Erectile Dysfunction and Impotence
The problem most men won’t talk about
Impotence – the inability to have or sustain an erection long enough to have intercourse – is one of the most devastating problems a man can face. Yet it’s a common condition, afflicting an estimated 10 million American men.
In the last decade, enormous strides have been made in understanding impotence – to lessen the stigma, sex therapists prefer to call it erectile dysfunction – and treating it. Once viewed almost exclusively as a psychological problem, it’s now known to have a physical basis as often as not.
Treatment runs from a simple adjustment in medication to the surgical implantation of a penile prosthesis. Sexual function can almost always be restored. That is the good news. The bad news is that so many men with chronic erectile dysfunction never seek help.
Armed with an understanding of the bodily systems that work together to produce an erection and the factors that interfere, a sensitive nurse can steer those who need it in the direction of treatment.
The physiological responses that produce an erection
In order to have and sustain an erection a man needs proper hormonal balance and healthy nerves, blood vessels, and penile tissue.
As the brain responds to sexual stimuli, it signals the parasympathetic nervous system to release a transmitter substance that causes small arteries in the penis to dilate, creating a temporary increase in blood flow. The extra blood fills a network of sinusoids inside the corpora cavernosa – the erectile chambers, one on each side of the penis – causing the penis to enlarge and stiffen. The expanded sinusoids press against the veins that would normally drain blood from the penis, trapping the blood inside.
After ejaculation or when sexual stimulation recedes, the arteries constrict, the veins expand, the blood runs out, and the penis becomes flaccid. Because orgasm and ejaculation are controlled by a different set of nerves called the sympathetic system, both can occur without an erection.
As a man ages, sexual function declines. He’s slower to arouse, for instance, and has a longer refractory period between erections. But impotence is not a normal consequence of the aging process. For a healthy man, the ability to have erections and enjoy intercourse lasts a lifetime.
Still, the older the patient, the more likely he is to develop a condition or require a medication that blocks normal sexual response. Our rule of thumb: The likelihood that erectile dysfunction has a physical basis is roughly equivalent to the patient’s age.
When to suspect sexual dysfunction
Knowing the organic causes of impotence is the first step in helping patients get treatment. The second step: Broaching the subject of sex whenever you encounter a patient who’s at risk for impotence because of medication he’s taking or the condition he has.
Antihypertensives, especially beta blockers and diuretics, are likely offenders. Some others are cimetidine (Tagamet), digoxin (Lanoxin), antihistamines, antipsychotics, tranquilizers such as diazepam (Valium) and other antianxiety drugs, narcotics, phenobarbital, and anticholinergics. Don’t overlook topical solutions; even nasal spray and eye drops have been known to interfere with erectile function. Tricyclic antidepressants have been linked to impotence also, but the depression itself may be the cause.
Tell a patient taking any of these drugs that loss of erection is one possible side effect. Ask if he’s had any problem with sexual function. That’s less intrusive than asking if he’s sexually active and allows him to say as much or as little as he chooses. Urge him to contact his physician at once if a sexual problem develops, and remind him that it may be easily corrected with a simple change in medication or dosage. Warn him not to adjust the dosage or stop taking the drug, however, without consulting his doctor.
Although we don’t always consider them in a drug history, alcohol, a CNS depressant, and nicotine, a vasoconstrictor, can also cause impotence. Include specific questions about their use in patient assessments and ask men who drink or smoke about any problems with sexual function.
Certain medical problems may also lead you to suspect that impotence might be a problem – diabetes, for instance, or multiple sclerosis, spinal cord injury, or Parkinson’s disease. Broach the subject, too, with a patient who has arteriosclerosis, liver or kidney disease, or a recent history of MI, CVA, or bypass or deep pelvic surgery.
A post-MI patient may simply need reassurance that his ability to perform sexually is apt to return naturally, possibly with just a reduction in anxiety level. Even for a patient with diabetic neuropathy or another permanent condition, it’s highly likely that his ability to be sexually active can be restored. If he hasn’t already done so, urge him to visit an endocrinologist or a urologist who specializes in sexual disorders.
Diagnosis: The first step toward treatment
Evaluation begins with a thorough medical and sexual history, including questions about diagnosed conditions, medication and substance use, libido, and onset and extent of dysfunction.
Sudden rather than gradual onset suggests the problem is psychological. It’s often linked to a stressful event such as a divorce or loss of a job. Situational impotence – becoming erect with one partner but not another, for example, or with masturbation – and awakening with an erection indicate normal physical function as well.
