AIDS TO SEX (INCLUDING SURGICAL) FOR THE IMPOTENT
by Prof Peter H C Lim
AM(Msia),MBBS,MMed(Surg)D.Urol(Lond),MIUrol(Lond)(Hon),FAMS,
Senior Consultant Urological Surgeon & Head,
Division of Urology, Dept of Surgery,
Toa Payoh Hospital, Singapore 1129.
President, Singapore Urological Association
INTRODUCTION
Today, aids for satisfactory sex abound for the impotent.
Counselling & oral medication helps psychogenic problems &
oral sex stimulants & drugs for sexual asthenia are readily
also available. The use of intracavernosal injections for an
adequate "erection on demand" has found acceptability amongst
patients with no fear of the needle. Surgical Appliances are
available that can stimulate and maintain an otherwise
inadequate erection or create an erection where none was
possible before. They are used either extra-corporally
meaning that they are used as external appliances or intra-
corporally which implies that an operation is needed for
implantation of the device so that it simulates a naturally
occuring erection. For patients seeking surgical help by way
of an operation to restore erections without the use of
prostheses, venous leak impotence can be treated by ligation
of the offending vessels, and arteriogenic impotence can
likewise be managed by arterial revascularisation.
COUNSELLING
Counselling helps for most psychogenic problems. Psychosexual
therapy is most effective when both partners participate. The
case in point would be impotence caused by performance
anxiety. The prescription of psychotropic drugs or the
occasional referral to the psychiatrist may be necessary for
deep seated problems.
MEDICATIONS
Impotence due to asthenia easily responds to
salbutiamine (Arcalion)
tablets every morning.
It is also useful as an adjunct for the treating psychogenic impotence.
Low male hormone levels are found in men undergoing
"andropause". Replacement therapy either orally or by
injection can often restore potency. Low libido states are
helped if supplemented by counselling. On the other hand,
elevated levels of serum prolactin can cause impotence & is
easily treated by bromocriptin without recourse to surgery.
Other medicines eg. Yohimbine, a sex stimulant which works at
both the cerebral & genital level may restore erections in
20-40% of men but require medical practitioner close
surveillance. Cantor is used for psychogenic impotence whilst
Arcalion is useful for sexual asthenia. The most effective
albeit slightly painful way of restoring erections is by the
intracavernosal "Self-Injection Program" performed by the
patient himself. This provides an erection on demand when
PGE-1, for example
alprostadil (Caverject)
, Papaverine, etc. is injected directly into the penis by
the patient. It is a simple, cost-effective outpatient mode
of treatment permitting use up to 10 times a month.
Complications are negligible with PGE-1.
STIMULATORY DEVICES
An industry stardard electrical vibrator (Viricare) is
available that can stimulate a proper erection & help produce
an ejaculation if the patient also has the problem of
anejaculation. The device is also being currently used to
help diagnose causes for impotency in sexual dysfunction
clinics worldwide.
THE VACUUM SUCTION DEVICE (VCD)
Pos-T-Vac MVP-700
Pos-T-Vac AVP-1000
The last 5 years have seen the VCD emerging from being a mere
commercial product to being a scientifically accepted device
for the non-surgical treatment of impotence. Today, there are
more than 20 types available. Essentially there are 3 main
types with one or more of the following characteristics:
External Splint, Negative Pressure (Vacuum), and Tension
(Constriction). The VCD works by a passive mechanism
decreasing venous outflow which is maintained by a
constrictor band after the pump is withdrawn. The various
brands differ by being either one- or twohanded devices, by
providing a Toll-Free Hotline/Counselling Service &
Warranties ranging from 6 months to lifetime, presence or
otherwise of a Pressure Governor/Pressure Limiting Valve, and
a host of other features including a Loading Cone, Chamber
Insert, Pump & Chamber Interconnect Tubing, a wide range of
Constrictor Bands & often packaged with a Battery-operated
Pump which in some models is an optional item. They are
indicated for patients with either organic or psychogenic
(arterial & venous), neurogenic, diabetic & postsurgical
dysfunction. Interestingly, they work also in Peyronie's
Disease & after explantation of a prosthesis. There are
relatively few contraindications i.e. those at risk of
priapism, eg. sickle cell disease, polycythemia. Those on
anticoagulants can use it with caution & some manual
dexterity is required, even with use of the battery operated
versions. 80-85% success rates have been reported with few
complications eg. petechiae & occasional ecchymoses in those
at risk, initial discomfort which improves with time,
pivoting of the penis at the base in a few, occasional penile
numbness, coolness or decreased orgasmic intensity. Painful
ejaculation is rare while some consider it cumbersome,
nonspontaneous and occasional partner non-acceptability.
REVASCULARISATION FOR ARTERIOGENIC IMPOTENCE
The patient best suited for this surgery is a young man with
arteriogenic disease due to trauma. He should have no
neurologic deficit on physical examination & a normal
hormonal profile. Investigations should show an absent or
severely impaired NPT, a consistently absent or subnormal
response to high doses of intracavernous agents, & duplex
sonography of the penis before & after injection of
papaverine & phentolamine should reveal normal dilatation of
the of the cavernous arteries even though significant flow is
not measurable. Lastly dynamic infusion cavernosmetry should
no evidence of corporovenous leak & selective arteriogram
confirms the site of block. Older men with blockage due to
artherosclerosis would be unsuitable for arterial
reconstructive surgery.
CORPORO-VENO-OCCLUSIVE DYSFUNCTION SURGERY
The advent of venous ligation with crural plication surgery
helped many a young male patient afflicted with venous leak
impotence, presenting to the clinician with the complaint of
a soft erection. The latter is readily diagnosed by means of
Dynamic Infusion Cavernosometry & Cavernosography. However,
it became clear with longer follow-up that the initial
success rates with this technique fell the longer the follow-
up. Fortunately, the recently introduced procedure of Deep
Dorsal Vein Arterialisation can help men with a combination
of arteriogenic & venous leak etiologies. As at 1994
therefore it would appear that corpus cavernosum
revascularisation techniques appear to hold greater promise
for a sustained benefit for venous leakers.
THE PENILE IMPLANT
When all else fails or other methods of treating impotence
are deemed inappropriate, the implantation of a penile
prosthesis remains the most effective means of restoring the
ability to have coitus. The implants range from the Semi-
rigid rods, the 2-Part inflatables or the Rolls-Royce, 3-Part
Inflatables. Comfort, performance, concealability & user
as well as partner satisfaction improves with the higher
grade models. Satisfactory surgical results can be obtained
in at least 95% of cases. When patients and their partners
are well-informed pre-operatively & receive adequate
counselling after surgery, the level of their satisfaction
can echo the surgical success rate.
AIDS FOR THE DISABLED
The disabled e.g. the paraplegic, also can be helped. There
are a range of external devices to enhance either the
paraplegic's sexual life or especially that of his partner.
He is not exempted from additionally using the entire
repertoire of surgical operations & other appliances that
were outlined earlier above.