Impotence, often called erectile dysfunction
, is the inability to achieve or maintain an erection long enough to engage in sexual intercourse.
Under normal circumstances, when a man is sexually stimulated, his brain sends a message down the spinal cord and into the nerves of the penis. The nerve endings in the penis release chemical messengers, called neurotransmitters, that signal the corpora cavernosa (the two spongy rods of tissue that span the length of the penis) to relax and fill with blood. As they expand, the corpora cavernosa close off other veins that would normally drain blood from the penis. As the penis becomes engorged with blood, it enlarges and stiffens, causing an erection. Problems with blood vessels, nerves, or tissues of the penis can interfere with an erection.
Causes and symptoms
It is estimated that up to 20 million American men frequently suffer from impotence and that it strikes up to half of all men between the ages of 40 and 70. Doctors used to think that most cases of impotence were psychological in origin, but they now recognize that, at least in older men, physical causes may play a primary role in 60% or more of all cases. In men over the age of 60, the leading cause is atherosclerosis
, or narrowing of the arteries, which can restrict the flow of blood to the penis. Injury or disease of the connective tissue, such as Peyronie's disease, may prevent the corpora cavernosa from completely expanding. Damage to the nerves of the penis, from certain types of surgery or neurological conditions, such as Parkinson's disease or multiple sclerosis
, may also cause impotence. Men with diabetes are especially at risk for impotence because of their high risk of both atherosclerosis and a nerve disease called diabetic neuropathy
Certain types of blood pressure medications, antiulcer drugs, antihistamines
, tranquilizers (especially before intercourse), antifungals (hetoconazole), antipsychotics, antianxiety drugs
, and antidepressants, known as selective serotonin reuptake inhibitors
(SSRIs, including Prozac and Paxil), can interfere with erectile function. Smoking
, excessive alcohol consumption, and illicit drug use may also contribute. In rare cases, low levels of the male hormone testosterone may contribute to erectile failure. Finally, psychological factors, such as stress
, guilt, or anxiety
, may also play a role, even when the impotence is primarily due to organic causes.
The doctor also obtains a thorough medical history to find out about past pelvic surgery, diabetes, cardiovascular disease, kidney disease
, and any medications the man may be taking. The physical examination
should include a genital examination, a measurement of blood flow through the penis, hormone tests, and a glucose test for diabetes.
In some cases, nocturnal penile tumescence testing is performed to find out whether the man has erections while asleep. Healthy men usually have about four or five erections throughout the night. The man applies a device to the penis called a Rigiscan before going to bed at night, and the device can determine whether he has had erections. (If a man is able to have normal erections at night, this suggests a psychological cause for his impotence.)
Years ago, the standard treatment for impotence was an implantable penile prosthesis or long-term psychotherapy. Although physical causes are now more readily diagnosed and treated, individual or marital counseling is still an effective treatment for impotence when emotional factors play a role. Fortunately, other approaches are now available to treat the physical causes of impotence.
The first line and by far the most common treatment today is with the prescription drug sildenafil citrate
, sold under the brand name Viagra. An estimated 20 million prescriptions for the pill have been filled since it was approved by the FDA in March 1998. It is also the most effective treatment with a success rate of more than 60%. The drug boosts levels of a substance called cyclic GMP, which is responsible for widening the blood vessels of the penis. In clinical studies, Viagra produced headaches in 16% of men who took it, and other side effects included flushing, indigestion
, and stuffy nose.
The primary drawback to Viagra, which works about an hour after it is taken, it that the FDA cautions men with heart disease or low blood pressure to be thoroughly examined by a physician before obtaining a prescription.
In the summer of 2002, two investigational drugs were announced to become available in the near future to also treat erectile dysfunction. Vardenafil and tadalafil both helped men who also had such conditions as diabetes, high blood pressure and benign prostatic hypertrophy. The drugs are awaiting final FDA approval.
Vardenafil and tadalafil belong to the same group of chemical compounds as sildenafil, namely phos-phodiesterase type 5 (PDE-5) inhibitors. Some men cannot benefit from sildenafil or the two newer PDE-5 inhibitors because they have low levels of nitric oxide. British investigators reported in late 2002 that three different types of compounds are being studied as possible medications for men with low levels of nitric oxide. They are Rho-kinase inhibitors, soluble guanylate cyclase activators, and nitric oxide-releasing PDE-5 inhibitors.
Other medications under investigation as treatments for impotence are topical agents. Topical means that they are applied externally to the skin rather than being injected or taken by mouth. If approved, these drugs would provide a noninvasive alternative for men who cannot take sildenafil or other oral medications for impotence.
Injection therapy involves injecting a substance into the penis to enhance blood flow and cause an erection. The Food and Drug Administration (FDA) approved a drug called alprostadil (Caverject) for this purpose in July of 1995. Alprostadil relaxes smooth muscle tissue to enhance blood flow into the penis. It must be injected shortly before intercourse. Another, similar drug that is sometimes used is papaverine—not yet been approved by the FDA for this use. Either drug may sometimes cause painful erections or priapism
(uncomfortable, prolonged erections) that must be treated with a shot of epinephrine.
