For example a man may be able to have good erections which last long enough to allow him to ejaculate during masturbation but is unable to attain or maintain his erection when he is with his partner.
Impotence is also classified in to primary and secondary. In primary impotence, the man has suffered the problem all his life without ever having a normal erection. In contrast, in secondary impotence, the problem starts after a period of normal erectile function. Secondary impotence is very much more common than primary impotence.
Many doctors now prefer to use the more medical terms erectile disorder or erectile dysfunction rather than impotence.
Q. How big a problem is it?
A. Impotence is a much more common problem than most people think affecting at least one in every ten men. Although it occurs much less frequently in men under the age of 40 years than in older men, it can occur at any age. The proportion of men who experience impotence increases with age and by 80 years at least 50% of men suffer this problem. Approximately 85% of sufferers of impotence are over the age of 50 years. The Department of Health estimated that there are 2 million men with impotence in the UK. This is probably an underestimate.
Q. What are the principle causes?
A. Impotence is not a disease but rather a symptom of some underlying medical or psychological condition. Evidence of medical disease is said to be found in at least 80% of men with impotence and it is for this reason that all men who suffer impotence are advised to be examined by a doctor. However, because a man who has impotence is found to have a medical disease, it does not necessarily mean that the disease is the cause of the impotence and very often both physical and psychological (including relationship problems) conditions combine to cause impotence. Unfortunately, many doctors address the physical causes but leave concomitant psychological problems unrecognised and untreated. This may lead to failure to re-establish long term, mutually satisfying sex life.
Q. What are the physical causes of impotence?
A. Among the physical causes of impotence are many commonly occurring diseases including diabetes, high blood pressure, narrowing of the arteries (such as may occur with raised cholesterol) and diseases that affect the nervous system such as multiple sclerosis. Impotence may occur as a result of damage to the nerves and blood vessels supplying the penis. Such damage might occur as a result of injury (eg fractured pelvis, fractured spine) or extensive surgery such as might be needed for the treatment of some forms of cancer arising the abdominal or pelvic structures. It can also occur as a result of prostate surgery, especially when the prostate gland is removed (radical prostatectomy). Impotence can also be caused by hormonal disturbances, especially reduced levels of the male sex hormone, testosterone.
Alcohol
Whilst a small amount of alcohol taken before sex may not affect erections (it may actually help them by releasing inhibitions) larger amounts have a depressant effect on sexual function and may impair erections. Alcohol abuse frequently causes impotence.
Smoking
Most studies have shown cigarette smoking to be associated with increased risk of developing impotence. This is because smoking damages blood vessels causing them to become blocked and when this affects the arteries in the pelvis it reduces blood flow to the penis.
Prescribed drugs
Many commonly prescribed drugs sometimes cause impotence. The list of drugs that have been reported to do this is very long and it is not always certain that the drug involved in a particular cause actually caused the impotence.
Especially important in this respect are drugs that lower blood pressure, drugs used to treat depression and schizophrenia and drugs that block the effects of testosterone, such as may be used in the treatment of prostate cancer.
Some men who develop impotence whilst taking a drug try stopping the drug to see if the erections improve. Men should be encouraged to discuss the problem with their doctors before stopping a prescribed medication. Sometimes the doctor is able to change the treatment to a one that is less likely to impair erections.
Psychological causes of impotence
Perhaps the most frequent psychological cause of impotence is fear of failure. If a man fails to get or maintain his erection on one occasion (such as might occur following drinking excessive amounts of alcohol, tiredness or being disturbed while making love) he becomes fearful that it will happen again. So next time he tries to make love his mind is too focused on "will it fail again this time" which actually blocks him from getting an erection. If, when he loses his erection, he is ridiculed by his partner, then this fear of failure is aggravated.
Impotence can occur as a result of difficulties in the man's relationship with his partner. Conflict causing arguments and hostility are especially likely to affect sex. We often say that if things in the relationship go wrong in the kitchen then they will go wrong in the bedroom as well. Often forgotten factors in maintaining a good sex life is positive feedback and encouragement from one's partner and the partner's enthusiasm before, during and after sex. Hence some men develop impotence because their partner does not enjoy sex and regards it just as a chore, something she must involve herself in just to keep her partner happy. I refer here to a female partner but it could equally apply to a male partner in gay relationships.
