About 50% of diabetic patients with high blood sugar ultimately become
impotent. It can occur at young age or old age. It occurs more frequently
at older age & after many years of uncontrolled high blood sugar, but in
some it can occur at younger age also. It is more common in patients with
other associated complications as Nerve, Kidney or Heart involvement. In
those in whom sugar is not well-controlled chances of developing impotency
is more. It is also more in those who have hypertension & taking medicines
for that & also in alcoholics & smokersThe causes for impotency
in diabetes are as follows: -
(i) Hormones Disorder (Deficiency of male hormones or increase in some
inhibitory hormone as high prolactin & disorders of Thyroids can cause
dysfunctions.
(ii) Decreased penile blood supply due to deposition of cholesterol in
penile blood circulation or in arteries supplying blood to pennis.
(iii) Endothelial & smooth muscle disorders leads to decreased dilatation
of penile vessels on genital stimulation so that blood is unable to reach
in pennis thus full hardness is not achieved.
(iv) Involvement of penile nerve i.e. penile neuropathy.
(v) Psychogenic factors as presence of depression or other psychiatric
illness.
For detail investigation to diagnose the cause of disorder
DIAGNOSIS OF CAUSE OF IMPOTENCY
First step in proper treatment of Dysfunctions (impotency) is
accurate diagnosis of cause. So we first try to find out cause. We take
detailed history, thorough counseling, physical examination,
examination of nerves and penile arterial examination. After that
depending on likelihood of particular, cause relevant tests are done. All
testing facilities are available at our centre. Thus you may consult us at
our centre & at same time you may get all tests done. The time taken in
getting all the reports ready is 36 hours. So if you are from out of
Delhi, you may come here for two days.
DETAILED HISTORY: We take detail history about the onset of
dysfunction i.e. whether it started Sudden or gradual, Primary or
Secondary, Erections at other occasions, Response to previous therapy,
Libido, Stress (physical or mental), H/O precipitation by some drugs,
presence of Hypertension, Ischemic Heart Disease, claudication, trauma,
DM, Sec. Genital Characters, Hypothyroidisms, Hyperthyroidisms & Galactorrhoeas, Symptoms of sensory loss, epilepsy, Liver/Renal failure.
EXAMINATION OF GENITALS:
We examine whether Genital Development is adequate or subnormal. For this
testis size is measured by orchidometer (if patient is outstation then by
ultrasound of testis), Pennis Length & girth is measured by phallometer.
Galactorrhoea & features of other hormone disorder are checked up. Blood
supply of pennis is assessed by, palpating dorsal penile artery of pennis.
Nerves of pennis examined by V. P. sensation testing, Deep Tendon reflexes
& Bulbocavernosal reflexes. Then other systems are examined.
INVESTIGATIONS i.e. DIAGNOSTIC TESTS:
At our centre we have all the facility for complete investigation of
various causes of Erection difficulties & other problems. So we
perform following tests, step by step depending on their need based on
history & examination.
The various diagnostic tests needed/performed are as follows: -
Step- I: Hormone Testing: There are two types of hormones in
body some stimulates penile hardness whereas there are other hormones
which inhibit penile stiffness.
Male & Female hormones & other associated Hormones are tested by
latest-immunoassay techniques. These hormones includes total
Testosterones, free testosterones, Prolactins, LH, FSH, T3, T4, TSH others
as Cortical, E2, Free testosterones SHBG etc.. Among above tests relevant
hormones are tested in that particular patient. Results are available in
36 hours. In the hormone testing either stimulatory hormones may be
low leading to less erection or those hormones which are inhibitory may be
high leading toi inhibition of penile erection. These hormones are tested
by taking blood sample from forearm. When we find out any of above hormone
disorder simply correction of these hormone disorders corrects the
dysfunctions in two months time.
Blood glucose & other systemic test may be required depending on the need.
Step I1: Penile Blood Supply Testing:
This test is done to decide whether impotency is due to decreased blood
supply to pennis or disorders of nerves or due to some other causes. This
test is also called PIPE (Pharmacological induced penile erection) test.
In this test we examine the dorsal pennis artery & veins after giving the
various Vasodilators either orally or as injectable, also we asses whether
pennis is getting full hard or not after vasodilator use, how long hardness
is persisting in response to theses vasodilators. If pennis is not becoming
fully hard or not staying hard for at least fifteen minutes even after
adequate dose of vasodilators then cause of impotency is inadequate blood
supply to pennis or due to leakage of blood out of pennis due to venous
leak. If pennis is getting full hard and staying longer than fifteen
minutes then cause is nerves of pennis are not functioning or some other
cause. There are two types of blood supply disorders are found on blood
supply testing.
