What is impotence (ERECTILE DYSFUNCTION)?
Impotence is the inability to achieve or maintain an erection sufficiently rigid for sexual intercourse, ejaculation, or both. Sexual drive and the ability to have an orgasm are not necessarily affected. Impotence is medically defined as the inability to sustain an erection sufficient for intercourse on at least 25% of attempts.
Impotence is not new in medicine or human experience, but it is not easily or openly discussed. Cultural expectations of male sexuality inhibit many men from seeking help for a disorder that can, in most cases, benefit from medical treatment. The term "impotence"; comes from Latin and means loss of power; a more accurate term is "erectile dysfunction." The condition is normal and usually temporary, so it is highly unfortunate that the common term for it implies a sweeping diminution in a man's overall capabilities.
The Penis & Erectile Function
The Structure of the Penis.
The penis is composed of the following structures:
1. A pair of parallel spongy columns called the corpus cavernous .
2. A central chamber called the corpus spongiosum , which contains the urethra, the tube that carries urine from the body
Erectile Tissue. These structures are made up of erectile tissue Erectile tissue is rich in tiny pool-shaped blood vessels called cavernous sinuses . Each of these vessels are surrounded by smooth muscles and supported by elastic fibrous tissue composed of a protein called collagen.
The penis is either flaccid or erect depending on the state of arousal. In the flaccid, or unrest, normal penis, the following occurs:
1. Small arteries leading to the cavernous sinuses contract, reducing the inflow of blood.
2. The smooth muscles regulating the many tiny blood vessels within the penis are also contracted.
During arousal the following occurs:
1. The man's central nervous system stimulates the release of a number of chemicals, including acetylcholine and nitric oxide.
2. These chemicals relax the smooth muscles in the penis. This allows blood to flow into the tiny pool-like cavernous sinuses, flooding the penis.
3. This increased blood flow nearly doubles the diameter of the spongy chambers.
4. The veins surrounding the chambers are squeezed almost completely shut by this pressure.
5. The veins are unable to drain blood out of the penis and so the penis becomes rigid and erect.
Important Substances for Erectile Health
A proper balance of certain chemicals, gases, and other substances is critical for erectile health:
Collagen is the major component in structural tissue in the body, including in the penis. Excessive amounts, however, form scar tissue, which can impair erectile function.
Oxygen-rich blood is one of the most important components for erectile health. Oxygen affects two substances that are important in achieving erection:
1. Oxygen suppresses transforming growth factor beta 1 (TGF-B1). TGF-B1 is a component of the immune system called a cytokine and is produced by smooth muscle cells. It appears to stimulate collagen production in the corpus cavernosum, which can lead to erectile dysfunction.
2. Oxygen enhances prostaglandin E1. Prostaglandin E1 is produced during erection by the muscle cells in the penis. It activates an enzyme that initiates calcium release by the smooth muscle cells, which relaxes them and allows blood flow. Prostaglandin E1 also suppresses production of collagen.
Oxygen levels vary widely from reduced levels in the flaccid state to very high in the erect state. During sleep, oxygen levels are high and a man can normally have three to five erections per night, each one lasting from 20 to 40 minutes.
Testosterone and Other Hormones. Normal levels of hormones, especially testosterone, are essential for erectile function, though their exact role is not clear.
WHO BECOMES IMPOTENT?
A large 2000 survey suggested that nearly 620,000 American men between ages 40 and 70 experience erectile dysfunction of any degree each year, and an estimated 20 million and 30 million men in the US have erectile dysfunction at some point during their life.
Being older is primarily associated with impotence in most men. At a major professional meeting in 2000, experts reported survey results finding that 44% of men over age 50 experienced some degree of erectile dysfunction, but less than a quarter of them discussed their problems with a physician. Many felt this was simply an aging problem. Nevertheless, impotence is not inevitable with age. In another survey of men over 60 years old, 61% reported being sexually active, and nearly half derived as much if not more emotional benefit from their sex lives as they did in their 40s.
Severe erectile dysfunction in elderly men often has more to do with disease than age itself. For example heart disease, diabetes, and hypertension can cause sexual dysfunction and are more likely to occur in older than younger men.
