Male Impotence

continued from

The Treatment of Physical Impotence

The treatment of physical impotence is now sophisticated. Several options are available after full investigations have suggested the likely cause.

Oral Drugs

International trials of an oral drug treatment for impotence are currently under way. The drug, a derivative of yohimbine hydrochloride, is derived from the African Pausinystalis yohimbe tree. Results of the trials are expected soon but it will be a few years before it becomes widely available on the market.

Topical GTN

Glyceryl trinitrate (GTN) is a drug normally used to treat heart angina pains. GTN dilates blood vessels and increases blood flow. Research has found that GTN patches applied to the penis for one to two hours before intercourse can help to overcome impotence. Of 10 males aged 45­71 who had suffered impotence for an average of five years, four achieved an erection with intercourse and ejaculation ­ a success rate of 40 per cent.

The use of GTN patches has an advantage over GTN creams, as the latter are absorbed by vaginal tissues and cause the side-effect of headaches in any female partners.

Vacuum Erections

For a vacuum erection the penis is placed in a plastic cylinder from which air is extracted via a pump. The resultant partial vacuum makes the penis fill with blood and triggers an erection. A tight ring is then placed around the base of the penile shaft to trap the blood and maintain rigidity. The penis then remains erect once the vacuum cylinder is removed. Obviously, as it acts rather like a tourniquet, the penis looks a little blue, and the ring can only be left in place for a short while (otherwise the blood supply of the penis may be compromised). Another problem is that the elastic band prevents semen coming out of the tip of the penis during ejaculation. Semen may seep out later, or may wash into the bladder to be urinated away. This is not harmful but does affect fertility.

P.I.P.E.

Some patients are taught to give themselves an injection into the shaft of the penis. This is known as P.I.P.E. ­ Pharmacologically Induced Penile Erection. The injections are given via a very fine needle inserted into the corpora cavernosa. The shaft of the penis is not very pain-sensitive and the injections are described as no more painful than a mosquito bite. After withdrawing the needle, the injection site is pressed firmly for 30 seconds so that no bleeding occurs. After 5­10 minutes, an erection starts to form as the arteries supplying blood to the penis dilate and draining veins constrict.

The commonly used drug, papaverine, can induce prolonged erections and priapism, however. Priapism is a surgical emergency ­ the penis needs to be drained of trapped blood to restore the circulation. Papaverine can also cause internal scarring and curvature (Peyronie's disease) in a few males. In the majority of cases, nevertheless, P.I.P.E. is very successful and has transformed the lives of many impotent males.

Another drug, prostaglandin E1, is prescribed instead of papaverine by some doctors as it has a lower risk of side-effects.

A new development is a self-injection system known as Caverject (alprostadil). This works in a similar manner to prostaglandin E1 and can be prescribed by doctors. Some men find it more painful than other drug treatments, however.

Vascular Surgery

If there is a physical blockage to penile blood inflow, it is possible to have an arterial by-pass graft operation in which the blockage is by-passed using a length of vein, or synthetic tubing. In some cases, a single stricture can be dilated with a special balloon inserted into the artery under X-ray control.

Another successful approach is to hook up another artery, which normally delivers blood to the lower abdominal muscles, to the penis. This is joined to one of the penile arteries using microsurgical techniques; the procedure instantly increases the blood flow to the penis. The lower abdominal muscles do not suffer either, as several other arteries also supply them with blood. Some of the penile-draining veins are usually tied off at the same time to increase the effect: this combines a better blood flow coming in with a weaker blood flow draining out. Success rates are as high as 70 per cent.

Arterial by-pass surgery involves a fairly large incision extending up the lower abdomen, and requires a stay of several days in hospital.

If impotence is due solely to a slow venous leak, this is simply corrected by tying off the major veins draining the penis. This procedure is known as venous ligation, and is successful in 50 per cent of cases. Occasionally, new veins open up after the operation and venous leaking may recur after a few years.

Surgical Implants

Prostheses are devices that can be surgically implanted into the penis to produce erection. There are two main types:

1. semi-rigid rods giving the patient half an erection all of the time

2. complicated, inflatable devices with small pumps implanted in the scrotum and a fluid reservoir bag implanted in the abdomen or pelvis. These devices are activated by squeezing the pump or activating a trigger button in the scrotum. Deflation is brought about by pressing another button.

Some semi-rigid implants have an embedded silver wire to make them bendable. The penis can then be bent and 'parked' when not in use. Newer designs consist of implanted, interlocking discs made of plastic. These can be rotated in one direction to lock and become rigid, then, after intercourse, rotated the other way to become flaccid when not required.

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Insertion of an implant takes from one to three hours, depending on the type selected. The procedure is done under a local anesthetic, or under a spinal epidural (the body is numbed from the waist down).

It takes around two weeks for the discomfort and swelling of the operation to settle down, especially under the scrotum where the base of the penis is situated. Intercourse can be resumed from four to six weeks after the operation, depending on the procedure used. The main risk with penile implantation is post-operative infection, but this seems to be relatively rare. Ninety per cent of men with an implant are entirely happy with its performance. Most implants are invisible, although the semi-rigid rods can make the penis stick out a little bit at all times. This does not look abnormal, however.

Next: Psychological Causes of Impotence

Last updated: 10/05

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