Erectile Dysfunction (Impotence)

Erectile Dysfunction (Impotence)

What is Erectile Dysfunction? What do we mean by Erectile Failure: is defined as persistent or recurrent, partial or/ complete, failure to obtain or sustain, an erection until completion of satisfactory sexual activity. Alternative terms for erectile dysfunction are Impotence, erectile failure, erectile dysfunctions, sexual inadequacy, sexual weakness, less erection, decreased erection, failure in intercourse, sexual incompetence, unable to sex i.e. intercourse, erection problem, napunsakata, less hardness of penis, looseness of penis in mid of sex or before penetration, E. D., ED, etc. The symbol for the man's "masculinity" is the erect penis. It represents manhood and is expected to be ready to perform at a moment's notice. When man suffers with erectile failure it comes as a major shock, when suddenly the symbol of his masculinity does not respond on. It usually means much more to the man than the simple fact that he is not responding sexually at that moment. It causes him to question his status as an adequate male. Thus when he fails, becomes panicky. Severity of Impotence: It can take on many forms as: I t may be complete erectile disorder: i.e. some men achieve no erection at all. For others, an erection may occur in the regular manner, but as the love play continues the erection is lost (we call it mid failure). For still others, the erection may be maintained very adequately up to the point of entry. As soon as entry is either contemplated or attempted, the erection disappears. For some, erection may be maintained beyond the point of entry, and then wane after a period of activity inside the vagina. No matter when the erection goes away, its loss is always troublesome. Erectile dysfunctions though a benign disorder has a great impact on the affected individual. Patient feels frustrated, depressed, ashamed, has lowered self-esteem & may even disturb his family relationship. There has been an explosion in the interest in male sexual dysfunction with the development in techniques of modern scientific diagnosis & treatment of male sexual disorders with very good treatment outcomes. Now majority patients are cured by proper diagnosis & correction of the defect. Thus now more & more people are seeking medical advice regarding their problems. How common erectile disorder is? In a survey in USA (1994) 39% of 40 Yr. old men, 67% of 70 Yr. old men complained of some degree of impotency. Complete erectile failures were present in 5% at age of 40 Yr., 15% at age 70 Yr. In India 1 in every 10 men suffers from some degree of impotence. How much erectile dysfunction affecting your quality of life? If you are suffering with some of these problems it means you need treatment. I feel frustrated because of my erection problem, My erection problem makes me feel depressed, I feel like less of man because of my erection problem, I have lost confidence in my sexual ability. I worry that I won't be able to get or keep an erection. I feel that I have lost control over my erections I worry about the future of my sex life, I have lost pleasure in sex because of my erection problem I try to avoid having sex, I worry that I am not satisfying her because of my erection problem The above questionnaire will decide that whether your problem is significant or not, if answer of any one question is yes then you must consult us either personally or through online & get cure of your sex problem. CAUSES OF ERECTILE DYSFUNCTIONS Impotence due to some well-defined causes (Internal defect i.e. organic or physical causes) 1) Hormones disorders are one of the common causes of impotence. There are two types of hormones in body, some hormones as male sex hormones stimulates erection & desire. Where as some other hormones inhibit the erection as prolactins & others. There are many male hormones in the body as serum testosterone, free testosterone DHEAS, Androstenidiones which, stimulate the sexual activity. So we have to test these hormones to finds out hormones disorders. Once the diagnosis is made they are easily treatable in few months time. Causes of hormone disorder may be Diabetics, Hypogonadisms (Testosterone deficiency), Hyperprolactinemias, Hypothyroidisms or Hyperthyroidisms, Cushing syndrome, Endocrines dysfunction Secondary to drugs/toxin & systemic diseases, Hypothalamic – pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome, Hypothalamic deficiency, pituitary hypoplasia, Trauma, post surgical, postiradiation, Adenoma: craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, hemochromatosis), Autoimmune hypophysitis, drug-induced hyperprolactinemias, Untreated endocrinopathies , Diabetics , Glucorticoid excess, Hypopituitarisms, Addison disease. Isolated gonadotropin deficiency, Pituitary or Hypothalamic defects, Associated with multiple pituitary hormones deficiencies: Idiopathic pan hypo-pituitarism (hypothalamic defects), Pituitary dysgenesis, Frohlich syndrome, fertile eunuch syndrome, Idiopathic hypopituitarism,Testicular failure, development defect, drugs, trauma, congenital defect, congenital adrenal hyperplasia, Chromosomal