However, these difficulties can last some time when the causes mentioned above are particularly serious or when illnesses or changes that affect the mechanisms which control the erection, such as nerves, blood vessels or hormones, are involved. Another category of difficulty may concern the inner structure of the penis. We shall now take a look at the form of this organ and how it works, so as to understand where such difficulties can arise.

The cavernous body of the penis can be compared to that of a sponge, with numerous meshworks which delimit a lacunary system, that is, of cavities with a high capacity. These meshworks are made up of connective fibres and smooth muscles.

When the penis is flaccid there is essentially a circulation of blood that ensures nutrition in which the blood of the arteries enters partly into the cavernous body, this circulation is regulated by a system of little cushions inside the lumen of the penile arteries and onto the surface of venous shunts. In the course of an erection there is an arterial vasodilation with the release of the arterial cushions and the closure of the venous valves and in this way the blood fills the cavernous body and is held inside the cavities, creating an erection. There is, therefore, at the basis of an erection a hydraulic mechanism, although this is controlled from a higher level.

Any erectile problem, therefore, can generally be attributed to the decrease of the inflow of blood to the penis, to its rapid outflow, to both, or even to problems concerning the very structure and erectile capacity of the cavernous tissue. Evidently this concerns the actual penis itself; because there can be other causes which concern the various control and regulation systems at another level, such as the neurological system, the hormonal system, the metabolic system, etc. These will be examined later on.

The term impotence (erectile disfunction) means the permanent inability to get or maintain a rigid erection which allows for satisfying sexual intercourse, or rather

1. total absence of the erection
2. decrease in the rigidity of the penis to the point of not being able to penetrate
3. involuntary loss of the erection during intercourse
4. Impotence can also exist in the sense that satisfying sexual intercourse is difficult to perform even when the penis is rigid, due to other symptoms and problems, for example, pain, burning, or deformations in the penis incompatible with normal penetration. This might be due to congenital deformities or acquired ones ( for ex. “induratio penis plastica” or “La Peyronie” disease.

INDURATIO PENIS PLASTICA

It involves an inflammation of the erectile tissue of the penis which will bring about the hardening of the tissues and the man will notice internal but palpable nodules in the penis. In many cases the first major discomfort is the pain that will always accompany the erection and which will not allow normal intercourse; when this disease is serious one can even experience curvature of the penis, and sometimes the bend can be so great that it will not allow penetration.

The problems concerning ejaculation should also be considered. Ejaculation can be normal, absent or premature. The latter is known as primary when it involves a person at the beginning of his sexual life and secondary when it occurs after a period of normality. In many situations premature ejaculation is the result of erectile problems. Indeed premature ejaculation, in the majority of cases, is a sign of the inability to maintain an erection for the sufficient time to have intercourse. In other cases, premature ejaculation is a symptom of a neurological hypersensitivity that can derive from diseases of the peripheral nerves: or from diseases and irritations in the spinal cord, for example, in the case of a disc hernia. The inflammation of the male genitalia, for example, the inflammation of the gland (the base of the penis), of the urethra, of the prostate and of the seminal vesicles can lead to premature ejaculation which can obviously be resolved when the inflammation is cured. In other cases the cause may lie in psychological difficulties, due to anxiety, stress or fear.

As one might imagine premature ejaculation can sometimes be understood easily, for example, when it affects people who rarely have intercourse, or when it happens with one partner and not with another. In this last case, the cause should evidently be attributed to the dynamics of the relationship.

Finally, a situation which deserves particular medical attention. That is, when the ejaculation is lacking the release of the seminal fluid. When this occurs one must quickly consult a specialist since, as well as being the result of certain surgical operations, for example, the removal of the prostate, it can also be a symptom of disease, sometimes serious, in the male genitalia (prostate cancer).

The seminal fluid which is expelled during the orgasm should be distinguished from the transparent fluid which is released during the first moments of sexual excitement. This fluid, which is not fertile, is produced by the Cowper urethral glands and is used to lubricate the urethra. It is also necessary to consult the specialist when one notices significant changes in the seminal fluid, for example when one notices the presence of blood or otherwise of a reddish colour (haemospermia).

Sometimes ejacluation can be accompanied by pain and this occurs in several pathological situations such as inflammation.

3 CAUSES OF IMPOTENCE

Impotence has an aetiopathogenisis essentially of two types: psychological and physical, which, in some cases, can obviously be linked to each other in various ways.

