parkinson's disease, and spinal cord injuries are among those that may lead to loss of potency. Spinal cord and brain injuries can cause impotence because they interrupt the transfer of nerve impulses from the brain to the penis.
Pelvic Trauma in Surgery: Surgery of the colon, prostate, bladder, or rectum, may damage the nerves and blood vessels involved in erection. Surgeries, especially the radical prostate surgery for cancer, can injure nerves and arteries near the penis, causing erectile dysfunction. Injury to the penis, spinal cord, prostate, bladder, and pelvis, can lead to erectile dysfunction by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa. Removal of the prostate or bladder often results in impotence. There are some new nerve-sparing techniques aimed at lowering the incidence of impotence from 40% to 60% are now being developed and used in these surgeries. To read more about the da Vinci Robotic surgery for prostate cancer removal click here.
Peyronie's Disease: Peyronie's disease is an inflammatory condition that causes scarring of the erectile tissue. The French surgeon Francois de la Peyronie first described it in 1743. It is estimated that up to 1-4% of all men may have some form of it. The scar tissue, or Peyronie's plaque, forms in the wall of the tissue that surrounds the corpus cavernosum. This is the structure that fills with blood to create a normal erection. When the plaque is large enough it may interfere with the ability of the muscles within the corpora to compress the veins that drain the penis during an erection. Therefore blood leaks from the penis back into the general circulation, making it impossible to maintain an erection. The penis is curved. Most cases occur between 40-70 years of age but it can develop at any time. The cause of Peyronie's disease is unknown, although trauma to the penis has been implicated. This curvature can be so severe that it prevents intercourse.
Psychological Causes: Though the physical reasons for ED are many, once a man has difficulty with erections, psychological factors often become a factor. Men who experience a sudden loss of erectile capability often have a psychological origin to their condition. Just as an erection can result from thinking about sex, negative thoughts can prevent an erection from occurring. In addition, depression and other psychological problems can affect both erections and sexual drive. Typically, patients whose erectile dysfunction is primarily psychological in nature continue to have erections while they sleep or when they get up in the morning. Psychological causes of impotence can include stress or anxiety from home or work, worry about poor sexual performance, marital problems, unresolved sexual orientation and depression. Psychological factors in impotence are often secondary to physical causes, but they magnify their significance.
WHICH DOCTORS TREAT E.D.?
As a group, urologists are the most knowledgeable about erectile dysfunction. Urologists regularly diagnose and treat the condition and who stay up to date on the latest ED research and treatments. Many psychiatrists and psychologists also treat the condition. It is very important that medical professionals discuss the pros and cons of all treatment options with their patients.
FINDING THE CAUSE OF ERECTILE DYSFUNCTION
Medical History: The first visit with start with an extensive medical history, including psychological and sexual aspects of your life. Remember, there are many potential causes for impotency, and most of these are identified in a detailed history. The doctor will also interview the patient for possible risk factors. The doctor will ask questions about stress and fatigue and the relationship between you and your partner. This will probably include questions of a personal nature, but they are necessary to get an overview of your whole sex life. Further information obtained regarding lifestyle issues such as smoking and illicit drug use may affect the man's ability to obtain an erection, and this information is equally as important. The doctor will also make sure to ask questions about any contributing factors to your erection problems, like diabetes, alcohol abuse, medications, etc. Once a medical history is complete, a physical exam will follow.
Physical exam: A physical exam is straightforward and can give clues to systemic problems. For example, if the penis is not sensitive to touching, a problem in the nervous system may be a cause. Abnormal secondary sex characteristics, such as hair patterns, can point to hormonal problems, which can mean that the endocrine system is involved. The examiner might discover a circulatory problem by observing decrease pulses in wrists and ankle. An unusual characteristic of the penis itself could suggest a source of the problem. For example, a penis that bends or curves when erect could be the result of Peyronie's disease. The physician may also do a rectal exam to check the condition of the prostate and also feel the thyroid gland.
Laboratory: Blood tests can indicate conditions that interfere with normal erectile function. These tests measure hormonal levels, such as testosterone, cholesterol, blood sugar (diabetes), liver and kidney function, and thyroid function. As mentioned early, excessive prolactin can lower testosterone levels, which can diminish libido. A urinalysis may be ordered to rule out bladder infections. If necessary, additional special tests may be conducted.
A high frequency sound wave (ultrasound) is used to check the condition of the penile arteries. Ultrasound is used to evaluate blood flow, venous leaks, signs of atherosclerosis, and scarring or calcification of the erectile tissue. Another test is observing the response to drugs that normally stimulate an erection when injected into the penis. Erection is induced by injecting prostaglandin, a hormone-like stimulator produced in the body. Ultrasound is then used to see vascular dilatation and measure the penile pressure, which may also be measured with a special cuff. Measurements are compared to those taken when the penis is flaccid.
