As a result of the intense study of impotence and the technologic advances of the last 20 years, we can better define impotence.  We know that the majority of impotence cases have a physical cause and are not psychological.  We know that impotence can have a devastating effect on the individual and his family.  We know how to better diagnose impotence.  And most importantly, we know how to treat impotence and are quite successful at doing so; we now have treatment options for impotence.

The most frequent cause of organic (non-psychogenic) impotence is vascular/blood flow impairment.  Changes to the flow of blood into the penis (cavernosal arterial insufficiency) or impedance of blood flow out of the penis (corporal veno-occlusion) result in impotence.

Although tremendous progress has been made in the diagnosis and treatment of impotence, work remains to be done.

Q:  Does age have anything to do with erections?

Dr. Green:  Yes.  Nocturnal penile tumescence and rigidity testing (NPTR) reflects the integrity of the brain and spinal cord to the penis; when nighttime erections during sleep are of appropriate duration and strength, the brain and spinal cord are intact.  Three to five erections per night are normal.  NPTR shows age-specific variations:  total erect time during sleep peaks at the age of puberty, when as much as 20% of total sleep time may be spent with an erection.  In the second decade of life, the average duration of a nocturnal erection is approximately 30 minutes.  Likewise, rigidity of nocturnal events diminishes with age.

Q:  Does lifestyle affect erections?

Dr. Green:  Yes.  Smoking and excess alcohol adversely affect erections.  Alcohol abuse also diminishes one's interest in sex (libido).  Stress, obesity, poor physical conditioning, and poor self image adversely affect sexual performance.  In addition, some prescription drugs and illicit street drugs alter sexual performance.

Q:  What causes impotence?

Dr. Green:  The causes of impotence are many.  We divide the causes into two categories, physical and psychological.  In years past we thought that the majority of impotence was psychologically based.  However, recent data would suggest that over one-half of the time there is a physical (organic) cause for impotence.  Here are some examples of both categories:

• Psychological:  Stress, Martial/Family discord, Job instability, Depression, and Performance anxiety.
   
• Physical: Hormone imbalance, Drugs, Penile diseases, Nerve disorders, Pelvic surgery, Diabetes, Radiation treatment, Chronic illness, and Vascular disease (poor circulation).
   
• Drugs: Antihypertensives (blood pressure), Antidepressants, Antipsychotics, Sedative-hypnotics, Antiandrogens, and illicit street drugs.

Q:  How do you evaluate patients suffering from erectile dysfunction?

Dr. Green:  Our protocol is as follows:

1. a complete medical history with a special emphasis on medications, illicit drugs, alcohol use, cigarette smoking, chronic illness, surgeries, radiation treatments, and previous surgeries.
2. a physical examination.
3. laboratory blood tests with a focus on the blood, liver, kidney, and hormonal systems.
4. psychological assessment.
5. erection testing.

Q:  What methods are used to measured NPT and what does it mean?

Dr. Green:  Commonly used methodologies for NPT are as follows:  Postage stamp test, Snap gauges, Strain gauges, RigiScan, and Sleep laboratory.  In the majority of cases a normal NPT suggests that the problem is psychogenic, whereas abnormal NPT suggests that the problem has an organic basis.

Q:  I was told that "poor circulation" caused me to be impotent.  Is that true?

Dr. Green:  Poor circulation, specifically poor blood flow to the penile arteries due to hardening and narrowing of the arteries (arteriosclerosis), or thickening of the blood, can cause impotence.  Likewise, an abnormal leakage of blood from the penis can result in an inability to sustain a satisfactory erection.

Q:  How do you evaluate circulation to the penis?

Dr. Green:  There are two basic ways to evaluate penile blood flow:

• Non-invasive diagnostics such as penile injections with a vasoactive drug with/without Doppler Ultrasound.
   
• Invasive diagnostics such as cavanosometry, cavernosography, and pelvic arteriography;  these tests are usually done only with the expectation that one is contemplating surgical correction of the penile blood vessels.