defect, testosterone hormone biosynthetic defect, Mumps orchitis leading to testicular atrophy, Primary testicular defect of testicular differentiation, inborn errors of testosterone synthesis, Klinefelters syndrome. (2) Decreased blood supply to penis: Due to many disorders of penile artery & veins, decrease in blood circulation (flow) to penis occurs so that blood is unable to reach in the phallus so that penis does not becomes full hard. Or some times blood reaches in normal amount resulting in full hardness of organ but any time before or after vaginal penetration blood starts leaking back in to body leading to loss of erection. The causes of this may be as follows: (i) Obstruction to arterial blood flow i.e. Decreased Penile blood supply to penis may be due to various diseases so that blood supply to penis may be decreased. So that either penis does not become fully hard or even if it becomes hard it soon become loose before intercourse or during intercourse. It can occur in young people or in older people also. This is one of the common causes of impotence. The causes of decreased blood supply may be Atherosclerotic, Diabetics, Hypertension, Heart Diseases & other vascular diseases as Arterial dysplasia, Post-Traumatic & Post-Surgical & damage to blood circulation due to various local disorders. (ii) Veno - Occlusive dysfunction i.e. Venous Leak: There are certain conditions in which penis becomes full tight initially but very soon becomes loose because blood from penis leaks back. Normally during sexual excitation blood flows into penis & this blood is not allowed to go back in body by various venous valves. Due to certain disorder these valves may not work. So that blood coming in penis keeps leaking in body all the time so that either penis does not becomes fully hard or even if becomes fully hard it becomes loose any time during sex due to leakage of blood. 3) Penile Nerve Abnormality: When erectile dysfunction is caused by disorder of central nervous system or due to peripheral nerve is called neurogenic erectile disorder. This can be due to disorder of nervous system & Neuropathy d/t various causes, Ant. temporal lobe lesions: Stroke/epilepsy, Dis. of Spinal Cord: T-12 or below & Dis. of Peripheral Nerves :(Peripheral polyneuropathies, Autonomic neuropathies, Pelvic nerve trauma). All these disorders leads to decreased sensitivity of penis & sex centre to female touch & sexual excitation leading to less erection. 4) Sex Centre Disorder: In the brain there is a particular centre in the hippocampus of the brain, which regulates the penile erection during intercourse, the desire of sex time, taken in discharge & enjoyment of sexual act. So any disorder of sex centre due to various causes can lead to impotency, less desire & premature ejaculation. The causes of sex centre induced impotence can be divided into two groups: (1) immediate cause, and (2) remote cause. Such a classification is helpful in the treatment of impotence. If the impotence is due to immediate causes, a removal of these factors results in adequate sexual functioning. When impotence is due to remote causes, detailed sex therapy may be necessary for a more lasting cure. (6) Penile corporal muscle abnormality due to various disease penile smooth muscles do not dilate so that blood is unable to reach in penis & it could not erect. 7) Local Causes Peyronies dis. (painful penile curvature d/t fibrosis), Penile trauma, carcinoma. Following Priapism (i.e. prolong longstanding erection) etc. 8) Other Systemic diseases (liver failure, renal failure, cardiac failure or other system failure etc.) B) Drugs & Toxins various drugs impair sexual activity. So detailed drug history taking is must. Antihypertensive (ß blocker, Thiazide diuretics,Clonidine & methylodopa) Antiandrogens (Spironolactone & Ketoconazole) Antidepressants (Tricyclic antidepressants, Major Tranquillizers & Antipsychotics & Addictions of (Alcohol, Smoking, Heroine, methadone, Cannabis, opiates & marijuana) (c) Psychogenic: Many psychiatric disorders as obsessive-compulsive disorder, Neurosis, schizophrenia, depression can cause impotence. Primary Cause of Impotence: due to any of the above causes patient may fail during sex. Once a person fails due to any of the above causes as hormone disorder or decreased penile blood supply or any other cause after that patient starts thinking that he has some serious internal defect in sex organ. Secondary to this failure in sex, virtually all patient develop following three things, these three factors further worsen the erectile dysfunction caused by primary cause, and these are called. These secondary factors are as follows: 1) Fear of failure In this the moment person thinks of going for sex, he start fearing that I may fail again thus he loses confidence in his sexual competence. This fear decreases his confidence further leading to further worsening of sex dysfunction. Many times due to this fear patient starts avoiding sex & his desire for intercourse decreases. 