The Nocturnal Penile Tumescence (NPT) test, the patient attaches a pair of special guages to his penis before going to sleep. Normally, men of all ages have erections during the dreaming (rapid eye movement) stages of their sleep. The NPT test measures those erections. If no nocturnal erection occurs, or if the erection is impaired, the causes of Erectile dysfunction are likely to be physical. By contrast, a normal NPT in a man with erectile dysfunction suggests a psychological cause. Many of these test were previously done in centers and cost about $1000.00-$4000.00 per night. The patient would be required to stay three to four nights to get the best results. For a more reasonable cost, monitors that check erections of men sleeping at home are now available. One of these is the Rigiscan® a small take home computer.
The ultimate test for the arteries of the penis is arteriography. A radiologist places a small tube in the femoral artery in the upper thigh, then finds the artery that goes to the penis (pudendal artery) and injects contrast dye to show blockages in the penile arteries. A physician performs this test only when considering surgery to unblock the artery or bypass a blockage, usually on young men with a previous history of trauma to the penis.
Cavernosometry/Cavernosography: This is the definitive test for venous leak. In normal erection, the swelling of the penile tissue pinches off the veins to prevent blood from leaving the penis. With the condition called venous leak, the blood goes into the penis, then immediately leaks out of the veins. Cavernosometry evaluates if venous leakage occurs. Cavernosography is then performed to identify where the leak is. Physicians usually do this rare test only when they want to find the exact cause of impotency or fix the leak.
The known treatment options are from least invasive to most invasive. The therapy will be governed by the cause of the erection problem. Although some men will be found to have some psychogenic impotence and will be referred for counseling, most men will be found to have organic impotence or physical impotence, and at this point, we will review various treatment options.
Oral Medications: Three common oral medications used to treat erectile dysfunction are Sildenafil (Viagra®), Vardenafil (Lavetra®), Tadalafil (Cialis®), also known as PDE-5 inhibitors. The Yohimbine tree, was the only one available showing to have some effect in some men, although scientifically speaking, the effect was never considered proven. It is still used especially if a psychological problem is suspected to enhance libido and sexual desire. More recently, PDE-5 inhibitors were introduced in 1998. PDE-5 inhibitors acts by narrowing the exit of the blood from the cavernous bodies, thus enhancing erection. It is shown to work in 70 to 80% of men with erection problems. PDE-5 inhibitors have helped men with erectile dysfunction associated with diabetes, spinal cord injury, and radical prostatectomy. A word of caution about PDE-5 inhibitors. They amplify the effects of Nitrate medication, used by many patients with heart problems, and as a result, the combination of PDE-5 inhibitors and Nitrates may prove hazardous to the heart. Therefore, check with your physician before taking this medication.
Another drug being tested is Uprima®, works on the brain and nervous system to trigger an erection. Oral testosterone can reduce erectile dysfunction in some men with low levels of natural testosterone, but is often ineffective and may cause liver damage.
Self-injections: This therapy is a great example of how understanding the basic science of erections has helped us develop new treatments for impotency. Injection involves using a short needle to inject medication through the side of the penis directly into the corpus cavernosum, which produces an erection that lasts from thirty minutes to several hours. Currently Commonly used medications are papverine, phentolamine, or prostagladinE1 (Caverject® and Edex®), and a combination of these. It causes vascular dilatation and a relaxation of smooth muscle. It produces similar results to Viagra, but is localized in the penis after injection. Injections are relatively painless and create an erection in five to fifteen minutes after the injection. It is recommended that self-injection be performed no more than once every 4-7 days. There is a small risk for Priapism, an erection that lasts for more than six hours and requires medical relief. Repeated injections may cause scarring of erectile tissue, which can further impair erection. Another medication, Phentolamin, is a heart medication with similar effects used by some physicians to treat impotence.
Urethral Suppositories: In 1997 a new product was introduced called MUSE®. It is somewhat less non-invasive form of medication for erectile dysfunction, which consists of a very small tablet to be introduced into the urethra while using a special tube-like device. This pre-filled applicator delivers a pellet about an inch deep into the urethra. An erection will begin within eight to ten minutes and may last thirty to sixty minutes. The pellet consists of prostaglandin E1 or alprostadil a hormone with a limited and largely unknown function, which is capable of narrowing the blood vessels, exciting the cavernous bodies. Absorbed into the corporal tissue, the medication helps the blood vessels to open and the penis to fill with blood causing an erection. Response rates are 20-50%.
Hormonal Treatment: Testosterone is the male hormone produced by the testis. Its primary effect is to maintain a high level of libido, or sexual drive, but it also has a smaller effect on the penis. This decrease in testosterone may cause a loss of sexual appetite and therefore, erection problems. In those cases, testosterone may be administered either by injection, tablets or skin pads. Less than 4% of men have a shortage of hormones and may benefit from this therapy. As with all forms of therapy, testosterone has its side effects. It can cause the prostate to swell in a way similar to having prostatic hypertrophy. In men with a diagnosis of prostatic cancer, testosterone will make the cancer grow more rapidly. So men using testosterone injections must have a PSA blood test and a rectal examination to check the prostate before therapy begins. Follow-up visits every six months are a must. Testosterone can also increase the number of blood cells produced, causing a thickening of the blood. This is easily diagnosed by drawing blood and checking the blood level in a test called a hematocrit.
