Impotence or Erectile dysfunction (ED), is defined as failing to obtain and/or maintain an erection satisfactory for intercourse more than 20% of the time. Every man strikes out once in a while, but if it occurs more than once out of every five times, there is a problem.
For years impotence was rarely mentioned or discussed. It was commonly believed to be due to psychological problems and treatment remained in the hands of the psychologists and psychiatrists. We know now that 80-90% of impotence is caused by physical problems, usually related to the blood supply of the penis – the arteries and veins which carry blood to and from the penis.
A man has nowhere to hide. A woman can feign arousal and orgasm. But when a man fails to obtain an erection or goes limp, the failure is obvious, humiliating and frightening. But these problems are fixable! Sometimes the cause itself can be corrected. Other times the effects of problems will be corrected.
Almost every patient with erectile dysfunction has a psychological problem because he is not functioning adequately as a male. But once the physical sexual dysfunction is fixed, the psychological problem usually goes away.
Depression and impotence
Depression is another cause of psychogenic impotence. Unfortunately, most anti-depressant medications themselves produce erectile failure, the last thing a depressed man needs. Intensive counseling is the first line of defense here, helped by techniques that will provide usable erections. If quality psychotherapy is not effective, or the patient cannot get along without his medications, a vacuum constriction device, oral or self-injection therapy or the insertion of a penile prosthesis may be appropriate in selected cases.
Performance anxiety
Another form of psychogenic impotence is performance anxiety. When you are stressed and anxious, erections may be difficult or impossible. Stress increases the body’s production of catecholamines such as adrenaline and nor-adrenaline, which are specific erection inhibitors. Your therapist will work with you to teach you to reduce your stress levels and, at the same time, to make it possible for you to give yourself long-lasting erections while you are mastering these techniques. This, in turn, helps reduce stress by ensuring useful, long-lasting erections.
Organic impotence
By far, the most common cause of organic impotence, especially in older men, involves the penile arteries, the penile veins or both. When the problem is arterial, arteriosclerosis or hardening of the arteries is the usual culprit. Blunt trauma, sometimes from sports injuries, is a less frequent cause. Many experts believe that venous leak or “veno-occlusive incompetence” is the single most common cause of impotence in younger men. Venous leak is a generally understood term which can be likened to a loose plug in the bathtub drain. In a potent man, during sexual excitement, arterial inflow increases 5 to 8-fold and the penile drainage system closes down, thus sustaining erections. When the drainage system fails to hold the blood in the penis, the erection becomes soft and may fail.
Impotence and diabetes
Impotence is common in diabetics. There are 9 million diabetic adult men in the U.S. and it is estimated that half are impotent and the other half will become impotent in time. The process involves premature and unusually severe hardening of the arteries. Peripheral neuropathy, with involvement of the nerves controlling erections, is seen commonly in diabetics.
The controllable risk factors for arteriosclerosis – overweight, lack of exercise, high cholesterol, cigarette smoking and high blood pressure – will produce erectile failure often before progressing to affect the heart. The coronary arteries (heart) are 1.5 – 2.0mm in diameter; the penile arteries are 0.6 – 0.7mm in diameter – 1/3 the size of the coronaries – and can become clogged sooner. Unless there is a change in lifestyle, coronary artery disease may follow impotence within a few years.
Neurologic causes of impotence
There are many neurological causes of impotence. Diabetes, as noted, chronic alcoholism, multiple sclerosis, heavy metal poisoning, spinal cord and nerve injuries, and nerve damage from pelvic operations such as prostatectomy can produce erectile dysfunction.
Drug-induced impotence
A great variety of prescription drugs such as blood pressure medications, anti-anxiety and anti-depressant drugs, glaucoma eye drops, and cancer chemotherapy agents are some of the many drugs associated with impotence.
Hormone-induced impotence
Hormonal abnormalities such as increased prolactin (a hormone produced by the anterior pituitary gland), steroid abuse by body-builders, too much or too little thyroid hormone and hormones administered for prostate cancer may cause impotence. Rarely is low testosterone alone responsible for poor erections. Testosterone stimulates desire, but is believed to have little effect on erections.
Penile curvature; Peyronies disease
Sometimes congenital or acquired anatomic abnormalities prevent erections, such as Peyronie’s Disease, an acquired curvature of the penis.
Premature ejaculation
Premature Ejaculation (PE) is the inability to maintain an erection long enough for mutual satisfaction.