Impotence Definition: Impotence is the inability to achieve and maintain penile erection sufficient to complete satisfactory intercourse.

Alternative Names: Male impotence; Sexual dysfunction - male; Erectile dysfunction; Organic impotence; Inorganic or psychogenic impotence Considerations: Between 2 and 30 million men in the United States are affected by impotence problems, according to recent estimates. About 52% of men between 40 and 70 years-old have some degree of erectile dysfunction (ED). Approximately 90% of ED is caused by physical, not psychological, problems. Risk factors for ED include:

hypertension (high blood pressure) hyperlipidemia (high cholesterol) diabetes coronary artery disease peripheral vascular disease anemia medications smoking alcohol abuse surgical procedures (vascular surgeries, abdomino-perineal resection, radical prostatectomy, other pelvic surgeries, etc.) neurological conditions

depression endocrine disorgers (low testosterone, thyroid disease, hyperprolactinemia, etc.) trauma.

NOTE: The risk of impotence increases with age. Impotence can be classified as primary or secondary. A man with primary impotence has never had an erection sufficient for intercourse. This is rare. The more common condition, secondary impotence, is the loss of erectile function after a period of normal function. Except for impotence caused by injury or sudden illness, secondary impotence usually comes on gradually. Treatment of secondary impotence is usually more successful than that for primary impotence because it is easier to restore function that has been lost than it is to discover why function has never occurred in the first place. AGING ALONE DOES NOT CAUSE IMPOTENCE! There are several components required for a satisfactory erection:

A responsive emotional state of mind A normally functioning pituitary gland Adequate testosterone Intact brain and nervous system

Adequate penile blood supply

Premature ejaculation (when orgasm comes on too quickly to satisfy either partner) is different from impotence. The couple should seek counseling for this problem, which is usually due to psychological factors. Male infertility is also quite different from impotence. A man who is unable to maintain an erection may be perfectly normal in every other way and very capable of producing sperm which can fertilize a woman. An infertile male is usually able to have intercourse normally, but he may be unable to father a child due to problems with sperm count, quality, or other factors.

Common Causes:
Medications Smoking High blood pressure

Diabetes mellitus Low testosterone states (Patients with prostate cancer on hormonal therapy, patients with hypogonadotropic hypogonadism, etc.)
Liver disease,

usually caused by

alcoholism

Heart disase (coronary artery disease) Circulation problems (arteriosclerosis, anemia or following vascular surgery) Neurological problems (injury, trauma, disease) Endocrine disorders (thyroid disease, hyperprolactinemia, etc.) Pelvic surgery/radiation (abdomino-perineal resection, radical

prostatectomy, radiation therapy, etc.)

Penile implants (or prostheses) that are not functioning properly Stress Recreational drugs (cocaine, marijuana, alcohol, heroin, etc.) Psychiatric illnesses (anxiety disorders, depression, obsessive-compulsive disorder, etc.)

Home Care: Treatment varies depending on the cause and the significance of the problem to the individual man and his partner. The cause should be treated. For example, if the impotence is caused by a medication, consult your health care provider about changing medications. Do not discontinue medications without consulting a physician first, however, because some may cause life-threatening reactions if they are not tapered or switched appropriately. Counseling (for both the patient and the partner) may be advised. Rest and an active imagination are often effective measures for impotence caused by stress. For impotence caused by fear of infection -- use safe sex practices. Abstinence should be considered if in doubt. Talk to your health care provider if impotence is related to fear of recurring heart problems -- sexual intercourse is usually safe in these circumstances. If certain preventable risk factors are identified in the evaluation,

cessation of such activities will be recommended (i.e., quitting smoking or marijuana, cocaine, alcohol, or other heavy drug use). Depending on your evaluation, different therapies will be initiated. In order to treat ED effectively, you must be aware of and comfortable with the possible side-effects and complications which may occur with each therapy. One of the risks with ED therapy is the development of a priapism, which is an unwanted painful, long-lasting (over an hour) erection. Mixing medications and/or not following instructions are common causes of this problem. If this occurs, you must contact your physician and/or go to the nearest emergency room. If you do not, permanent impotence or other lasting damage to your penis could occur.

Call your health care provider if: If you are on ED medication/therapy and have long-lasting (over an hour), unwanted, painful erections, contact your physician immediately, go to the nearest emergency room, or call the local emergency number (such as 911). What to expect at your health care provider's office: A thorough history and physical examination will be obtained. Medical history questions documenting impotence in detail may include:

Quality
o

Have you been able to achieve and maintain erections in the

past?
o

Is the difficulty in achieving erections or maintaining the erection? Do you have erections during sleep? How long have you had difficulty with erections? What medications are you taking (including prescription medications, over-the-counter medications, mood-altering recreational drugs)? Do you smoke?

Time pattern
o

Aggravating factors
o

Cigarettes, cigars, marijuana, cocaine, etc.? How much each day? How much? How frequently?

Do you use alcohol?

o o

Have you recently had surgery? Have you ever had surgery or treatments for your blood vessels? Have you noticed changes in your emotional state?

Are you depressed? Are you afraid or worried about something? Are you experiencing a lot of stress? Has your energy level decreased?

o o

Are you sleeping well each night? Are you afraid of sexual activity because of physical problems?

What changes in your life have recently occurred? What other symptoms are also present? Have you noticed changes in sensations in your penis? Do you have any problems with urination?

Other
o o o

Physical examination may include:

Examination for secondary sexual characteristics Lower extremity pulses Neurological examination Rectal examination Penile examination (for Peyronie's disease)

Diagnostic evaluation may include:

Urine analysis Blood work (CBC, metabolic panel, hormone profile, PSA, etc.) Pharmacologic penile duplex ultrasound (to evaluate for vascular insufficiency) Nocturnal Penile Tuemscence (NPT) and rigidity monitoring -Rigiscan Dynamic infusion caversometry & cavernosography (to rule out venous leak) Neurological testing Psychometric testing

INTERVENTION Treatment depends on the cause. For example, if impotence is caused by

a hormonal abnormality, medication correcting this underlying endocrine disorder will be prescribed. Consult your health care provider for appropriate evaluation and management. There are many treatment options for ED today. These include the vacuum constriction device (VCD), oral medications, medication patches & gels, urethral and penile injection therapies, and surgical therapies including penile prosthesis. Currently, Sildenafil (Viagra) is the only FDA approved oral medication for ED. Viagra is a very effective treatment for most men with mild to moderate ED. Sildenafil is best taken on an empty stomach (without alcohol ingestion) one hour prior to time erection is desired. Stimulation (visual, verbal or tactile) is usually required to initiate an erection. Common side effects include, headache, stuffy nose, and blue vision. If your erection lasts for more than one hour, you should seek immediate medical attention. You should only use Sildenafil if it is prescribed for you by your doctor. Sildenafil should not be used in conjunction with certain other medications. If oral therapy fails, various injectable medications are available. These are usually injected into the penis directly with a needle. Inject able therapy may help those patients that are not helped by oral medications. For some selected patients, penile prostheses may be recommended. Consult your health care provider to see if one of these treatments is right for you.