Impotence is a violation of potency, sexual impotence, manifested in the inability of a man to perform sexual intercourse. It often serves as a manifestation of the underlying disease and is eliminated by its cure (endocrine, nervous, cardiovascular disorders, diseases of the genitourinary sphere). Erectile dysfunction can cause deep psychological depression, disharmony of sexual and family relationships. Erectile dysfunction or impotence is manifested by the inability to achieve an erection sufficient for full sexual intercourse while maintaining psychological comfort during it.
Meaning
Impotence is a violation of potency, sexual impotence, manifested in the inability of a man to perform sexual intercourse. It often serves as a manifestation of the underlying disease and is eliminated by its cure (endocrine, nervous, cardiovascular disorders, diseases of the genitourinary sphere). Erectile dysfunction can cause deep psychogenic depression, disharmony of sexual and family relationships.
Erectile dysfunction or impotence is manifested by the inability to achieve an erection sufficient for full sexual intercourse while maintaining psychological comfort during it. Recently, the pathogenesis and causes of erectile dysfunction have been sufficiently studied in order to restore normal sexual life and today the problem of impotence is not intractable.
Physiology of erection and detumescence
The smooth muscles of the cavernous bodies and the walls of the arteries and arterioles perform the main function in the process of erection and in the process of detumescence – the decline of erection after ejaculation or due to reasons that prevented the natural end of sexual intercourse. In a calm state, the smooth muscles of the penis are influenced by sympathetic nerve endings. At the moment of sexual arousal or stimulation of the penis, impulses transmitted through parasympathetic nerve fibers cause the release of erection neurotransmitters, blood filling of the cavernous bodies occurs. This complex chemical process takes place with the obligatory participation of nitric oxide. Initially, there is relaxation and relaxation of smooth muscles, which in turn contributes to unhindered blood supply. Increasing in size from the incoming arterial blood, the cavernous bodies partially block the outflow of venous blood. Due to the difference in the volume of blood inflow and outflow, intracavernous pressure increases, which contributes to the development of a rigid erection.
Immediately after ejaculation, termination of sexual stimulation or for other reasons, the reverse process begins – detumescence. After activation of synaptic structures, neurotransmitters such as norepinephrine and neuropeptide are released into the blood.
Both of these processes are controlled by the middle preoptic zone of the cerebral cortex, in general, the sexual activity and sexual behavior of a man depends on the concentration of dopamine-like substances that have a stimulating effect, and seratonin-like substances that have an overwhelming effect. Violations in any link of the whole process can lead to impotence.
Symptoms
Depending on the pathogenesis of erectile dysfunction, there are several types of impotence.
Psychogenic impotence can be both permanent and temporary, this type of impotence can occur in men who are subjected to frequent mental and physical fatigue, who have certain psychological difficulties or problems finding a partner. Temporary psychogenic impotence passes after normalization of lifestyle.
Psychogenic impotence, the pathogenesis of which is a decrease in the sensitivity of the cavernous tissue to neurotransmitters due to the overwhelming influence of the cerebral cortex or due to indirect influence through the spinal centers, can occur against the background of sexual phobias and deviations, associative psychotrauma and religious prejudice. To date, thanks to the development of diagnostics between true and psychogenic erectile dysfunction, psychogenic impotence in its purest form, as for example, happens with serious sexual deviations (pedophilia, bestiality) is diagnosed less often.
Neurogenic impotence occurs against the background of injuries and diseases of the central nervous system and peripheral nerves. The pathogenetic link is the difficulty or complete absence of the passage of nerve impulses into the cavernous bodies. In 75% of cases, spinal cord injuries are the cause of neurogenic impotence. The remaining 25% are neoplasms, cerebrovascular pathologies, intervertebral hernia, multiple sclerosis, syringomyelia and other neurogenic diseases.
Arteriogenic impotence is an age-related pathology, since atherosclerotic changes in the coronary and penile vessels are identical. At an early age, arteriogenic impotence can occur due to congenital vascular abnormalities, smoking, hypertension, diabetes mellitus or as a result of trauma. Insufficient arterial blood flow is not able to fully nourish the cavernous tissues and vascular endothelium, local metabolism is disrupted, which can lead to irreversible dysfunctional disorders of the cavernous tissue.
The pathogenesis of venogenic impotence has not been studied enough, but its development is facilitated by disorders in the venous bloodstream, in which the lumen of the veins increases. This happens with ectopic drainage of the cavernous bodies through the venous vessels of the penis, with traumatic ruptures of the protein membrane, as a result of which its insufficiency develops. Venogenic impotence often accompanies Peyronie’s disease and functional insufficiency of cavernous erectile tissue. Smoking and alcohol abuse aggravate the symptoms of venogenic impotence.
