Erectile Dysfunction (impotence)
What should I do if I have problems with impotence?
Your GP will normally wish to review both you & your partner together and several visits may be needed before a full picture of the problem can be obtained. Following initial discussions, it is not unusual for some couples to decide not to pursue any further investigations or treatment for impotence (erectile dysfunction).
What are the facts about impotence?
- Impotence becomes commoner with increasing age and is seen in 50-55% of men between 40 and 70 years old
- It is often associated with the so-called “deadly quartet” of obesity, high blood pressure, high cholesterol & diabetes which are all significant risks to health
- Investigation is only indicated if both partners wish to pursue treatment
- Most treatable causes can be identified by a clinical history, physical examination and routine blood tests
- If there is no treatable cause, treatment with tablets is the first option for most men
- Other methods of treatment are only indicated if tablets prove ineffective, cause side-effects or cannot be used because of specific medical conditions
What should I expect when I visit my GP?
1. A full history
Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption). He/she will take a detailed sexual history to determine why your erections are failing and under what circumstances you are having sexual difficulties. It is also normal to ask about your sex drive (libido), whether you still get night-time or early-morning erections and whether your partner is also concerned about your difficulties.
It is important to tell your GP if you have premature ejaculation (uncontrolled ejaculation before or immediately after penetration) or symptoms of prostatic obstruction because they are often associated with impotence (erectile dsyfunction).
Your GP may help you to complete a symptom questionnaire (the International Index of Erectile Function) as an aid to further assessment and discussion of treatment options. This will allow your GP to:
- identify your needs & expectations
- help you & your partner share in decision-making
- decide whether psychosexual counselling might be helpful.
2. A physical examination
A general physical examination will be performed to assess the development of your male sexual characteristics and to detect any abnormality of your penis or genitals. Your blood pressure will normally be measured as part of this examination. The pulses in your legs will normally be assessed and the nerve reflexes involving your legs and your penis or anus (back passage). Rectal examination (pictured) is normally performed to assess the tone of your anal muscles and to feel your prostate gland.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function, liver function, cholesterol & prostate-specific antigen (PSA) as well as checking your blood cells for anaemia or other problems. A blood sugar measurement will be performed to exclude diabetes.
b. Routine urine tests
Your urine will normally be assessed by stick-testing to see whether it contains sugar which might indicate diabetes.
c. Hormone measurements
Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured.
d. Other specific tests
Other tests, if indicated, are normally arranged by the urology clinic. Your GP may be able to arrange measurement of blood flow in your penis by ultrasound, formal nerve conduction tests and even a trial injection of a drug called prostglandin E1 (Caverject®) into your penis. A good erection after the injection means that the arterial blood flow to your penis is likely to be normal.
What could have caused my impotence?
Although a psychological component, often called “performance anxiety”, is common in men with impotence, a purely psychological problem is seen in only 10%.
Of the 90% of men who have an underlying physical cause, the main abnormalities found are:
- Vascular disease in 40%
- Diabetes in 33%
- Hormone problems (e.g. high prolactin or low testosterone levels) & drugs (e.g. antihypertensives, antipsychotics, antidepressants, antihistamines, heroin, cocaine, methadone) in 11%
- Neurological disorders in 10%
- Pelvic surgery or trauma in 3-5%
- Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie’s disease, inflammation, penile curvature)
What treatments are available for this problem?
Initial treatment will usually involve:
- treatment of any anatomical abnormality (e.g. circumcision, frenuloplasty, penile straightening)
- treatment of any hormone abnormality (testosterone treatment is only indicated if your testosterone levels are low and may be harmful if your the levels are normal)
- lifestyle modification (e.g. reduce stress, stop smoking & drinking, stop all drugs)
- weight loss & increased exercise (which may reduce the risk of impotence by up to 70%)
- specific support for psychological problems
If these fail to help, your GP will issue a prescription for Viagra®, Cialis® or Levitra®. These drugs require sexual stimulation to be effective and will not produce an erection without it. They will have no effect on your sex drive. There is no evidence that these drugs are dangerous if you have underlying heart disease. However, they should not be taken if you are taking nitrates (e.g. GTN, isosorbide for angina).
You should only take Viagra, Cialis or Levitra by getting a prescription from your GP & you should have a detailed discussion about the risks & benefits before starting treatment.
1. Penile injections to produce erections
Self-administered injections of prostaglandin E1 (Caverject®) provide a simple means of obtaining a natural erection. You will be taught how to administer the injections (pictured) and told what to do in the event of problems such as an erection which will not go down.
2. Medicated urethral system for erection (MUSE)
Insertion of a prostaglandin pellet in the urethra (water pipe) is no longer widely used because of its poor success rates and significant side-effects.
3. Vacuum erection assistance devices (VEDs)
VEDs provide a simple way of obtaining an erection for 30-45 minutes by sucking blood into the penis and holding it in place with a constriction (pictured). Ejaculation may be restricted by the ring but this technique is simple, safe and has no known side-effects. Unfortunately, most patients have to purchase VEDs themselves.
4. Vascular surgery/angioplasty
If you have blockage of the large blood vessels to the legs and the pelvis, it may be possible to undergo reconstruction of the arteries or angioplasty to re-establish erections. Re-vascularisation for small artery blockage is rarely successful.
5. Penile prostheses
Insertion of artificial penile implants (pictured) is highly effective. It is reserved as a last resort when all other forms of treatment have failed. It involves major surgery with a significant risk of complications. You will need to undergo long-term follow-up in a specialist andrology unit for many years after the surgery.