The first pattern is suggestive of penile arterial blockade in
which blood does not flows in pennis from blood circulation due to block in
arterial supply of pennis. This obstruction in vascular supply is diagnosed
by above mentioned blood supply test in which after giving blood flow
medicine we find that there is increase in blood flow in arteries of pennis
is less than normal with resultant absence of achievement of full hardness
of pennis for sufficient time. This test is very simple to perform if the
concerned doctor is well trained & experienced. This is an O. P. D.
procedure & takes approximately 30 minutes to perform the test. We do
these tests daily at our centre as we have all the required instruments to
do these tests. Once we diagnose that there is decreased blood supply to
pennis then we find out the cause of this inadequate blood flow.
Once the cause of decreased blood supply is diagnosed then treatment
becomes very easy with virtually full chances of permanent cure.
Second pattern found on blood supply testing is Leakage of blood out of
pennis back into circulation after initial full erection (also
known as Veno-occlusive dysfunction): In this defect, blood flows from
circulation to pennis normally but due to continuous leak of blood out of
pennis due to defect in penile valves whose job is to stop the leakage of
blood out of pennis, enough pennis hardness is either not achieved or even
if pennis becomes fully hard it become loose there after due to leakage of
blood out of it. When we do blood supply testing, in this disorder there
is good blood flow in arteries of pennis through out study, but there is
continuous leakage of blood is seen through valves of penile veins.
Step-3: N.P.T. MONITORING: Penile Erection assessment at
night (called as nocturnal penile tumescence) is done by Rigiscan
device (it measures penile rigidity & diameter) to differentiate
between impotency of psychogenic origin or due to some internal cause. If
N.P.T. monitoring shows Normal results it means impotency is Psychogenic,
if results are impaired means impotency is due to some internal cause.
Step 4: DUPLEX SCANNING: (Doppler & ultrasound scanning
before & after vasodilator use) In this Testing with use of vasodilator
drugs/Duplex vascular scanning is done to decide which type of problem
patient is suffering, accordingly treatment is prescribed. It assesses
arterial diameter & blood flow status. It helps in differentiating &
pinpointing the cause of impotency i.e. whether it is arterial or venous
cause & what is the specific cause, of that problem so that it can be
treated properly.
Step 5: Counseling:
After detail discussion with our male & female therapist, we try to
finds out the root cause of problem then we treat accordingly. For
counseling we take detail history of Genital development, his thoughts, his
misconception about , his old experience in , his unconscious fears
about . This counseling session unravels all the hidden psychological
causes of Genital inadequacy.
Step 6: Other tests
(If required)
1) Penile Nerve Testing: By conduction and sensory testing (NCV, EMG & VPT).
2) Psychoanalysis: To find different factor leading to psychogenic
impotency.
3) Functional Studies: To see the penile response in provocation to
various drugs.
5) Arteriography: It is a Specialized X-Ray of pennis before
arterial opening i.e. opening of the blockade surgery. In this test a drug
(dye) is infused which detects whether block is situated , whether it is
localized or diffused. Once we localized the obstruction & its cause, then
we decide whether it can be cured through medicine or surgery.
6) Cavernosometry & cavernosography (before venous leak surgery).
TREATMENT OF DYSFUNCTIONS
After diagnosing the cause of impotency, we prescribe medicines that
patient has to purchase himself from any medical store The success of
various drugs we use in dysfunction depends on accurate diagnosis
of cause. If empirical treatment is prescribed as most doctors do, it
often does not achieves permanent cure. These tonics & ayurvedic
medicines can improve your Genital life temporarily but they cannot give
permanent cure. Thus please get yourself fully investigated before
starting treatment.
The various treatment option for patient with impotency are:
1) Hormone Therapy
2) Medicines to increase blood supply to pennis (Oral & Local Gels)
3) Viagra & like drugs
4) Therapy
5) Vacuum Erection Pumps
6) Injection therapy
7) Penile Blood Supply increasing Surgery
8) Penile Hardness Increasing Implants (Penile prosthesis)
(1)
Hormone Therapy:
Hormone therapy is given to cure the problem whatever defect is found.
Hormones Therapy: Depending on the type of hormone disorder i.e.
whether male hormones decreased or inhibitory hormones has increased,
Hormone therapy is directed towards that. Hormone therapy usually cures
the Hormone problem in 2 to 3 months time and they do not have any adverse
effects as they given to only those patients in whom some hormone disorder
is found.
