Treatment Options for Impotence

Impotence is the inability of a man to achieve or maintain tumescence sufficient for his sexual needs. It becomes commoner with age, affecting 5% of men in their 40s and 20% of men in their 60s. It is important to remember that all men can be made potent somehow.

Causes of impotence
Psychogenic - stress, anxiety or depression (50%).
Chronic disease - diabetes, kidney disease, alcoholism, atherosclerosis, radiotherapy (20%).
Drugs - mainly cardiac drugs and antidepressants (20%).
Pelvic surgery - either because of division of the erectile nerves in the pelvis in order to achieve better cancer clearance, or to bruising of them if they have been preserved (10%).

Blood tests - to exclude diabetes, kidney dysfunction, hormonal imbalance and prostate cancer (PSA).
Physical examination.

Treatment of impotence

Psychosexual counselling - this aims to reduce tension, improve sexual communication and create realistic expectations. It is often combined with one of the treatment options below.

Drugs - phosphodiesterase type 5 (PDE-5) inhibitors (sildenafil, vardenafil, tadalafil) improve partial tumescence by inhibiting the enzyme that causes their reduction. They usually work within ½ to 1 hour. Side-effects include headache, facial flushing, indigestion, temporary blue-green colour blindness and muscle and/or back ache (tadalafil).

Often one drug will work better than the other two in an individual patient, so you should not assume that if one does not work that the others will not either. It is important to take a high dose of the drug following pelvic surgery as lower doses are usually ineffective. The following patients should not take these drugs: men taking cardiac nitrates drugs (for chest pain) and/or a blockers (used to treat high blood pressure and BPH).

Men who have had a heart attack or stroke within the past 6 months.Men with uncontrolled high or low blood pressure, liver disease or unstable angina). Sildenafil is the best-known drug in the PDE5 family and has the advantage of being available in 3 doses (25, 50 & 100 mg). Its absorption is delayed by alcohol and fat in the stomach. Vardenafil (10 or 20 mg) has a reputation for having the fastest onset of action and fewer side-effects. Tadalafil - (10 or 20 mg) lasts for 2 days and so improves spontaneity.

Urethral pellet (MUSE) - this rice-sized pellet containing alprostadil is inserted 2 cm into the urethra using a specially-designed straw-like device. It then dissolves and diffuses into the erectile tissue, causing tumescence in 20-30 minutes by increasing local blood flow via a direct effect on the penile arteries. It tends to be effective in only 50% of men who use it. Some degree of urethral discomfort is common. Self-injection therapy - alprostadil can be administered directly into the erectile tissue, improving results and allowing a much smaller dose to be used (5-20 microgrammes).

Self-injection is easily taught and involves using a very small needle which is similar in size to that which diabetics use to inject insulin. Tumescence begins 15-20 minutes after the injection and lasts for about an hour. Patients are encouraged to reduce the dose of the drug used on each occasion until they find the minimum dose which produces tumescence sufficiently rigid for easy penetration, as larger doses cause penile discomfort and increase the risk of priapism.

This condition describes prolonged (>4 hours), painful tumescence which requires medical relief. Patients also need to be aware that repeated injection over a prolonged period may cause scarring of erectile tissue, which can further impair tumescence.

Vacuum device - this works by encouraging local blood to flow by creating low pressure around the organ and then trapping the blood in it using a constriction ring placed at its base. The vacuum is created by inserting the organ into a plastic tube, which is pressed against the body to form a seal. A hand pump attached to the tube then creates the vacuum, which causes tumescence within 2-3 minutes. Vacuum devices are suitable for use in men with ED of any cause. The principle disadvantage is that as the base of the organ is flaccid, some directional control with the hands is necessary to achieve penetration.

Surgery - surgical insertion of a penile prosthesis is a major step but for the right patient represents a very good option in that it guarantees penetrative intercourse without the need for any other drug or device, re-creating spontaneity. The disadvantages are the need to an operation to implant the device and the 1% risk of device infection, which would necessitate its removal.

The device consists of 2 cylinders, which replace the erectile tissue contained on either side of the organ in the structures known as the corpora cavernosa. Penile prostheses come in 2 main types:

Malleable - a semi-rigid device which can be bent up or down as necessary. The device does not re-create the full length or girth of natural tumescence.

Inflatable - a 3 part device consisting of inflatable cylinders within the organ, a fluid reservoir implanted within the abdominal cavity and a control pump implanted in the scrotum. To obtain tumescence one squeezes the control pump, which diverts fluid from the reservoir into the cylinders, causing the organ to increase in length and girth, just as in the natural situation. After sex, pressing the pump again allows the fluid to return to the reservoir.

Alternative treatments for impotence
Regular exercise, weight loss (if overweight), stopping smoking and reducing alcohol intake are all likely to improve the situation.

Good nutrition may help improve impotence. Eat more fruit, vegetables, whole grains, soy, beans, seeds, nuts, olive oil, and cold-water fish (salmon, tuna, sardines, halibut, and mackerel).Eat less dairy products, refined food, fried foods, hydrogenated oils, alcohol and caffeine.

Christopher Eden is a leading UK Consultant Urological Surgeon who has had an extremely broad urological training which has included working at internationally-renown specialist centres for urology. He has published more than 50 peer-reviewed scientific papers, 10 book chapters and one book. Experience matters:


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