Contemporary Issues in Management of Impotence

Sex is a man's second strongest instinct, afterthat of survival. This means that if a man's life is not immediately imperiled, the next thing he will automatically think of is sex. This is a fundamental reality of life and explains why sexual impotence or erectile dysfunction is associated with so much of distress, guilt, shame ' and embarrassment. The past decade has witnessed scientific breakthrough that have changed the concept and clinical management of erectile disorders. The term impotence has been replaced by the 'erectile dysfunction' proposed by Consenses Development Conference (1992) at the National Institute of Health (NIH), and defined as the "Inability of the male to achieve an erect penis as part of the overall multifaceted process of male sexual function". Impotence is a fairly common condition and recent study have estimated that at least 10-20 million people in America suffer from impotence (Feldman et al.,1994). One can only imagine the prevalence in Indian population, but if flourishing aphrodisiac industry is any indication, it seems to be fairly common. Advances in anatomy, physiology and neurovascular factors responsible for erection * have advanced our knowledge of how exactly an erection occurs. With the advancement in these fields, various medical risk factors for impotence have also been delineated and now it is very well recognized that large majority of patients have impotence secondary to some organic cause. The leading causes include diabetes, heart disease, hypertension and certain drugs which include hypoglycemic agents, antihypertensive, vasodilators and cardiac drugs. Obesity, heavy alcohol intake and smoking are additional risk factors. It is well known now that erection rs essentially a neurovascular phenomena. Blood vessel and smooth muscle contraction depends on adrenergic mechanisms while cholinergic impulses cause blood vessel and corporeal smooth muscle relaxation. It has been recently demonstrated that penile nerves as well as penile blood vessels and corporeal smooth muscle endothelium releases nitric oxide, which mediates vasodilatation of the penile vascular resistance bed. Nitric oxide stimulates formation of cyclic guanosine monophosphate (cGMP) which promotes smooth muscle relaxation (Burnett et al.,1992). Vasodilatation then results in tumescence. It is also known that phosphodiesterase is responsible for breakdown of cGMP and may play an important role in detumescence, and hence inhibition may result in improved erection. The wonder pill "Viagra" which contains Sildenafil is infact inhibitor of this particular enzyme system. As the research has advanced into the understanding of various factors responsible for erection and erectile dysfunction. It has resulted in a subtle "turf wars" to determine whether psychiatry, urology, endocrinology, medicine or surgery should dominate the field. Masters and Johnson's (1970) had declared that 90% of sexual impotence is psychogenic, whereas urologists have more recently declared that 90% of impotence is organic. Both sides are over emphasising the importance of their respective speciality, not just for their disrespectful attitude towards one another but for having