Impotence: Symptoms, Causes and Treatment

Our topic is impotence, its symptoms, causes and treatment.

Could you explain how impotence happens?

Impotence is an incredibly common problem. More than 25 percent of men over age 60 have major problems with maintaining or achieving erection. Probably a greater number have occasional difficulties with erection.

Doctors used to think that most men with impotence had psychological problems. However, we now know that up to 90 percent of men have a medical cause for their impotence. Vascular disease probably accounts for most cases. The common term for this is “hardening of the arteries.”

Men with high blood pressure, high cholesterol, diabetes, or heart disease appear to be at the highest risk. Smoking is also a major contributor. Other common causes include nerve damage (especially with diabetes), medications such as those used for high blood pressure, psychological problems such as depression or anxiety, and hormonal problems such as low testosterone.

Can this problem be emotional or due to stress?

Absolutely. Studies suggest that about 15 percent of men have a psychological issue as the major reason for their impotence. We also know that for many other men, even if their main problem is physical, once they develop a problem with erection they may lose confidence or become embarrassed. So often there are several factors at play. In young men – especially those under age 40 – psychological issues may be the most common reason for impotence.

It is, therefore, important to discuss possible psychological issues with your partner or physician. Also bear in mind that psychological counseling can be effective for many men with impotence.

how often does not being able to achieve an erection have to occur to be concerned about a physical condition such as hardening of the arteries?

Many men will have an occasional problem achieving or maintaining an erection. If the problem is infrequent, then a medical evaluation is probably not necessary. On the other hand, many men develop impotence due to vascular disease or other medical problems. These same men are at risk for heart attacks and stroke. Occasionally, impotence will even be the first sign of a serious problem such as a brain tumor. However, this accounts for only a small fraction of cases.

The most important reason to see your doctor is to get the right treatment. During the evaluation for impotence, your doctor may wish to check you for other problems such as high cholesterol, high blood pressure, hormone problems or depression.

Are there any improvements in treating nerve-damage impotence following prostatectomy?

Radical prostatectomy is a type of surgery used to treat prostate cancer. Many men experience impotence after this procedure. This is particularly likely to happen if nerves that travel next to the prostate are cut as part of the surgery. If at least one of the two nerves remain intact, a man may be able to have an erection with or without a medication such as Viagra.

If Viagra doesn’t work, other treatments such as injections of medication may be effective. However, there are some men who will develop permanent impotence from prostatectomy that is not helped by our current medications. Surgery to implant a prosthesis may be an alternative for those patients. While a number of new medications are under development, it is unlikely that any of them will help these men if they don’t respond to treatments we have now.

Are there any new treatments coming soon? I am thinking of a substitute for Viagra with fewer side effects.

Viagra is probably the best treatment we have for most men who have difficulty with erection. This is because it is easy to use, generally safe, has relatively few side effects, and is effective in the majority of men.

However, up to 50 percent of men will experience some minor side effects with Viagra. Possible side effects include headaches, flushing, nasal congestion, or a change in vision. A new drug under development, called vardenafil, is chemically related to Viagra. It works by the same mechanism but may cause fewer side effects. This drug is likely to be released within the next few years. There is a possibility that vardenafil may be a good alternative for men who have bothersome side effects with Viagra.

There are several other new drugs that are presently under development. Apomorphine, which has tentatively been given the trade name Uprima, is chemically unrelated to Viagra. It also comes in pill form but is taken under the tongue. Like Viagra, men still require sexual stimulation to achieve an erection.

Preliminary studies suggest that up to 50 percent to 60 percent of men respond to this medication. However, apomorphine also causes significant side effects such as nausea. Unlike Viagra, apomorphine does not appear to pose any risk for men with heart disease.

An additional medication under development is oral phentolamine, which goes by the trade name Vasomax. This is another pill treatment for impotence. It also appears to work by different mechanisms than Viagra. Clinical trials are under way. At present, neither Uprima nor Vasomax are FDA approved.

Are there alternatives to Viagra that are presently on the market?

Let’s start with other prescription medications. At present, Viagra is the only medication that comes in pill form that is effective for most men. There are good alternatives that are taken by other means. For example, medications can be injected into the penis using a tiny needle and syringe. These medications, such as alprostadil, are actually quite effective. Some studies show that up to 90 percent of men respond. However, alprostadil can cause side effects such as pain in the penis, or priapism — which is a prolonged, painful erection. The fact that the medication has to be injected by needle into the penis makes many men hesitant to use it. However, it is quite effective and should be considered for men who do not respond to Viagra.

Alprostadil also can be given as a tiny suppository that is inserted into the tip of the penis. The medication is less effective when given in this manner, but some men find it to be a preferable method. About 40 percent to 60 percent of men respond to alprostadil suppositories, which go by the trade name MUSE.

As far as herbal alternatives to Viagra — if you walk into any nutrition or vitamin shop, go on the Internet, or read any men’s magazine, you will be bombarded by advertisements for herbal remedies for sexual problems. There are a wide variety of herbal products promoted to improve sexual desire and performance.

Unfortunately, we have little or no good evidence to support these claims. Nor do we have any good information that these products are safe. My advice would be to have a high degree of skepticism about these products and to proceed with caution. If you are taking an herbal product regularly, make sure you let your doctor know.

Impotence is an embarrassing and difficult problem for many men. However, we’ve made considerable strides in finding new effective treatments for this problem. I am certain that additional alternatives will become available within the next few years.

If you are having problems with erections, make sure to talk with your health-care provider. Although it may be embarrassing, I’m sure your doctor has heard it all before.

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