All about male impotence: Causes and cures

Here is all that you ever wanted to know about sexual dysfunction in males -- causes, diagnosis and treatment.

Male impotence is also known as erectile dysfunction and is the lack of a person's physiological sexual ability. In this condition, a man suffers from the inability to develop or maintain an erection of the penis sufficient for satisfactory sexual performance. To understand the causes and reasons for impotence in males, it is necessary to understand the mechanism of the erection.

An erection occurs when blood enters the many spaces inside the penis; it may be understood as hydraulic action. The blood is then retained inside the penis to maintain the erection.

This process occurs as a result of sexual arousal, in which the signals are first transmitted from the brain to the nerves in the pelvis, through a complex procedure which controls the erection.

If it is difficult to achieve and maintain an erection regularly for several occasions, it is known as erectile dysfunction. As an erection is the result of a very complex procedure with several factors involved, the fault may lie in one or more of these factors.

Erectile dysfunction may be secondary to various medical conditions like cardiovascular diseases, diabetes, neurological diseases like trauma due to prostatectomy surgery, hormonal imbalances and due to various side effects from medication.

So one should keep in mind that it may be the result of some underlying health issue which could be dangerous, like heart disease and may need urgent attention.

Impotence can also be caused by lack of emotion or due to problems in a relationship. This type of impotence is termed as psychological impotence, as the erection fails to occur due to psychological reasons.

It has been proved that more than 90 percent of men fail to achieve/ maintain an erection at some stage in their lives, but on a few occasions only. If the erection fails to occur or hold multiple times or in succession, than the condition may be classified as erectile dysfunction.

If the cause of impotence is psychological, then placebo medication can have a dramatic effect on the condition. Most men benefit from the use of placebos. Some patients are advised PDE5 inhibitor drugs like sildenafil or Viagra, while in some cases intravenous, intracavernous and intraurethral drugs may also be injected.

Diagnosis of impotence

No particular tests are available to diagnose impotence, but blood tests are conducted to diagnose underlying problems such as obesity, thyroid level disturbances, heart diseases and other disorders like hypogonadism and decreased levels of growth and sex hormones. Generally, the diagnosis is by physical examination and is based on the symptoms.

Doctors can easily detect whether impotence is due to some organic reason or psychological problems. If a patient of erectile dysfunction has had previous erections which have not created any problems, then it is a case of psychological erectile dysfunction and the doctor will think along those grounds.

Investigations and tests to diagnose erectile dysfunction

Duplex ultrasound: It is used to evaluate blood flow, venous leaks, signs of atherosclerosis, and scarring or calcification of erectile tissue. By injecting prostaglandin, a stimulator produced in the body, an erection occurs. Then an ultrasound is used to see the vascular dilation and measure penile blood pressure. All the measurements are compared with flaccid penile state measurements.

Penile nerve function tests: These tests are used to determine if there is sufficient nerve sensation in the penis. The tests include bulbocavernous response. While squeezing the glans of the penis, contraction will be seen in the anus if the nerve functions are normal. Using this procedure, the doctor will examine if there is a delay in the two responses and will accordingly make some interpretations. Particular nerve tests are performed on patients with suspected nerve damage due to diabetes or other nerve disorders.

Nocturnal penile tumescence test: Normally a man has five to six erections while sleeping when in the rapid eye movement (REM) sleep phase. The absence of erection indicates a problem with nerve function or blood supply to the penis. Using the snap gauge and strain gauge technique, penile rigidity and circumference during nocturnal erection are measured and interpreted.

Penile biothesiometry test: Using electromagnetic vibration, sensitivity and nerve function in the glans and shaft of the penis are evaluated and interpreted. A decreased feeling of vibration indicates nerve damage in the pelvic region, leading to impotence.

Penile angiogram test: It is performed to visualise the blood circulation inside the penis. This test also has value in the treatment of priaprism.

Dynamic infusion cavernosometry test: Fluid is injected into the penis in this test at a known volume and pressure and the results are interpreted. Prostaglandins have value in the procedure of this test.

Corpus cavernosometry test: This test is based on complex fluid dynamics. Test fluid is injected into the penis and later, using some calculations of flow dynamics, venous leakage is worked out.

Digital subtraction angiography test: Digital images are taken in a dark room and the blood vessels are studied using this technique.

Magnetic resonance angiography test: It works on the principles of magnetic field and generally produces high quality and detailed images which are very helpful for a clinician. Sometimes a contrast medium can also be used to enhance the images.

Treatment of impotence

Treatment of male impotence or erectile dysfunction will depend upon the cause of erectile dysfunction. Most of the treatments work on a temporary basis as they will lead to a successful erection for intercourse, but will not cure the underlying condition. Therefore, these treatments are generally prescribed before intercourse only. If someone is using these approved treatments, he will be able to successfully maintain erection for the duration of intercourse.

Testosterone supplements are offered frequently to patients who have secondary erectile dysfunction or hormonal deficiency. Generally, the main cause for the erectile dysfunction is the lack of adequate blood supply to the penis as a result of damage to the inner walls of blood vessels, which leads to a faulty erection. As the age of a male progresses, he is predisposed to this type of damage, but it can also occur due to some diseases like diabetes and manifest as vascular complications.

Drugs prescribed are usually in the form of oral medication, injections and penile suppositories. All the drugs will increase the efficacy of the enzyme nitric oxide, which dilates the blood vessels of the corpora cavernosa and ultimately results in an erection. Penile injections are also offered to patients after the failure of oral medications and penile suppositories, but the injections may sometimes result in painful erections or priaprism.

In some cases refractory to medication, an external vacuum pump can be used to attain erection, with a separate compression ring fitted to the penis to maintain it. These are used as a treatment for erectile dysfunction rather than to increase penile size. Implants are very expensive. If the patient has some vascular problem, then surgical treatment is an option offered. These treatments are based on the principles of hydraulics and simple mechanics and are reliable also, but they may have certain side effects.

Oral treatment: PDE5 inhibitors like sildenafil or Viagra, vardenafil or Levitra and tadalafil or Cialis are prescribed orally. These drugs block the action of PDE5, which leads to cGMP degeneration. CGMP specific phosphodiesterase type 5 causes the smooth muscle relaxation of the arteries in the penis, thus allowing the corpus cavernosum to fill with blood. These medications will work after sexual stimulation only and the time taken for the optimum erection will vary from a few minutes to one hour, so it is advisable to take the medicine 45 minutes before intercourse.

Alprostadil: It is a prostaglandin and is injected into the penis or inserted using a special applicator just before sexual intercourse. Nowadays a topical application preparation is also available.

Vacuum therapy: In this procedure, a vacuum cylinder device is placed on the penis. The device applies negative pressure and draws blood into the penis. A tension ring is applied at the base of the penis to help maintain the erection. It is also known as a penis pump and a variety of such devices is available.

Surgery: A prosthetic implant, which may consist of a rod, may be placed in the penis if other measures are not working.

Counselling: It is used to manage distress if the doctor suspects that there is some psychological problem.