What is Impotence?

Introduction

Until recently, there was only little choice in treatment in cases of diminished erections or impotence. Fortunately, times have changed. Due to the fact that much research has been successful over the years, many men may now be treated for this problem.

Possible therapies differ from medication to injections to sexuologic counseling to surgery.

Most therapies are within the scope of the urologist, although many general practitioners feel confident enough to prescribe medication or engage in counseling.

Seventeen percent of males between the ages of 18 and 55 (occasionally) suffer from erection problems.

Six percent of males in that age group have a problem with erections on a regular basis or even permanently. Of the males above age fifty-five, about one in three has an occasional erection problem or worse.

Most of the men in that age group regularly consult their general practitioner for some reason or another.

If both patient and doctor are not too shy to bring up the problem, then those contacts may prove to be a good opportunity to determine the cause of the erection problem and maybe start therapy.

Are you impotent?

Many men have erection problems but don’t have the guts to confirm that. This denial, unfortunately, makes it impossible for them to enjoy sexual activities.

It may help to realize that about one in four men have erection problems, so they are in the company of many. On the other hand, only five percent of those have touched on the problem with their doctor.

Only a short while ago, it was common just to ignore the problem, but nowadays the sexual wellbeing is considered to be an indicator of general health.

Also, since males tend to live longer, they are even more entitled to treatment of erection disorders. Personal pride does no longer prohibit treatment.

Today, a choice of many effective forms of treatment presents itself, either surgical or non-surgical.

The first step towards successful treatment must however be taken by the patient, who must acknowledge that a problem exists.

What is an erection disorder?

The term erectile dysfunction is used to designate a problem with penile erections, when the penis does not harden enough or not at all, or when the erections does not last long enough during sexual encounters.

Therefore, different types of erectile dysfunction exist. The impotence may be complete, i.e. ‘nothing happens’, or partial, when something does happen but the penis does not get hard enough to allow intercourse. A third possibility is that the penis does get erect rather normally, but falls limp again too quickly.

There is also a difference when we look at the duration of the erection disorder: some men have always had problems with erections, while others had good erections before, but these have become a problem later in life.

Lastly, some erection disorders only come up in certain situations, while, in general, erections are okay.

These different types of erection problems are important when it comes to determining a cause, which in turn leads to a decision about the type of therapy.

Most erection disorders are caused by a combination of physical and psychological problems. It is important to keep this in mind when it comes to treating the problem.

Should it be treated?

An erection disorder is not life-threatening. The need for treatment depends on the amount of discomfort the problem is causing and the motivation of the patient. A long period of abstinence may induce a loss of interest in sexuality in one or both partners.

Being curious when a new treatment is made public in the press may just not be enough. To enhance the chance of success, the patient and his partner should be really longing to be sexually active again.

Most therapies depend on the patient being able and willing to put some effort in it. It may take some motivation to learn medical procedures. If proper motivation is lacking, then the therapy will certainly fail.

A success will also depend on the partner, who must want to be sexually active again. In addition, the partner must also be willing to assist in certain therapies and will need to feel comfortable with the ‘hassle’ needed for a proper erection.

A certain commitment is necessary to solve the erection problems. If this is lacking in one of the partners, it will have a negative effect on the success of treatment.

Erection: how does it work?

Normal and satisfying erections depend on three things:

• there must be a longing for sexual activity
• the bloodvessels to the penis must be in good condition
• the nervous system controlling the erection must function normally

A normal amount of hormones is less important, and is seldom lacking. On the other hand, the male hormones play a part in the sexual longing, the libido. If the longing is therefore lacking due to a shortage of hormones, often in old age, erections are often not desired.

Erotic stimulation, through one of the five senses or from memory, will start the ‘erection procedure’. The nervous system will send chemical messages to the lower abdomen and back again.

These messages will ensure that the muscle fibers within the so called cavernous bodies inside the penis will relax, causing the bloodvessels to enlarge, thus allowing more blood flow towards these bodies.

The two parallel cylindric erectile bodies are made up of spongy tissue and are filled with blood. The cylinders will then lengthen and stand out straight, thus causing an erection of the penis.

The mounting pressure within the cavernous bodies will close the bloodvessels, responsible for the backflow of blood from the penis, thus ensuring that the penis will remain rigid for some time.