Psychological causes, contrary to popular belief, make up only 10% of the total, although psychological unease understandably almost always accompanies these problems in their physical form.

Psychological impotence can be primary, that is when the subject has never managed to have sexual intercourse, or secondary, when it occurs with people who in the past have had a normal sexual life. Impotence with psychological causes can derive from problems such as anxiety, stress, depression, neurosis, psychosis and from problems in the relationship.

Impotence with organic causes can be generated from any problem which concerns the mechanism of development, activating and maintaining of the erection. That is to say, it can affect the various stages of control, such as the development and the functioning of the organs and of the genitalia, of the endocrinological system, that is hormonal system, of the neurological system and perhaps all circulatory systems.

The circulatory causes referred to also as Vascular, are perhaps the most widespread making up more than 50% of the cases and they are also a result of the many diseases that cause the decrease in the flow of blood to the penis creating the difficulty in getting a strong erection. This decrease of blood to the penis can also be caused by a complete or partial obstruction to the penile arteries due to arteriosclerosis of the aortic axis fostered by well-known factors of vascular risk, such as smoking, hypercholesterol, hypertrigliceridemia and high levels of uric acid, or as a result of significant diseases such as diabetes, with its complications known as microangiopathy, arterial hypertension which causes arteriosclerosis, or even the well-known vascular diseases such as the aneurysm of the abdominal aorta which causes Lerich syndrome and can lead to embolisms and thrombosis. Vascular impotence also occurs as a result of direct traumas on the penile arteries; the fracturing of the penis also in some cases causes impotence due to lack of blood.

In addition to the arterial causes discussed above, there are also the venous causes, that is the inability of the penis to hold the blood inside with the result of its rapid deflux, and consequent difficulty in maintaining the erection. This situation is defined as “venous leakage”, and is associated with several innate deformities of the penis such as its curvature and various hormonal imbalances.

Neurological causes affect much more the lesions of the spinal cord, for example the diseases of the marrow known as mielopathia and mieldisplasie, in spinal traumas, fractures in the vertebral column and in disc hernias. Another group of neurological causes is represented by the peripheral nervous lesions which may be a result of traumas or surgical operations or of systems or nerve disorders, such as diabetes with the so called diabetic neuropathy, Parkinson’s disease, multible plaque sclerosis, alcoholism etc.

Congenital deformities of the penis can create erectile problems, or even make penetration physically impossible. The most common deformities are that of the micropenis, the bending and the rotations of the penis and the hypospadia and epispadia, that is the presence of an urethral opening in a place other than its natural position, most frequently in the lower part of the penis. Acquired deformities on the other hand, can arise because of fibrousis or calcifications inside the erectile tissue, due either to a disorder called “Induratio Penis Plastico” which causes pain, the bending of the penis and impotence, or to traumas or therapeutic or surgical operations on the penis.

The lack of hormones actually occurs in a very low percentage of cases and it usually concerns disorders which alter hormonal control mechanism rather than an actual decrease in the secretion of male sexual hormones like in hypophysis adenomas, in hyper and hypothyroidisms etc.

The use of certain pharmaceuticals such as anti-hypertensives, diuretics, tranquilizers, anti-ulcerouses, anorexiants and others can bring about erectile difficulties.

Erectile disorders can also arise as a consequence of certain surgical operations on the bladder, prostate, rectum, and abdominal aorta etc. quite apart from base illnesses. Also inflammatory disorders of the male urogenitalia such as inflammation of the urethra, bladder or prostate, can cause problems linked to sexual performance.

Lastly a small percentage of cases are due to acute poisoning, a history of drug use, heavy metals and from polluting agents. In a very small amount of cases, the cause remains unknown in spite of research.

4 EVALUATION OF ERECTILE
INSUFFICIENCY

A real understanding of male sexual disorders requires a thorough physiological analysis concerning habits which can include smoking, alcohol, diet, work etc. and an interview with a doctor to clarify every aspect of the problem, what form the problem takes, if it is accompanied by other aspects when it reoccurs and if the problem is sporadic or persistent. Also to be clarified is the presence of system disorders such as diabetes, hypertension, hypercholesterol, and other disorders or surgical operations and therapies, use of pharmaceuticals, allergies etc.

At this early stage it is necessary to undergo a complete general clinical examination, measuring the pulse, blood pressure, and examining the genital region, more specifically the penis, the testicles and the prostate.

