Once the diagnosis of the cause or causes of impotence are determined, a proper therapy must be established.
Nowadays, physicians specializing in sexual impotence have a great variety of treatments available to use against the problem. Generally, when the impotence is of a purely psychological origin, supportive psychotherapy and sexual therapy may be indicated. However, sometimes a physical or drug therapy is also recommended in these cases, to increase the confidence of the patient in his ability to achieve and maintain erection, and/or to reduce performance anxiety in face of a more sure-fire method. On the other hand, pure organic disease has to be treated with physical or drug therapy, but supportive psychotherapy and counseling is also indicated, in order to re-educate the patient and reduce the damaging effects of short- or long-term impotence to him and his partner.
We will not deal in this chapter with the treatment of impotence caused by other dominant diseases, such as Parkinson's or diabetes. It is clear that adequate therapy in these cases may be enough to restore sexual function in man. Instead, we will address here primary therapeutic methods related to the basic pathology of erection or to achieve erection even in the failure of normal, physiological methods.
As a rule, when trying the recommended therapies, physicians try first those which are less invasive, which can be reversed, or which are simpler and less expensive. Only when these initial approaches fail is that more drastic, invase, irreversible, complex or costly approaches should be tried.
These methods work well with the majority of men who are not able to achieve or to maintain erection due to vasculogenic factors. The vacuum device is a hand- or battery-operated air pump which attaches to a plastic cylinder. The penis is inserted into this cylinder and its mouth is tightened. The pump provokes a vacuum inside the cylinder, leading to a pressure difference with the pelvis. Blood rushes into the penis and makes an erection, with minimal side effects. Then, a silicone or rubber ring is fastened around the base of the penis, in order to block the outflow of venous blood. The erection ensues quickly and may last for long periods (20 minutes or more). The method has proved to be effective in more than 90 % of the cases, but the main complaint is that it is too intrusive into the intimacy of the sexual moment. Side effects are minimal (hematomes or pain).
There is a number of prescription and non-prescription drugs which have been tested for promoting sexual potency, for increasing sexual libido and for reducing the effects of vasculogenic or hormonal factors. Many of them have only folklore value and have not been scientifically proved to have any effect which might be higher than a psychological one (the so-called placebo effect). This is the case of Ginseng, Yohimbine and Catuaba extracts from plants from Asia, Africa and South America.
Well proved and significant effects have been achieved with only two drugs:
Sildenafil: manufactured by Pfizer, this drug has become available recently to the worldwide market, under the brandname Viagra, rapidly becoming an impressive medical, cultural and economical phenomenon. It is a tablet taken in oral form 30 to 60 minutes before intercourse. There are three different dosages: 25, 50 and 100 mg and the effect (duration and firmness) is dose-proportional. Erection must occurr (sexual excitation) in order to the drug make its effect, and is effectively helped in about 60 to 80 % of cases, even when the cause is psychogenic. The duration ranges from 1 to 3 hours, in the average. Sildenafil citrate acts specifically inhibiting an enzyme which controls the relaxation of outflow blood vessels in the cavernous bodies of the penis, thus maintaining the erection. There are no major side effects (exception made to a potentially hazardous interaction with nitrite-based heart vasodilators, such as nitroglycerin). The treatment is somewhat expensive. There is some concern that this drug might be used in a "recreational " manner, i.e., men who are not impotent may use sildenafil as an aphrodisiac. Scientifically controlled studies involving more than 2,500 patients in the last years have demonstrated that sildenafil is effective and safe and has a huge potentiatlity as the therapy of choice for a great range of erectile dysfunctions. It is not applicable to all forms of impotence, however. See the section on Internet resources to read more up-to-date news and articles on Viagra.
Alprostadil: this a generic drug derived from a class of local-acting vascular hormones called prostaglandins E1. Alprostadil has been available in the USA and in other countries for a number of years under the brandname Caverjet. It is usually injected with a fine needle into the cavernous bodies of the penis. There, it promotes a vascular action which leads to erection in about 15 minutes, and maintains it by 20 to 40 minutes, in 80 to 90 % of the cases. Sometimes the injection compound includes papaverine, a vascular-acting enzyme, to potentiate the effect, or phentolamine. Although this method is effective and simple, it is relatively expensive and is abandoned by more than 50 % of the patients after six months of use, by reasons of fear of injections, pain, fibrosis in the sites of injection and intrusion with intimacy. A dangerous side effect, particulary with unwarranted high doses, is priapism, a condition whereby an erection may stay for hours, leading to an interruption of the blood supply to the penis and necrosis.
A less invasive form of prostaglandin therapy has recently been approved in the USA and elsewhere and is called MUSE, developed and manufactured by Vivus. A small pellet of alprostadil is inserted with a hand-operated device into the penis urethra. A rolling movement with both hands around the penis shaft dissolves the pellet, which is absorbed and acts locally on the penis circulation. The effect takes longer to appear than in the injection, but the other complaints associated to the injected form are avoided.