So many physical and psychological situations can cause erectile dysfunction, in fact, that a man should consider brief periods of impotence to be as normal as having a cold. In fact, a cold is one common condition that can cause temporary impotence. It is safe to say, then, that every man experiences erectile dysfunction from time to time. [ See What Are Life Style and Psychologic Factors Contributing to Erectile Dysfunction? and What are the Physical Causes of Impotence?.]
WHAT ARE LIFE STYLE & PSYCHOLOGIC FACTORS CONTRIBUTING TO ERECTILE DYSFUNCTION?
Differentiating between Physical and Psychological Causes of Erectile Dysfunction
Over the past decades, the medical perspective on the causes of impotence has shifted. Common wisdom used to attribute almost all cases of impotence to psychological factors. Now investigators estimate that between 70% and 80% of impotence cases are caused by medical problems.
It is often difficult to determine if the cause of erectile dysfunction is a physical or psycho logic one, or even some combination. The following may be helpful:
1. Psychological impotence tends to be abrupt and related to a recent situation. The patient may be able to have an erection in some circumstances but not in others. Being unable to experience or maintain an erection upon waking up in the morning suggests that the problem is physical rather than psychological.
2. Physical impotence occurs gradually but continuously over a period of time. If impotence persists over a three-month period and is not due to a stressful event, drug use, alcohol, or medical conditions, then the patient needs medical attention by a urologist specializing in impotence.
In virtually every case of impotence, there are emotional issues that can seriously affect the man's self-esteem and relationships, and may even cause or perpetuate erectile dysfunction. Many men tend to fault themselves for their impotence even if it is clearly caused by physical problems over which they have little control.
Anxiety. Anxiety has both emotional and physical consequences that can affect erectile function. It is among the most frequently cited contributors to psychological impotence. Anxiety over sexual performance is often referred to as performance anxiety and may provoke an intense fear of failure and self-doubt. It can sometimes set off a cycle of chronic impotence. In response to anxiety, the brain releases chemicals known as neurotransmitters that constrict the smooth muscles of the penis and its arteries. This constriction reduces the blood flow into and increases the blood flow out of the penis. Simple stress may even promote the release of brain chemicals that negatively affect potency in a similar way.
Depression. Depression is strongly associated with erectile dysfunction. In one study, 82% of men who reported moderate to severe erectile dysfunction also had symptoms of depression. Depression can certainly reduce sexual desire, but it is often not clear which condition came first.
Problems in Relationships
Problems in relationships often have a direct impact on sexual functioning. Partners of men with erectile dysfunction may feel rejected and resentful, particularly if the affected man does not confide his own anxieties or depression. Both partners commonly experience guilt for what they each perceive as a personal failure. Tension and anger frequently arise between people who are unable to discuss sexual or emotional issues with each other. It can be very difficult for the man to perform sexually when both partners harbor negative feelings.
Losing a job or having lower income or education increases the risk for impotence.
Heavy smoking is frequently cited as a contributory factor in the development of impotence, mainly because it accentuates the actions of other disorders of the blood vessels, including high blood pressure and atherosclerosis.
Alcohol has also been implicated in causing impotence. In small doses, alcohol releases inhibitions, but in doses larger than one drink, it can depress the central nervous system and impair sexual function.
Lack of Frequent Erections
Infrequent erections deprive the penis of oxygen-rich blood. Without daily erections, collagen production increases and eventually may form a tough tissue that interferes with blood flow. The spontaneous erection men experience while sleeping or awake may be a natural protection against this process.
WHAT ARE THE PHYSICAL CAUSES OF ERECTILE DYSFUNCTION?
Oxygen Deprivation & its Causes
Erectile dysfunction most commonly occurs when the penis is deprived of oxygen-rich blood. When oxygen levels to the penis are low, an imbalance occurs in two important substances, TGF-B1 and prostaglandin E1:
TGF-B1 levels increase, which trigger production of collagen, a tough protein that forms all connective tissue, including scar tissue.
In addition, there is a reduction in prostaglandin E1, a chemical that suppresses collagen production and relaxes the smooth muscles to allow blood flow resulting in an erection.
When TGF-B1 levels increase and prostaglandin E1 levels decrease, smooth muscles waste away and collagen is overproduced, causing scarring, loss of elasticity, and reduced blood flow to the penis. A number of conditions can deprive the penis of oxygen-rich blood.