Sometimes impotence develops as a response to guilt caused by being unfaithful. It may occur at times when a man's self-esteem is low, such as after being made redundant from work or after serious illness or surgery. Men who work very long hours, and perhaps take additional work home to complete, sometimes develop problems with their erection probably because of over-tiredness or because they are not left with enough time to devote to their partner. In this situation, sex may become harried with insufficient time for foreplay.
Effect of age
Although the incidence of impotence increases with age it is not a direct consequence of ageing. It is because, as men age, they are more likely to develop diseases that can cause impotence. One thing that does happen as men age is that their sexual responses tend to become slower (as they do in women). They require more stimulation to gain an erection than they did when they were younger. Sometimes, impotence can be reversed simply by the man and his partner spending longer in foreplay with more direct and intense penile stimulation. A vibrator may prove helpful.
Q. What are the effects of impotence?
A. Impotence can be a devastating condition and may lead to depression, increased alcohol use, relationship problems, even marriage breakdown. Men are often ashamed that they suffer impotence or feel guilty that they have brought it on themselves, often relating it to masturbation or excessive sexual intercourse. There is absolutely no basis for such guilt, neither masturbation nor excessive intercourse predispose a man to developing impotence. A common response of men with impotence is to avoid situations in which he may be expected to have sexual intercourse. For example, he may stay up after his partner has gone to bed hoping that she will be asleep when he eventually retires. As the man repeatedly avoids sexual situations, he grows further apart from his partner and because of this, his partner may think he is having an affair. The partner may feel guilty: is it her fault that he has the problem? Is she no longer sexually attractive? All these thoughts and feelings put more stress on the relationship and on the individual partners leading to unhappiness and tension all round.
Q. What about self help?
A. As a first step it is important to try to make life-style changes. Stop smoking, drink less, lose weight if overweight and try to arrange work schedule so that you have time with your partner (if you have one) and are not too tired.
If you have a partner, one of the most important steps in overcoming impotence is to discuss the problem with her/him. The support of a loving partner is very important, even if you eventually need medical treatment. Then try to reverse the effects impotence might have had on your relationship. Spend more time with your partner. Put a ban on intercourse, even if you and your partner feel like it, but spend time caressing each other, including genital stimulation. Even if you get an erection, at first don't try to have intercourse. In this way you will be able to regain confidence in your sexual ability. It sometimes helpful to change the "love environment". If you usually made love in the bedroom, and that is where your impotence began, then this room will have negative connotations reminding you of failure. It is not always practical to change rooms but you can change the appearance of the room - different colour light bulb, incense or candles all make the room seem different and create a sexually conducive atmosphere.
The Impotence Association provides various fact files including some on impotence. These may be obtained by telephoning the Association's Helpline on 0181 767 7791.
If these simple steps fail you may be tempted to purchase one or more of the many herbal products and ointments now advertised in men's magazines and elsewhere. Don't. None have been proven effective and their safety may be questionable. Vacuum constriction devices are effective and safe if used correctly, but before purchasing one it would be wise to consult a doctor.
Q. What help can can a doctor provide?
A. Because impotence may be the first symptom of an underlying medical condition all men who experience the problem should consult a doctor. It is recommended that in the first instance the man should consult his regular general practitioner because the GP will know all about the man's medical history. Some GPs may not appear interested in this problem; if this is true in your case, then asked to be referred to a NHS specialist.
The doctor will ask you questions about the sexual problem and about your general health. The doctor will probably also ask how you are getting on with your partner, are there any problems in the relationship. Usually the doctor will examine you focusing on the penis and testicles. These days, only a minimum of tests are usually done; these should include measuring blood pressure and checking the urine for glucose (sugar). If, in addition to impotence, you have also lost your sex drive, the doctor will probably arrange a blood test.
Q. Who can have treatment on the NHS?
A. Doctors (both general practitioners and hospital specialists) are now restricted by the Government in prescribing treatment on the NHS. Whether you can get treatment on the NHS depends on what medical conditions you have. The following groups of men are eligible for NHS treatment:
Men with diabetes
Men who have had pelvic surgery
Men who have had their prostate removed and/or have been treated for prostate cancer
Men who have been treated for renal failure (by dialysis or transplant)
Men who have had spinal cord or severe pelvic injury
Men who have multiple sclerosis or Huntington's chorea
Men with Parkinson's disease
Men with spina bifida.