Alprostadil may also be administered into the urethral opening of the penis. In MUSE (medical urethral system for erection), the man inserts a thin tube the width of a vermicelli noodle into his urethral opening and presses down on a plunger to deliver a tiny pellet containing alprostadil into his penis. The drug takes about 10 minutes to work and the erection lasts about an hour. The main side effect is a sensation of pain
and burning in the urethra, which can last about five to 15 minutes.
Mechanical and surgical treatments
Another approach is vacuum therapy. The man inserts his penis into a clear plastic cylinder and uses a pump to force air out of the cylinder. This forms a partial vacuum around the penis, which helps to draw blood into the corpora cavernosa. The man then places a special ring over the base of the penis to trap the blood inside it. The only side effect with this type of treatment is occasional bruising if the vacuum is left on too long.
Implantable penile prostheses
are usually considered a last resort for treating impotence. They are implanted in the corpora cavernosa to make the penis rigid without the need for blood flow. The semirigid type of prosthesis consists of a pair of flexible silicone rods that can be bent up or down. This type of device has a low failure rate but, unfortunately, it causes the penis to always be erect, which can be difficult to conceal under clothing.
The inflatable type of device consists of cylinders that are implanted in the corpora cavernosa, a fluid reservoir implanted in the abdomen, and a pump placed in the scrotum. The man squeezes the pump to move fluid into the cylinders and cause them to become rigid. (He reverses the process by squeezing the pump again.) While these devices allow for intermittent erections, they have a slightly higher malfunction rate than the silicon rods.
Men can return to sexual activity six to eight weeks after implantation surgery. Since implants affect the corpora cavernosa, they permanently take away a man's ability to have a natural erection.
In rare cases, if narrowed or diseased veins are responsible for impotence, surgeons may reroute the blood flow into the corpus cavernosa or remove leaking vessels. However, the success rate with these procedures has been very low, and they are still considered experimental.
A newer investigational approach to the treatment of erectile dysfunction is gene therapy
. As of late 2002, several preclinical studies have shown promise, but none of the gene-based strategies so far have yet been tested for safety.
A number of herbs have been promoted for treating impotence. The most widely touted herbs for this purpose are Coryanthe yohimbe
(available by prescription as yohimbine, with the trade name Yocon) and gingko (Gingko biloba
), although neither has been conclusively shown to help the condition in controlled studies. In addition, gingko carries some risk of abnormal blood clotting and should be avoided by men taking blood thinners such as coumadin. Other herbs promoted for treating impotence include true unicorn root (Aletrius farinosa
), saw palmetto
), ginseng (Panax ginseng
), and Siberian ginseng (Eleuthrococcus senticosus
). Strychnos Nux vomica
has been recommended, especially when impotence is caused by excessive alcohol, cigarettes, or dietary indiscretions, but it can be very toxic if taken improperly, so it should be used only under the strict supervision of a physician trained in its use.
With proper diagnosis, impotence can nearly always be treated or managed successfully. Unfortunately, fewer than 10% of impotent men seek treatment.
There is no specific treatment to prevent impotence. Perhaps the most important measure is to maintain general good health and avoid atherosclerosis by exercising regularly, controlling weight, controlling hypertension
and high cholesterol levels, and avoiding smoking. Avoiding excessive alcohol intake may also help.
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American Foundation for Urologic Disease. 1128 North Charles Street, Baltimore, MD 21201. (410) 468-1800.
American Urological Association (AUA). 1120 North Charles Street, Baltimore, MD 21201. (410) 727-1100. www.auanet.org.
Center for Biologics Evaluation and Research (CBER), U. S. Food and Drug Administration (FDA). 1401 Rockville Pike, Rockville, MD 20852-1448. (800) 835-4709 or (301) 827-1800. www.fda.gov/cber.
Impotence Institute of America, Impotents Anonymous. 10400 Little Patuxent Parkway, Suite 485, Columbia, MD 21044-3502. (800) 669-1603.
National Kidney and Urologic Diseases Information Clearinghouse. 3 Information Way, Bethesda, MD 20892-3580. (800) 891-5390.
— A smooth muscle relaxant sometimes injected into the penis or applied to the urethral opening to treat impotence.
— A disorder in which plaques of cholesterol, lipids, and other debris build up on the inner walls of arteries, narrowing them.
— A menthod of treating a disorder by replacing damaged or abnormal genes with normal ones. Some researchers think that gene therapy may offer a new way to treat impotence.
— Chemicals that modify or help transmit impulses between nerve synapses.
— A smooth muscle relaxant sometimes injected into the penis as a treatment for impotence.
— A disease resulting from scarring of the corpus cavernosa, causing painful erections.
— A type of medication that is applied to a specific and limited area of skin, and affects only the area to which it is applied.
— The small tube that drains urine from the bladder, as well as serving as a conduit for semen during ejaculation in men.
— Trade name of an orally administered drug for erectile failure first cleared for marketing in the United States in March 1998. Its generic name is sildenafil citrate.
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