An erect penis contains about eight times the amount of blood as a flaccid one. As long as the sexual arousal continues, the penis will remain rigid until orgasm and/or ejaculation.

Causes of erection disorders

Thirty years ago, a man who consulted his doctor for erection problems was told that no cure was available because the problem was caused by either old age or the psyche. Since then, much research has gone into the male erection.

The accumulated knowledge has resulted in the ‘official’ classification of causes:

• Psychological
• Physical
• Mixed – psychological and physical
• Unknown

In the majority of cases, the causes are mixed in a combination of physical and psychological factors.

When a man does not succeed in having a (sustained) erection, he will strain himself to perorm better next time. A failure to do so will cause further psychological problems.

A psychological cause exists if no physical cause can be found. This type of erection problem usually takes root ‘overnight’, because of stress at the workplace, marital problems or financial trouble.

Just about any situation that rambles around in one’s mind all day long, may cause erection problems.

A depression may too cause bad sexual performance (‘stage fright’).
Apart from this, every man will encounter a period in his life when erections are not as desired. This is part of a normal life cycle and needs no treatment.

Physical erection problems can have various causes. Most experts in the field agree on the following table:

vascular disease	33%
diabetes	25%
radical pelvic surgery	10%
injuries, especially to the spinal cord	8%
endocrine and hormonal dieseases	6%
medication	8%
drug and other abuse	7%
multiple sclerosis	3%

Vascular disease (bloodvessels and heart) is the predominant cause of erection problems. Narrowing (arteriosclerosis) of the bloodvessels, high blood pressure, high cholesterol and other vascular diseases lower the bloodflow to the penis.

A low bloodflow in and around the heart may cause a cardiac infarct, the same problem in the brain may cause a stroke; in the penis, it causes erection problems.

Another cause of erection trouble may be venous leakage, if the veins that drain blood from the cavernous bodies in the penis do not sufficiently close during erection, thus causing blood and pressure to ‘leak’ out of the penis.

This in turn will make it impossible to build up enough bloodpressure in the cavernous bodies for a sufficient erection.

Diabetes is a major cause of erection problems. The disease can damage bloodvessels and nervous tissue. Both may have an effect on erections. In case of nervous tissue damage, especially the small nerve bundles leading towards the penis, the brain may be unable to conduct enough signals to the penis for a normal erection.

In addition, the small bloodvessels may also be affected in diabetes, further adding to a lessening potency. About half of the male diabetics will get erection problems later in life (55 and older).

Radical pelvic surgery can also lead to erection disorders. Surgery involving the prostate, bladder or large bowel may damage the nerves that play a role in erections. External radiation therapy to this area can have the same effect.

Neurological disorders signify another possible cause. Multiple Sclerosis, Parkinson’s Disease and spinal cord injuries are among those that may lead to loss of potency.

Endocrine and hormonal disorders signify an indirect cause of erection disorders. A low concentration of the male sex hormone testosterone causes a diminished libido, i.e. a lesser amount of sexual desire.

A too high production of prolactin by the hypophysis, a small gland near the brain, may add to a low testosterone production and, thus, cause a lower libido. Diabetes may also be considered an endocrine disorder.

Medication may also cause erection problems as an side effect. More than 200 different types of medication fall into this category.

Patients should however never change the dose of the medication on their own without consulting their physician; the medication is always prescribed for a reason, so changing the dose may prove hazardous.

Drug and other abusive use, like drinking alcohol or smoking may damage the nerves and bloodvessels needed for a normal erection.

What doctor should I go to?

A few different kinds of doctors and specialists are involved in the diagnosis and treatment of erection disorders:

• General practice
• Urology
• Internal medicine
• Endocrinology
• Sexuology
• Psychology

The doctor you see most may be the best one to consult for your erection disorder. If you are already seeing a urologist because of another problem, or visiting the internal medicine department because of diabetes, it would be preferable to put the problem to that doctor, becaue he/she will have your medical history at hand.

For many men, the general practitioner may be the first to consult. If the first-choice doctor prefers not to treat you, he/she may then advise you on the choice of another.

Urologists are often consulted in case of erection disorders, especially when a physical cause is suspected. Many have ‘subspecialised’ on erection disorders.

If a psychological cause is suspected, then a sexuologist or psychologist may be the first option when considering treatment.