During a physical exam the doctor will look for signs of prostate enlargement, tumor, or infection. He will inspect the penis for abnormalities like Peyronie’s disease, a rare disorder that causes disfigurement and fibrous plaques that can interfere with erection. Perineal sensation and anal sphincter tone are assessed to rule out any damage to the nerves that supply the penis. He’ll also look for signs of gynecomastia, an indication of hyperprolactinemia.
A patient whose problem is clearly psychological requires no further testing. Instead, he’s referred to a sex therapist, preferably one who is certified by the American Association of Sex Educators, Counselors, and Therapists. (You can get a list of certified therapists in your area by contacting AASECT, 435 N. Michigan Ave., Chicago, Ill. 60611, (312) 644-0828.) If the exam and history don’t point to a cause, then diagnostic testing begins.
The nocturnal penile tumescence (NPT) test can be done at home while the patient sleeps. A computerized device called a Rigi-Scan is attached to the patient’s leg, with leads to the base and tip of his penis. It monitors nocturnal erections (healthy men experience several a night) and measures the circumference and the degree of rigidity. Just seeing on the computer printout evidence of normal erections and rigidity sufficient to allow penetration often convinces a patient that he needs psychological, not medical, treatment.
Diagnostic lab work includes urinalysis and a fasting blood sugar to rule out diabetes, liver and kidney function tests, serum prolactin levels, and total and free serum testosterone levels to assess hormone production. Low testosterone or elevated prolactin can lead to impotence and loss of libido.
Penile blood flow may also be evaluated. Papavarine, a vasodilator that mimics the action of a neurotransmitter, is injected directly into the penis. If the arteries leading into the penis are obstructed, the patient gets a weak erection or none at all. If they dilate normally, he develops a full erection within 15 minutes. It should last approximately an hour. An erection that fades rapidly is a sign of venous leakage.
If the doctor needs more information about vascular defects, he may do a procedure called dynamic infusion cavernosometry. Under local anesthesia, papavarine is again injected into the penis to create an erection. Then a saline solution is infused into the penis and pressure is recorded. By measuring the rate at which the fluid leaves the penis, the physician can estimate the amount of venous leakage. Cavernosography – a contrast study of the penis – can locate the site of the leak.
Matching the treatment to the cause
Treatment for impotence may be pharmacological, psychological, mechanical, or surgical. While the method selected usually depends on the cause, patients should be told that they have a variety of options.
Pharmacological treatment will also vary depending on the cause. A patient who is on anti-hypertensives, for instance, may be switched to a different class. A hormone imbalance may be corrected with testosterone injections, or bromocriptine (Parlodel) may be prescribed to treat hyperprolactinemia caused by a benign pituitary tumor.
In an attempt to restore erectile function by increasing penile blood flow, some physicians prescribe oral medication – usually, yohimbine (Aphrodyne, Yocon, Yohimex), which has a cholinergic effect – but success with this method has been uneven.
Papavarine, injected into one of the cavernous bodies using an insulin syringe and a 28- or 30-gauge needle, yields far better results. Unless a man has vascular disease, an injection of up to 2 cc produces an erection that lasts 45 minutes to an hour. After trials in a doctor’s office to discover the optimum dose, the patient is then taught how to self-inject.
Priapism is a rare but serious side effect of papavarine injections, more common when the cause of erectile dysfunction is psychological than when it’s organic. Since prolonged erection can damage penile tissue permanently, papavarine users are instructed to get to a physician’s office or hospital ED should an erection last any longer than four hours. Reversal is achieved through irrigation with saline and, if needed, with a solution of ephedrine, phenylephrine, or epinephrine.
Short-term behavioral conditioning under the guidance of a sex therapist is the treatment of choice when impotence has psychological basis. Frequently, 10 to 20 sessions are all that’s necessary. A patient for whom the problem is not so easily resolved or who can’t or won’t use penile injections may prefer an easy-to-use mechanical suction device.
Surgical repair via bypass or venous ligation is an option for some men with penile vascular disease. Surgical implantation of a penile prosthesis is another choice.
A penile implant works regardless of the cause of a man’s dysfunction. But because it permanently destroys erectile tissue, it should not be performed on patients whose dysfunction is psychologically based. You’ll find more details about penile implants and nursing care of the patient who has one in the companion article that begins on this page.
Whatever the cause of a patient’s impotence, you can help him find the appropriate treatment he needs. By spreading the word that impotence is a treatable condition, however, you’ll offer hope to all those who have not yet felt hopeful enough to seek treatment.
Erectile Dysfunction Exercises
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