In patients who only have partial erections or who either do not respond to other treatments or prefer not to use them, a vacuum device maybe useful. The device consists of a plastic cylinder connected to a pump and a constriction ring. A vacuum pump uses either manual or battery power to create suction around the penis and bring blood into it; a constriction device is then released around the base of the penis to keep blood in the penis and maintain the erection. A vacuum device can be used safely for up to 30 minutes, which is when the constriction device should be removed. The advantage of such a device is it is relatively inexpensive, easy to use and avoids drug interactions and side effects. Side effects may include temporary penile numbness, trapping the ejaculate and some bruising.

Penile prosthesis

For men with erectile dysfunction who have failed or cannot tolerate other treatments, a penile prosthesis offers an effective, but more invasive alternative. Prostheses come in either a semi-rigid form or as an inflatable device. Most men prefer the placement of the inflatable penile prosthesis.

The placement of the prosthesis within the penis requires the use of an anesthetic. A skin incision is made either at the junction of the penis and scrotum, or just above the penis, depending on which prosthesis and technique is used. The spongy tissue of the penis is exposed and dilated; the prosthesis is then sized and the proper device is then placed. The inflatable device — a pump that contains the inflation and deflation mechanism — is placed in the scrotum. The patient can control his erection at will by pushing a button under the skin. Although placement of the prosthesis requires a surgical procedure, patient and partner satisfaction rates are as high as 85 percent. Full penile length might not be restored to the patient’s natural erect status. Rare side effects include infection, pain and device malfunction or failure. As the nerves that control sensation are not injured, the penile sensation and the ability to have an orgasm should be maintained.

Psychological Causes of Impotence

Common causes of psychogenic impotence include depression and performance anxiety. Depression is associated with decreased energy, interest and decreased libido or desire. Performance anxiety, work stress or strained personal relationships can affect erectile function in both conscious and subconscious ways.

Neurogenic Impotence

Penile erection depends on an intact nervous system so any injury to the nervous system involved in erections may cause impotence. Diseases such as Parkinson’s disease, Alzheimer’s disease, stroke or head injury can lead to impotence by affecting the libido, or by preventing the initiation of the nerve impulses responsible for erections. Patients with spinal cord injuries will have decreased erections related to the extent of the injury. Patients who have undergone pelvic surgery such as radical prostatectomy, cystectomy or colectomy may have injury to the cavernous nerves that control erection. Long-standing diabetes may affect some nerves as well as causing impotence.

Hormonal Causes of Impotence

Diseases and conditions that decrease circulating testosterone in the body, such as castration or hormonal therapy used to treat prostate cancer, will decrease libido and impair erections.

Vascular Causes of Impotence

Diseases such as high blood pressure, high triglyceride and cholesterol levels in the blood, cigarette smoking and diabetes mellitus, and treatments such as pelvic irradiation to treat prostate, bladder and rectal cancers, may damage blood vessels to the penis over time. There is strong epidemiological association between heart disease, hypertension, low levels of high-density lipoproteins (HDL) and impotence. Patients with Peyronnie’s disease which causes curvature of the penis, trauma, diabetes or old age may have damage to the spongy tissue of the penis, causing the veins to be more “leaky,” which can lead to impotence.

Drugs and Impotence

Certain anti-depressants or anti-psychotics have been associated with impotence, especially those drugs that regulate serotonin, noradrenaline and dopamine. These include Prozac, Zoloft and Paxil. Beta-blockers and thiazide agents used to treat hypertension are associated with impotence. Cimetidine, a drug to treat acid reflux disease; chronic alcoholism; estrogens and drugs with anti-androgen action such as ketoconazole, and spironolactone can cause impotence, decreased libido and male breast enlargement. Even moderate alcohol intake may have an effect.

Aging and diseases which cause impotence

Aging, even in healthy men causes a progressive decline in sexual function. Medical studies have discovered that as men age, there is a decrease in turgidity, or “stiffness,” of erections as well as a decrease in the force and volume of ejaculation. Also, with normal aging, there is an increase in the length of time required between erections after orgasm, called the refractory period. Further, the sensitivity to touch decreases over time as do serum testosterone levels, with an associated decrease in desire. Studies indicate that half of all men with diabetes will eventually develop impotence. In addition, those with liver cirrhosis, chronic renal failure or coronary artery disease have a high incidence of impotence.