In many cases of erection disorders, a psychological problem is present, either from the beginning or due to ‘stage fright’ when it was discovered that the erection was not as granted as it was before because of a physical problem.

A visit to your doctor must be based on two questions:

• Why do I have erection problems?
• What can be done about them?

What tests can be done?

The first visit will start with an extensive medical history, including psychological and sexual aspects of your life. The doctor will ask questions about stress and fatigue, and about the relationship between you and your partner.

This will probably include questions of a personal nature, but these are necessary to get an overview on the whole of your sex life, in turn necessary to determine the best possible treatment.

In order to determine the cause the doctor must make sure if there are any factors contributing to the erection problems, like diabetes, alcohol abuse, medication. Stress at work or home needs also to be evaluated.

When the medical history is complete, a physical examination will follow. This will include a rectal examination to check the prostate and an examination of the genitals, i.e. penis and testicles. In some men there might also be a curvature of the penis in erection, usually known as Peyronie’s disease, which is caused by scar tissue in one or both cavernous bodies.

If the curvature is serious, then this problem will need to be addressed first. Blood pressure measurements may also be necessary during the examination.
Laboratory tests will usually be done to make sure that the hormone levels are normal.

If a general practitioner, which will often be the first doctor to present the erection problems to, is unable to come to the right diagnosis, or feels to inexperienced with the subject, he will most probably refer the patient to a urologist.

A urologist may decide to do additional examinations, which will make a more defined diagnosis possible. These may include a so called Rigiscan and a cavernosography/metry.

A Rigiscan is a device that measures the force of the erection and looks a bit like a small version of the devices used for bloodpressure measurements. In order to be able to measure the erection, the patient is often subjected to watching erotic movies in a special, private, room.

A simpler version of the Rigiscan is the ‘postal stamp’ method, in which a couple of postal stamps are glued together around the penis before going to sleep. A lot of men with erection problems have normal erections during sleep; every normal man has an erection a couple of times during the night.

With the postal stamp method, a normal erection reveals itself because the stamps will have been torn in the morning.

Since a lot of men find it a bit ridiculous to put postal stamps around their penis, a few companies are now manufacturing special strips of paper, which has the additional advantage of measuring the maximum diameter of the erect penis.

A cavernosometry is always combined with a cavernosography. This test is usually done only to exclude certain bloodvessel problems, when previous therapy has failed, so it is not a ‘standard test’.

With a fine needle one of the cavernous bodies is punctured, so these can be filled with a special solution.

This makes it possible to visualize the blood vessels leaving the cavernous bodies in order to check for leakages. Also, the amount of flow to the penis through the needle, which is needed for a sufficient erection will give information about the functioning of the bloodvessels.

Treatment options

Known treatment options are (from least invasive to most invasive):

• psychotherapy or sextherapy, physical therapy
• medication
• hormonal therapy
• vacuum therapy
• pressure rings
• self-injection therapy
• prosthesis implantation
• vascular surgery

The choice of therapy will be governed by the cause of the erection problems. Sextherapy will be the first choice if a psychological/sexual problem is considered the main cause of the erection disorder.

However, often a mix of physical and psychological causes exists, so non-invasive methods to regain erections may be used either alone or in combination with sex therapy.

The vacuum therapy and self-injection therapies are currently most widely used, because side effects are minimal and together they seem to work for most men with erection problems.

Both may also be used in combination with sex therapy.
In some men, a low hormone level may cause loss of sufficient erections, but these cases are rare. If so, the hormones may be added using oral medication or injections.

Psychotherapy consists of sessions in which a psychotherapist will try to help the patient and his partner to understand what the problem is, identify stress factors and deal with them.

Sex therapy is more to the point as far as sex is concerned. Patient and partner are taught to explore eachother in a sexual way and practical exercises are prescribed to lessen the tension between both partners, so as to improve their sexual relationship. These exercises may consist of sexual acts. 

Physical therapy, in case of overactivity of the pelvic muscles, may enable the patient to relax these muscles, thereby making sex a more relaxing experience and making it easier to sustain a normal erection.

Medication for erection problems has been available for centuries. Impotence has been a problem of all times, our own not excluded.

Until recently, Yohimbin^®, extracted from the yohimbine tree, was the only one available showing to have some effect in some men, although, scientifically speaking, the effect was never considered proven.

