Treatment of impotence

Medical therapy with androgens offers little more than placebo benefit except in hypogonadal men. If a prolactin-secreting pituitary tumor is present, however, either surgical removal or treatment with bromocriptine usually results in return of potency. Surgical therapy may be useful in the treatment of decreased potency related to aortic obstruction; however, potency can be lost rather than improved after aortic operation if the autonomic nerve supply to the penis is damaged. This complication is minimized if an endarterectomy is done or, in a grafting procedure, if the reconstruction of the distal end is performed above the origin of the external iliac arteries.

A useful surgical technique for improvement of potency in refractory patients such as individuals with diabetic neuropathy is the implantation of a penile prosthesis, namely the insertion within the corpora of a small, blunt Silastic rod. The patient must be made aware that full erection is not produced and that the device only prevents buckling during intercourse. Furthermore, the complication rate is high in some series. Alternatively, an inflatable prosthetic device has been devised for implantation on either side of the corpora. A connecting reservoir of material is placed in the perivesicular space and pumps are located in the scrotum. By means of these pumps the penis can be made to become nearly fully erect at the appropriate time and to relax after intercourse. Intracavernous injections of papaverine and/or phentolamine in patients with nonvascular causes for impotence can cause transitory penile tumescence sufficient for coitus. Whether self-injection of these agents will be successful for the management of sexual dysfunction is not clear.

In the larger group of anxiety states and depressive illnesses, measures directed at their alleviation may restore sexual potency, and sexual counseling, education, and psychotherapy are beneficial in alleviating psychogenic factors.