Impotence

Impotence or Erectile Dysfunction is the inability to achieve an erection suitable for the satisfactory performance for sexual intercourse.

There are many factors that are involved in achieving and maintaining an erection for sexual intercourse. Those factors may be psychological or physical.The factors associated with the ability to get an erection, including desire (libido) and good circulation. These things can be adversely affected by such conditions as smoking, high blood pressure, high cholesterol, obesity, Diabetes and neurological (nerve) disorders. Surgery or medical conditions in the lower bowel or pelvic region may be a factor also.

It is often necessary for the patient to fill out a questionnaire in a quiet, private environment in order to assess the patient'­s symptoms. With a couple, it is often helpful for both to be consulted together.

The questionnaire may involve the ability to get an erection, the length of time it lasts for, whether or not there is premature ejaculation, whether there is any deformity of the penis, (possible Peyronie'­s Disease) and general medical problems which may affect the ability to obtain erections, such as diabetes or neurological lesions.

Generally a physical examination of the patient will be carried out and following that it may be necessary to perform various blood tests and possibly tests on the circulation of the penis.

In order for a penis to maintain erection it requires the inflow of blood to be greater than the outflow. It is rather like trying to fill up a bucket with water when the bucket has holes in it. Either the holes have to be plugged up or the water poured in faster.

TREATMENT

There are many treatments available for erectile dysfunction:

Oral medication

Medications such as Sildenafil(Viagra®), Vardenafil (Levitra®) or Tadalafil (Cialis®) are generally taken some time prior to anticipated intercourse. Usually the tablets require some degree of stimulation (foreplay) to be able to have an effect. The erection is caused by increasing the blood flow into the penis.

Intracavernosal Injections

The most commonly used substance is Prostaglandin which is injected into the shaft of the penis. This leads to dilation of the blood vessels and increase of flow of blood into the penis and thereby gaining an erection. Generally speaking an erection lasting approximately half an hour is desirable.

Priapism

Sometimes erections are prolonged and may require treatment in order to deflate the penis. This is called priapism and usually occurs when non-standard medications and doses are used. It is very important not to exceed the recommended dose as Priapism may cause damage to the penis preventing further erections and leaving the only option a penile implant. In extreme cases even that may not be possible.

Vacuum Enhancement Devices

These are devices rather like a bike pump which is a cylinder placed over the penis and the object is to draw the venous blood into the penis through suction. An occlusive device, which is a type of rubber band, is then placed around the base of the penis, restricting the flow of the blood back into the body, thereby retaining an erection. The erections obtained using these devices usually give the penis a bluish appearance rather than the pink appearance with the treatments which cause arterial dilation. It is important with these devices that the occlusion is only in place for 30-60 minutes and that the patient does not fall asleep with the ring still in place. The rings are usually specially designed in order to have handles on the side so that they are easily removed.

Penile Prostheses

These are devices inserted through a surgical procedure into the penis which enables an erection on demand. There are several types available.

They may be:

  • Semi rigid, which is made of "bendy wires" covered with a substantial silicon coating. Once these are inserted
    the penis is semi-erect all the time and the penis is bent downwards when a non-erect appearance is desired and manipulated upwards for intercourse.
  • Inflatable penile prostheses usually have a small pump and valve placed in the scrotum beside the testicles and a reservoir under the lower abdominal skin. The reservoir contains fluid which is pumped into the prosthesis in order to obtain the erection. After intercourse the valve is pressed and the penis is deflated. The fluid passes back into the reservoir, giving a much more normal appearance.

The type of prosthesis best suited to the patient is best discussed with the patient and the Doctor.

 

ERECTILE DYSFUNCTION AND HYPO ANDROGEN-METABOLIC SYNDROME (ED and HAM)

Presentation

On presentation for erectile dysfunction to a Urologist may lead to a concomitant diagnosis of the Hypo Androgen-Metobolic Syndrome (HAM Syndrome).

What is it?

The diagnosis for the metabolic-syndrome requires any three of the following:

  1. Waist circumference from 88cm
  2. Blood Pressure greater than or equal to 130mm Hg systolic or 85mm Hg diastolic or on hypertensive medication.
  3. HDL-C less than 0.9mmol/L or drug treatment to reduce HDL-C
  4. Fasting Tryclicerides great than or equal to 1.7mmol/L or drug treatment for elevated Tryclicerides.
  5. Fasting Glucose greater than or equal to 5.6mmol/L or drug treatment for elevated Glucose.

These criteria are taken from the American Heart Association/National Heart Lung and Blood Scientific statement 2005.

Hormone Facts

Erectile dysfunction is common in over weight men and may be associated with low serum Testosterone (male hormone) levels. As men get older male hormone levels decrease and after the age of 30, may decrease by 1-2% per year. This is a very gradual decline, unlike female hormones which decrease significantly more rapidly at the time of menopause.

Approximately 10% of men aged 40-60 and 30% of men aged 60-80 have decreased hormone levels.It is not certain whether the decrease in hormone levels leads to the increase in weight but it is thought that the increase in weight will lead to more symptoms of a decreased hormone level and the hormone level to decrease further, as it may be absorbed into the fat cells of the body and therefore be less effective for other usage.

With the obesity epidemic occurring in a number of countries including Australia, it is possible that almost half the men over the age of 50 have the metabolic syndrome.

What symptoms are likely to develop with low Testosterone?

Psychological symptoms:

  • Tiredness
  • Depressed mood
  • Irritability
  • Poor concentration
  • Reduced short term memory

Physical symptoms:

  • Weakness
  • Muscle and joint pains
  • Sweating and hot flushes
  • Dryness of skin
  • Reduced muscle mass and strength
  • Increased abdominal girth and obesity
  • Breast enlargement
  • Reduced body and facial hair

Sexual symptoms:

  • Reduced libido (desire)
  • Erectile dysfunction (impotence)
  • Disturbance of ejaculation (may be premature or failure)
  • Low Hormone Levels in Males may be associated with male osteoporosis (thinning of bones).

What Can Be Done?

Generally speaking, the assistance of a dietitian and a regular exercise program may be the most likely to succeed in conjunction with the General Practitioner who is best placed to look after the man's general health and be able to judge his ability to exercise and carry out a diet.

However a lot of patients prefer to “do it themselves”. Generally speaking, diet such as those advocated by the CSIRO and such commercial publications as Men's Health® may well be the simplest and easiest approach. In some cases obesity is so significant the man may be advised to seek further advise regarding the possibility of laparoscopic stomach banding or gastric bypass.

From the point of view of exercise, generally speaking, a 40 minute period of exercise 3 days per week of walking/running, bike riding or swimming along with 2 days per week of 20-40 minute of resistance exercises (lifting light weights) along with the dietary measures is likely in the long term to provide some degree of weight loss.

Please note that is is essential that the man has a medical check up with his General Practitioner prior to contemplating changes in levels of his physical activity.

Hormone Replacement

In some men it is necessary to provide hormone replacement and that may be carried out through oral (tablets) medication which is easily personalized to the correct level because of the ease of variability in dosage. Patches will allow hormone absorption through the skin, gels which are similar to the patches and injections which may last for 12-14 weeks therefore not needing regular ingestion are alternative methods. It is important for treatment to be individualised and requires regular monitoring.The need for supplementation is best determined by the Doctor.

Erectile Dysfunction (ED) Assessment

Download the following Erectile Dysfunction (ED) Assessment Questionnaire. These 5 questions could help you restore the intimacy of relationships. The answers to the ED Assessment questions can help you determine the level and extent of erectile dysfunction and may indicate a need for treatment.

» Download ED Assessment Questionnaire