Hormonal impotence most often develops against the background of diabetes mellitus, since changes in the penile vessels and cavernous tissue are quite serious in diabetes mellitus. But at the same time, the reason for hormonal impotence is not so much a decrease in testosterone levels, as a violation of its digestibility, because there were no problems with erection in people with hypogonadism when stimulating. But with hypogonadism and male menopause, hormone replacement therapy is performed as the main treatment for erectile dysfunction.
Cavernous insufficiency or dysfunction of the cavernous tissue can also lead to impotence. In the pathogenesis of this type of impotence are changes in the cavernous bodies, vessels and nerve endings that disrupt the work of the erectorial mechanism.
Kidney diseases in which patients are shown extracorporeal dialysis are combined with erectile dysfunction in half of the cases, while after kidney transplantation, two-thirds of patients restore erectile abilities. Prostatitis can cause impotence both due to insufficient testosterone content in the blood serum and due to circulatory psychogenic disorders: soreness during ejaculation, premature ejaculation and iatrogenic conditions in which the failure syndrome is formed.
In patients with bronchial asthma, in a post-infarction state, impotence is caused by the fear of exacerbation of the disease during sexual intercourse.
Prostatitis is not the main cause of impotence, it can only aggravate its course, this should be borne in mind, since most men believe that only prostatitis can cause erectile dysfunction.
Diagnostics
All diagnostic procedures are aimed at establishing the cause of impotence, which means the possibility of restoring erectile function and eliminating emotional experiences. To do this, first of all, it is necessary to differentiate psychogenic and organic impotence. A simple and reliable method is the monitoring of nocturnal erections and intracavernous injection test (coverject test). If, according to these methods, the organic nature of impotence is confirmed, then a number of additional examinations are carried out to identify the underlying cause.
Treatment
Modern andrology has a fairly wide range of schemes and methods for the treatment of erectile dysfunction. The choice of treatment method is based on the decision of the andrologist and on the acceptability of use for this patient. Drug therapy of impotence is a traditional method of treatment, usually resorting to replacement therapy with testosterone and drugs from the group of adrenoblockers. Against the background of the main treatment, courses of drugs such as trazodone, trimipramine, nitroglycerin, metachlorophenylpiperazine are periodically carried out – they are used in the form of ointment applications. The effectiveness of drug therapy does not exceed 30%, so medications are not indicated for all patients.
Psychotherapy can be the main method of treating psychogenic and neurogenic impotence, but provided that psychotherapeutic procedures are carried out professionally. Vacuum-erectile therapy, which was developed in 1970 by Dr. D. Osbon, when carried out correctly, gives an efficiency of up to 83%; complications in the form of spot hemorrhages, painful sexual intercourse occur in isolated cases.
Intracavernous drug therapy is a relatively new method of treating impotence. For the first time, papaverine was injected intracavernosally to improve erectile function (1982), then they began using phentolamine, prostaglandin E1 and other drugs. Minimal side effects, high efficiency and ease of use are provided by the drug prostaglandin E1; the use of this technique in 80% of cases allows you to have a high-quality sex life without any restrictions.
When using papaverine and phentolamine for intracavernous drug therapy of impotence, priapism and cavernous fibrosis sometimes occurred as complications, which is extremely rare when using prostaglandin E1. The only disadvantage of this method of impotence therapy is the soreness of injections, therefore, after injections of prostaglandin E1, 7.5% sodium bicarbonate is injected to relieve pain. Since this method of treating impotence with minimal interventions gives good results, non-injection methods of intracavernous medication management are being developed.
Intracavernous falloprosthetics was first successfully performed in 1936 by Soviet Professor Bogoraz, rib cartilage was used as a prosthesis. And already in the mid-70s intracavernous falloprosthetics became widely used for the treatment of impotence. To date, prostheses have different principles of action and give complete freedom to lead a normal sexual life. The reliability of the systems used for prosthetics and the quality of the technique allowed to reduce the number of complications to 3.5-5%, and among patients using falloprostheses to correct impotence, more than 80% give good recommendations to this technique.
At the same time, if impotence has an organic character, it should be recommended that patients immediately undergo a phaloprosthesis. Because according to statistics, most of the men who use phalloprostheses first used drug therapy, vacuum therapy and intracavernous self-injections. The main reason why intracavernous falloprosthesis is preferred by most patients who are faced with the problem of impotence is the naturalness of erection, the absence of the need for painful injections and constant medication and the minimum number of complications.