Blockage of Blood Vessels (Ischemia)
The primary cause of oxygen deprivation is ischemia, the blockage of blood vessels. The same conditions that cause blockage in the blood vessels leading to heart problems may also contribute to erectile dysfunction. For example, when cholesterol and other factors are imbalanced, a fatty substance called plaque forms on artery walls. As the plaque builds up, the arterial walls slowly constrict, reducing blood flow. This process, known as atherosclerosis, is the major contributor to the development of coronary heart disease. It may also play a role in the development of erectile dysfunction.
Common Medical Conditions That Contribute to Erectile Dysfunction
Diabetes may contribute to as many as 40% of impotence cases . Between one third and one half of all diabetic men report some form of sexual difficulty. Atherosclerosis and nerve damage are both common complications of diabetes; when the blood vessels or nerves of the penis are involved, erectile dysfunction can result.
High Blood Pressure.
Erectile dysfunction is more common and more severe in uymen with hypertension than it is in the general population. Many of the drugs used to treat hypertension are thought to cause impotence as a side effect; in these cases, it is reversible when the drugs are stopped. More recent evidence is suggesting, however, that the disease process that causes hypertension itself is the major cause of erectile dysfunction in these men. Newer anti-hypertensive agents, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) are less associated with erectile dysfunction. In fact, ARBs may be particularly effective in restoring erectile function in men with high blood pressure who suffer from impotence.
As a risk factor for impotence, Parkinson's disease (PD) is an under-appreciated problem. It is estimated that about one-third of men with PD experience impotence. The physical cause of PD-related impotence is most likely an impaired nervous system. Depression and lowered self-esteem also contribute to erectile dysfunction in these patients.
Other Medical Conditions.
Multiple sclerosis (MS), which affects the central nervous system, also precipitates sexual dysfunction in as many as 78% of male patients. Corticosteroids, which are common treatments for MS, may improve sexual function. Other medical conditions that contribute to erectile dysfunctions include spina bifida, a history of polio, and chronic kidney failure.
Physical Causes of Erectile Dysfunction
The origins of erectile dysfunction are twofold: physical and psychological. Up to thirty years ago, psychological factors were thought to be most important. Sex therapists Masters and Johnson went so far as to claim that nine out of ten men with erectile dysfunction had a psychological problem. For example, men with depression are very often impotent. But nowadays, we know that even though the psychological aspect is very important, a lot of men with erectile dysfunction have physical problems.
Of course, it isn't necessarily as simple as you might think to separate the two, because erectile dysfunction causes changes in a a man's emotional state: all of us who have found ourselves impotent on occasion will know the anxiety and depression this can produce. One can therefore legitimately ask whether stress, anxiety and depression cause erectile dysfunction or whether they are a result of it.
But in all cases, we should keep in mind the way in which erections develop so we can see how these basic principles may be affected by physical or psychological factors. First, the erectile tissue may not fully fill with blood because arterial blood flow to the penis is partially impeded. This means a man will not get an erection. On the other hand, when a man loses his erection before orgasm and ejaculation, he most likely has some problem in his venous occlusive mechanism: this is the system that keeps blood in the penis and thus holds his erection firm. A failure in either of these areas can cause erectile dysfunction.
Blood vessel abnormalities as a cause of erectile dysfunction
As we said above, if the arteries which carry blood to the penis are blocked or damaged, or if the veins which drain blood from the penis are damaged, a good erection may fail to develop, or be maintained, respectively. Most often, a blockage of the arteries which carry blood to the penis is responsible: as little as fifteen percent blockage (occlusion) of these very small blood vessels can cause a problem with erectile dysfunction. This blockage is often caused by risk factors like smoking cigarettes, high blood pressure, diabetes, and elevation of blood cholesterol levels. Injury caused by pelvic trauma or pelvic radiation therapy may also be responsible.
Most men with erectile dysfunction caused by a reduction in arterial blood flow will show other cardiovascular problems in the body. For even if they have not had a heart attack, impotent men often have a history of coronary artery disease, and some men with erectile dysfunction have poor blood circulation to their feet and legs, again as a result of arterial occlusive disease.
A past pelvic fracture which has blocked one of the arteries carrying blood to the penis may also cause erection problems: this is sometimes seen in young patients, in their twenties, who have undergone pelvic trauma or fracture. And as is fairly well known, diabetic men may show erectile dysfunction as an effect of damage to the nerve and vascular supply to the penis. Diabetic men, and some older men, have large amounts of scarring, or fibrosis, on the inside of the walls of the arteries which supply the blood to the penis. Scarring, caused by arterial plaque buildup, can reduce the internal diameter of the arteries.