2) Sexual Performance anxiety means development of severe anxiety before real sex. Patient develops obsessive concern for full erection i.e. whether or not he can get a normal erection and if he does whether he can keep it long enough for intercourse to occur & his partner to be satisfied. Due to this anxiety He tries to erect his penis hard by concentrating more on it & contracting the pelvic & leg muscles rather than allow it to occur in natural response to erotic pleasure. But unluckily most people do not know that penis hardness occurs spontaneously & automatically in response to more & more enjoyment one gets in touching & loving the female body. Thus the more patient tries too make penis hard, the just opposite happens i.e. penis becomes looser. Thus this anxiety to perform better really further worsens the hardness of penis. This performance anxiety can be cured by sex therapy in few sittings. 3) Spectator attitude means whenever patient goes for sexual activity though he may be touching the body of female but his brain is always thinking and involuntarily (unconsciously) looking towards his penis i.e. whether his penis is getting hard or not. This is called spying of penis. Thus his mind is always preoccupied about penile hardness. Patient loses confidence in his performance, and instead of relaxing & enjoying he starts watching their sexual responses like 'spectators', rather than being involved in what is going on. So that in place of enjoying the female touch, he always keeps spying his penis leading to lack of enjoyment of sexual activity thus\leading to repeated failures. These all above problems contributes to repeated failures. So that in all cases of impotency after proper diagnosis & treatment of primary cause, these three secondary problems also need to be tackled by sex therapy then only patient can get permanent cure. So by sex therapy, the patient is taught how to avoid spectator role and become free of fear of failure & performance anxiety. So above three secondary problems hinder into normal recovery of sexual function even if the original cause may have been cured. It does not means that person is suffering from psychological erectile failure; instead it is a normal fear everybody develops due to failure in sex. Thus one should try to find out why he failed on very first time i.e. one should try to finds out any of the above nine causes of impotence. Thus the anxiety of sex, fear of failure and spectatoring (the patient watching all the time to see if he is getting an erection or not) are also the important. After correcting primary cause the normal potency does not returns, because these three secondary factors interfere with normal sexual functioning. If these factors are also removed by sex therapy, sexual functioning soon becomes normal. The new, intensive team treatment of sexual dysfunction has revolutionized sex therapy. 'In most cases, for cure of impotence detailed sex counseling & sex therapy is necessary. How common is impotence due to some well-defined internal causes? Old belief is that most cases of impotence are Psychogenic is not correct. In one study Koremann & colleague found impotence due to some internal causes in > 90% of men & Psychogenic in 10%. Thus Psychogenic cause should never be labeled unless Hormonal & other causes have been excluded by thorough ex amination, hormon.examination, hormon.0es & penile blood supply test. DIAGNOSIS OF CAUSE OF IMPOTENCE First step in proper treatment of Erectile Dysfunctions (impotence) is accurate diagnosis of cause. So we first try to find out cause. We take detailed history, thorough sex counseling, physical examination, examination of nerves and Penile arterial examination. After that depending on likelihood of particular, cause relevant tests are done All testing facilities are available at our centre. Thus you may consult us at our centre & at same time you may get all tests. done. The time taken in getting all the reports ready is 36 hours. So if you are from out of Delhi, you may come here for two days. DETAILED HISTORY: We take detail history about the onset of eredtile dysfunction i.e. whether it started Sudden or gradual, Primary or Secondary, Erections at other occasions, Response to previous therapy, Libido, Stress (physical or mental), H/O precipitation by some drugs, presence of Hypertension, Ischemic Heart Disease , claudication, trauma, DM, Sec. Sexual Characters, Hypothyroidisms, Hyperthyroidisms & Galactorrhoeas, Symptoms of sensory loss, epilepsy, Liver/Renal failure. EXAMINATION OF GENITALS: We examine whether Sexual Development is adequate or subnormal. For this testis size is measured by orchidometer (if patient is outstation then by ultrasound of testis) , Penis Length & girth is measured by phallometer. Galactorrhoea & features of other hormone disorder are checked up. Blood supply of penis is assessed by, palpating dorsal penile artery of penis. Nerves of penis examined by sensation testing, Deep Tendon reflexes & Bulbocavernosal reflexes. Then other systems are examined. INVESTIGATIONS i.e. DIAGNOSTIC TESTS: At our centre we have all the facility for complete investigation of various causes of Erection difficulties & other sex problems. So we perform following tests, step by step depending on their need based on history & examination. The