Impotence is treatable at any age, and awareness of this fact
has been growing. More men have been seeking help and returning
to normal sexual activity because of improved, successful treatments
for impotence. Urologists, who specialize in problems of the urinary
tract, have traditionally treated impotence.
Most physicians suggest that treatments proceed from least to
most invasive. Cutting back on any drugs with harmful side effects
is considered first. For example, drugs for high blood pressure
work in different ways. If you think a particular drug is causing
problems with erection, tell your doctor and ask whether you can
try a different class of blood pressure medicine.
Psychotherapy and behavior modifications in selected patients
are considered next if indicated, followed by oral or locally
injected drugs, vacuum devices, and surgically implanted devices.
In rare cases, surgery involving veins or arteries may be considered.
The increase treatment happens gradually, presumably as treatments
such as vacuum devices and injectable drugs became more widely
available. Perhaps the most publicized advance was the introduction
of the oral drug sildenafil citrate (Viagra) in March 1998. NAMCS
data on new drugs show an estimated 2.6 million mentions of Viagra
at physician office visits in 1999, and one-third of those mentions
occurred during visits for a diagnosis other than impotence or
Experts often treat psychologically based impotence using techniques
that decrease the anxiety associated with intercourse. The patient's
partner can help with the techniques, which include gradual development
of intimacy and stimulation. Such techniques also can help relieve
anxiety when impotence from physical causes is being treated.
Drugs for treating impotence can be taken orally, injected directly
into the penis, or inserted into the urethra at the tip of the
penis. In March 1998, the Food and Drug Administration (FDA) approved
Viagra, the first pill to treat impotence or ED. In August 2003,
the FDA gave approval to a second oral medicine, vardenafil hydrochloride
(Levitra). Additional oral medicines are being tested for safety
Taken an hour before sexual activity, Viagra and Levitra work
by enhancing the effects of nitric oxide, a chemical that relaxes
smooth muscles in the penis during sexual stimulation and allows
increased blood flow.
While oral medicines improve the response to sexual stimulation,
they do not trigger an automatic erection as injections do. The
recommended dose for Viagra is 50 mg, and the physician may adjust
this dose to 100 mg or 25 mg, depending on the patient. The recommended
dose for Levitra is 10 mg, and the physician may adjust this dose
to 20 mg if 10 mg is insufficient. Lower doses of 5 mg and 2.5
mg are available for patients who take other medicines or have
conditions that may decrease the body's ability to use Levitra.
Neither Viagra nor Levitra should be used more than once a day.
Men who take nitrate-based drugs such as nitroglycerin for heart
problems should not use either drug because the combination can
cause a sudden drop in blood pressure. Also, Levitra should not
be taken with any of the drugs called alpha-blockers, which are
used to treat prostate enlargement or high blood pressure.
Oral testosterone can reduce impotence in some men with low levels
of natural testosterone, but it is often ineffective and may cause
liver damage. Patients also have claimed that other oral drugs--including
yohimbine hydrochloride, dopamine and serotonin agonists, and
trazodone--are effective, but the results of scientific studies
to substantiate these claims have been inconsistent. Improvements
observed following use of these drugs may be examples of the placebo
effect, that is, a change that results simply from the patient's
believing that an improvement will occur.
Many men achieve stronger erections by injecting drugs into the
penis, causing it to become engorged with blood. Drugs such as
papaverine hydrochloride, phentolamine, and alprostadil (marketed
as Caverject) widen blood vessels. These drugs may create unwanted
side effects, however, including persistent erection (known as
priapism) and scarring. Nitroglycerin, a muscle relaxant, can
sometimes enhance erection when rubbed on the penis.
A system for inserting a pellet of alprostadil into the urethra
is marketed as Muse. The system uses a prefilled applicator to
deliver the pellet about an inch deep into the urethra. An erection
will begin within 8 to 10 minutes and may last 30 to 60 minutes.
The most common side effects are aching in the penis, testicles,
and area between the penis and rectum; warmth or burning sensation
in the urethra; redness from increased blood flow to the penis;
and minor urethral bleeding or spotting.
Research on drugs for treating impotence is expanding rapidly.
Patients should ask their doctor about the latest advances.
Mechanical vacuum devices cause erection by creating a partial
vacuum, which draws blood into the penis, engorging and expanding
it. The devices have three components: a plastic cylinder, into
which the penis is placed; a pump, which draws air out of the
cylinder; and an elastic band, which is placed around the base
of the penis to maintain the erection after the cylinder is removed
and during intercourse by preventing blood from flowing back into
One variation of the vacuum device involves a semirigid rubber
sheath that is placed on the penis and remains there after erection
is attained and during intercourse.
Surgery usually has one of three goals:
· to implant a device that can cause the penis to become
· to reconstruct arteries to increase flow of blood to
· to block off veins that allow blood to leak from the
Implanted devices, known as prostheses, can restore erection in
many men with impotence. Possible problems with implants include
mechanical breakdown and infection, although mechanical problems
have diminished in recent years because of technological advances.
Malleable implants usually consist of paired rods, which are inserted
surgically into the corpora cavernosa. The user manually adjusts
the position of the penis and, therefore, the rods. Adjustment
does not affect the width or length of the penis.
Inflatable implants consist of paired cylinders, which are surgically
inserted inside the penis and can be expanded using pressurized
fluid (see figure 3). Tubes connect the cylinders to a fluid reservoir
and a pump, which are also surgically implanted. The patient inflates
the cylinders by pressing on the small pump, located under the
skin in the scrotum. Inflatable implants can expand the length
and width of the penis somewhat. They also leave the penis in
a more natural state when not inflated.
Surgery to repair arteries can reduce impotence caused by obstructions
that block the flow of blood. The best candidates for such surgery
are young men with discrete blockage of an artery because of an
injury to the crotch or fracture of the pelvis. The procedure
is almost never successful in older men with widespread blockage.
Surgery to veins that allow blood to leave the penis usually involves
an opposite procedure--intentional blockage. Blocking off veins
(ligation) can reduce the leakage of blood that diminishes the
rigidity of the penis during erection. However, experts have raised
questions about the long-term effectiveness of this procedure,
and it is rarely done.