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Impotence is the inability to maintain or obtain an erection of
sufficient firmness to permit the initiation or completion of intercourse.
Impotence comes in two forms, primary and secondary. Primary impotence
is defined by never being able to have intercourse, whereas secondary
impotence is experiencing erectile dysfunction after a previous
period of normal functioning.
Transient occurrences of impotence, either losing an erection during
intimacy, or not obtaining an erection, can be caused by a variety
of factors such as fatigue, alcohol intake, distraction, and/or
anxiety. Approximately 12% of all men are affected by impotence.
It appears there also can be an organic basis for this sexual dysfunction.
Common causes include the use of some anti-hypertensive medications,
beta blockers such as Inderol, marijuana usage, endocrine disorders,
prostatitis, anemia, diabetes, cerebral palsy, multiple sclerosis,
and a variety of other illness and issues can cause impotence.
Approximately 85% of impotence is due to a psychogenic cause, as
opposed to a metabolic factor or physiological problem. There are
many causes of psychogenic impotence. We will briefly mention a
few: Some developmental factors are maternal or paternal dominance,
parent/child conflicts, a traumatic childhood sexual experience,
gender identity issues, traumatic first intercourse experience,
anxiety, depression, poor self esteem, fear of pregnancy, fear of
sexually transmitted diseases, communication issues, hostility or
anger towards the partner, lack of attraction, and performance demands.
It is not uncommon when a child is growing up to have very rigid,
negative attitudes towards sex impressed upon the child. This can
definitely lead to sexual impotence or erectile dysfunction in adulthood,
especially when it included punishment with masturbation.
Widower’s syndrome. This is
a fairly common disorder, usually occurring after the 5th-6th decades
of life, after a husband loses his spouse. There will be a normal
grieving period. During that time, sexual interest will decrease.
Also it is fairly typical that if and when the husband is involved
in his first relationship after the death of his spouse, he may
experience impotence secondary to a variety of issues. It is important
to note that this is similar to panic attacks in that it does cycle
back and forth, where the frequency of impotence increases anxiety
and depression, which then increases the likelihood of impotence
at the next sexual encounter. A very common question to ask when
taking a history is, “Do you notice an erection upon awakening?”
This is a normal physiological response. If there is not an erection
in the morning, other physiological factors have to be ruled out
inclusive of depression.
All men with low libido (low sex drive) with a history of possible
organic origin should have their glucose checked, as well as testosterone
levels measured.
Impotence Treatments
Treatment of psychogenic impotence:
Below are some basic guidelines of therapeutic interventions by
Kolodny, Masters and Johnson Textbook of Sexual
Medicine.
- It is not useful to blame one’s partner or oneself for
the occurrence of sexual problems.
- There is no such thing as an uninvolved partner when sexual
difficulties do exist.
- Sexual dysfunctions are common problems, and do usually indicate
psychopathology.
- It is not always possible to be certain of the origin of the
sexual dysfunction.
- In general, cultural stereotypes about how men and women should
behave or function sexually are grossly misleading and counterproductive.
- Sex is not something a man does to or for a woman. It is something
a man and woman do together.
- Sex does not only mean intercourse. The developing of awareness
of one’s feelings, and the ability to communicate feelings
and needs to one’s partner sets the stage for effective
sexual interaction.
Treatment approaches:
Goal setting which can be measured is very important so that the
patient can monitor his progress.
- We need to reduce any type of performance anxiety, and at the
beginning we need to prohibit any type of sexual activity for
the couple. This usually results in a calming effect, and there
is immediately decreased anxiety.
- We need to bring the individual’s anxieties into the open,
and at the same time, communicate to his wife what these are so
she is not in the dark, and he is able to communicate directly
around his concerns.
- Lastly, sensate focus is very effective. Sensate focus has
been around for quite awhile, and is very beneficial. It begins
with, basic interactions such as talking, communicating, sharing
with each other concerns, anxieties and fears. I recommend this
occur in the bedroom. It can occur in other places. (It if fantastic
if it can occur outdoors with Mother Nature. It is amazing what
kind of stimulation can occur in the outdoors, and people are
getting back to Mother Earth.) This process should occur over
the course of a week or two. There can be touching, backrubs,
shoulder rubs, leg rubs, with clothes on. This slowly accelerates
into shoulder rubs, backrubs, leg rubs with shorts on, no shirt,
which then slowly progresses the following week to both individuals
being nude, still no touching of genitalia, no touching of breasts,
rubbing fronts and backs. (This does increase arousal states,
but individuals have to be instructed to be very disciplined and
not to have intimacy even if the individual does have an erection.)
This then slowly progresses to the next week where they can touch
genitalia, and over a period of time touch breasts, but they are
still not allowed to have intercourse. The final week, they can
utilize the same technique of touching, a lot of rubbing and caressing,
but now then can move into intercourse.
Clearly, sensate focus is a very effective method. However, Viagra
has now entered the picture. We are a “fast food society”
and we want things now, problems fixed immediately, and people don’t
want to wait. We have fast food restaurants, and we want our medical
care to be immediate. With the onset of Viagra, the sensate focus
has fallen by the wayside. However, even with Viagra, there are
certain psychogenic problems which are not 100% resolved with Viagra.
Treatment of impotence with Viagra
Viagra is very effective. It is common that the first or second
time Viagra it is used, there is not much of a response. However
after that, there has been enormous success with this medication,
with minimal to no side-effects. It should be noted that Viagra
should be used cautiously in individuals with a history of cardiovascular
disease, arrhythmias, myocardial infarctions, strokes, individuals
over the age of 65, or those with renal or hepatic impairment. It
should not be taken with Nitrates in any form, which can result
in serious and potentially fatal hypotension. Other than those side-effects
and concerns, it is very safe in the correct population.
It is also important to understand when treating impotence with
sex therapy that the fears may come back. There can be some recurrence.
They will never be 100% resolved. It is important to set the stage
for that so people do not get frustrated if the impotence does recur.
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