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 CAUSES OF ERECTILE DYSFUNCTIONS

A)    Impotence due to some well-defined causes (Internal defect i.e. organic or physical causes)

1.  Hormone Disorders (male hormone may be less or other hormone defect)
2.  Decreased Blood Supply to Penis (less blood flow disorder)
3.  Disorders of Nervous System (penis nerve disturbance)
4.  Penile Nerve Abnormalities
5.  Sex Centre Disorder
6.  Other Systemic Diseases
7.  Local Causes
8.  Drugs & Toxins

B) Drug induced

c) Psychogenic Impotence: - i.e. erectile disorders due to various psychiatric disorders 

All above causes may be discussed in detail in following sections:

1) Hormones disorders are one of the common causes of impotence. There are two types of hormones in body, some hormones as male sex hormones stimulates erection & desire. Where as some other hormones inhibit the erection as prolactins & others. There are many male hormones in the body as serum testosterone, free testosterone DHEAS, Androstenidiones which, stimulate the sexual activity. So we have to test these hormones to finds out hormones disorders. Once the diagnosis is made they are easily treatable in few months time. Causes of hormone disorder may be Diabetics, Hypogonadisms (Testosterone deficiency), Hyperprolactinemias, Hypothyroidisms or Hyperthyroidisms, Cushing syndrome, Endocrines dysfunction Secondary to drugs/toxin & systemic diseases, Hypothalamic – pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome, Hypothalamic deficiency, pituitary hypoplasia, Trauma, post surgical, postiradiation, Adenoma: craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, hemochromatosis), Autoimmune hypophysitis, drug-induced hyperprolactinemias, Untreated endocrinopathies , Diabetics , Glucorticoid excess, Hypopituitarisms, Addison disease. Isolated gonadotropin deficiency, Pituitary or Hypothalamic defects, Associated with multiple pituitary hormones deficiencies: Idiopathic pan hypo-pituitarism (hypothalamic defects), Pituitary dysgenesis, Frohlich syndrome, fertile eunuch syndrome, Idiopathic hypopituitarism,Testicular failure, development defect, drugs, trauma, congenital defect, congenital adrenal hyperplasia, Chromosomal defect, testosterone hormone biosynthetic defect, Mumps orchitis leading to testicular atrophy, Primary testicular defect of testicular differentiation, inborn errors of testosterone synthesis, Klinefelters syndrome. 

(2) Decreased blood supply to penis: Due to many disorders of penile artery & veins, decrease in blood circulation (flow) to penis occurs so that blood is unable to reach in the phallus so that penis does not becomes full hard. Or some times blood reaches in normal amount resulting in full hardness of organ but any time before or after vaginal penetration blood starts leaking back in to body leading to loss of erection. The causes of this may be as follows: 

(i) Obstruction to arterial blood flow i.e. Decreased Penile blood supply to penis may be due to various diseases so that blood supply to penis may be decreased. So that either penis does not become fully hard or even if it becomes hard it soon become loose before intercourse or during intercourse. It can occur in young people or in older people also. This is one of the common causes of impotence. The causes of decreased blood supply may be Atherosclerotic, Diabetics, Hypertension, Heart Diseases & other vascular diseases as Arterial dysplasia, Post-Traumatic & Post-Surgical & damage to blood circulation due to various local disorders.

(ii) Veno - Occlusive dysfunction i.e. Venous Leak: There are certain conditions in which penis becomes full tight initially but very soon becomes loose because blood from penis leaks back. Normally during sexual excitation blood flows into penis & this blood is not allowed to go back in body by various venous valves. Due to certain disorder these valves may not work. So that blood coming in penis keeps leaking in body all the time so that either penis does not becomes fully hard or even if becomes fully hard it becomes loose any time during sex due to leakage of blood. 

3) Penile Nerve Abnormality: When erectile dysfunction is caused by disorder of central nervous system or due to peripheral nerve is called neurogenic erectile disorder. This can be due to disorder of nervous system & Neuropathy d/t various causes, Ant. temporal lobe lesions: Stroke/epilepsy, Dis. of Spinal Cord: T-12 or below & Dis. of Peripheral Nerves :(Peripheral polyneuropathies, Autonomic neuropathies, Pelvic nerve trauma). All these disorders leads to decreased sensitivity of penis & sex centre to female touch & sexual excitation leading to less erection.

4) Sex Centre Disorder: In the brain there is a particular centre in the hippocampus of the brain, which regulates the penile erection during intercourse, the desire of sex time, taken in discharge & enjoyment of sexual act. So any disorder of sex centre due to various causes can lead to impotency, less desire & premature ejaculation.