various diagnostic tests needed/performed are as follows: - Step- I: Hormone Testing: There are two types of hormones in body some stimulates penile hardness whereas there are other hormones which inhibit penile stiffness. Male & Female sex hormones & other associated Hormones are tested by latest-immunoassay techniques. These hormones includes total Testosterones, free testosterones, Prolactins, LH, FSH, T3, T4, TSH others as Cortical, E2, Free testosterones SHBG etc.. Among above tests relevant hormones are tested in that particular patient. Results are available in 36 hours. In the hormone testing either stimulatory sex hormones may be low leading to less erection or those hormones which are inhibitory may be high leading to inhibition of penile erection. These hormones are tested by taking blood sample from forearm. When we find out any of above hormone disorder simply correction of these hormone disorders corrects the erectile dysfunctions in two months time. Blood glucose & other systemic test may be required depending on the need. Step I1: Penile Blood Supply Testing: This test is done to decide whether impotence is due to decreased blood supply to penis or disorders of nerves or due to some other causes. This test is also called PIPE (Pharmacological induced penile erection) test. In this test we examine the dorsal penis artery & veins after giving the various Vasodilators either orally or as injectable, also we asses whether penis is getting full hard or not after vasodilator use, how long hardness is persisting in response to theses vasodilators. If penis is not becoming fully hard or not staying hard for at least fifteen minutes even after adequate dose of vasodilators than cause of impotence is inadequate blood supply to penis or due to leakage of blood out of penis due to venous leak. If penis is getting full hard and staying longer than fifteen minutes then cause is nerves of penis are not functioning or some other cause. There are two types of blood supply disorders are found on blood supply testing. The first pattern is suggestive of penile arterial blockade in which blood does not flows in penis from blood circulation due to block in arterial supply of penis. This obstruction in vascular supply is diagnosed by above mentioned blood supply test in which after giving blood flow medicine we find that there is increase in blood flow in arteries of penis is less than normal with resultant absence of achievement of full hardness of penis for sufficient time. This test is very simple to perform if the concerned doctor is well trained & experienced. This is an O. P. D. procedure & takes approximately 30 minutes to perform the test. We do these tests daily at our centre as we have all the required instruments to do these tests. Once we diagnose that there is decreased blood supply to penis then we find out the cause of this inadequate blood flow. Once the cause of decreased blood supply is diagnosed then treatment becomes very easy with virtually full chances of permanent cure. Second pattern found on blood supply testing is Leakage of blood out of penis back into circulation after initial full erection (also known as Veno-occlusive dysfunction): In this defect, blood flows from circulation to penis normally but due to continuous leak of blood out of penis due to defect in penile valves whose job is to stop the leakage of blood out of penis, enough penis hardness is either not achieved or even if penis becomes fully hard it become loose there after due to leakage of blood out of it. When we do blood supply testing, in this disorder there is good blood flow in arteries of penis through out study, but there is continuous leakage of blood is seen through valves of penile veins. Step-3: N.P.T. MONITORING: Penile Erection assessment at night (called as nocturnal penile tumescence) is done by Rigiscan device (it measures penile rigidity & diameter) to differentiate between impotence of psychogenic origin or due to some internal cause. If N.P.T. monitoring shows Normal results it means impotence is Psychogenic, if results are impaired means impotence is due to some internal cause. Step 4: DUPLEX SCANNING: (Doppler & ultrasound scanning before & after vasodilator use) In this Testing with use of vasodilator drugs/Duplex vascular scanning is done to decide which type of problem patient is suffering, accordingly treatment is prescribed. It assesses arterial diameter & blood flow status. It helps in differentiating & pinpointing the cause of impotence i.e. whether it is arterial or venous cause & what is the specific cause of that problem so that it can be treated properly. Step 5: Sex Counseling: After detail discussion with our male & female sex therapist, we try to finds out the root cause of sex problem then we treat accordingly. For counseling we take detail history of sexual development, his thoughts, his misconception about sex, his old experience in sex, his unconscious fears about sex. This counseling session unravels all the hidden psychological causes of sexual inadequacy. Step 6: Other tests (If required) 1) Penile Nerve Testing: By conduction and sensory testing (NCV, EMG & VPT). 