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Impotence treatment
Psychosexual therapy :
Aims to understand and address underlying psychological issues, and provides information and treatment in the form of sex education, instruction on improving partner communication skills, cognitive therapy, and behavioural therapy (programmed re-learning of couple's sexual relationship).
Oral medication :
- Phosphodiesterase type-5 (PDE5) inhibitors: sildenafil (Viagra); tadalafil (Cialis); vardenafil (Levitra). PDE5 inhibitors enhance cavernosal smooth muscle relaxation and erection by blocking the breakdown of cGMP. Sexual stimulus is still required to initiate events. Side-effects: headache; flushing; visual disturbance. Contraindications: patients taking nitrates; recent myocardial infarction; recent stroke; hypotension; unstable angina.
- Dopamine receptor agonist: apomorphine (Uprima). Apomorphine is administered sublingually, and acts centrally on dopaminergic receptors in the paraventricular nucleus of the hypothalamus to enhance and co-ordinate the effect of sexual stimuli. Adverse effects: nausea; headache; dizziness.
Androgen replacement therapy
testosterone replacement is indicated for hypogonadism. It is available in oral, intramuscular, pellet, patch, and gel forms. In older men, it is recommended that PSA is checked before and during treatment.
Intraurethral therapy
alprostadil (MUSE). Synthetic prostaglandin E1 (PGE1) pellet administered into the urethra via a specialized applicator. Once inserted, the penis is gently rolled to encourage the pellet to dissolve into the urethral mucosa, from where it enters the corpora. Side-effects: penile pain; priapism; local reactions.
Intracavernosal therapy
alprostadil/Caverjet (synthetic PGE1); papaverine (smooth muscle relaxant) ± phentolamine (α-adrenoceptor agonist). Training of technique and first dose is given by health professional. Needle is inserted at right angles into the corpus cavernosum on the lateral aspects of mid-penile shaft. Adverse effects: pain; priapism; haematoma.
Vacuum erection device
it contains 3 components: vacuum chamber, pump, and constriction band. The penis is placed in the chamber and the vacuum created by the pump increases blood flow to the corpora cavernosa to induce an erection. The constriction band is placed onto the base of the penis to retain blood in the corpora and maintain rigidity. Adverse effects: penile coldness; bruising.
Penile prosthesis
semi-rigid, malleable, and inflatable penile prostheses are available for surgical implantation into the corpora to provide penile rigidity and sufficient erectile size for sexual intercourse. Side-effects: mechanical failure; erosions; infections.
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