It is still used, especially if a psychological problem is suspected, to enhance libido, i.e. the sexual desire. It can be prescribed in two ways. Either the patient uses Yohimbin 5 mg 3 times daily for 4-6 weeks, or one tablet of Yohimbin is used 45 minutes before the ‘scheduled’ intercourse.

The results seem to be about the same: Yohimbin hepls in about 30% of cases. The erection disorder may return after the medication is stopped. side effects include headaches, sweating, dizziness and nausea. Men suffering from stomach ulcers or high blood pressure better avoid Yohimbin.

Recently, Viagra^® (sildenafil) was introduced by a company called Pfizer. Viagra is an inhibitor of the enzyme phosphodiesterase-5 (PDE-5) and acts by narrowing the exit of the blood from the cavernous bodies, thus enhancing and prolonging erection. The tablets were shown to work in 70-80 percent of men with erection problems.

The problem is that we don’t know yet in which cases it works and when it doesn’t. The tablets are to be taken if an erection is desired and Viagra will then enhance erections if an appropriate sexual desire is present.

The effect of Viagra will commence after about 45 minutes and will last for 3-4 hours. Possible side effects include possible other effects of the PDE-5 enzyme inhibition, such as headaches, dyspepsia, flushes and a blue discoloration of vision.

Viagra counteracts the effects of nitrate medication, used by many patients with heart trouble; the combination of Viagra and nitrates may prove hazardous to the heart.

Although there have been reports in the lay press about Viagra causing heart problems, this has not been confirmed scientifically. It is thought that men with underlying heart disease may possibly suffer problems after taking Viagra because of the strenious exercises involved in making love.

More recently, a few other pharmaceutical companies have put Viagra lookalikes on the market. One of these is Levitra^® (vardenafil), manufactured by Bayer and GlaxoSmithKline. Levitra works in the same way as Viagra and supposedly works faster and should have less side-effects.

But for all practical purposes, it works as fast as Viagra and has the same side effects (although their website lists more than with Viagra). Some studies report less effect of Leivitra compared to Viagra. 

Cialis^® (tadalafil) by Eli Lilly is another lookalike, but with a difference. Cialis starts having effect a little faster than Viagra and Levitra (about 20-30 minutes), but works longer. Although 24-36 hours are claimed, in reality Cialis will remain active for about 20 hours in most men.

This is an advantage compared to the other two pills, which generally stop working after 3-4 hours.

So with Cialis, there is no rush to have sex before the pill wears out, which often has a relaxing effect on men who do not perform well under pressure. The side effects of Cialis are the same as with the other PDE5 inhibitors Viagra and Levitra.

Cialis does, however, have less effect than Vigra or Levitra. Since it takes longer for Cialis to get cleared from the body, taking the pills too frequently may potentially lead to an overdose.

Because of the limited experience with Cialis to date, some of the possible side effects may still be unknown, partly because Cialis also inhibits a neighbouring enzyme, PDE-11, which acts on the heart and muscles.

Another, somewhat less non-invasive form of medication is Muse^® by Abbott, which consists of a very small tablet to be introduced into the urethra using a special tube-like device.

Muse consists of a prostaglandin (called alprostadil), a hormone with a limited and largely unknown function, which is capable of narrowing the bloodvessels exiting the cavernous bodies, the same way as Viagra does. It works in over fifty percent of cases, but is rather expensive.

Adverse affects include penile pain and irritation of the urethra. Uprima^® (apomorphine), also by Abbott, has also been introduced after the Viagra hype. Apomorphine is a cousin of morphine, which has been known for years to induce nausea.

In very small dosages, the tablets can be administered subligually, i.e. underneath the tongue, so that the apomorphine get into the blood stream rapidly. It works very different from the other medication mentioned above.

