by Dr. M. P. Vora
The Bombay Hospital Journal
(A Medical Research Centre Publication)
Volume No. 15, Number. 3 of July 1973.
Page no. 54/194 to 56/196.
Impotency means inability to perform normal sexual intercourse due to either premature ejaculation or failure to have or maintain satisfactory erection. This should not be confused with sterility. An impotent may be sterile or fertile, so also sterile man may be potent or impotent.
Penile erection and involuntary ejaculation of the semen depend on a reflex act at the sacral level. Two opposing nerves regulate the phenomenon of ejaculation. The reflex is under the control of automatic nervous system. Sympathetic nerves (L2 &3) through hypogastric nerve control the act of ejaculation; while parasympathetic nerves (S2, 3 &4) through nervi erigentis control the erection. When the centre becomes hypersensitive or over sensitive, the premature ejaculation occurs. While physiological stimuli transmitted by the central nervous system from the higher centre and androgen secretion in conjunction with higher cerebral impulses govern libido. Impotence may result from organic or psychic disturbances. It may be complete or partial. It may be with normal or impaired libido.
Organic or secondary impotence may be further divided:
Endocrine affections or disorders may be due to eunachism, pituitary syndrome, hypopituitarism, dwarfism, Frohlich’s syndrome, Cushing’s syndrome, acromegaly, gigantism, myxodema, Addison’s disease, androgen deficiency, pigmentary cirrhosis, hypogonadism and absence of libido.
Neurological disorders may be diabetic neuropathy, peripheral neuritis, medullary or spinal cord lesion, tabes dorsalis, general paralysis of the insane, trauma, Aorto-iliac endaterectomy or tumour of the spine, spina bifida, cauda equine, disseminated sclerosis, and blocking of sympathetic ganglia by drugs for hypertension.
Toxic affections: Farmers who happen to handle chemicals, insecticides and pesticides are known to develop impotency. But it is reversible on suspension of work.
Psychic impotence also called primary or functional may be due to:
This group comprises of 90 percent cases of impotence, while the remaining 10 percent is due to organic lesions which are often obvious at sight. In psychic impotence, there is no harmony of the body and mind or the brain and mind.
In all cases of impotence, a careful comprehensive and systemic examination to exclude organic lesions is of utmost importance. This also helps to gain confidence of the patient. Once this is done, one would be dealing mostly with common cases of psychological impotence.
Premature ejaculation is most common especially when a male is worried, fatigued or apprehensive. When it occurs occasionally in between long periods of sexual relations, one need not worry about it. It may be taken as temporary set back. But when it occurs frequently and persistently, it ought to cause concern and needs an urgent attention. Premature ejaculation may be “post-partus” or “ante-partus”. In the former the involuntary ejaculation occurs immediately on intromission or very soon after that. In the latter, the more serious of the two, ejaculation occurs even before the penis is introduced into the vagina. Ejaculation may take place with semi-erect condition or without erection.
Premature ejaculation is often due to hypersensitivity which may be due to:
In both forms of premature ejaculation, the female partner does not get an opportunity to achieve full satisfaction and orgasm. She naturally feels hurt and rejected. This finds itself in her behaviour, expression and talk. The male, being very touchy and sensitive of his potency, begins to feel inadequate, maladjusted and unhappy. He remains under constant tension and fear. This is the time when the wife has to be very tactful, considerate, and affectionate and refrain from remark and criticism. In fact she must do everything in her power to reassure him of his manliness and potency. This assurance must be by word, action, gesture and thought. In absence of her genuine co-operation, he is not likely to improve his functioning as a husband. A wife can be directly responsible for her husband’s poor performance. A tactless wife who often nags her husband, who is sarcastic or caustic in her remarks, who is over-critical of his actions, which constantly argues or devalues her husband, is very likely to be neglected by her husband. Her attitude towards ‘sex is shameful’ or her refusal to participate in certain sexual fore-play may have profound effect on his potency. In some cases, a man’s impotency may be due to his anxiety about the past experiences such as masturbation, guilt feeling or due to his homosexual tendencies. Occasionally, a man may be impotent with his own wife but potent with other women. This is called relative impotency.