Patients with high lipid levels in their bloodstream are definitely at increased risk of arteriosclerosis, because the excess lipid builds up in the internal walls of the arteries and eventually leads to a blockage. Hypertension - high blood pressure - is yet another risk factor. It's no surprise, therefore, that almost half of one series of impotent men who were the subject of a research study had hypertension. But it's not the increase in circulating blood pressure itself that is the cause of erectile dysfunction; in fact, it's the arterial stenosis found in men with high blood pressure that is most likely to be the origin of their erectile dysfunction.
As we said above, failure of the mechanism that closes the veins that allow blood to drain from the penis is one of the more common causes of vasculogenic erectile dysfunction. In some men, the the veins are never fully clamped as the arterial blood flows into the penis early in the erection - though this is mostly a problem for older men, it may be seen in relatively young men who have had erection problems through their entire life. These men tend to report that a normal erection begins to develop, but after seconds of sexual activity (at most, a minute or so), they will lose their erection. Surgery may be one answer for this kind of problem.
Peyronie's disease is characterized by non-elastic scar tissue forming on the inner surfaces of the tunica albuginea, which in turn prevents adequate compression of the veins under the tunical surface. This means the arterial blood is not held within the penis in the normal way.
In an anxious man, the trabecular smooth muscle of the penis and the vascular spaces of the penis may not relax sufficiently to allow adequate sinusoidal expansion, in which case the subtunical veins will not become compressed sufficiently to maintain an erection. This may happen when a man is overanxious. In effect, his adrenalin impairs relaxation of the smooth muscle of his penis in response to the stimulation of nitric oxide.
Interestingly, smoking cigarettes, apart from causing widespread arterial blockage, may also prevent the cavernous smooth muscle from dilating enough. Once more, there is not enough clamping of the penile veins to permit the increase in intracavernous arterial pressure which is required for an erection.
Hypogonadism (Testicular Failure).
Hypogonadism in men is a deficiency in male hormones, usually due to an abnormality in the testicles, which secrete these hormones. It affects 4 to 5 million men in the United States. In addition to impotence, hypogonadism causes reductions in energy, sex drive, lean body mass, and bone density. Hypogonadism can be caused by a number of different conditions. Among them are the following:
1. Disorders in the pituitary or hypothalamus glands.
3. Genetic factors.
4. Myotonic dystrophy.
5. Orchitis (inflammation of the testicles).
6. Physical injury.
8. Radiation treatments.
- Exercise-induced hypogonadism
Only a few cases of exercise-induced hypogonadism have been identified in men, but some researchers believe certain athletes may be at risk, including those who began endurance training before full sexual maturity, have very low body weight, and have a history of stress fracture.
Low Testosterone Levels.
Only about 5% of men who see a physician about erectile dysfunction have low levels of testosterone, the primary male hormone. In general, lower testosterone levels appear to reduce sexual interest, not cause impotence. A 1999 study, however, suggests that testosterone levels are not an accurate reflection of sexual drive.
Other Hormonal Abnormalities.
Other hormonal abnormalities that can lead to erectile dysfunction in men are the following:
High levels of the female hormone estrogen may cause impotence (which may occur in men with liver disease).
Abnormalities of the pituitary gland that cause high levels of the hormone prolactin are particularly likely to cause impotence.
Other, uncommon hormonal causes of impotence include abnormalities of the thyroid gland and the adrenal glands.
HOW SERIOUS IS ERECTILE DYSFUNCTION?
Impotence can be a symptom of serious medical conditions, such as atherosclerosis, diabetes, and hypertension. It can also indicate injury, age-related changes in tissue, or long-term effects of smoking, heavy drinking, or unhealthy diet. Psychological effects can be significant; erectile dysfunction can have a devastating impact on a relationship and can cause extreme depression, which may become chronic if not treated. When a consistent pattern of sexual dysfunction extends over a prolonged period of time, a serious physical or emotional disorder may be indicated.
HOW IS ERECTILE DYSFUNCTION DIAGNOSED?
The physician typically interviews the patient about many physical and psycho logic factors. The patient must be as frank as possible for his physician to make a diagnosis. He should not interpret these questions as intrusive or too personal if he expects to obtain help. These questions are very relevant and important for determining the proper approach. Even when erectile dysfunction has a clear physical cause, relationships and psychological factors can also have an effect.
