THE EVALUATION & TREATMENT OF THE IMPOTENT MAN: ---------------------------------------------- by Dr Peter Lim Huat Chye, FAMS, MBBS, MMed(Surgery), D.Urol(Lond), M.I.Urol.Lond.(Hon), Head &, Senior Consultant Urological Surgeon, Division of Urology, Toa Payoh Hospital, Singapore 1129. SYMPTOMS: Symptoms/Presentation: Inability to obtain or maintain an erection suitable for sexual intercourse & is common in men of all ages & especially so in the elderly. CAUSES: Causes: Psychological Impotence can be caused by anxiety, depression, tension, guilt, stress, marital problems & fear of failure to perform sexually(performance anxiety). Physical impotence occurs when disease or injury affects the nerves, blood vessels or hormones that control erection. Diabetes & hardening of the arteries eg. in high blood pressure or heart disease, constitute the commonest causes. Others include pelvic surgery, spinal cord injury, prostate infections, drug abuse, alcoholism, smoking & as a result of the side effects of some medications. HOW TO DETECT THE CAUSE: Diagnosis: The Urologist takes a complete medical & sexual history including the presentation & nature of the patient's impotence, sexual experience, performance & medical background. The patient's partner should be included in the assessment of the problem. A full Psychological Screening to uncover feelings of guilt, frustration, embarassment, fear & other problems inimical to the emotional health of the couple is conducted. If a diagnosis is still not forthcoming, blood sexual hormone levels are estimated & a simple dynamic papaverine injection test is done. A special "sleep" test to examine the quality of nocturnal (night-time) erections follows which measures the number of erections & the quality, duration & strength of these that should occur in men during deep sleep. In selected patients suspected of "venous leak" impotence i.e. impotence caused by a condition equivalent to varicose veins of the legs but occurring in this instance in the veins drainning the penis, a special Xray study called Cavernosography with Cavernosometry is done. In young men whose impotence is caused by damage to the arterial supply of the penis due to an accident, an Arteriogram Xray is done. Finally, Nerve Conduction Studies will demonstrate difficult nerve related causes if the above tests are still insufficient. TREATMENT & COMPLICATIONS: Medical Treatment: Counselling helps for most psychogenic problems. This is most effective when both partners participate. Low male hormones levels are found in men undergoing andropause (male equivalent of the menopause in women). Replacement therapy either orally or by injection can often restore potency. On the other hand, elevated levels of another hormone called prolactin can cause impotence & is easily treated by a special medication. Other medicines eg. Yohimbine may restore erections in approximately 20% of patients but require medical practitioner close surveillance. The most effective albeit a little painful way of restoring erections on demand is by a special Self-Injection Programme of injection by the patient himself of a medication called papaverine or prostaglandin into the penis when the need arises. The primary disadvantage of this method is a small risk of a prolonged painful erection following the injection which can only be corrected by injecting an antidote by a urologist. This is not common but nonetheless the patient must be ready to return to the hospital for this antidote should the erection lasts longer than 4 hours. A special device to create a vacuum which causes an erection is now available in Malaysia which is quite effective. However it is not suitable for some patients with various penile injuries, sickle cell disease, leukemia, pelvic infections or blood clotting problems & it requires some dexterity & strength to apply, operate & remove & has a 25 minute maximum time limit for each use. Surgical Treatment: For "Venous Leak" impotence, removal of the offending veins gives a cure in 60% of cases with some degree of improvement in the rest. Reconstruction of the arterial blood supply using microsurgery is indicated only for the young man with blocked arteries due to trauma. When successful, these procedures result in normal, natural penile erections. For most patients especially those older men with diabetes & blood pressure/heart problems, the implantation of a penile prosthesis is usually the only sure way of restoring erections. These implants produce erections but will not affect sensation, ejaculation or orgasm. The overall success rate with these devices is about 90%. Three main types are available: The semi-rigid or malleable, the self-contained inflatable or the multi-component inflatable. The last named gives the most natural & effective results & is also the most expensive. All surgical implants carry a small risk of infection but the main patient at risk is the diabetic patient. Also like all artificial devices, mechanical failure may occur(although this is not common) & thus may require revisional surgery. PREVENTION: As the most common cause of psychogenic impotence is due to performance anxiety, this is best prevented by the avoidance of a target oriented approach to love-making amongst couples i.e. penetration & intercourse should not be the end point. By removing this objective the man is not "performing under duress to deliver". He is therefore not going to be disappointed if he fails to reach this point & thus will not enter the vicious cycle of performance anxiety caused impotence. Avoid taking drugs unnecessarily especially tranquilisers & sedatives and this includes alcohol & smoking cigarettes. Early detection & treatment of diabetes may not halt the progression of impotence but it certainly delays the onset. Those on high blood pressure drugs should consult their doctor & change to drugs that do not cause impotence. Avoid rough sports that land blows on the perineum (area below the penis & testicles) which may injure the arteries supplying the penis eg. karate kicks. And finally, lots of exercise & healthy living style. WHEN TO CONSULT A UROLOGICAL SURGEON: When all the simple measures mentioned above simply does not work, professional help in the way of psycho-sexual counselling helps most cases of psychogenic impotence. A urological surgeon should be seen once a physical cause is deemed likely.