Impotent? Maybe Not

Impotency is defined as the inability to achieve a full erection that is capable of penetration during sexual relations, an inability to maintain an erection during sex and short erection time that is not sufficient to maintain enjoyable sexual contact between the couple. 

Sexual dysfunction is extremely common among men over 50. Up to 30% of men in this age group will suffer from erectile dysfunction for a variety of reasons. The incidence of erectile dysfunction increases with age, reaching 60% among men over the age of 70. These disorders are not rare in younger men, affecting between 10%-15% of men below the age of 40. 

70,000 new cases of impotence are estimated to occur each year in Israel, but only 10% of patients seek help. One of the main causes when dealing with impotence is the fact that a year or more can pass before the patient recognizes the problem and seeks help – due to lack of awareness, embarrassment, neglect or denial.

Causes of Erectile Dysfunction  

• Impotency has several underlying causes – physical, emotional or a combination of the two. 20%-25% of erectile dysfunction is attributed to emotional factors: depression, stress, anxiety, relationship problems and stress, performance anxiety, unsupportive sexual partner, etc. Other cases are attributed to physical causes, including: 
• Disruption in blood supply to the penis 
• Disruption in nerve activity in various sites in the body 
• Various medications 
• Bruises and pelvic surgery 
• Hormone changes 
• Radiation therapy and chemotherapy 
• Disease (such as diabetes, the most common cause since it damages nerves and interferes with blood flow to the penis) 
• Obesity 
• Smoking and alcohol as well as drug use 

How is impotency treated?  

1. The first step is a diagnosis. A diagnosis includes providing the attending physician with a complete sexual history, followed by a medical history – diseases, drugs, hormone therapy, accidents, emotional state. Nocturnal penile tumescence (spontaneous erection during sleep or in the morning).

Other aspects that must be examined include the time when the impotence occurred, the relationship between impotency and other events (stress or pressure) – impotency that is the result of failed sexual activity is not like impotency attributed to heart disease or diabetes, despite the cause being psychological in nature in both cases.

2. A physical examination of the patient. The physical examination will include an examination of peripheral pulses, signs of vascular disease, examination of the testicles and penis, a rectal exam and a neurological exam. The laboratory tests include blood tests, kidney function, blood count and hormone tests that include testosterone, prolactin, hormone function of the pituitary gland and thyroid gland.  

Another test performed is nocturnal penile tumescence monitoring, which facilitates a diagnosis between a disorder that is organic in nature and an emotional disorder. 

Various recent studies have shown that impotency might be an early indicator of coronary heart disease in 8%-10% of men complaining of impotency.

3. Following the clarification and diagnosis is treatment. In recent years there has been a revolution in impotency treatments available to men. An understanding of the patho-physiology of impotency disorders has significantly expanded.

Current standard treatments include:  

Emotional background – Patients are referred to a sexologist or psychologist. On occasion, joint therapy that includes a urologist and couples therapist/sexologist.

Organic background –   

• Hormone therapy – Provided when there is a decrease in testosterone level – administered by injection or gel. The goal is to improve the quality of the erection and increase sexual desire. 
• Various illnesses: A specific treatment is provided for the illness causing impotency. In hyperactivity or hypoactivity of the thyroid gland, drug therapy is provided to create a balance. 
• Oral drugs: There are three types of oral drugs – Viagra, Levitra and Cialis. These drugs selectively inhibit PDE-5 enzymes, which play a key role in the erection mechanism. These drugs have revolutionized treatment of impotency and have since become the preferred treatment for impotency. 
• Mechanical therapy: Therapy with a vacuum device or constriction ring, which pull the genitalia and cause increased blood flow to it. This is the treatment provided when pills do not work. 
• Pharmacologic erection program (PEP): Treatment that involves injection of vasodilators into the penis. This was a common form of treatment prior to the aforementioned drug treatment. If drug treatment fails, or when various drugs cannot be taken, injections are used. If necessary, this treatment can be combined with pills. 
• Treatment with topical creams – Creams that cause blood vessels to temporarily dilate. These creams are currently in development and are not routinely used. 
• Surgical treatment of impotency: Surgeries to reconstruct the damaged blood vessels in the area, although they have a low rate of success in the long-term. 
• Prosthetic implant surgery – When injections and pills do not help – prosthetics, which have proven to be highly effective, are implanted.    
• One of the newest treatments currently available is treatment with a cool gel that is applied to the penis region that apparently improves the flexibility of blood vessels in the penis area – this is the latest treatment today.

In conclusion: when discussing impotency, it is important that treatment be focused on the cause and not merely on the problem itself. Drug therapy for impotency for a person suffering from uncontrolled diabetes or obesity can ultimately exacerbate their condition if left untreated.  

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