Male impotence, or erectile dysfunction, is the inability to produce or maintain an erection strong enough for a successful sexual relationship. This erectile dysfunction can have several causes, physical or psychological, and can even combine the two. Male impotence is most often linked to poor blood circulation, due to vascular disease affecting the arteries in the penis. Several treatments exist, the first of the therapies consisting of practicing regular physical activity.

Definition of impotence

Male impotence, also called erectile dysfunction, is defined as a partial or complete inability to achieve or maintain an erection sufficient for satisfactory sexual performance. This disorder is quite common in men, especially from the age of 40. This reduced sexual function strongly impinges on the quality of life of the affected subject and of his partner.

This condition can cause a loss of self-esteem in men, tarnish their self-image, and even lead to anxiety or depression. Impotence can greatly damage a couple’s intimacy, and even lead to an avoidance of all physical contact of a man with his partner. It can also increase emotional stress. This stress can then, by itself, strengthen the psychogenic components of erectile dysfunction.

Causes

There are many causes that can lead to sexual dysfunction, which can even be the first symptom of a previously undiagnosed condition.

Erections are ensured by the balance of blood flow between the inside and the outside of the penis. Thus, the erection of the penis is a neurovascular phenomenon: it requires the dilation of the vessels of the penis, the relaxation of the smooth muscles, the increase of blood flow in the cavernous bodies, and the occlusion of the veins.

The two cavernous bodies located at the level of the penis in fact constitute a spongy and extensible tissue. Composed of spaces gaps, these cavernous bodies are gorged with blood during the erection. Reason for which, the vascular diseases of the penis are the most frequent causes, and explain approximately 80% of the cases of organic erectile dysfunction.

Other diseases can cause this erectile dysfunction, such as:

• Diabetes ;
• Neurological diseases, such as the aftermath of pelvic cancer surgery, with removal of the prostate, which affects the erectile nerves. Or also, in case of section of the spinal cord, as in quadriplegic and paraplegic patients.
• Endocrine disorders: hypogonadism (reproductive system defect leading to loss of testicular function), hyperprolactinemia (overproduction of a hormone called prolactin) or thyroid disease;
• Benign hyperplasia of the prostate, the causes of which are poorly defined. Here, even if a factor such as endothelial dysfunction, or malfunction of blood vessels, may be found, a psychogenic component, linked to performance anxiety, also plays strongly. Sometimes, just treating this psychological element is enough to restore a normal erection.

When psychogenic in origin, impotence is more common in younger men, who describe a sudden onset of erectile dysfunction, and early and persistent morning or night erections. This psychological impotence can be caused by various problems, mainly performance anxiety, but also guilt, depression, relationship problems, or fear, as well as personal anxiety.

Diagnostic

Several questionnaires have been developed in order to objectively assess erectile dysfunction. The questionnaire in five short questions, developed by the International Erectile Function Index (IIEF), also called IIEF-5, is thus widely used both for diagnosis and for evaluating the response to be provided in terms of treatment.

The diagnosis can be made by a general practitioner, who can also possibly refer the patient to a urologist or sexologist. It should also be borne in mind that erectile dysfunction can be an early symptom of major systemic failures, such as diabetes or cardiovascular disease.

The elements relating to the history and auscultation of the patient may be supplemented by further investigations, in order to identify the cause of erectile dysfunction. Thus, a diagnosis will ultimately aim to:

• confirm that the patient is indeed suffering from erectile dysfunction and or some other sexual dysfunction, such as lack of desire or premature ejaculation;
• assess the severity of the disease;
• determine whether the erectile dysfunction has a psychogenic or organic origin;
• identify risk factors or co-morbidities;
• assess the patient’s physical condition allowing him to resume sexual activity.

At the level of the physical examination, will be evaluated:

• the external genital organ;
• endocrine and vascular systems;
• the prostate.