Fertility problems
What should I do if I have fertility problems?
If you have been trying unsuccessfully to produce a pregnancy for 1-2 years, without using any form of contraception, you should contact your GP for further advice.
Your GP will normally wish to review both of you initially. Further investigations may reveal that only one partner has a problem contributing to the infertility. As a general rule, most urologists only deal with problems affecting the male partner. Investigations in the female partner are not considered on this website.
What are the facts about male infertility?infer
- 10% – 15% of couples in Kenya are unable to have a child.
- In 60% of these couples, the problem lies wholly or partly with the male partner
- Urological investigation may reveal a reversible underlying cause for male-factor subfertility and full assessment by a urologist is recommended
- In many cases, no underlying cause is found, in which case assisted conception may offer the best chance of pregnancy
- Infertile couples are often assessed in gynaecology gepartments and, therefore, subfertile men may wish to seek a urology assessment from a urologist specialising in andrology
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for men with infertility. This will normally include some or all of the following:
1. A full history
Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption) as well as asking whether you have previously fathered children. Your past medical history may also be relevant in identifying a reason for your infertility, especially if you have had previous testicular infections or operations. You will be asked about when you have been having sexual intercourse. Ideally, this should be timed to coincide with your partner’s ovulation (approximately 7-10 days before the next menstrual period).
2. A physical examination
A general physical examination will be performed, paying particular attention to the development of your male sexual characteristics. Your blood pressure will normally be measured as part of this examination.
Special attention is paid to your genitals – shape, size and consistency of your testicles, and the presence or absence of all the structures which attach to the testicles and carry sperms. Your GP will also look for evidence of enlarged, varicose veins (a varicocele) in your scrotum, usually above the left testicle but, very occasionally, on the right.
3. Additional tests
The usual tests performed are:
a. Sperm counts
You will need to provide at least two semen specimens for analysis. Click here for information on how to do these specimens (opens a PDF file in a new browser window). A sperm count of more than 15 million normal, motile (active) sperms per ml should be sufficient to allow pregnancy by natural means
b. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function & liver function and to check the blood cells for anaemia or other problems
c. Hormone measurements
Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured. Anti-sperm antibodies are not routinely measured during assessment of male infertility
d. Other specific tests
Other tests, usually performed by specialists, may include chromosomal studies, ultrasound of the scrotum and, possibly, the prostate area.
What could have caused my infertility?
In 75% of infertile men, the cause remains unexplained (this is termed “idiopathic infertility”). It may, however, still be possible for couples to conceive naturally, provided some sperms are present.
Physical abnormalities
Absence or blockage of the tubes that carry sperms (vas deferens) is uncommon but may be treatable. The best-known cause of blockage is, of course, vasectomy which, like scarring due to infection, may be treatable surgically by reconstruction or bypass.
A Varicocele is seen in 20% of infertile men (and in 10% of the normal male population). Surgical treatment has little effect on natural pregnancy rates and is usually reserved for those with symptoms (aching discomfort) or to improve semen quality in couples undergoing assisted conception.
Childhood surgery, especially for undescended testicles or hernias, may be associated with reduced fertility in later life.
Genetic causes
10% of infertile men have an underlying genetic problem. Typically they have very poor sperm counts or no sperms at all. In men with no sperms, hormone measurements help to determine whether this is genetic (primary testicular failure) or associated with obstruction. The former is untreatable whilst the latter can usually be treated successfully.
Other factors
All of the following can have harmful effects on sperms:
- smoking
- excess alcohol consumption
- tight-fitting clothing
- prolonged sitting
- drugs, both prescribed (e.g. steroids) and recreational (e.g. cannabis, cocaine)
What treatments are available for this problem?
Many couples produce a pregnancy whilst undergoing investigations or treatment for infertility (85% within the first year) but, for those who do not, a number of treatments are available
General Measures
If you have poor sperm counts, you should wear loose-fitting trousers and boxer shorts. You should stop smoking, reduce your drug consumption and endeavour to adopt a “healthy” lifestyle. Spraying or splashing the scrotum with cold water 2-3 times a day may also be beneficial.
Drug treatment
Many drugs have been used to improve sperm counts. None has been found to be beneficial although steroids may be useful if you have anti-sperm antibodies after vasectomy reversal.
Surgery
Surgical bypass may be possible for obstruction caused by infection or surgical injury. There is, however, an increasing tendency to avoid surgery in this situation and to use sperm retrieval with assisted conception.
Vasectomy reversal is 75-90% successful in restoring sperm production. Unfortunately, restoration of sperms does not guarantee a pregnancy if your sperm count is low or if your sperms are of poor quality.
Intrauterine insemination (IUI)
Selecting out the most motile sperms and injecting them directly through the cervix at the time of ovulation, whilst employing drug-induced ovarian stimulation in the female partner, results in a 7-8% pregnancy rate for each cycle of treatment.
Intracytoplasmic insemination (ICSI)
In this type of in vitro fertilisation (IVF) a single sperm is injected directly into an egg to fertilise it. It is useful if you have a very low sperm count. It may be necessary to extract useful sperms directly from the testicle or from the epididymis (sperm-carrying mechanism). The procedure carries risks for the female partner and has a pregnancy rate of 20-30% per cycle.
Donor insemination (DI)
Donor semen is carefully screened for infections and a donor selected to have similar attributes to you. This is the only viable option if you have no sperms at all and you do not have obstruction which can be relieved surgically.
Adoption
If you are unfortunate and do not to have any success with other treatments, you may wish to consider adopting a child. Your GP and local / national adoption agencies can help with this process.