IMPOTENCE

Sex is important for the normal physical and mental development of an individual. Thus sexual disorders of any type will have some deleterious effects.

IMPOTENCY
This is a male sexual disorder, whereby a male cannot maintain an erection of penis during copulation.
Impotence is a very delicate yet complex topic for a practitioner. Although a lot of passions are involved around the sexual life of a human being, this topic is poorly understood and requires thorough education of the patient. An attempt has been made here to resolve the mysteries regarding impotence.
Above the age of 65 years about 25% males develop impotence. Most of the cases have a psychogenic cause.

NORMAL CHANGES WITH AGE
Although sexual activity normally continues throughout man’s life time, the response varies with age. He takes longer to climax and his erections may come and go. He needs more recycling time before he can get another erection.
The 20’s: A young man needs little stimulation and can get an erection in a few minutes. He usually climaxes quickly but he can regain his erection in minutes.
The 40’s: With age there is more need of direct stimulation and fantasy. An erection takes several minutes, climax is slower and erection can be regained only after an hour or so.
The 60’s: An older man needs even more direct stimulation and fantasy. He takes longer to get an erection, can maintain it longer. But may take a day (or) more to regain it.

PHYSIOLOGY OF A PENILE ERECTION
The penis consists of corpus cavernosum; two spongy paired cylinders contained in a thick envelope, the tunica albuginea, and corpus spongiosum and glans with very thin tunica, in both the structures, with in the tunica are numerous sinusoids among the interwoven trabeculae of the smooth muscles and supporting connective tissue that harbour the terminal cavernous nerves and arterioles, the paired internal pudendal artery is the main source of blood supply to the penis while venous drainage is through multiple small veins to dorsal vein and then internal pudendal vein.

The nerve supply of the penis plays an important role in erection. The penis is innervated by 2 sets of nerves; autonomic nervous system (sympathetic and parasympathetic) and somatic nerves (sensory and motor). From the neurons in the spinal cord and peripheral ganglia the sympathetic and parasym-pathetic nerves merge to form the cavernous nerves and these nerves are responsible for neurovascular events during erection and detumescence. The somatic nerves are responsible for sensation of penis and contraction of the bulbocavernous and ischiocavernous muscles.

The parasympathetic supply comes from 2,3 and 4 sacral spinal cord segments which is responsible for tumescence (erection) while sympathetic supply comes from thoracic 11 to lumbar 2 spinal segment, which is responsible for detumencence (ejaculation). The sensory pathways go via dorsal nerves of penis to internal pudendal nerve to dorsal roots of 2nd to 4th nerves of spinal cord and spino thalamic tract to the thalamus and sensory cortex of brain. Onuf’s nucleus is the centre of somatomotor penile innervation. These nerves travel in the sacral nerves to the pudendal nerves to innervate bulbocavernosus and ischioca-vernosus muscles.

The contraction of the ischiocavernosus muscle causes rigid erection phase while rhythmic contractions of the bulbocavernous muscles expels the semen down the narrowed urethral lumen and results in external ejaculation from the meatus.
The spinal erection centres are located at intermedilateral column of the sacral cord and sends processes in to the areas of laminate 5 and 7 and the dorsal commissure. In the brain medial preoptic area (MPOA) is the important integration centre for sexual drive and penile erection.

According to nature of stimulus there are 3 types of erections.
1. Reflexogenic Erection
This erection is provided by tactile stimulus to the genitalia and is mediated through lower spinal centres.

2. Psychogenic Erection
This erection originates from audiovisual impulses and fantasies and signals are mediated through brain to spinal centres.

3. Nocturnal Erection
This type of erection occurs during REM sleep through unknown mechanism.


PATHOPHYSIOLOGY OF IMPOTENCE
1. Psychogenic Importance
Psychogenic stimuli (Visual impulses, fantasies) themselves are very strong inducers of erection and also can enhance the erection induced by Genital Stimulus. On the other hand, anxiety (or) depression, religious inhibitions, sexual phobias or deviation, obsessive compulsive personality or a traumatic past experience can send strong messages from brain to inhibit or to terminate erection. This inhibition is through a direct inhibition from brain to the spinal centres or through increased level of peripheral catecholamine that renders cavernous smooth muscles less sensitive to neuro-transmitters.

2. Neurogenic Impotence
Lesions affecting brain like cerebrovascular accidents, park-inson or Alzheimer’s disease, tumors, injury etc, act through direct central hypothalamic suppression or over inhibition of spinal centres.
A dysfunction at spinal level e.g. spinabifida, disc herniation, syringomyelia, tumor and multiple sclerosis may affect either efferent or afferent nerve pathways.
Neuropathy such as seen in alcoholism, vitamin deficiency or diabetes may affect cavernous nerve terminals leading to impotency. Injury to cavernous nerve or pudendal nerve from pelvic injury or surgery may disrupt the neural pathway causing impotence.