The causes of sex centre induced impotence can be divided into two groups: (1) immediate cause, and (2) remote cause. Such a classification is helpful in the treatment of impotence. If the impotence is due to immediate causes, a removal of these factors results in adequate sexual functioning. When impotence is due to remote causes, detailed sex therapy may be necessary for a more lasting cure.

(6) Penile corporal muscle abnormality due to various disease penile smooth muscles do not dilate so that blood is unable to reach in penis & it could not erect.

7) Local Causes Peyronies dis. (painful penile curvature d/t fibrosis), Penile trauma, carcinoma. Following Priapism (i.e. prolong longstanding erection) etc.

8) Other Systemic diseases (liver failure, renal failure, cardiac failure or other system failure etc.)

B) Drugs & Toxins various drugs impair sexual activity. So detailed drug history taking is must. 
Antihypertensive (ß blocker, Thiazide diuretics,Clonidine & methylodopa) Antiandrogens (Spironolactone & Ketoconazole) 
Antidepressants (Tricyclic antidepressants, Major Tranquillizers & Antipsychotics    & Addictions of (Alcohol, Smoking, Heroine, methadone, Cannabis, opiates & marijuana)

(c) Psychogenic: Many psychiatric disorders as obsessive-compulsive disorder, Neurosis, schizophrenia, depression can cause impotence.  

Primary Cause of Impotence: due to any of the above causes patient may fail during sex. Once a person fails due to any of the above causes as hormone disorder or decreased penile blood supply or any other cause after that patient starts thinking that he has some serious internal defect in sex organ. Secondary to this failure in sex, virtually all patient develop following three things, these three factors further worsen the erectile dysfunction caused by primary cause, and these are called.  

These secondary factors are as follows:

1) Fear of failure In this the moment person thinks of going for sex, he start fearing that I may fail again thus he loses confidence in his sexual competence. This fear decreases his confidence further leading to further worsening of sex dysfunction. Many times due to this fear patient starts avoiding sex & his desire for intercourse decreases.

2) Sexual Performance anxiety means development of severe anxiety before real sex. Patient develops obsessive concern for full erection i.e. whether or not he can get a normal erection and if he does whether he can keep it long enough for intercourse to occur & his partner to be satisfied. Due to this anxiety He tries to erect his penis hard by concentrating more on it & contracting the pelvic & leg muscles rather than allow it to occur in natural response to erotic pleasure. But unluckily most people do not know that penis hardness occurs spontaneously & automatically in response to more & more enjoyment one gets in touching & loving the female body. Thus the more patient tries too make penis hard, the just opposite happens i.e. penis becomes looser. Thus this anxiety to perform better really further worsens the hardness of penis. This performance anxiety can be cured by sex therapy in few sittings.

3) Spectator attitude means whenever patient goes for sexual activity though he may be touching the body of female but his brain is always thinking and involuntarily (unconsciously) looking towards his penis i.e. whether his penis is getting hard or not. This is called spying of penis. Thus his mind is always preoccupied about penile hardness. Patient loses confidence in his performance, and instead of relaxing & enjoying he starts watching their sexual responses like 'spectators', rather than being involved in what is going on. So that in place of enjoying the female touch, he always keeps spying his penis leading to lack of enjoyment of sexual activity thus\leading to repeated failures.

These all above problems contributes to repeated failures.

So that in all cases of impotency after proper diagnosis & treatment of primary cause, these three secondary problems also need to be tackled by sex therapy then only patient can get permanent cure. So by sex therapy, the patient is taught how to avoid spectator role and become free of fear of failure & performance anxiety. 

So above three secondary problems hinder into normal recovery of sexual function even if the original cause may have been cured.

It does not means that person is suffering from psychological erectile failure; instead it is a normal fear everybody develops due to failure in sex. Thus one should try to find out why he failed on very first time i.e. one should try to finds out any of the above nine causes of impotence.

Thus the anxiety of sex, fear of failure and spectatoring (the patient watching all the time to see if he is getting an erection or not) are also the important. After correcting primary cause the normal potency does not returns, because these three secondary factors interfere with normal sexual functioning. If these factors are also removed by sex therapy, sexual functioning soon becomes normal. The new, intensive team treatment of sexual dysfunction has revolutionized sex therapy. 'In most cases, for cure of impotence detailed sex counseling & sex therapy is necessary.

How common is impotence due to some well-defined internal causes?

Old belief is that most cases of impotence are Psychogenic is not correct. In one study Koremann & colleague found impotence due to some internal causes in > 90% of men & Psychogenic in 10%.

            Thus Psychogenic cause should never be labeled unless Hormonal & other causes have been excluded by thorough ex        amination, hormon.examination, hormon.0es & penile blood supply test.
            
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