Q:  Can you really do bypass surgery on the penis the way heart operations are done?

Dr. Green:  Yes, to a certain degree.  Penile vascularization procedures have been and are being done.  The degree of success varies.  A good approximation of the success is 50%.  When limited to focal arterial obstruction secondary to trauma the results are better (70%). Experience reveals that surgery for venous leaks has not provided long term success.

Q:  This impotence phenomenon appears so complicated.  Can you briefly and simply explain how an erection occurs?

Dr. Green:  Yes. For a good quality erection to occur and sustain itself several body parts must work as a team.  The brain is the quarterback and send signals to control the psychic, nervous, spinal cord, vascular, and musculoskeletal systems.  Specifically:

• the brain perceives arousal and stimulation.
   
• hormones are released from the brain and testes supporting the sex drive.
   
• arteries increase the blood flow to the penis 10 fold and cause it to become firm.
   
• nerve impulses relay signals of arousal to and from the penis.
   
• at the completion of climax the veins drain the blood from the penis.

Q:  Do men go through "menopause"?

Dr. Green:  In men there is no true counterpart to the female menopause, which is characterized by an abrupt decline in serum estrogen levels, lack of menses, and the development of "hot flashes".  The value of hormone replacement is well documented.  In contrast, androgen levels gradually decline 30 to 40% in men from their late 40s to early 70s; sperm production continues into the eighth decade of life. In addition, men do not experience hot flashes unless testosterone declines to castration levels, such as when the testes are removed for advanced prostate cancer.

Q:  What is DHEA (Dehydroepiandrosterone)?

Dr. Green:  DHEA is an adrenal steroid which can be converted in the body to more active androgens.  It has been referred to in the lay press as "the fountain of youth pill".  DHEA is produced in response to ACTH stimulation, but unlike other corticosteroids there is no feedback control of DHEA secretion at the hypothalamus-pituitary. DHEA does not have any androgenic activity nor does it bind to androgen receptors.  However, numerous tissues contain enzymes which can convert DHEA to testosterone or 5-alphadihydrotestosterone (DHT); these sites include bone, muscle, breast, prostate, skin, and brain.  Maximal concentrations of endogenous DHEA are reached in the third decade of life, then there is a slow, steady decline of 2% per year, reaching a level of 10-20% during the eighth decade. Many men are availing themselves of androgen replacement therapy, the most prominent being DHEA.

Q:  Can low male hormones cause erectile dysfunction?

Dr. Green:  Yes, but this is not as common as one might suspect.  The hormonal abnormalities most commonly associated with erectile dysfunction are hypogonadism and hyperprolactinemia.  Thyroid and adrenal dysfunction play a smaller role.

Q:  What does DHEA actually do in the body?

Dr. Green:  Low levels of DHEA have been implicated in the development of breast cancer in women.  A therapeutic effect in diabetes and a protective effect against the development of arteriosclerosis have been suggested.  Low levels have been observed in obese patients, and replacement has been reported to decrease cholesterol, LDLs, and body fat.  DHEA is thought to play a role in the stimulation of the immune system and in brain function.  Cancers, arteriosclerosis, decreased immunological responsiveness, and deteriorating brain function are all consequences of aging.  Metabolic studies suggest that 25-50 mg orally per day will return serum DHEA levels to those of a 30- to 40-year-old, without leading to excess levels of testosterone or DHT.  DHEA is naturally occurring and is neither a food or a drug, and thus companies manufacturing it do not need FDA approval.  It can be obtained as a nutritional supplement.

Q:  Is DHEA dangerous?

Dr. Green:  Potential adverse effects could result if too much DHEA is consumed.  These effects would be due to the excessive production of sex steroids.

Q:  How do you treat impotence?

Dr. Green:  The treatment of impotence falls into one of five categories:

1. Lifestyle and medication changes.
2. Psychosexual therapy.
3. Medical therapy.
4. Medical devices.
5. Surgery.

Q:  What are the specific therapies?