There are other drugs which were in development and testing as this article was being published, all of them acting on the erection vascular mechanisms, such as apomorphine, Vasomax and Erectil.
These forms of therapy are strictly recommended only for cases of hypogonadism, i.e, a pathological decrease in the levels of testosterone, and even so in very limited circumstances. Testosterone is artificially replaced by intramuscular injections or by skin patches (applied to the shaved scrotum). Normal levels are reached very quickly, and an effect of the sexual libido and erectile function may be felt after a few days. Male hormone replacement therapy seems to have other beneficial effects also, particularly in elderly man, Muscular mass is increased, fat is decreased, the patient feels better and more vigorous, with less fatigue and higher mental concentration. There is evidence that osteoporosis (a lack of calcium in the bones, which can lead to easy fractures and other ailments) is avoided by hormone therapy.
However, testosterone replacement therapy is more dangerous than its female counterpart (using estrogen). Its clinical use is warranted only after a certain age, and only when the absence of prostate disorders is ascertained by a thorough prostate examination (including ultrasound, rectal touch and clinical history) and the measurement of levels of PSA, an antigenic factor present in the blood in abnormal concentrations when prostate cancer is beginning. In fact, prostate carcinoma is so testosterone-sensitive, that a drastic surgical therapy for highly aggressive cases is castration (removal of the testes) or the use of anti-testosterone drugs. In addition, testosterone replacement therapy in hypogonadrotrophic hypogonadism may lead to even lower FSH levels, an effect which is opposite to the desired one, because higher levels of testosterone inhibit the pituitary.
Even more controversial is taking testosterone precursors, such as DHEA (dihydroxiepiandrosterone), a substance needed by the testes to synthesize testosterone. The use of this substance has been triggered by reports that DHEA levels decrease considerably in function of age, and that DHEA replacement have a number of positive side effects, very much like increasing testosterone. It has been hailed by the lay press as a "miracle drug" to combat the effects of aging, to increase longevity and quality of life in old age. However, its effects on erectile dysfunction are not clear, as well as its long-range effects on the organism, such as on the incidence of prostate cancer. More dangerously, DHEA has been branded as a non-prescription diet supplement, because it is present in many natural foods. Thus, DHEA can be bought over the counter, without medical supervision.
For erectile dysfunctions which have a clear diagnosis of vascular etiology (cause), there are several kinds of vascular or arterial surgeries. Depending on the nature of the disorder, these surgeries aim at closing or decreasing the number of malfunctioning "escape" vessels (which lead to more firm and longer-actig erections), or by bypassing or cleaning obstructed arteries. The success rate is high, but it is a irreversible and expensive procedure. If the causes of the clogging or vessel integrity are not removed by other treatments, sometimes the surgery must be repeated.
These are the most irreversible and drastic ways of achieving artificial erection. Only when all other measures have been exhausted with no longer-lasting effects are achieved is that penile implants are warranted. These are prosthetic devices made of inert silicone, which are surgically inserted into the penis. Normal erection cannot be achieved after that. There are two kinds of penile implants:
Passive implants: two rods of silicone are inserted into the penis, which remains erect all the time. The silicone rods can be put in different angles, but this may be an embarassment in public occasions such as swimming. Orgasm may be achieved unless there are hormonal or neural factors which impede it.
Active implants: these are inflatable silicone pouches which are also implanted into the penis. The penis remains in flaccid state until a proper manipulation of the prosthesis causes its inflation and consequent erection. One type of implant is activated by pressing the glans (the head of the penis) with one hand. Liquid is transferred from a reservoir to the main inflatable pouches. In another type, the liquid reservoir is implanted into the scrotal sac, and can be pumped by hand.
Other surgical and non-surgical treatments for impotence are being tried in an experimental basis, and there may be a promising future for some of them. For instance, groups of physicians in Russia and Germany have been experimenting with electrical stimulation of the pelvic area using an external pad applied to the abdomen and back. There are already commercial devices using this principle, which seems to increase the blood flow in the genital area. Direct stimulation of pelvic nerves (leading to a nerve-induced erection) by using implanted electrodes and an electrical pacemaker-like device are also being considered.
"Natural" or alternative methods do abound. They range from "natural" foods which have high testosterone or DHEA levels, such as green oats (marketed under the brandname of SEXATIVA) or saw palmetto; to yoga exercises to increase muscle tone and blood flow in the genital area. It is hard to say whether there are real effects or they are just the effect of suggestion or placebo phenomena.
One thing has been scientifically determined, however. The blood levels of testosterone increase just after exercise, or by loosing excessive weight. Thus, a natural way of combating mild hypogonadism might be frequent exercising and keeping a normal weight.
From: Sexual Disorders. 1. Sexual Impotence
By: Renato M.E. Sabbatini, PhD and Silvia Helena Cardoso, PhD
In: Brain & Mind Magazine, August-November 1997
Updated: June 5, 1998.