The following step is the monitoring of the nocturnal penile erections (NPT), which is conducted with sophisticated equipment at the patient’s home for one or more nights. This examination makes it possible to make a distinction between impotence with psychological causes or impotence with medical causes. With NPT we can measure the two fundamental parameters of erectile activity, that is the swelling and the rigidity of the erections that take place during the REM phase of sleep, that is during the period in which one is dreaming. Indeed, we are completely unconscious of these erections and they are not controlled by will. The data collected consists of the variations in the penile circumference at the base and at the tip of the penis (measured in cm) and the variations in rigidity (measured in percentage) as well as duration (measured in minutes). If the results of the NPT are normal, i.e. that they display the presence of erections with normal duration and frequency, with significant voluminous increases and penile rigidity, the patient can be given therapy of a psychosexual nature, with possible pharmaceutical support. If on the other hand the nocturnal study displays pathological results, that is a lack of erectile activity, or even sporadic or incomplete erections with rapid de-swelling, the patient should undergo other diagnostic investigations concerning other specific sectors (vascular, using the Doppler examination, cavernosometry, neurological, using a study of reflexes and the potentials evoked, endocrinal using hormonal dosage).

Vascular Sector

This area can be researched using the Doppler Ecovelocimetry of the vascular system of the penis, an ultrasonic examination that enables us to evaluate the speed of the flow of the sfigmica wave and the resilience of the walls of the penile arteries (dorsal, cavernous, bulbari). This examination is conducted when the penis is flaccid and after an endocavernous infusion of a vasoactive pharmaceutical (PgE1 : 5). After 5 out of 10 of these injections a Doppler examination is carried out in dynamic conditions, measuring the variations of the flow. A failure in this test (due to a partial and or absent erection, or a lack of rigidity or swelling) necessitates other tests, which are more invasive, such as a superselective arterygraph of the pudendum arteries in order to explore the arterial plane; or a cavernosometria with or without a basale and dynamic cavernosograph after pharmaceutical stimulation with papaverine, in order to obtain information on the venous draining of the penis to discover possible venous leaks.

Neurological Sector

This area can be researched using the Sacral Evoked Potentials (PES). With this examination we test two nervous aspects: the sympathetic and parasympathetic nervous system which carry the nervous fibre which are necessary for an erection. Theses sacral evoked potentials are the reflex pudendo-pudendo (penis sfintere -anal) and the pelvic pudendum reflex (urethra posterior sfintere anal). Such an examination enables us to investigate possible medulary or peripheral nervous disorders of the erectile mechanism.

Metabolic endocrinal sector

A complete study of the hormonal endocrinal sector should include: hormonal dosages especially those produced by the follicle stimulant hormone (FSH), the luteinising hormone (LH) and prolattine; the male sexual hormones especially plasmatic testosterone, and the thyroid hormones and possibly specific investigations such as ecographs and scintigraphs etc.

An ecographic study of the prostate, testicles and penis should also be carried out both in basale conditions and when the penis is erect in order to check for the presence of deformities which might be studied with this methodology. In other cases more sophisticated examinations might be carried out such as nuclear magnetic resonance (RMN), cavernoscopia or a biopsy of the cavernous tissue. These latter mentioned examinations would clearly only be carried out under specific conditions and only when considered appropriate.

5 Medical Therapy

The first of the therapies will address the basic disorder. Even if in the majority of cases the problem cannot be resolved quickly, this will obviously reduce the probability of the problem getting any worse, for example, diabetes can be put under control, blood pressure can be normalized, diet can adjusted, possible hormonal deficiency, even if it is very rare, can be balanced and risk factors such as smoking and alcohol can be eliminated.

This therapy can be medical or surgical, the latter, however, is reserved for patients that have innate disorders or acquired disorders which can only be cured surgically. Specific therapy will concern the use of pharmaceuticals capable of re-introducing erections quickly. So-called vasoactive pharmaceuticals may be used which are capable of improving the afflux of blood. Such pharmaceuticals are injected completely painlessly with microinjections inside the penis, and their regular use allows sexual activity to be immediately restored, even if at the beginning it is assisted by the pharmaceutical. The problem is resolved in a high percentage of cases. This pharmaceutical has been used for several years and at the moment it is the only one of its kind. It is called prostoglandine PgE1. The use of other pharmaceuticals is for the moment not advisable; papaverine, for example, can often create very serious complications. These injections however are used under the supervision of a specialist who can ensure that possible complications do not arise.

Intercavernous therapy is carried out using painless microinjections which are easily applied by the patient himself after training from the specialist, who must be available and contactable for the patient at all times in case of necessity.