The various hormone preparations & their route of administration are:
1. Oral testosterone preparations that is available in capsule form. It
needs to be given one to three capsules daily. These have no side
effects.
2. Transdermal Testosterone given as scrotal patch. It is very effective &
has no side effects. It can be also given as Testosterone gel, which can
be applied on any part of the skiin.
3. Sublingual Testosterone cyclodextrin is now available which is very
fast acting & very effective is fast & has better effects on organs.
4. Local application of D.H.T. gel is new preparation for male hormone
replacement. It is very effective without any side effects.
5. Injection Testosterone esters these includes Testosterone enanthate &
testosterone cypionate given intramuscular injections every 10 to 14
days.
6. New human androgen receptor modulators they increase the effect of male
hormone over androgens sensitive organs.
7) DHEAS tablets are available which are effective & has no side effects.
8)Treatment of hyperprolactinemia with cabergoline & Bromocriptine is done
with quick cure of Genital dysfunctions.
(2) Medicines to increase blood
supply to pennis: (oral & local gel)
Medical treatment (i.e. prescription of various drugs to increase blood
supply to pennis, nerve rejuvenating etc are given to correct the basic
cause found on investigations.
These drugs open the blockade of penile arteries so that blood flows into
pennis increases and pennis becomes fully hard. The various drugs, which are
effective to increase penile blood supply, are as follows. The particular
drug needed in particular patient depends on the cause of
dysfunctions.
Oral Drugs: The various oral drugs are:
a. Yohimbine: By acting on alpha-receptors it dilates the penile
blood supply. It is one of the common drug used for increasing penile
blood supply. It is freely availalable as oral tablet.
b. Phentolamine: is also a good drug to increase blood flow in the
pennis. The effect of this drug increases manifold when it is used along
with other commonly used vasodilators. It is used as oral, sublingual
tablets. In advance cases it is given as injectable also.
c. Sublingual apomorphine is very effective in increasing penile blood
supply.
d. Trazadon works on centre & increase penile blood supply.
e Oral Prostaglandin.
f Nalaxone
g Gene Therapy: In this modality of treatment blood supply to pennis
is increased by gene therapy. By the introduction new genes in body the
generation of penile blood increasing substance nitric oxide generation
increases in penile blood tissue leading to more blood supply & hardness
of pennis. This is a slow process takes longer time to have effect but once
the effect starts coming the results are permanent. Thus it achieves the
cure of impotency. This is effective & achieves permanent cure of
impotency
3)
Local Application of Gels / Drugs
a. MUSE is per urethral use of PGE1. In this medicated pellet is
inserted into the Urethra. After insertion pennis becomes hard with in 20
minutes. This hardness lasts for up to 60 minutes.
b. Topical preparations of papaverine
c. Topical preparations of prostaglandin E1
d. Vasoactive intestinal peptide
e. Local application of Minoxidil
f. Local application of Nitroglycerine
g. Local application of l-arginic acid
4) Viagra & Like drugs
These drugs are good but temporary method of treatment because it does
not treats the basic cause of problem. These drugs belong to following
the groups:
Sildenafil,( Viagra, penegra, caverta) : one tablet works for 4
hours.
Tadalafil (Cialis, tadalis, megalis ) : one tablet works for 24
hours.
Vardenafil (Levitra): one tablet works for 6 hours.
It is a temporary therapy. After consumption of this tablet, patient gets
hardness only temporarily. Once this tablet is consumed, the blood flow
into pennis increases & pennis becomes fully hard in many patients. But this
is an effective short-term treatment but it does not cures the basic
problem. It also has certain side effects & many deaths have been reported
after its use if not used with proper precaution. Thus it should not be
consumed without the advise of experts. There need to have detailed
physical examination before one is prescribed Viagra. So never take it
without expert advise.
Dose used is 25 mg to maximum of 100mg. It should be taken 60
minutes before Genital intercourse.
5. Detailed Education: In this patient is explained in detail about
what is normal physiology of erection and what we can do in our daily life
to increase strength & staying it hard for longer time. Also we
educate the patient how to satisfy the women so that she gets satisfactory
orgasm and considers you a wonderful partner.