Uprima act directly on the brain, thereby provoking easier erections by enhancing the ‘erection signals’ from brain to penis. The main reported side effect is nausea. The succesrate is ‘low’.

	vardenafil Levitra®	tadalafil Cialis®	sildenafil Viagra®	apomorfine Uprima®	alprostadil Muse®	papaverine/fentolamine Androskat®
Use	tablet	tablet	tablet	under the tongue	gel into the urethra	injection into the penis
Duration of Action	½ – 4 hours    After sexual stimulation   Delayed after meal	½ – 24 hours     After sexual stimulation   No effect of meal	½ – 4 hours     After sexual stimulation   Delayed after meal	Onset after 20 minutes     After sexual stimulation	Onset after 10 minutes   No sexual stimulation needed	Onset after 15 minutes   No sexual stimulation needed
How often	Once every 24 hrs max.	Once every 24 hrs max. Not daily	Once every 24 hrs max.	Once every 24 hrs max., repeat after 8 hrs minimum	Twice every 24 hrs max., 7 times per week max.	One a week max.
Dose	Start 1 dd 10 mg Max. 1 dd 20 mg Start 5 mg in elderly and when impaired kidney/liver function	Start 1 dd 10 mg Max. 1dd 20 mg	Start 1 dd 50 mg Max. 1dd 100 mg Start 25 mg in elderly and when impaired kidney/liver function	Start 2 mg Max. 6 mg	Start 0.25 mg Max. 1 mg	Start 0,25-0,5 ml Max. 2 ml
How effective	50-90% depending on other health problems, unknown after neurologic disorders, after trauma, surgery and radiotherapy	70-80% depending on other health problems, unknown after spinal cord injury, after radical prostatectomy, optimal effect after several times used	50-80% depending on other health problems, studies in several disorders optimal effect after several times used	40-50% optimal effect after several times used	60-70%	50-85%
Do not use when	Instable Heart Diseases Cerebrovascular Accident or Myocardial Infarct less than 6 months before Nitrate Use Low Blood Pressure (<90/50) Liverproblems Retinitis Pigmentosa	Instable Heart Diseases Cerebrovascular Accident or Myocardial Infarct less than 6 months before Nitrate Use Low Blood Pressure (<90/50) Liverproblems Retinitis Pigmentosa	Instable Heart Diseases Cerebrovascular Accident or Myocardial Infarct less than 6 months before Nitrate Use Low Blood Pressure (<90/50) Liverproblems Retinitis Pigmentosa	Instable Heart Diseases Myocardial Infarct less than 6 months before Low Blood Pressure (<90/50) Heart Failure	Sickelcell Anaemia Pregnancy Partner Peyronie’s disease Urethral Stricture Hypospadias	Sickelcell Anaemia Peyronie’s disease Antocoagulant Use
Side Effects	Headache Flushes Dyspepsia Rhinitis	Headache Flushes Dyspepsia, Rhinitis Muscle Cramps	Headache Flushes Dyspepsia, Rhinitis Blue or Blurry Vision	Nausea Headache Dizziness	Burining or Pain in Urethra	Pain Haematoma Scars Priapism

Hormonal treatment is only indicated in cases of a serious shortage of the male sex hormone testosterone.

This may cause a loss of sexual appetite and therefore erection problems. In those cases, testosterone should be administered, either by injection, tablets or skinpads. Less than 4 percent of men have a shortage of hormones and may benefit from this therapy.

Side effects can be prostate enlargement, liver damage and fluid retention in the body; patients with liver problems, heart disease, kidney problems or prostate cancer should refrain from using additional male sex hormones.

The vacuum therapy is a non-invasive and safe method to regain a certain amount of erection capability. The device used consists of a clear tube made of plastic, which can be placed over the penis.

The tube is put into place before or during love making. When properly placed, it completely surrounds the penis, shutting it off from outside air. A small pump is then used to create a vacuum around the penis, thus drawing blood to the cavernous bodies and inducing an erection.

When erection is complete, an elastic ring is then pushed off the cylinder around the penis, ensuring that the blood will not flow out again once the vacuum is released.

This method will work in about 90 percent of men, even in cases where vascular problems exist and in some cases after removal of a prosthesis implant. On the other hand, many men cease to use the device, because it is a rather ‘artificial’ method of obtaining an erection.

The erection only takes place in the outside portion of the penis, while the remainder of the cavernous bodies remain flaccid; this may cause the penis to be unstable and difficult to steer.

The penis may feel a bit colder than expected due to a restrained blood flow. The elastic ring may remain in place for about 30 minutes without harming the penis. In some men a slight bleeding of the superficial bloodvessels may result either from creating a vacuum too quickly or leaving the ring on too long.