Dr. Green:  For lifestyle changes, we encourage regular exercise, a healthy diet, smoking cessation, and alcohol in moderation, and we discourage long-distance bike riding. When medications can be identified that interfere with erectile function such as some antihypertensives and antidepressants, we work in conjunction with your prescribing physician to alter the medicine and substitute one with less anti-potency effect.

In some instances, for psychogenic or mixed impotence, we recommend psychosexual therapy or minimally invasive therapy, e.g., a vacuum erection device, penile self-injections, or transurethral therapy.  For defined medical entities such as hypogonadism or hyperprolactinemia, we recommend the following:

Hypogonadism:  testosterone replacement therapy, particularly in a young man with low serum testosterone levels. Supplemental testosterone can be given with either injectable preparations or skin patches.

General medical therapies include the following:

• Yohimbine, an alkaloid derived from the bark of an African Coryanthe johimbe tree, is chemically similar to reserpin.  It is considered an "aphrodisiac".
   
• Bromocriptine is used for the treatment of hyperprolactinemia.
   
• Vasodilan (Isoxsuprine) is a peripherally acting drug used to increase blood flow.
   
• Trazadone (Desyrel) is a non-tricyclic antidepressant which has shown some positive effect on night time erections.
   
• The following are experimental drugs:
   
• Apomorphine (Dopaminergic agonist) is a centrally acting drug reported to have some success in treating impotence.
• Sildenafil (Viagra) is an inhibitor of phosphodiesterae enzyme (PDE 5) which breaks down cGMP which dilates smooth muscle in the penis, thus enhancing erections.
• L-arginine influences the nitric oxide pathway; under investigation.
• Phenolamine can improve erections in some men by oral or buccal administration.
• Minoxidil (Rogaine 2%) applied to the glans can cause significance penile tumescence.
• Nitroglycerin Paste is a nitric oxide donor which after being applied directly to the penis causes an erection; however, headaches occur in both patient and partner.

Intracavernosal Drug Therapy

In 1982 Dr. Virag reported that an erection could be achieved by injecting papaverine into the penis.  Since that time injection therapy has become a successful form of diagnosing and treating erectile dysfunction.  A number of different agents are used singularly or in combination.  Contrary to a normal erection, detumescence does not occur with ejaculation but only when the medication becomes metabolized in the penis or diffuses into the systemic circulation.  The most commonly used drugs are papaverine, phentolamine, and prostaglandin E1.  These drugs all increase arterial blood flow into the penis.  Some potential side effects are pain, headache, nausea, hypotension, priaprism, fainting, and penile scarring with deformity.  Firm erections lasting up to one hour or more can be obtained with this therapy.  NB:  If one develops an erection that lasts longer than four hours, he should immediately contact his urologist or report to a hospital emergency department for treatment.  Prolonged erections can cause pain and penile damage!

Intraurethral Prostaglandin E1 (Muse)

Prostaglandin E1 packaged as a pellet suppository placed in the urethra results in erections in approximately two-thirds of men.  Side effects are minimal. It can be harmful to pregnant females and therefore should not be used with pregnant partners.

Mechanical Devices

• Vacuum Erection Device (VED).  An erection can be achieved in some individuals with a VED.  A clear cylinder chamber is placed over the penis.  A hand- or battery-operated pump is used to create a vacuum which draws blood into the penis.  This blood is held in the penis with a "constrictor band" which must be worn during coitus.  Approximately 70% of patients achieve satisfactory erections with VEDs.
   
• Venous Flow Controllers (VFCs).  In some men the erectile dysfunction is due to their inability to store/trap blood in the penis necessary to sustain an erection.  VFCs are available that reduce the blood outflow from the penis, thereby assisting in maintaining the erection.