In terms of clinical investigations:

• blood testosterone concentrations will be assessed; 
• glucose, fasting lipids will be measured; 
• in men over 50, specific antigens of the prostate will be analyzed;
• Based on these initial investigations, further research will assess the luteinizing hormone, prolactin, and the HDL and LDL fractions of cholesterol; 
• Finally, if necessary, a Doppler (examination which allows to evaluate the blood flow in the arteries and the veins) can provide information on the hemodynamics of the penis, the aim then being to distinguish an arterial insufficiency or a dysfunction of the venous occlusion. other causes of erectile dysfunction.

The people concerned

Impotence mainly affects men from the age of 40. Total erectile dysfunction thus concerns:

• about 5% of men over 40;
• 10% of men in their sixties;
• 15% of men aged 70 and over;
• and 30-40% of men aged 80 and over.

However, young men can also be affected; in them, the main cause of impotence will be more of psychogenic origin.

Erectile dysfunction could, according to projections, affect up to 322 million men around the world around 2025. One element still needs to be emphasized: according to several studies, 55 to 70% of men aged between 77 and 79 years old are sexually active.

Risk factors

Aside from age, the predominant risk factors for erectile dysfunction are the same as for cardiovascular disease:

• the tobacco ;
• diabetes ;
• l’hypertension ;
• lipid abnormalities;
• obesity;
• lack of physical exercise.

Essentially, all conditions that damage the functioning of blood vessels. Among the other risk factors: depression, or endocrine disorders.

Certain drugs for hypertension or lowering the level of lipids in the blood could also exacerbate this erectile dysfunction.

The most common symptoms of erectile dysfunction are the inability to get and maintain an erection during sex, low libido, and high anxiety about sexual performance.

Other types of male sexual dysfunction can include:

• libido problems, either of sexual interest;
• orgasm;
• ejaculation.

The treatment options to fight against impotence are varied, and the choice will be made according to factors such as the severity of the erectile dysfunction, its cause, as well as the choice of the patient and his partner. Warning: many products that are released on the Internet or in stores, with the claim that they can help with erectile dysfunction, may be ineffective or even harmful.

The lifestyle change that can most affect the incidence of erectile dysfunction is physical activity. Other lifestyle changes cannot always restore erectile activity – sometimes it is too late. Weight loss, through diet and exercise, may help improve erection.

If impotence is related to a side effect of a drug, the doctor may prescribe an alternative molecule.

Psychosocial therapy may be effective when emotional or psychological factors contribute to erectile dysfunction. Psycho-sexual treatments can vary from simple sex education, through improving communication between the two partners, to cognitive behavioral therapies. They are often combined with drug therapy.

Medicines are commonly used to treat erectile dysfunction. All of the molecules work by increasing blood flow to the penis. These pills have proven to be harmless as well as their effectiveness, when their prescription is supervised by a doctor: they are mainly sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra). 65 to 70% of men thus regain quality erectile function.

If these pills do not work, there is a medication that can be delivered directly into the penis, intracavernously: thus, after training with the doctor or nurse, patients can carry out their own injection of alprostadil themselves. used alone or in combination with papaverine and phentolamine. These injections are effective in over 70% of cases, however up to 30% of patients experience pain at the injection site.

Finally, when the drugs do not work, there are other options: devices using a vacuum pump, also called penis pumps, allow an erection through a purely mechanical action. By creating a vacuum, blood is drawn into the penis. The erection is then maintained by means of a tourniquet.

Penile implants, placed inside the penis, make it powerful enough for sexual activity. These implants are effective, however they must be placed by means of surgery. This type of treatment, the complications of which are significantly higher than with drug molecules, will only be offered to certain patients, in whom more traditional therapies have failed.

Among the non-medicinal solutions, a method of Chinese medicine such as acupuncture seems, according to initial studies, to show convincing results. They have yet to be confirmed.

Treatments for erectile dysfunction resolve the depressions associated with it, and help restore self-esteem, and therefore, gain in quality of life.

The preventive factors for avoiding erectile dysfunction are to adopt a healthy lifestyle. The practice of regular physical activity is essential. The other protective factors are related to diet, in order to prevent diabetes, obesity and hypertension. Finally, tobacco and the consumption of illicit drugs should be banned. Likewise, alcohol consumption should remain moderate.