In hypogonadism, if present from the puberty, the patient seldom complains of impotency because he has little or no libido. The same is true of cases of impotence due to generalized debility or convalescence following severe illness. When an organic neurologic lesion is present, the patient may complain of impotence and fail to achieve an erection. Impotence is a common complication of diabetes mellitus and hypertensive state. In actual practice, organic lesion count for about ten percent of cases of impotence; while the rest owe their condition to psychological factors. History of these cases is very important, in making the diagnosis. Early morning erection with full bladder or rectum is a good evidence of normal anatomical and physiological function. It has been noted that mean urinary testosterone level is significantly higher in psychogenic impotence than in constitutional impotence.
The treatment of impotency must be on the etiologic basis. To deal with various causes individually would be beyond the scope of this article. A physician has to identify the actual cause at the root and guide the patient and his wife towards correctness and adjustment, if the treatment has to be effective and successful. Any cause in the operation has to be found out and removed by appropriate measures. Most patients need reassurance and full cooperation from their wives and physicians. It must be impressed on every male that a man, at some time or other during his life, suffers from either want of erection or premature ejaculation or both, and that this does not mean that the condition is permanent. It should be regarded as temporary inconvenience, which passes of itself in majority of cases. It is a mistake to depend solely and immediately on drugs and their massive doses. The wife’s role in reclaiming and rehabilitating her husband’s manhood should not be belittle or made small. A good deal of success will depend on her sincere cooperation. Yet many wives are prone to be guilty in weakening and worsening their husband’s sexual power. She must learn not to feel rejected or hurt because of his failure. She must build up his ego and at the same time her ability to arouse him. At times which may suit her partner, she must take initiative in love-making. The wife who shows undue shyness and is afraid to manifest of evidence of being aroused, is really uninviting to her husband. When she behaves in bed as she should, her husband is less likely to find himself impotent.
In patients with hypogonadism, potency can be initiated and restored by giving androgen but this is not likely to influence his infertility. Neurological causes can seldom be treated effectively. Prognosis is generally poor except in cases of spinal compression, where timely surgery can be of great help.
A patient with psychic impotence could possibly help himself to relax and decrease the amount of tension by taking on himself a less active role during coitus. He can assign the active role to his female partner. Use of tranquillizers can be helpful in relieving tension. Phenothiazine, Thioridazine, Methoxitone and Imipramine have been in use with good results in premature ejaculations. Local hypersensitivity can be dealt with by circumcision in case of phimosis or applying one to 2% xylocain ointment to the glans penis, half an hour before the intercourse. To reduce sensitivity and congestion of the posterior urethra, weekly prostatic massage followed by urethral installation of 1 to 2ml silver nitrate solution, gradually increasing the strength from 1 in 2000 to 1 in 500, should be prescribed for 8 to 10 weeks. Recent research works have brought new facts to light. It is observed that the sexual performance of the male depends on the endocrine status of the female partner. The mounting activity and the ejaculatory capacity of the male is diminished or increased by giving progesterone or estroidol respectively to the female. Estroidol given to the female partner stimulates male copulatory activity and ejaculation. Administration of ethinyl oestradiol 00.01mg twice a day orally to the male helps to reduce hypersensitivity and control his early ejaculation. These observations have a practical utility in this subject.
Surgical measures to improve and maintain erection:
Mechanotherapy to help erection: Dr. J.T.Loewenstein has devised an appliance, coitus training apparatus, to help patients regain confidence. Two splints incased in rubber and with a ring at each end to support the under-side of the penis.
Active and Passive Desensitization as suggested by Dr. J.H.Semen and Dr.J.Wolpe (U.S.A) respectively:
In the former method, the wife is required to stimulate the male organ manually till he feels the sensation that precedes ejaculation. Repetition of this exercise or procedure day by day establishes a condition in which intense sexual stimulation is tolerated without ejaculation. Thus he learns to postpone precipitate ejaculation.
In the latter method, the couple is to engage in sexual closeness without either expecting an intercourse. They indulge in only as much actively as the male can tolerate without anxiety. As there is no set goal he must reach or no level of sexual performance he must attain, his anxiety is considerably reduced. By repeating this procedure daily, he gradually becomes more and more relaxed and is able to indulge in more intense closeness and embrace without being least anxious. He thus learns to tolerate greater amount of stimulation without precipitate ejaculation. His sexual mechanism gets re-trained to respond in the union without fear.
Authors of these techniques of desensitization have successfully used these methods in their practice.
One may prescribe many harmless preparations to help the patients to overcome his fears and to regain his confidence until the impaired natural forces are able to take over routine sexual activity. However, its value could not be more than a placebo.