2) Psychoanalysis: To find different factor leading to psychogenic impotence. 3) Functional Studies: To see the penile response in provocation to various drugs. 4) 5) Arteriography: It is a Specialized X-Ray of penis before arterial opening i.e. opening of the blockade surgery. In this test a drug (dye) is infused which detects whether block is situated , whether it is localized or diffused. Once we localized the obstruction & its cause, then we decide whether it can be cured through medicine or surgery. 5) Cavernosometry & cavernosography (before venous leak surgery). TREATMENT OF ERECTILE DYSFUNCTIONS After diagnosing the cause of impotence of cause we prescribe medicines that patient has to purchase himself from any medical store The success of various drugs we use in erectile dysfunction depends on accurate diagnosis of cause. If empirical treatment is prescribed as most doctors do, it often does not achieves permanent cure. These sex tonics & ayurvedic medicines can improve your sexual life temporarily but they cannot give permanent cure. Thus please get yourself fully investigated before starting treatment. Response of Treatment: As we have fully dedicated team of highly qualified, experienced, doctors, sex counselors, sex therapist, who are expert in field of sexology. After finding the cause of erectile dysfunction by above tests it is cured in most patients by two months treatment. The various treatment option for patient with impotence are: 1) Hormone Therapy 2) Medicines to increase blood supply to penis (Oral & Local Gels) 3) Viagra & like drugs 4) Sex Therapy 5) Vacuum Erection Pumps 6) Injection therapy 7) Penile Blood Supply increasing Surgery 8) Penile Hardness Increasing Implants (Penile prosthesis) (1) Hormone Therapy: Hormone therapy is given to cure the problem whatever defect is found. Hormones Therapy: Depending on the type of hormone disorder i.e. whether male sex hormones decreased or inhibitory hormones has increased, Hormone therapy is directed towards that. Hormone therapy usually cures the Hormone problem in 2 to 3 months time and they do not have any adverse effects as they given to only those patients in whom some hormone disorder is found. The various hormone preparations & their route of administration are: 1. Oral testosterone preparations that is available in capsule form. It needs to be given one to three capsules daily. These have no side effects. 2. Transdermal Testosterone given as scrotal patch. It is very effective & has no side effects. It can be also given as Testosterone gel, which can be applied on any part of the skin. 3. Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & has better effects on sex organs. 4. Local application of D.H.T. gel is new preparation for male hormone replacement. It is very effective without any side effects. 5. Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days. 6. New human androgen receptor modulators they increase the effect of male hormone over androgens sensitive organs. 7) DHEAS tablets are available which are effective & has no side effects. 8)Treatment of hyperprolactinemia with cabergoline & Bromocriptine is done with quick cure of sexual dysfunctions. (3)Medicines to increase blood supply to penis: (oral & local gel) Medical treatment (i.e. prescription of various drugs to increase blood supply to penis, nerve rejuvenating etc are given to correct the basic cause found on investigations. These drugs open the blockade of penile arteries so that blood flows into penis increases and penis becomes fully hard. The various drugs, which are effective to increase penile blood supply, are as follows. The particular drug needed in particular patient depends on the cause of erectile dysfunctions. Oral Drugs: The various oral drugs are: a. Yohimbine: By acting on alpha-receptors it dilates the penile blood supply. It is one of the common drug used for increasing penile blood supply. It is freely availalable as oral tablet. b. Phentolamine: is also a good drug to increase blood flow in the penis. The effect of this drug increases manifold when it is used along with other commonly used vasodilators. It is used as oral, sublingual tablets. In advance cases it is given as injectable also. c. Sublingual apomorphine is very effective in increasing penile blood supply. d. Trazadon works on sex centre & increase penile blood supply. e Oral Prostaglandin. f Nalaxone g Gene Therapy: In this modality of treatment blood supply to penis is increased by gene therapy. By the introduction new genes in body the generation of penile blood increasing substance nitric oxide generation increases in penile blood tissue leading to more blood supply & hardness of penis. This is a slow process takes longer time to have effect but once the effect starts coming the results are permanent. Thus it achieves the cure of impotence. This is effective & achieves permanent cure of impotence 3) Local Application of Gels / Drugs a. MUSE is per urethral use of PGE1. In this medicated pellet is inserted into the Urethra. After insertion penis becomes hard with in 20 minutes. This hardness lasts for up to 60 minutes. b. Topical preparations of papaverine