IMPOTENCE
IMPOTENCE: Excerpt from Differential Diagnosis in Primary Care
Impotence is now more commonly referred to as erectile dysfunction.
Impotence may be due to local end-organ disease, dysfunction of the
peripheral nerve pathways, disease of the spinal cord or brain, pituitary
and other endocrine disorders, and supratentorial disorders. Thus recall of
the various causes is based on both anatomy and physiology.
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End-organ disorders. These include phimosis, paraphimosis,
prostatitis, prostate carcinoma, and Peyronie disease.
-
Peripheral nerve disorders. Diabetic neuropathy is a common cause
in this category, but alcoholic neuropathy and other neuropathies may
occasionally cause impotence.
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Spinal cord disorders. Transverse myelitis, poliomyelitis,
compression fractures, spinal cord tumors, multiple sclerosis, and tabes
dorsalis are important disorders to be considered here.
-
Disorders of the brain. In addition to general paresis, brain
tumors, vascular occlusions, and arteriosclerosis, degenerative diseases
such as Alzheimer disease, senile dementia, and Schilder disease will cause
impotence.
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Pituitary and other endocrine disorders. Impotence is found in
pituitary tumors, acromegaly, testicular atrophy from hemochromatosis,
mumps, Klinefelter syndrome, Cushing disease, and hypothyroidism.
Hyperprolactinemia is associated with impotence.
-
Supratentorial disorders. This is the cause of perhaps 90% of
the cases of impotence. There are several reasons for this. After years of
marriage and intercourse with the same sexual partner, one’s libido may
decline considerably. The first time the male patient has trouble reaching
an erection, he begins to believe he is “over the hill.” If he should
happen to acquire a young mistress he may find convincing proof that his
impotence is psychologic.
Sometimes, in search of variety in his sexual life, a married man may decide
to find a new sexual partner. When the moment of truth arrives he may be
unable to get an erection because of the associated guilt involved.
Premature ejaculation is common under these circumstances also. After his
first failure, the fear of a repeated performance may make him impotent not
only in extramarital relations, but also in marital relations.
Young men, whether married or unmarried, may “fall into impotence” quite
by accident because of alcoholic intoxication. As Shakespeare correctly
surmised, “alcohol provokes the desire, but it takes away the
performance.” Under the influence of alcohol, the inspired lover may fail
miserably. When sober once more, he may begin a pattern of failure to get an
erection simply because of the fear that it will happen again and he will be
embarrassed beyond belief.
Some other supratentorial causes of impotence are endogenous: depression,
schizophrenia, latent homosexuality, repressed hostility toward the partner,
and fear of pregnancy. It is important to note that all of the above
psychologic causes may occur in the female patient as well as the male.
There are many more causes too numerous to mention in a book of this scope.
Approach to the Diagnosis
A careful examination of the external genitalia, the prostate, and
secondary sex characteristics is essential. The laboratory workup may
include a glucose tolerance test, blood testosterone, free testosterone and
cortisol levels, thyroid function studies, a spinal tap, a skull x-ray, and
a chromosomal analysis. A nocturnal penile tumescence study is performed to
rule out organic causes. If the physical examination is normal, it may be
wise to administer psychometric tests or to refer the patient to a
psychiatrist before doing an extensive endocrine and neurologic workup. A
sympathetic physician may be able to find the supratentorial cause and cure
it with a few long discussions with the patient. A female physician may have
more success in this area than a male.
Other Useful Tests
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Serum follicle-stimulating hormone (FSH) and luteinizing hormone
(LH) levels (pituitary or gonadal insufficiency)
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Sperm count (testicular atrophy)
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Penile blood pressure (Leriche syndrome, arteriosclerosis)
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Spinal tap (multiple sclerosis, neurosyphilis)
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Computed tomography (CT) scan of the brain (pituitary tumor)
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Testicular biopsy (testicular atrophy)
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Cystometric studies (neurogenic bladder)
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Doppler sonogram of dorsalis penis artery (arteriosclerosis)
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Drug screen (drug abuse)
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Interview of spouse
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Nerve conduction velocity (NCV) and electromyogram (EMG)
(peripheral neuropathy)
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Serum prolactin
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Medical Books Excerpts
- IMPOTENCE
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- IMPOTENCE
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
- Impotence
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Impotence
- "A Pocket Manual of Differential Diagnosis" (1999)
- [ read ]
- Dyspareunia
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
- Dyspareunia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Impotence
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Impotence
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Vaginal Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Impotence
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
- IMPOTENCE
- "Differential Diagnosis in Primary Care" (2007)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: VAGINAL DISCHARGE (Differential Diagnosis in Primary Care)
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