3. Arteriogenic Impotence
Diseases of terminal aorta or the hypogastric, pudendal, or penile arteries can results in erectile failure; trauma or congenital anomaly can cause arterial insufficiency. But generalized atherosclerotic process due to hypercholesterolemia, cigarette smoking, diabetes, radiation, hypertension and perineal trauma are more common cause of arteriolar impotence.

4. Venous Impotence
Abnormal venous channel following a shunting operation for priapism. Tunical abnormality as in pyronie’s disease or functional impairment of the cavernous erectile tissue can cause venous impotence.

5. Hormonal Impotence
Diabetes mellitus in an important cause for impotence but acts not mainly through hormonal changes but through vascular, neurologic and psychologic causes.
Androgens are essential for male sexual maturity but testosterone is not absolutely essential for erection. Therefore androgen replacement therapy is absolutely indicated in cases of hypogonadism only.
Hypothalamic pituitary Gonadal axis dysfunction can result in hypogonadism, Hypogonadotrophic hypogonadism can be due to malignancy, injury or aging while hypergonadotrophic Hypogondism can be due to diseases of testes like malignancy, surgery, injury or mumps.

Hyperprolactinemia caused by pituitary adenoma, chronic renal failure, or medication can result in lowered testosterone levels leading to impotence. Hyperthyroidism and hypothyroidism can also affect sexual function.

6. Erectile tissue dysfunction
Pyronie’s disease, trauma, diabetes, tumor infiltration, scleroderma, and priapism all these lead to gross microscopic changes as well as macroscopic changes in erectile tissues of penis.

7. Impotence from aging, systemic disease and other causes.
Hypothalamic pituitary dysfunction leading to testosterone deficiency is responsible for impotence of old age, the other factors like psychogenic, vascular, neurogenic etc. also add to the problem.
Chronic renal disease needing dialysis also leads to impotence in around 50% patients. Myocardial infarction, angina, heart failure, and Emphysema patients develop impotence. One of the reasons being, they fear aggravation of the disease following intercourse. Others diseases like liver cirrhosis, sclerdoderma, chronic debility and cachexia also can cause impotence.


CAUSES OF IMPOTENCY
The normal sexual function can be divided into five events each of which is under diverse regulation, libido, erection, ejaculation, orgasm and detumescence. Hence anything hampering the normal sexual functions will give rise to impotency as stated below;

1. Loss of desire
In a small percentage of organic cases, pituitary or testicular disease gives rise to androgen deficiency which in turn causes a decreased libido; hypogonadism also gives rise to such states.


2. Failure of erection
Which may arise from the following conditions.

a. Endocrine causes
Pituitary tumors which give rise to hyperprolactinemia.
b. Neurologic causes
Lesions of anterior temporal lobe, spinal cord disorders; loss of sensory input in diabetics; neuropathies; tabes dorsalis and damage to parasympathetic nerves following surgical procedure, such as total prostatectomy, retro sigmoid operations and aortic bypass surgery if autonomic nerve supply to penis is damaged.
c. Vascular causes
Leriche syndrome
d. Penile diseases
Peyronie’s disease, priapism and penile trauma.
e. Drug induced
Prolonged use of antihistamines, antihypertensive etc., which are potentially correctable, causes of impotency.
3. Premature ejaculation
Always related to anxiety states or emotional disorder and unreasonable expectations about performance, it may rarely have an organic cause.

4. Absence of Emission
It may be due to the following conditions.

a. Retrograde ejaculation
Following surgery on the bladder neck or may develop spontaneously in diabetics.

b. Sympathetic Denervation
May occur following sympathectomy.
c. Androgen deficiency
Results in a decrease in secretions of the prostrate and seminal vesicles and diminution of the volume of ejaculate.
d. Drugs
Such as phenoxy benzamine.



e. Absence of orgasm
It is always almost due to psychological disorder if the libido and erectile functions are normal.
f. Failure of detumensence
It is due to priapism but can be associated with sickle cell anemia, chronic granulocytic leukemia or spinal cord injury.

EVALUATION OF IMPOTENCY
The central issue of Evaluating impotency is to separate those instances due to psychological factors from those due to organic causes. A good case-taking usually makes the separation possible.
The commonest cause is an anxiety or depressed state. Psychological factors like disinterest in sexual partner, marital discord etc reduce the sexual impulse.
However, if organic cause is deduced, its aetiology should be well known.

INVESTIGATION AND EXAMINATION
a. Laboratory investigation
Laboratory evaluation is probably of minimal value. Measurement of serum testosterone in the absence of evidence of feminization or hypogonadism is seldom helpful. If there is an indication from either history (or) physical examination of vascular aetiology, a doppler procedure or arteriography may be indicated.
b. Physical examination
Thorough genital examination to identify abnormalities of the penis; testicular size and abnormal masses. Evidence of feminization such as gynaecomastia and abnormal body hair distribution should be sought. All pulses should be palpated, including the penile pulse, to exclude the presence of deep cavernous arterial occlusion.
c. Systemic examination
Neurological examination is necessary for detecting peripheral neuropathy and also to assess the perianal sensation, anal sphincter tone and bulbo cavernous reflex.