Vacuum Erection Devices: Vacuum constrictive devices (VCD) have been around more than 10 years and constitutes initial, first line therapy for non-endocrine related organic erectile dysfunction. It has been a great advancement for patients with impotency. Virtually any man with erectile dysfunction can use it. Many VED's are on the market. Vacuum devices are external penile appliances that generate a negative pressure on the penis, thus creating an erection. The device causes a partial vacuum, which draws blood into the penis, engorging and expanding it. The Penis is removed from the tube and a soft, rubber ring is placed around the base of the penis to trap the blood and maintain the erection until it is removed. The ring can be left in place for about 25 to 30 minutes. Vacuum devices can work best in men who are able to achieve partial erection on their own. They are easy to use at home, require no other procedure, and typically improve erections regardless of the cause of impotence. One variation of the vacuum device involves the semi-rigid rubber sheath that is placed on the penis and remains there after erection is attained and during intercourse. The pressure rings may also be used on their own, in cases where sustaining an erection is the problem. In those cases, the ring is placed at the base of the penis when the erection is complete, making sure that the blood will not be able to flow out and keeping the penis rigid. Like the vacuum therapy, the ring may remain in place for thirty minutes. It is important for safety to use only a prescription vacuum device in which all parts including the pump and the elastic constriction band are made by a reputable manufacturer. Individualized instruction in its proper use is necessary for the best results. The primary advantage of this non-invasive treatment is that firm erections are possible up to 98% of impotent men.
Surgical Option: Surgical therapy for erectile dysfunction consists mainly of the penile prostheses. Although both semi-rigid and inflatable devices are available, most men choose an inflatable prosthesis because it results in a much more normal looking penis in both the flaccid and erect state. Prosthesis does not change the ability to urinate, ejaculate, or have an orgasm. Surgery is necessary to implant the devices. The cylinders are placed inside the cavernous bodies and will take over their function in erection. It will usually take 4-6 weeks before normal intercourse is possible. The surgery will permanently damage the cavernous bodies and should be regarded as a last resort.
There are two basis types of prostheses.
The simpler type is the semi-rigid, but malleable cylinder. The other type is inflated with fluid to make the penis stiff. Though prostheses require surgery, they usually perform well and their satisfaction rate is high. To learn more about penile prosthetics click here.
Vascular Surgery: Vascular surgery may consist of constructing a bypass as in heart surgery to improve the blood flow toward the penis. This involves microsurgery. Nowadays, this kind of surgery is rarely done because less than 1% of the men may benefit, and the failure rate is very high. In men where venous leakage is a major contributing factor in the erection disorder, it may then be an option to try to locate the vein that is causing the leak and closing it using a suture. In many cases, however, there is not just one vein responsible, but many, causing the surgery to fail after some time when the other blood vessels start leaking as much as the sutured one did before. Surgery to repair arteries can reduce erectile dysfunction caused by obstructions that block the flow of blood. The best candidates for such surgeries are young men with discrete blockage of an artery because of an injury to the perineum or fracture of the pelvis. The procedure is less successful in older men with widespread blockage.
Sex Therapy: A significant number of men develop impotence from psychological causes that can be overcome. Therapy consists of sessions in which a psychotherapist will try to help the patient and/or his partner to understand what the problem is, identify stress factors, and to deal with them. Experts often treat psychologically based erectile dysfunction using techniques that decrease the anxiety associated with the intercourse. The patient's partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques can also help relieve anxiety when erectile dysfunction from physical causes is being treated. Psychological therapy may be effective in conjunction with medical or surgical treatment.
THE BOTTOM LINE
A satisfactory treatment for some patients may be unsatisfactory for others. It has its own set of advantages and disadvantages. In addition, each patient has his own preferences. On the basis of individual preferences, patients may weigh treatment advantages and disadvantages quite differently in making a choice. In addition to the advantages and disadvantages, cost and loss of time from work or other activities may be considerations in choosing a treatment. There is hope through research. Advances in oral medication, suppositories, injectable medications, implants and vacuum devices have expanded the options for men seeking treatment for erectile dysfunction. These advantages have also helped to increase the number of men seeking treatment. The good news for many men and their partners is that erectile dysfunction can be treated safely and effectively. In light of recent medical advances, men no longer need to suffer from erectile dysfunction in silence, nor must their impotency be a driving force in their relationship. Most importantly, couples can now fully enjoy the enriching and exhilarating joy of intimate sexual contact. The key to regaining long-term sexual function is to trust and open communication between the motivated man and his supportive partner. Success also requires the knowledgeable and caring healthcare professional; one who understands both the physical and psychological impact of the condition on both the patient and his partner. With teamwork, communication, and a mutual commitment to regaining sexual function, many couples can experience renewed passion and excitement in their physical and emotional relationship.
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