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MALE ERECTILE DISORDER (IMPOTENCE) Definition Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate erection. This is also known as ‘Erectile Dysfunction’. The disorder may cause marked distress or interpersonal difficulty. There are different patterns. Some individuals report inability to obtain erection from the beginning of sexual experience, while others reports being able to experience erection only during masturbation or on awakening, but not during the coitus. Some experience adequate erection, but lose it when attempting penetration. Still others report that they have an erection that is sufficiently firm for penetration, but they lose erection before or during thrusting. Male Erectile disorder is frequently associated with anxiety, fear of failure, pressure of sexual performance, and decreased sexual excitement and pleasure. This can disrupt marital relationship and may be the cause of unconsummated marriage and infertility. Etiology Aging: With advancing age, The orgasm is less intensive, The ejaculate is reduced The interval between the two-successive act is increased. Psychological factors: Fatigue Depression, Stress, Mental disorders, Guilt, Fear of failure, Low self esteem Religious restrictions Homosexuality Long/ serious illness Traumatic initial experience Negative feeling towards the partner Resentment Hostility Lack of interest Vascular causes: Use of tobacco/alcohol Atherosclerosis Peyronie’s disease Diabetes Hypertension Venous leak or occlusion Trauma Surgery Radiation Hormonal causes: Hypogonadism Hyperprolactinemia Diabetes Thyroid disease Androgen deficiency Estrogen excess Adrenal, pituitary or hypothalamic disease Neurogenic causes: Peripheral neuritis Automatic neuropathy (in diabetes) Multiple sclerosis Spinal cord disease Drug related causes: Antiandrogens (cyproterone acetate, flutamide, estrogen) H2 receptor antagonists (cimetidince, famotidine) Diuretics (spironolactone, thiazides) Antihypertensive (beta blockers, ace inhibitors, ganglion blockers) Anticholinergics (atropine, probanthine, dicyclomine) Antidepressants (M. A. O., Tricyclic) Antipsychotics (tranquilizers) CNS Depressants(barbiturates) Substance abuse (heroin, marijuana, alcohol, tobacco) Miscellaneous Renal failure Prostatectomy Pitfalls A detailed history is essential before arriving at the diagnosis of impotence. Many times, sexual stimulation is not adequate in duration and intensity. Morning erection while awakening is suggestive of psychological origin of impotence. Psychological aspects of erectile problem should always be evaluated in all the cases of erectile difficulty even when the cause is organic. Performance anxiety, fear of failure, over concern with pleasing the partner, ignorance about sexual anatomy and physiology are major causes of erectile problem. The degree of penile erection required for successful vaginal penetration should be enquired. There are individuals who feel that they need a steel hard erection for penetration. This is not necessary. Nature has designed vagina in such a way that the male gets maximum erection followed by ejaculation in the vagina. The male needs to be convinced that if the alignment of vagina and penis is perfect, and the women is stimulated enough, the male will be successful in penetration even if he gets partial erection. Fur there he gets the rigidity during penile thrusting. Sometimes premature ejaculation is associated with impotence. At times, anejaculation is misinterpreted as impotence. Many times, vaginismus in female is the root cause of impotence in the male. He tries at the right site and in the right direction, but since the vaginal opening does not relax, the penis gets tried and he loses the erection. In unconsummated marriage, he may try at a wrong site and lose the erection. Some individuals try penetration at the right site and in the right direction, but since the vaginal opening does not relax, the penis gets tried and he loses the erection. In unconsummated marriage, he may try at a wrong site and lose the erection. Some individuals try penetration at the right site but in a wrong direction, and so they may lose the erection. Some are not aware that they have to make to-and-fro pelvic movements. Such individuals remain quiet after penetration, and ultimately lose the erection. Man is the only animal doing coitus in a face to face position. Coitus is the only act that is performed in the dark and the individual has no opportunity to learn from others. Investigations Blood Sugar estimation: Fasting and P.P. Lipid Profile F.S.H., L.H., Prolactin & Testosterone T3, T4, T.S.H. Diagnostic tests Stamp Test: A long strip of postal stamps is wound around the base of the penis at night before going to bed. Next morning if the perforations of the strip are found to be torn off, impotence is supposed to be of psychological in origin. Peno- brachial index: The ratio of penile systolic blood pressure to that of brachial systolic blood pressure is normally 0.6. If found to be low impotence is vascular in origin. Papaverine Injection Test: Papaverine is a vasoactive drug. Using a 26 gauge needle, 30 mg Papaverine is injected at the mid-shaft of Corpus cavernosum of penis. He is isolated, asked to stoke the penis and exposed to erotic literature (or erotic fantasy). Erection will occur in 10 to 15 minutes. If the erection is short-lived or partial, then impotence is considered as vasculogenic. If the erection is full, then impotence is considered to be neurogenic or psychogenic in origin. Caution: This test should be performed in a hospital setting or where the facilities for detumescence are available. The patient should be observed for next few hours till the erection subsides. Rigiscan Test: This is a gold standard for evaluation of Nocturnal Penile Tumescence and rigidity(NPTR). This test is based on the physiological principle that a male gets erections 3 to 5 times during REM sleep. At night before going to sleep one