The causes and management of impotence.

IMPOTENCE may be defined as the inability of the male to develop and/or sustain an erection of the penis sufficient to conclude coitus or orgasm and ejaculation to his own satisfaction. The condition may be 'primary', i.e. early onset-present since the first attempt at coitus, or 'secondary', i.e. late onset-developing from prior competency. The causes of impotence may be arbitrarily divided into three main groups: 'constitutional', 'organic' and 'psychogenic'. 'Extreme' constitutional impotence is likely to be associated with persisting evidence of low sexual drive and responsiveness; rarely, there will be no prior history of, or as is more usual, only spasmodic episodes of self-masturbation; and other types of sexual outlets, such as heterosexual petting/ coitus and/or homosexuality, will have taken place only very infrequently or not at all. As far as can be established there is no organic pathology in these cases, who seem merely to occupy one pole of a 'sexual responsiveness' continuum, at the other end of which is situated the high responder, i.e. >thirty outlets/week-Kinsey, Pomeroy & Martin (1948). Unless constitutional factors are dominant, 'organic' impotence will usually have developed from prior competency in association with some pathological lesion. The condition is generally held to be constant and persists largely unchanged, irrespective of the nature of any sexual stimulation which might be provided. On the other hand 'psychogenic impotence' is stated to be selective and transient, occurring in certain situations and at certain times, but not others. In clinical practice, impotence is rarely seen in 'aetiologic pure culture', indeed, in the majority of cases aetiologic overlap may occur and it is important to realize that although a case may be predominantly 'organic'; 'psychogenic' and/or 'constitutional' factors may and usually are playing a part to some degree or other. Likewise with predominantly 'psychogenic' and predominantly 'constitutional' types. This paper is aimed mainly at the non-psychiatrist; its purpose is to summarize the main causes of impotence and to describe a practical management approach, which does not require much in the way of psychological expertise for its use. It is hoped thereby that many otherwise reluctant practitioners may be encouraged to try out their 'hand'. Organic impotence This probably accounts for less than 5% of cases and may occur with any debilitating disease, with metabolic disorders, with disorders of the central nervous system, cardiovascular diseases and endocrinopathies, as well as following the use of some drugs. Table 1, which is a slightly larger version of Masters' & Johnson's (1970) culling from the literature, shows the range of organic pathology which has beenheld to cause impotence. Since in manycases this is derivedfrom a few oreven single case studies, these 'causes' should beviewed, at best, only as probabilities.