DIAGNOSIS OF IMPOTENCE
Apart from history and clinical examination, Duplex and color Doppler sonography can give a complete status of the erectile function of penis; X-rays, caverno-sonography and selective pundendal arteriography have become obsolete.

PLAN OF TREATMENT
It can be broadly classified as follows;
1. Ancillary or extra medial line of treatment.
2. Surgical line of treatment.
3. Treatment with homoeopathic medicines like constitutional, inter-current medicines, mother tinctures, organopathic and rare medicines.
1. Ancillary or extra remedial line of treatment
a. Giving reassurance to the patients of anxiety states and corrective measures to depressive patients may restore sexual potency.
b. Sexual counseling, education and psychotherapy are also beneficial in alleviating psychogenic factors.
2. Surgical line of treatment
a. In case of hyperprolactinemia where prolactin secreting pituitary tumor is present; surgical removal usually results in return of potency.
b. Surgical therapy is also useful in treatment of decreased potency related to aortic obstruction.
c. Implantation of penile prosthetic by a small, blunt silastic rod (or) alternatively by an inflatable prosthetic device, can be advised. In refractory cases which are not improving with the allopathic mode of treatment or patients who are skeptical about the homoeopathic mode of treatment. However it should be remembered that these procedures are extremely costly and have a high risk of complications.

THERAPEUTICS OF IMPOTENCE
In homoeopathic prescribing, even after Repertorization, the final court of decision is the Materia Medica. Therefore I would like to suggest a few important remedies for impotency with their indications.
Abroma
Absence of sexual desire, exhausted after coitus, swelling and hanging of testicles impotency.
Adrenalin
Sexual desire increased with out erections.
Agnuscastus
Impotency after frequent attacks of gonorrhea. No erection, parts cold, relaxed desire gone.
Ant. Crud
Impotency, atrophy of penis and testicles.
Arg. Nit
Impotence, erections fail when attempt is made. Sexual desire wanting.
Avena. Sat
Impotency after too much of indulgence in sex.
Baryta .Carb
Diminished desire, premature impotency.
Baryta. Iod
Impotency, erections wanting.
Baryta. Sulph
No desire, wanting erections.

Caladium
No erection even after caress. Impotence, relaxation of parts even when excited, parts cold. No emission or orgasm after embrace.
Cal.iod
Erections wanting, sexual passions without erections.
Capsicum
Coldness of penis and scrotum with impotency, atrophied testicles.
Cal. sil
Sexual passion increased sexual desire strong without erections, swollen testicles.
Carbo. Sulph
Desire lost, parts atrophied.
Coca
Diabetes mellitus with impotency.
Chloral
Sudden impotency.
Conium
Desire increased, power decreased, sexual nervousness with feeble erections. Effects of suppressed sexual appetite.
Flour acid
Sexual passion increased with erections only at night.
Graph
Sexual debility with increased desire.
Hydrastis
Indifference to coitus, impotence.
Hyoscyamus
Impotence with lasciviousness.

Iodum
Loss of sexual power with atrophied testes.
Kali.br
Debility with impotency, effects of sexual excesses. Excitement during partial slumber.
Kali. Carb
Deficient sexual instincts.
Kali. Phos
Sexual power decreased.
Lecithin
Male power lost or enfeebled.
Lycopodium
No erectile power, impotence, premature impotence. Emissions premature. Old men with strong desire but with imperfect erections, falls asleep during an embrace.
Moschus
Impotence associated with diabetes mellitus, violent desire.
Nat. M
Impotence with retarded erections, impotence from spinal irritation.
Nat. P
Desire without erections.
Nuphar. L
Complete absence of sexual desire, parts relaxed and penis retracted.
Nux. V
Impotency with involuntary emissions during stool, when urinating, bad effect of excess of all kinds.
Onosomod
Constant sexual excitement, psychical impotency, loss of sexual desire, speedy emission. Deficient erections.
Phos. ac
Sexual powers deficient, testicles tender, swollen, parts relaxed during embrace.
Sabal. Serr
Loss of sexual power with wasting of testicles, sexual neurotics. Organs feel cold.
Selenium
Loss of sexual power with lascivious fancies penis relaxed on attempting coitus.
Staphysagria
Organs relaxed and powerless.
Sulphur
Organs relaxed and powerless, ejaculation before intromission.
Uran. N
Impotency with nocturnal emissions, organs cold, relaxed and sweaty.
X-Ray
Sexual desire lost. Testes relaxed, Feeling of impotence.
Yohimbinum
Neurastshenic impotency.