Management Failure of genital response (erectile dysfunction)

Management

1. Assessment

• full sexual history
• physical examination
• penile-brachial artery pressure index of less than 0.6 is indicative of arterial disease to penis; angiography may be necessary in younger patients
• nocturnal penile tumescence monitoring can distinguish organic (no nocturnal erections) from psychogenic causes
• dynamic cavernometry (normal saline infused into corpus cavernosum) can detect venous incompetence
• intracorporeal injection of PAPAVERINE or PHENTOLAMINE can be diagnostic to establish the capacity for erection

2. Treatment

a) Physical

i) intra-cavernosal injection of vasoactive drugs:

• PAPAVERINE, self-injected can give an erection lasting about an hour, and can be used up to twice a week
• complications include priapism, fibrosis, haematomas, and bruising

ii) suction devices:

• provide a safe method of obtaining an erection in up to 90% of patients
• problems include lack of spontaneity, decreased sensation, and delayed or absent ejaculation

iii) vascular surgery

iv) penile prosthetic implants:

• three types – malleable, self-contained inflatable, and multipart inflatable
• few problems with those with organic cause, but for those with psychogenic impotence, it can exacerbate pre-existing marital difficulties

b) Psychological

i) counselling

ii) psychotherapy

• CBT reports success rates of 70%
• couple therapy seems more effective than surrogate or individual therapies
• factors associated with better outcome include:

(a) good marriage
(b) better pre-treatment communication
(c) better general sexual adjustment
(d) female partners interest and enjoyment of sex
(e) absence of psychiatric history in female partner
(f) early engagement in homework assignments