Medical and Personal History. The physician should take a medical and personal history and may ask about the following:
1. Past and present medical problems.
2. Medications or drugs being used.
3. Any history of psychological problems, including stress, anxiety, or depression.
Sexual History. In addition the physician will ask about the patient's sexually history, which may include the following:
1. The nature of the onset of the dysfunction.
2. The frequency, quality, and duration of any erections, and whether they occur at night or in the morning.
3. The specific circumstances when erectile dysfunction occurred.
4. Details of technique.
5. The patient's motivation for and expectations of treatment.
6. Whether problems exist in the current relationship.
Interviewing the Sexual Partner. If appropriate, the physician might also interview the sexual partner. In fact, including the partner in the interview process may help the physician to better decipher underlying causes and in turn better recommend treatment choices.
The physician should perform a careful physical exam, including examination of the genital area and a digital rectal examination (the doctor inserts a gloved and lubricated finger into the patient's rectum) to check for prostate abnormalities.
Blood Tests for Hormonal Abnormalities.
Blood tests may be used to measure testosterone levels and, if necessary, prolactin levels to determine if there are problems of the endocrine system. A 1999 study suggests that testosterone level is an inadequate measure of sexual drive and that more research is needed to determine the value of routine assessments of this hormone in erectile dysfunction or low sexual drive. The physician may also screen for thyroid and adrenal gland dysfunction. In addition, various specific tests for erectile dysfunction can be performed.
Tests for Medical Conditions that may be Causing Erectile Dysfunction. Evidence of other medical conditions should be sought, particularly hypertension, diabetes, atherosclerosis, and nerve damage.
Monitoring Nighttime Erections
Tests that monitor night-time erections may be used to determine if the causes of erectile dysfunction are more likely to be psychological. Neither of the following methods is helpful in determining a physical cause for erectile dysfunction.
The snap-gauge test monitors the man's ability to achieve an erection during sleep. It is a very simple test.
· When the man goes to bed, he places bands around the shaft of his penis.
· If one or more breaks during the course of the night, it provides evidence of an erection. In this case, a psychological basis for the erectile dysfunction is likely.
A more sophisticated and more expensive device is the RigiScan monitor, which makes repetitive measurements of rigidity around the base and tip of the penis. This test is quite accurate but may fail to detect mild cases of erectile dysfunction.
Penile Brachial Index
The penile brachial index is a measurement that compares blood pressure in the penis with the blood pressure taken in the arm. Problems with the arterial flow to the penis can be detected using this method.
Imaging tests may be used in certain cases, but they are expensive and often limited to younger men. Anyone considering these tests should have them done in a specialized setting with professionals experienced in the use of the diagnostic instruments and in analyzing the data from them.
Dynamic Infusion Cavernosometry and Cavernosography. Dynamic infusion cavernosometry and cavernosography (DICC) is usually only given to young men in whom some blockage of the penis or physical injury of the pelvic area is suspected. After an erection is induced with drugs, the following four steps are taken:
· The penile brachial index is taken.
· The storage ability of the penis is gauged.
· An ultrasound of the penile arteries is performed.
· An x-ray of the erect penis is taken.
Unfortunately, this test and other similar imaging techniques used to determine blood flow in the penis are currently not very effective or accurate in diagnosing and determining treatment.
Venous insufficiency of the corpora cavernous in a patient with erectile dysfunction. Despite a satisfactory arterial response, there is continuous venous flow during the erection in the deep dorsal vein of the penis.
Ultrasound alone may prove to be useful in detecting some causes of erectile dysfunction, such as leakage from blood vessels.
WHAT ARE THE GENERAL GUIDELINES FOR TREATING ERECTILE DYSFUNCTION?
Approach to Treatment
The cause of impotence dictates the mode of treatment. The first step is to define the cause, if possible, and then try the simplest and least-risky solution.
Before a certain treatment is prescribed, the following factors should be considered:
· Any pre-existing illnesses and medications.
· The degree of comfort with the treatment method.
· Partner satisfaction, and safety profiles need to be considered. Experts strongly recommend that the patient's partner be involved to help with any necessary sexual adjustment.
No matter what the treatment, embarking on a healthy lifestyle is the first and critical step for maintaining and restoring erectile function.
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