Impotence is defined as the inability either to obtain or to maintain an erection so as to satisfy both partners during sexual intercourse. Ninety percent of impotence is due to a physical cause, while 10% of impotence is psychological in origin.

The physical causes of impotence are classified into three categories: failure to initiate an erection because the nerves to the erectile tissue do not function; failure to fill the penis because of poor arterial blood flow; and failure to store blood within the erection tissue because of damage to the smooth muscle of the penis.

The major causes of impotence today are diabetes, atherosclerosis or hardening of the arteries, and impotence following radical pelvic surgery. Other causes include spinal cord injuries, hormonal problems and multiple sclerosis. The abuse of drugs, alcoholism and smoking can interfere with normal erections, and well over 200 different prescription medications can cause impotence as a side effect.

Diagnosis

A complete history and physical, along with some psychological screening and an evaluation of the hormonal levels, are most important. Other tests may include an evaluation of erections while sleeping. A healthy male might have four to five erections during a night of restful sleep. This is something that cannot be suppressed by psychological means, and measuring these erections can be helpful in determining the cause of impotence. Other studies include evaluation of nerve function, blood flow measurements to the penis, ultrasound of the penis, and x-rays of the arteries and veins of the penis.

Treatment

Medical treatment for impotence includes counseling when a psychological problem is discovered. Working with couples as well as reducing tension, improving communications, and trying to obtain realistic expectations are areas where counseling can help.

Hormone Therapy

Hormone treatments, namely testosterone, can be used in men whose production of male hormones is low. Testosterone injections can not really help men who do not have low levels, which can be measured by the physicians at the initial evaluation.

Viagra (Sildenafil) Cialis (Tadalafil) Levitra (Vardenafil)

Viagra, Cialis, and Levitra are medications that affect an enzyme in penile erectile tissue. It will enable many men with erectile dysfunction to respond to sexual stimulation. When a man becomes sexually excited, these medications help the penis fill with blood to cause an erection. After intercourse, the erection subsides. These medications are contraindicated in men taking nitrates, and with significant cardiovascular disease, or angina retinitis pigmentation.

Self-Injection Therapy

This involves the patient or his partner giving an injection of medication directly into the side of the penis to create an erection. This erection created is a natural one and usually begins 5 to 10 minutes after injection. Not all patients respond to this type of treatment but those who do should develop an erection that lasts anywhere from 30 to 120 minutes. About 70% of men find their erections are satisfactory with self-injection therapy. The drugs used include prostaglandin (PGE-1 or Prostin or Alprostadil or Caverject), papaverine hydrochloride and phentolamine (Regitine). All of these drugs have been approved by the FDA for uses other than impotence treatment. Only prostaglandin has been approved by the FDA for uses other than impotence treatment. Papaverine and phentolamine have not yet been approved by the FDA for this specific purpose..

Urethral Suppositories

MUSE is the name of a drug treatment and represents a unique approach for the treatment of erectile dysfunction. It is based on the discovery that the urethra can absorb certain medications into the surrounding erectile tissues, thereby creating an erection. The MUSE system uses prostaglandin E₁, the same medication used in self-injection therapy, and has been approved by the FDA for the treatment of impotence.

Vacuum Erection Devices

The vacuum erection device is a simple mechanical tool which allows the man to develop an erection which is suitable for sexual intercourse. The vacuum erection device works by bringing more blood into the penis and then trapping it there.

Surgical Treatment

Penile Prosthesis

One of the options for treatment of erectile dysfunction is the placement of prosthetic inner tubes within the penis to mimic the inflation process and create an erection. Penile implants were first used in the 1950's, and hundreds of thousands of men throughout the world have been treated successfully with penile implants. There are three types of penile prostheses which include the semi-rigid implant, the inflatable implant, and the self-contained inflatable implant.

Semi-Rigid

Semi-rigid implants are paired silicone-covered malleable or bendable metal rods. The semi-rigid prosthesis allows the penis to be rigid enough for penetration, but flexible enough to allow concealment in a curved position. It is the simplest of all the prostheses and has the least chance of mechanical failure.

Inflatable Penile Prosthesis

Inflatable penile prostheses ar the most natural of the implants. These are soft, paired inner tubes made of silicone or bioflex, which are inert plastics. The inner tubes are filled with a solution that comes from a small reservoir placed under the muscles of the abdomen. A pump is used to transfer the fluid from the reservoir to the penile cylinders. When the erection is no longer desired, the fluid is returned to the reservoir leaving the penis soft and pliable. The major advantage of an inflatable penile implant is a more natural erection with total patient control.