c. Topical preparations of prostaglandin E1 d. Vasoactive intestinal peptide e. Local application of Minoxidil f. Local application of Nitroglycerine g. Local application of l-arginic acid (3) Viagra & Like drugs These drugs are good but temporary method of treatment because it does not treats the basic cause of sex problem. These drugs belong to following the groups: Sildenafil,( Viagra, penegra, caverta) : one tablet works for 4 hours. Tadalafil (Cialis, tadalis, megalis ) : one tablet works for 24 hours. Vardenafil (Levitra): one tablet works for 6 hours. It is a temporary therapy. After consumption of this tablet, patient gets hardness only temporarily. Once this tablet is consumed, the blood flow into penis increases & penis becomes fully hard in many patients. But this is an effective short-term treatment but it does not cures the basic problem. It also has certain side effects & many deaths have been reported after its use if not used with proper precaution. Thus it should not be consumed without the advise of experts. There need to have detailed physical examination before one is prescribed Viagra. So never take it without expert advise. Dose used is 25 mg to maximum of 100mg. It should be taken 60 minutes before sexual intercourse. 5. Detailed Sex Education: In this patient is explained in detail about what is normal physiology of erection and what we can do in our daily life to increase erectile strength & staying it hard for longer time. Also we educate the patient how to satisfy the women so that she gets satisfactory orgasm and considers you a wonderful partner. (4) Sex Therapy: Once we found out the cause we treat internal causes like hormone disorder & decrease penile blood supply. But even after treating above basic primary causes of impotence, Many times patients still do not recovers fully because of his fear of failure, sexual performance anxiety and spectatoring attitude. These secondary factors do not allow him to function normally. For cure of these secondary problem patient needs details sex therapy. Basic purpose of this exercise is to make patient free of any fear of sexual performance. After this exercises all performance anxiety disappears. In sex therapy the patient is taught various exercises & how to use various body part in particular way so that erection become good, sustained & patient does not have any fear. Normally in six to eight sittings patient's all fear disappears. Sex therapy is a very effective in impotence, premature ejaculation. Thus we advise all of our patients not to hurry, and take few sessions of sex therapy sittings for permanent cure. (5) Vacuum Pump Devices Vacuum Pump Devices is a small instrument, application of it on penis, makes penis fully hard within three minutes. With this instrument patient does not have to consume any medicine. So it has no side effect. (By this device a vacuum of > 100 mm of Hg is created around penis leading to Pooling of blood in penis resulting in full hardness). Efficacy: Approximately 80% of patients get full erection & satisfied. (6) Injection Therapy The various drugs used as injections are Injection of papaverine, ProstaglandinE1, & Phentolamine is used alone or in combination (bimix or trimix). This is a very effective mode of treatment of impotence. The dose of papaverine is 5mg. to 60mg. at one time. It work in 15 minutes & patient gets very hard erection, which lasts for at least thirty minutes. It is very good especially for those who fear that they may fail during sex. So that by taking this injection they can perform without fear & with hundred percent guarantee of success. It is a quiet popular form of treatment among boys & young adults. Especially for those, who have severe fear for failure for the first night or when expecting sexual encounter with a new partner. Response - Success is achieved in approximately 90% patients. Injection of ProstaglandinE1: dose used is 10 to 20 mg at one time .It is very effective with virtually no side effects. Injection of Phentolamine normally it is used in combination with papaverine or Phentolamine. Inj. Of Moxisylyte: available by the name of injection Erecnos. Inj. of Vasoactive Intestinal Polypeptide: available by the name of injection Invicorp. Treatment of underlying cause: When some underlying cause as diabetics, depression, high blood pressure (hypertension), or use of drug is diagnosed is treated accordingly. Surgical Treatment Surgical treatment is suggested only when all the above mode of therapy namely hormone therapy, blood supply increasing tablets, Viagra like drugs, & sex therapy has failed. (7) Penile blood supply increasing surgery: After investigations when it is diagnosed that blood supply is decreased. In majority of patient's blood supply can be normalized by many of the medicines as mentioned above, which have capacity to correct the vascular disorders. But in some cases surgery is required. Before surgery for vascculogenic impotence, exact site of blockade is localized by Arteriography. The various surgeries are as follows: a) Arterial Recanalization surgery: After localizing the block, we open the blocked part of artery by