There are also two other categories of men who are eligible for NHS treatment:
Men who started treatment for impotence before 14 September 1998
Men whose impotence is causing them severe distress. In this case treatment has to be prescribed by a specialist hospital consultant.
Q. What treatments are available?
A. No single treatment is effective and acceptable for all patients. There are several different effective and safe treatments available for treating impotence:
Sildenafil (Viagra)
This is the only oral treatment presently licensed as a treatment for impotence. Although taken by mouth it works within the erectile tissue of the penis. It is effective in many patients and trials have shown that it produces a gain of about 30% above pre-treatment levels of rigidity and frequency of erections. It is less effective in men who are totally unable to have even a soft erection before treatment.
The tablet should be taken one hour before intercourse. The drug only works in combination with sexual stimulation - just taking a tablet alone will not result in an erection. Common side effects include headache, facial flushing, nasal stuffiness and indigestion. Disturbed vision may occur when high doses are used.
Men who take nitrates either medically, for angina, or socially, to enhance sexual pleasure (eg poppers) should not take sildenafil as it causes the blood pressure to fall and this can be dangerous. Sildenafil should not be used by men with severe liver disease and those who have had a recent heart attach or stroke. Men with the eye disease retinitis pigmentosa should not take sildenafil.
Some commonly used drugs may interact with sildenafil and a man should never take sildenafil if he is taking other medications without first checking with his doctor.
Injection treatment
Injection of drugs directly in to the erectile tissue in the penis to produce an erection sounds worse than it really is. About 80% of men find the procedure relatively painless. At the present time only one drug is licensed, this is alprostadil, available as Caverject and Viridal. The doctor or clinic nurse teaches the man (ideally with his partner) how to inject and the dose has to be adjusted so that the erection lasts about an hour. Too much drug may cause an erection that does not go down within 4 hours and then hospital treatment may be required.
Intra-urethral treatment (MUSE)
This treatment involves inserting a very small pellet of alprostadil into the urethra (the hole on the end of the penis) by means of a specially designed disposable applicator. This is generally a relatively painless procedure although a few men experience discomfort. If it is going to work, erection generally occurs within 10 minutes and can lasts up to one hour. Success with this treatment depends only carefully following the administration instructions.
Vacuum Constriction Devices
These consist of a rigid plastic cylinder, which is placed over the penis. Prior to doing this, a constriction ring is placed around the open end of the cylinder. The cylinder is attached to an air pump which may be either manual or battery operated. When the pump is operated, air is sucked out from the cylinder creating a negative pressure which in turn sucks blood in to the penis causing it to enlarge and become stiff. When this occurs, the constriction ring is placed around the base of the penis, the 'vacuum' is released and the cylinder removed from the penis. The constriction device should be removed from the penis within 30 - 40 minutes.
Vacuum constriction devices are rarely available on the NHS. The makers instructions should be followed carefully. Men on anticoagulants (blood thinning drugs) may suffer extensive bruising of the penis with this type of treatment and it should therefore be avoided.
Psychological treatments
Psychosexual therapy is especially helpful when there are psychological factors, either in the man himself or in his partner, contributing to the impotence. In addition to helping restore erections, psychosexual therapy can improve the quality of sexual relationships. When there are marked conflicts in the relationship, couples therapy may be helpful. It is recommended that whenever possible, psychosexual and couples therapies are instigated before trying physical treatments such as drugs or vacuum devices.
Ideally, a holistic approach to the treatment of impotence should be used which combines physical treatments with psychological treatments but unfortunately this is not always available in the NHS.
Surgery
When all other treatments fail, surgical treatment is sometimes offered. This may involve inserting semi-rigid rods in the penis or inflatable cylinders in the penis and a pump in the scrotum. The number of operations for this type of surgery has fallen since the introduction of injection and other treatments.
Q. What treatments are in the pipeline?
A. The next few years will see exciting new developments in the treatment of impotence. There will be new orally active treatments, different drugs for injecting in to the penis and novel ways of delivering drugs in to the penis without injections.
Q. What about testosterone?
A. Testosterone is male sex hormone and it is probably the most abused treatment when it comes to impotence. Testosterone should only be used when there is a proven deficiency, ascertained by properly conducted blood tests. Very few men with impotence actually have testosterone deficiency.
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