Post Treatment: Sexual Function

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Impotence is defined medically as the inability to achieve an erection that allows satisfactory intercourse. In other words it does NOT just refer to the inability to achieve any type of erection. The operative word is satisfactory and unsatisfactory can result from many reasons. Impotence is a term that embraces all the following problems:

1. an erection that is not firm enough
2. an erection that does not last long enough
3. a combination of the above { 1 & 2 }
4. an erection that is not there at all
5. an erection that does not allow penetration eg "bent penis" etc

Causes

Difficulty in maintaining an erection is a common problem. There are many causes, such as:

• Diabetes
• Peripheral vascular disease eg cramps in legs
• Ischaemic heart disease eg angina, heart attack
• Hypertension
• Renal failure
• Neurological eg stroke
• Infections
• Trauma
• Hormone deficiency
• Thyroid problems

to name just a few. The final pathway for all these for difficulty in achieving or maintaining an erection is that there is insufficient blood in the cavernosal bodies (see diagram) to support an erection. So, in short, not enough blood gets into the penis or, too much leaks out..

Treatment

At this stage little can be done to reverse the disease processes which have led to the final symptom of impotence. Occasionally a hormone deficiency is reversible, changing blood pressure medication sometimes improves the situation or, rarely, surgery may be possible to correct a vascular abnormality (this is usually only possible following a very specific injury to the blood vessels).

However, the one area in the treatment of impotence where much advancement has been made has been in the final common pathway to ALL the causes of impotence - getting blood into the cavernosal bodies to support an erection. In summary, the problem can be treated but, the cause mostly CANNOT be reversed.

Before embarking on any of the treatments listed below, it is necessary to have a number of investigations - blood and urine tests. This is necessary because you may have one of the forms of impotence that is reversible, and secondly, you may well require some form of medication in your treatment and it is necessary to ensure there are no underlying problems which may put you at risk from any treatment. Occasionally, these tests may indicate you require some special X-rays - though overall this is unusual..

Having had the necessary tests it is possible to consider the various treatment options. There are 4 broad types:

1. Vacuum devices
2. Implants
3. Creams
4. Injections

Mechanical Post Treatment Options

Vacuum Devices

Vacuum devices provide a straight forward method of achieving an erection for those to whom it appeals.

Essentially a vacuum device is a tube that fits over the penis, within which a vacuum is created - either by a manual pump, or, a small electronic pump. The vacuum encourages blood into the penis, thus creating an erection. Once the erection has been achieved, a special band (basically an elastic band) is slipped off the tube to lie around the base of the penis, thus trapping the blood inside. The rubber band is removed upon completion of intercourse.

Advantages:

1. Relatively simple and easy to use - needs some practice and is occasionally awkward to use, especially at first
2. One time initial cost

Disadvantages:

1. Quality of erection is NOT always ideal for the individual patient
2. MUST remove band otherwise damage to the penis will be induced

Side-Effects:

1. Pain - if chosen band is too tight
2. Ischaemia if band left on too long

Implants

Implants or, as they should more correctly be known as Penile Prostheses, have long been considered the "Rolls Royce" treatment for the correction of erectile problems.

These are surgical devices which are implanted into the penis by an operation. Depending on which type is used, different methods are used to inflate or deflate the penis according to need. Their use is not required as much these days because drug therapy has improved, but there is no denying the fact that there are very few people in whom they don't work.

Advantages:

1. Most reliable system
2. Can use as often and long as desired

Disadvantages:

1. Requires surgery
2. Cost

Side-Effects:

1. Few, once the initial operation risks are through
2. Rare, but possible
   • malfunction
   • infection
   • rupture

To produce an erection, a man pumps sterile liquid from the reservoir into the tubes by squeezing the pump in the scrotum. The tubes act as erectile tissue and expand to form an erection. When the erection is no longer desired, a valve allows the fluid to return to the reservoir. Inflatable prostheses are the most natural feeling of the penile implants and they allow for control of rigidity and size.

Medication Post Treatment Options

Creams

The simplest and easiest way to help a person achieve an erection is a cream, which is rubbed onto the base of the penis. The drug in this cream is GLYCERYL TRINITRATE (GTN) also known as NITRO BID. This may be familiar to some people as a cream to rub onto the chest to prevent angina. It works for similar reasons - in angina, pain is caused by not enough blood reaching a part of the heart; impotence is caused by insufficient blood reaching the penis.

The cream come supplied with a small paper ruler, which is used to measure a certain amount of cream out (eg 1 cm) which is the way the correct dose is given. It generally takes about 10-20 minutes to work.

Advantages:

1. Simple and easy to use
2. Reliable
3. Can adjust dose easily

Disadvantages:

1. Cost (approximately $5-7:00 per injection)
2. Requires an injection
3. Drug not always readily available

Side-Effects: Possibility of

1. long duration of erection (PRIAPISM)
2. bruising
3. scarring
4. infection

Penile injections with one, or a combination of drugs, overall provide the best and most reliable mode of treatment of impotence short of surgery.

This form of treatment involves the careful working out of a specific drug dose which will result in an erection lasting 30-90 minutes. One, or a combination of the following drugs are generally used:

• Prostaglandin E1
• Papaverine
• Phentolamine

You are taught how to inject your particular "cocktail" into the penis using a very fine diabetic-type syringe and needle. The proper attention to detail is, of course, essential , as, with any injection there are certain routine precautions which need to be taken to ensure there are no complications.

Advantages:

1. Normal erection
2. Readily available

Disadvantages:

1. Does not work effectively enough in many people
   • it is worth trying mainly because of its ease of use

Side-Effects:

1. Some people experience a headache (only a very few)
   • this may be severe enough to require pain relief eg Panadiene
   • theoretically if erection is achieved some of the cream may be absorbed by your partner giving them a headache (this is very, very rare)

Other Treatments

Occasionally other methods of treatments are mentioned in the media as providing miraculous cures, and indeed, there are other forms of treatment both here in Australia and in other parts of the world. These treatments take the form of tablets, hormone therapies, surgery and other forms of therapy. A brief summary of these treatments follows for your information.

Tablets

 

There are tablets available in the USA and Europe which do, on occasion, help with erectile problems. They contain a drug known as Yohimbine and they have about the same success rate as the GTN cream. They are NOT available in Australia.

 

Hormone Treatments

 

Hormone therapy is required in very few people, as the male hormone. Testosterone, is mainly responsible for libido rather than erections. When it is appropriate, it is given as a series of injections over 3-6 weeks.

 

Surgery

 

Rarely, an operation may be required to correct an abnormality of the blood vessels to the penis, however these are usually only considered after other avenues have been exhausted.

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