vascular microsurgery, this is called recanalization vascular surgery. This is commonly done in younger patients. b) Arterial bypass surgery: When we find that there is blockade in broad segment of dorsal penile artery then such a long segment can not be recanalized. In such cases we bypass the blocked portion of the artery by use of other inferior epigastric artery. In this normal artery is connected with penis artery distal to blocked artery so that blood flow normalizes. c) Venous leak surgery: As we have mentioned above leakage of blood from penis to back into body in mid of erection is one of the cause of impotence. In this surgery the leaking veins is localized first by venography (cavernasometry & cavernosography). After localization of those veins through which blood is leaking are ligated i.e. tied. Thus venous leak stops & penis starts becoming full rock like hard & patient sexual problem normalizes. For this surgery we keep patient admitted for one day only. At our centre our micro vascular surgeon is very expert in doing all above surgeries. In this surgery artery in which blockade is present is either opened or blocked area is bypassed by use of other artery so that blood Supply to penis is established. Result is very good when candidate for surgery is properly selected. This operation needs expertise. It is done under the guidance of operating microscopes. (8) Penile Hardness Increasing Implants (Penile prosthesis): There are some patients in whom blood supply increasing surgery is not possible. Thus penile implant is a good treatment in all those patients in whom cure is not possible inspite of all above treatments. In such cases we put intrapenile implants. After these surgery patient can resume his normal sexual functions. There are two kinds of implants: a) Malleable i.e. semi rigid implants: b) Inflatable implants: Now days this implant is more in use as penile hardness is very good above all it may remain erect for longer time. This surgery takes approximately 30 minute by our surgeon. There are certain penile implants which when applied into penis then its hardness become very hard. Thus my advise to any body who is suffering with erectile disorder: 1) Please get yourself completely investigated, find out the cause, get complete treatment accordingly with good cure rate. 2) Never presume your problem as Psychogenic unless other causes have been excluded. 3) Remember males should be potent till late seventies unless they have some cause such as Hormone disorder or decreased penile blood supply. So at any age you may attain potency after complete diagnosis and treatment. 4) Remember Ayurvedic doctors do not have knowledge of various causes of erectile dysfunction and they just give empirical sex tonics with no improvement or only partial temporary improvement. Also unfortunately most Ayurvedic doctor exploit patients. 5) Now treatment of impotence is possible with satisfactory results with the availability of newer drugs. Impotence in Diabetics About 50% of diabetic patients with high blood sugar ultimately become impotent. It can occur at young age or old age. It occurs more frequently at older age & after many years of uncontrolled high blood sugar, but in some it can occur at younger age also. It is more common in patients with other associated complications as Nerve, Kidney or Heart involvement. In those in whom sugar is not well-controlled chances of developing impotence is more. It is also more in those who have hypertension & taking medicines for that & also in alcoholics & smokers. The causes for impotence in diabetics are as follows: - (i) Hormones Disorder (Deficiency of male sex hormones or increase in some inhibitory hormone as high prolactin & disorders of Thyroids can cause erectile dysfunctions. (ii) Decreased penile blood supply due to deposition of cholesterol in penile blood circulation or in arteries supplying blood to penis. (iii) Endothelial & smooth muscle disorders leads to decreased dilatation of penile vessels on sexual stimulation so that blood is unable to reach in penis thus full hardness is not achieved. (iv) Affection of penile nerve i.e. penile neuropathy. (v) Psychogenic factors as presence of depression or other psychiatric illness. For detail investigation to diagnose the cause of erectile disorder read page diagnosis of cause of impotence Treatment will be sex therapy, drugs, injection therapy, hormones & prosthesis etc. depending on the cause of impotence & etiology. For detail read treatment of impotence. Impotence after heart attack (MI) is very common it occurs due to decreased penile blood supply decreases hormone, fear of another myocardial infarction (M.I.) & sex center disorder. This can be treated in three months time after proper investigation. Erectile disorder in Chronic Renal failure: CRF & subsequent uremia are commonly associated with erectile dysfunctions (i.e. impotence) decreased desire. Approx. 60% of CRF patients suffers with impotence. It occurs due to decreased penile blood supply. Nerve involvement & hormone disorders. Treatment includes drugs hormone therapy & injections for detail in section treatment of impotence.