These side effects are not damaging to the penis and no treatment is necessary. Some technical insight is handy, while men with sickelcell anaemia, leukemia or clotting diseases should not use the device. Many men are quite happy with its use.

The pressure rings may also be used on their own, in cases where sustaining an erection is the problem, not getting one. In those cases, the ring is placed at the base of the penis when the erection is complete, making sure that the blood won’t be able to flow out and keeping the penis rigid. Like the vacuum therapy, the ring may remain in place for 30 minutes.

Self-injection therapy consists of injecting a solution into the penis to achieve an erection. In the 80’s it was found that certain medication could induce a sustained erection for some time when injected directly into the cavernous bodies.

Since the medication starts working within 15-20 minutes, it should be injected by the patients themselves or their partners. Fortunately, this is easily learned.

Different kinds of medication can be used to achieve this. Papaverin was the first to be used; nowadays it is used in a combination with phentolamine (Androskat^®), leading to a more stable erection.

Prostaglandin (Caverject^®) is also used in this regard. In all cases, the injection therapy works by narrowing the bloodvessels that drain the blood from the cavernous bodies, in much the same way Viagra, mentioned above, does.

The injection method is taught by a urologist, who must first figure out the right dose to inject. The target is to cause an hour’s worth of erection, which may then differ somewhat, since erotic stimulation usually lengthens the effect.

As with the vacuum device, the erection won’t stop after ejaculation or orgasm. The method works in about 70 percent of men, provided that the bloodvessels to the penis are functioning properly and there is no venous leakage.

The method may be used frequently, albeit with intervals of at least three days.

Side effects include pain in the penis, especially when prostaglandin is used, and a chance on priapism, a prolonged and painful erection, which is rare and usually only happens in the beginning.

The erection should not last longer than 4 hours, because the penis may be permanently damaged with a longstanding erection.

With this method, some handiness with needles and syringes is necessary, while some men are just ouright scared to use the needles on themselves. For this reason, injection devices have been developed, which take over much of the work.

A penile implant is a surgical solution to the problem. In the 70’s a number of implantable penile prostheses were developed. Today, three versions exist:

• semirigid rods
• inflatable rods with additional pump
• inflatable rods with internal pump

Surgery is necessary to implant the devices. The rods are placed inside the cavernous bodies and will take over their function in erection. It will usually take 4-6 weeks before normal intercourse is possible.

The surgery will permanently damage the cavernous bodies and should be regarded as a last resort; once performed, there is no going back to any other therapy. Complications of the implants may be wound infections and infection of the prostheses.

Since the prosthesis are mechanical devices, they may malfunction. In case of trouble, surgery will be needed for removal and repair.

The semirigid rods (or Jonas prosthesis, after its inventor) are made of meshed silver or steel and covered by a thick layer of silicone. After implantation of these devices, the penis will remain rigid at all times, but may be easily bent.

When intercourse is desired, the rods can be simply bent in the right direction. The surgical technique for implantation is rather straightforward and can often be done in day care under local anaesthesia.

The complication rate is low and the prostheses can be used many times and for a long time span before metal fatigue sets in and a new set must be implanted.

A problem may be the fact that the erection always remains; even a folded erection may be difficult to hide in swimming trousers.

The inflatable prosthesis consists of two inflatable rods, which are again implanted inside the cavernous bodies and connceted to a small pump, implanted in the scrotal sack near the testicle, which in turn is connected to a balloon-like reservoir in the lower abdomen, filled with a watery fluid.

The complete set is implanted under general anaesthesia and a few days’ hospital stay is necessary. It will take upto 6 weeks before the device may be used to achieve an erection.

Squeezing one side of the pump through the scrotal skin will pump some of the fluid from the reservoir to the rods, thus filling them and the surrounding cavernous bodies in very much the same way as in a normal erection.

The effect closely mimics a normal erection, except for the tip of the penis, the glans, which does not take part in this artificial erection, when it would in a normal one. Sqeezing the other end of the pump will open a valve, allowing the fluid to get back into the reservoir and ending the erection.

This type of device is more complicated than the previous one, which allows for a higher chance on mechanical trouble; the tubing nay kink, the pump may stop functioning properly.

In about 10 percent of cases, some mechanical defect will occur within the first five years.

Because the surgery takes longer and is more complicated also, chances on infections are greater than with the Jonas device.