This therapy is successful in a high percentage of cases, around 70%, although the patients who choose to undergo this therapy must be reliable and have sufficient dexterity. On average the process lasts 10 weeks with 2 injections a week. The patient must however remain under constant direction from the doctor.

This therapy is however not accepted by all patients and can create passing pains. Other possible complications include intercavernous fibres, prolonged erections and in rare cases priapism, although the latter is very rare.

Finally it should be stated that this therapy has costs which should not be underestimated.

Viagra

Medical therapy has recently seen a revolution with the introduction of Viagra. This pharmaceutical is taken orally three quarters of an hour before intercourse, and is successful in a high percentage of cases when it involves psychological problems or medical problems which are not too serious. The side effects are modest and often transitory, at most the patient might feel some heat in the face and may blush a little, he may experience muscular pains and sometimes diarrhea. The famous blue vision has been reduced some what statistically since the way in which it is used does not give way to “panoramic visions”. The use of Viagra has many advantages; firstly it is very easy to take, it has a high level of success (around 70%) and it may be used frequently (if need be it can be taken everyday). The disadvantages are first of all that the pharmaceutical does not constitute a definitive therapy to erectile disorder, but only a symptomatic therapy which as such taken each time it is needed. There is still no clinical proof that the frequent use of Viagra can in some way restore to normality the erectile mechanisms. Such improvements are probably due to psychological mechanisms from positive “feed back” (such as the decrease of anxiety as a result of performance, the recovery of one’s own capabilities and accumulation of positive experiences etc.). There also exist disadvantages of a psychological nature concerning the couple’s relationship in the sense that the patient might develop a dependency on the pharmaceutical, bearing in mind that sexual performance assisted by the pharmaceutical is surely better than that which is spontaneous. Because of this there is the risk of always having high expectations and as a consequence the risk of feeling “unarmed” when a comparison is made between sexual intercourse with and without the use of Viagra; especially when the partner notices and makes reference to this disparity. Many men taking this pharmaceutical without their partner’s knowledge therefore feel forced to always maintain a high level of performance thus developing a form of psychological dependency. Although the pharmaceutical’s immediate side effects, as has already been stated, are easily tolerable and transitory, nothing is known of the possible side effects of the prolonged (years) use of Viagra which is after all a pharmaceutical diffused through all the organs and tissues of the human body. Furthermore the high cost of this pharmaceutical should not be forgotten given that this type of therapy might be conducted indefinitely.

Other pharmaceuticals also exist which can be taken orally. Of these several are generic stimulants, the best known being yohimbina. It has been established that the use of this substance in a high percentage of cases improves both libido and erections.

SURGICAL THERAPY

Surgery constitutes the definitive therapy to erectile disorder, indeed the objective of surgical therapy is to recover “the freedom”. Surgery is resorted to when the basic condition requires a surgical operation. Such conditions include several innate defects, traumas, fibrosi and calcifications; with corrections to bends, extractions of plaque, and reconstructions of the normal anatomy.

Andrological vascular surgery enables the recovery of the afflux of blood to the penis with microsurgical operations which consist of turning round an artery of the anterior wall of the abdomen and rejoining it to the vessels of the penis. This operations however does not have good results, since in more than 50% of cases the anastomosi close up again.

When the patient does not respond to medical therapy with microinjections, or when complications occur, or when the patient wants to resolve the problem definitively, prosthetic therapy may be resorted to.

With a surgical operation two cylinders of inert material are inserted into the cavernous body. These replace the lack of blood obtaining in such a way a satisfactory erection. The operation is carried out in a day hospital regime with a small incision above the pubic area which once healed will leave no trace at all. The operation lasts on average around one hour. It is painless and there are no post operation complications. The patient can return to normal working life the day after the operation.

Penile prosthesis which is utilized at our surgery consist of tri-component hydraulics which can be activated and deactivated when necessary, reproducing the normal erectile mechanism, indeed both the state of the erection and that of repose are similar to the natural condition. It should be stated that prosthesis does not interfere with sensitivity, ejaculation and libido apart from in a positive way. In addition to this there are other types of prosthesis, used less frequently, such as semi-rigid and malleable.

In many instances psycho-sexological support is offered not only as a basic therapy but also as an important component of medical and surgical therapy.

In conclusion, erectile disorders can now be resolved, thanks to the high results attained by medical science in recent years, in diagnostic and therapeutic fields, with highly sophisticated technology and safe pharmaceuticals. These problems can therefore be confronted by consulting medical specialists.