Surgery

1. Vascular Surgery.  Penile arterial bypass, surgery likened to coronary artery bypass surgery, has been available for over 20 years.  However, the success of such surgery has varied from 20-80%.  Success has been achieved primarily in young patients with focal arterial lesions resulting from trauma.

2. Venous Ablation Surgery is rarely successful.  However, young men who have never achieved a satisfactory erection, those experiencing pelvic trauma, and who have undergone previous penile surgery for priapism" may be candidates for this type of surgery.

3. Penile Implant (Prosthesis) Surgery.  Penile Prosthesis Surgery became popular in the 70s with the development of the Small-Carrion semi-rigid prosthesis and the Scott inflatable penile prosthesis.  Implant surgery is fitted to the patient and is totally concealed.  The operation is either day surgery or a single overnight stay in the hospital.  Recovery from the surgery varies with the individual; however, most individuals recover in approximately 7-10 days.  Thus, we can divide penile prostheses into two categories: non-hydraulic (semi-rigid) and hydraulic (inflatable).

Hydraulic:

• One-Piece Malleable (AMS Dynaflex) is a paired system that houses the pump in the distal section of the device and the reservoir on the proximal section.  This prosthesis can be difficult to operate, produces suboptimal rigidity, protrudes when unclothed, and is expensive.
• Two-Piece Inflatable (Mentor Mark II & AMS Ambicor).  These prostheses consist of a pair of corporeal cylinders connected to a combined reservoir pump housed in the scrotum.  This can be advantageous in patients that have undergone previous abdominal surgery with subsequent scar formation.  The disadvantage is that the reservoir can accommodate a limited amount of fluid, which may not be adequate to obtain a maximum penile circumference and length.
• Three-Piece (Fully Inflatable) Penile Prosthesis.  This prosthesis comes the closest to simulating a normal erection.  It increases both girth and length with inflation and appears normal.  There is also excellent detumescence and concealment; there is no embarrassment due to protuberance.  A high degree of satisfaction with these types of prostheses has been obtained.  These multi-component prostheses require more skill to implant and there is the potential for increased malfunction.
   

Q: Will my insurance health plan cover the evaluation and management of impotence?

Dr. Green: Probably; most insurance or health plans cover the evaluation and management of "organic impotence", i.e., impotence of a non-psychological basis.  However, it is prudent for you to review that benefit with your insurance or health plan's benefits officer.

2. There are a number of new oral agents (Impotence Pills) being tested for use in Erectile Dysfunction. Phentolamine (Vasomax) and Apomorphine are being investigated.

3. Premature ejaculation can be a result of performance anxiety, an emotional disorder, or unreasonable expectations.  Although behavioral therapy is effective and has been the mainstay of treatment, a number of new drugs such as Anafranil, Sertraline, and Fluoxetine can delay ejaculation.

4. If libido and erectile function are normal, then anorgasmia usually has a "psychological origin".

5. Although genital aesthetic and penile enlargement surgeries are effective with low morbidity and are reported to receive high patient satisfaction, it is a new and evolving technique.

6. Priaprism is a painful, persistent (greater than 4 hours) erection.  Unlike a normal erection, in priaprism, the glans is soft. Patients on penile injection therapy programs should contact their Urologist or proceed to the nearest Emergency Department if they develop priaprism after penile injection.

7. Peyronies' Disease is a fibrosising disease of the penis of unknown origin.  Peyronies' disease may cause penile deformity, pain, or impotence.  Treatment, when necessary, may involve oral medications, intralesional injections, ultrasound, radiation, and surgery.

8. Medications such as antihypertensives, over the counter medicines that contain sympathomimetic agents, and excessive caffeine may cause erectile dysfunction.

9. Cycling may injure the blood vessels supplying the penis with blood and thus cause erectile dysfunction.

10. Because testosterone stimulates prostate cancer growth, androgen supplements should not be given in anyone suspected with or known to have prostate cancer.

11. Penile prostheses continue to be a good, reliable and predictable treatment option for erectile dysfunction.