Nevertheless, since the resulting erection is so much more natural, many men prefer this device instead of the semirigid one.

A third device consists of an inflatable prosthesis with an internal pump. The two cylinders, which are to be implanted in both cavernous bodies, each contain a reservoir and a pump. Surgery takes place under general anaesthesia.

Use of the device is possible after 4-6 weeks. Once implanted, squeezing the tip of the penis will pump the fluid from the lower part of the prosthesis to the upper part, which will cause the prosthesis to become more rigid and the penis to become erect.

After the sexual activity, bending the penis will cause the fluid to flow back to the lower part of the prosthesis again, and the erection will cease. This prosthesis is more easily implanted than the other type of inflatable prosthesis and chances on infection during surgery are less.

Since less tubing is used, mechanical trouble is less of a problem, although the device may still malfunction, necessitating it to be replaced.

Vascular surgery may consist of constructing a bypass, as in heart surgery, to improve the blood flow towards the penis. Nowadays, this kind of surgery is still rarely done, because less than 1 percent of men may benefit, the failure rate is very high and other treatment options, like implantable prostheses, offer better prospects.

In some men, venous leakage is a major contributing factor in the erection disorder. The leak causes the blood to drain from the penis too quickly, thus making it impossible to keep up the bloodpressure inside the cavernous bodies, leading to a loss of erections.

It may then be an option to try to locate the vein that is causing the leak and closing it using a suture. In many cases, however, there is not just one vein responsible, but many, causing the surgery to fail after some time, when the other leaking bloodvessels start leaking as much as the sutured one did before.

Which treatment?

In order to make a right decision about the type of treatment, several factors need to be taken into account:

• The opinion of the partner about the erection disorder and possible treatment options may be just as important as that of the patient himself. A lot of the therapies mentioned also involve the partner, since some ‘artificial’ effort is needed to achieve an erection. Apart from that, some patients think that a normal erection may be paramount in the partner’s view for a normal marital life, while the partner may think that erections are not that important at all.
• The frequency of the sexual activities. The choice of therapy may be different if erections need to be achieved once a month or many times a week.
• Some therapies will change your life. A semirigid prosthesis will probably make it less desirable to reveal a bend but erect penis in swimming trousers, so swimming will be impossible after surgery. In case of vacuum therapy or injection therapy, you will need to take everythinh with you when you go on holiday.
• Some therapies, like the implants, cause permanent damage to the penis, which cannot be reversed. As a first choice therapy, these options are therefore less desirable. Apart from that, if the future should bring forth a new therapy, for which intact cavernous bodies are necessary, previous implant surgery would unfortunately render it useless.
• Financial cost. Some therapies are covered by insurance, others are not, or will only be partly reimbursed. Some therapies involve costs on a regular basis, like medication, while others, like the vacuum device or surgery, are more or less one-time events – not including follow-up visits to the hospital an malfunction of the devices.
• The effectiveness and safety of the treatment. Some devices and medication have been ‘on the market’ for only a short period and longterm effects and safety is yet unknown.

Treatment overview

TREATMENT	ADVANTAGES	DISADVANTAGES
Psychotherapy / Sextherapy	may add to your personal life may improve the relationship with partner	successrate varies duration of therapy less useful if vascular/neurogenic problem
Oral Medication Yohimbin	may improve libido	minimal effect possible side effects continuous use
Oral Medication Viagra/Levitra	simple 70% success?	price side effects
Oral Medication Cialis	simple long acting	price side effects
Oral Medication Uprima	simple effect on brain	price side effect (nausea) little effect
Medication Muse	virtually no side effects	price little effect
Medication Testosterone	may improve libido	continuous use only effective when natural level low serious side effects
Vacuum Therapy	high successrate use when needed	poor erection quality cumbersome technical skill
Elastic Rings	simple ‘no side effects’	erection must be present poor erection quality
Injection Therapy	high succesrate use when needed ‘natural erection’	technical skill side effects
Surgery Semirigid Prosthesis	simple surgery reliable high successrate ‘natural erection’	surgical complications penile enlargement cost ‘no turning back’
Surgery Inflatable prosthesis	high succesrate ‘natural erection’ use when needed	surgical complications reliability cost ‘no turning back’
Vascular Surgery	elegant therapy	surgical complications difficult surgery ‘no lasting effect’ cost considered obsolete