(5) Therapy:
Once we found out the cause we treat internal causes like hormone
disorder & decrease penile blood supply. But even after treating above
basic primary causes of impotency, Many times patients still do not
recovers fully because of his fear of failure, Genital performance anxiety
and spectatoring attitude. These secondary factors do not allow him to
function normally. For cure of these secondary problem patient needs
details therapy. Basic purpose of this exercise is to make patient
free of any fear of Genital performance. After this exercises all
performance anxiety disappears. In therapy the patient is taught
various exercises & how to use various body part in particular way so that
erection become good, sustained & patient does not have any fear. Normally
in six to eight sittings patient's all fear disappears. therapy is a
very effective in impotency, premature ejaculation. Thus we advise all of
our patients not to hurry, and take few sessions of therapy sittings
for permanent cure.
(6)
Vacuum Pump Devices
Vacuum Pump Devices is a small instrument, application of it on pennis,
makes pennis fully hard within three minutes. With this instrument patient
does not have to consume any medicine. So it has no side effect.
(By this device a vacuum of > 100 mm of Hg is created around pennis leading
to Pooling of blood in pennis resulting in full hardness).
Efficacy: Approximately 80% of patients get full erection & satisfied.
(7)
Injection Therapy
The various drugs used as injections are
Injection of papaverine, ProstaglandinE1, & Phentolamine is used alone or
in combination (bimix or trimix). This is a very effective mode of
treatment of impotency. The dose of papaverine is 5mg. to 60mg. at one
time. It work in 15 minutes & patient gets very hard erection, which lasts
for at least thirty minutes. It is very good especially for those who fear
that they may fail during . So that by taking this injection they can
perform without fear & with hundred percent guarantee of success. It is a
quiet popular form of treatment among boys & young adults. Especially for
those, who have severe fear for failure for the first night or when
expecting Genital encounter with a new partner.
Response - Success is achieved in approximately 90% patients.
Injection of ProstaglandinE1: dose used is 10 to 20 mg at one time .It is
very effective with virtually no side effects.
Injection of Phentolamine normally it is used in combination with
papaverine or Phentolamine.
Inj. Of Moxisylyte: available by the name of injection Erecnos.
Inj. of Vasoactive Intestinal Polypeptide: available by the name of
injection Invicorp.
Treatment of underlying cause: When some underlying cause as diabetics,
depression, high blood pressure (hypertension), or use of drug is
diagnosed is treated accordingly.
(8)
Surgical Treatment
Surgical treatment is suggested only when all the above mode of therapy
namely hormone therapy, blood supply increasing tablets, Viagra like
drugs, & therapy has failed.
(9)
Penile blood supply increasing surgery:
After investigations when it is diagnosed that blood supply is
decreased. In majority of patient's blood supply can be normalized by many
of the medicines as mentioned above, which have capacity to correct the
vascular disorders. But in some cases surgery is required.
Before surgery for vascculogenic impotency, exact site of blockade is
localized by Arteriography.
The various surgeries are as follows:
a) Arterial Recanalization surgery: After localizing the block, we
open the blocked part of artery by vascular microsurgery, this is called
recanalization vascular surgery. This is commonly done in younger
patients.
b) Arterial bypass surgery: When we find that there is blockade in
broad segment of dorsal penile artery then such a long segment can not be
recanalized. In such cases we bypass the blocked portion of the artery by
use of other inferior epigastric artery. In this normal artery is
connected with pennis artery distal to blocked artery so that blood flow
normalizes.
c) Venous leak surgery: As we have mentioned above leakage of blood from
pennis to back into body in mid of erection is one of the cause of
impotency. In this surgery the leaking veins is localized first by
venography (cavernasometry & cavernosography). After localization of those
veins through which blood is leaking are ligated i.e. tied. Thus venous
leak stops & pennis starts becoming full rock like hard & patient
Genital problem normalizes. For this surgery we keep patient admitted for one day
only.
At our centre our micro vascular surgeon is very expert in doing all above
surgeries. In this surgery artery in which blockade is present is either
opened or blocked area is bypassed by use of other artery so that blood
Supply to pennis is established. Result is very good when candidate for
surgery is properly selected. This operation needs expertise. It is done
under the guidance of operating microscopes.
(10)
Penile Hardness Increasing Implants (Penile prosthesis):
There are
some patients in whom blood supply increasing surgery is not possible.
Thus penile implant is a good treatment in all those patients in whom cure
is not possible inspite of all above treatments. In such cases we put
intrapenile implants. After these surgery patient can resume his normal
Genital functions.
There are two kinds of implants:
a) Malleable i.e. semi rigid implants:
b) Inflatable implants: Now days this implant is more in use as penile
hardness is very good above all it may remain erect for longer time. This
surgery takes approximately 30 minute by our surgeon.
There are certain penile implants which when applied into pennis then its
hardness become very hard.
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