ring of Rigiscan is slid over the base of the penis and the other over the tip. Next morning, the tracing obtained are studied. This test can quantify erectile tumescence and rigidity. Rigiscan tracing indicates whether the impotence is organic or psychological in origin. Arterial insufficiency and venous leaks can also be suspected on the basis of Rigiscan graphs. Patients with purely artery disease have low levels of rigidity but of adequate duration (20 minutes or more). Patients with venous leak will have varying rigidity levels with shortened duration. Penile Ultrasound: This test is for evaluation of the functioning of the penile arteries. A simple acoustic Doppler emits auditory signals or a color Doppler can help visualization of arteries. Cavernosometry & Canvernosography: This hemodynamic test is useful for diagnosing Veno-occlusive Dysfunction of the corpora. Biothesiometry, electromyography (EMG), nerve conduction studies: these tests are for evaluation of impotence. Treatment Counseling Sexual dysfunction is a marital unit problem and therefore both, husband and wife, should attend. Counseling is towards strengthening marital relationship. Wife is requested to co-operate. Client is requested to quit smoking and alcohol. He is advised relaxation exercises, yoga. The couple is educated about anatomy, physiology of sexual organs and about sexual response. Their myths and misconceptions about sexuality are countered. They are also explained that he does not have to do anything to have an erection. Erection is a physiological response to effective stimuli. Sex therapy No sexual activity is permitted till specific instruction are given. To remove his performance fears he must stop mentally watching himself during the sexual activity. The couple is advised sensate focus exercise (mutual pleasuring) without any goal. Basic to the sensate focus is the recognition that touch is a vital part human communication that gives meaning to sexual responsiveness for both men and women. They are advised to touch each other in a communicative way. Tenderness, affection, solace, understanding desire, warmth, comfort- almost any feeling can be conveyed to the partner by touching. Though the problem is of one partner, both are involved. There is nothing like uninvolved partner. One partner is advised to trace, massage or fondle the other, using the information from verbal and nonverbal directions from the other getting partners about preferences for locations and intensity of touching. Partners are forbidden to touch breasts, genital organs or to have intercourse. After three or four days the partners are asked again to pleasure each other, but this time, caressing other part of the body, they are specifically instructed to touch the genitals and breasts but not to have intercourse. If erection occurs, as it does during the pleasuring sessions, the couple is not permitted to rush to complete the performance. They are encouraged to develop the ability to communicate with each other during the pleasuring sessions until erection regularly, but not proceeding to intercourse. After next three to four days the wife is instructed to tease the man’s genitals. When the erection is firm she stops teasing and they lie in each other’s arms until the erection goes away. She then repeats the process several times during the next half an hour. By use of teasing technique for the next three to four days, the man gradually overcomes the fear of losing his erection and getting it back. During the next step, after the preliminary sex play, the wife is instructed to straddle her husband and sit on his thighs. She Is asked to stimulate his penis to full erection and to insert it in her vagina. The therapist asks the wife to insert the penis because she knows exactly where the entrance is. After the entry has been accomplished, the wife moves forward and backward slowly on the penis (female superior coital position). If the erection is lost, the wife needs to withdraw and manipulate the penis to erection again. The couple has been told not to move demandingly. There is no pressure to perform. The therapist never instructs the couple to proceed to climax. If orgasm does occur, it should not be by plan, but allowed to be a natural involuntary happening. Once this is accomplished, the couple is instructed to resume intercourse in the man superior coital position Pharmacotherapy Pharmacotherapy alone may not be effective unless it is associated with education, counselling, reassurance, countering myths & misconceptions, behavior modification, relaxation and supportive psychotherapy. 1. PDE5 inhibitors are found to be most effective for impotence of no known cause. These drugs maintain the erection and do not initiate the erection or increase the libido. Therefore, sexual stimulation is must. The side effects are headache, facial flushing, nasal congestion, visual disturbance and dyspepsia. Visual disturbances can occur with Sildenafil. Backache or muscle pain has been reported with Tadalafil. Special precaution is to be taken in persons having cardiovascular disease or renal impairment. PDE5 inhibitor must never be given to patients taking nitrates(e.g. Sorbitrate, Angised). Erythromycin, Cimetidine, ketaconizole, grapefruit juice or alcohol should not be taken concurrently. Generally priapism is not observed. PDE5 inhibitors should be prescribed along with alpha blockers (e.g.Prazopress), since this may cause hypotension. Sildenafil (Viagra, Caverta): Dose 25 mg to 100 mg given ½ hour after food and 1 hour before the sexual activity. Not more than once a day. Duration of action is 12 hours. Tadalafil ( Forzest, Zydalis) : Dose 10mg to 20mg. No relation to food. Given ½ hour before sexual activity. Duration of action is 12 hours. Vardenafil (Levitra) : Dose 5 mg to 20 mg. given ½ hour after food and 1 hour before sexual activity. Only once a day. Duration of action is 12 hours. The action of these drugs is dose related. To start with, minimum dose is prescribed.