IMPOTENCE
IMPOTENCE: Excerpt from Differential Diagnosis in Primary Care
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.
- 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.
- 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.
- Pituitary and other endocrine disorders. Impotence is found in pituitary tumors, acromegaly, testicular atrophy from hemochromatosis, mumps, Klinefelter syndrome, Cushing disease, and hypothyroidism.
- 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 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 as well as the male. There are many more causes too numerous to mention in a book of this scope.
IMPOTENCE
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 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
- Serum FSH and LH levels (pituitary or gonadal insufficiency)
- Sperm count (testicular atrophy)
- Penile blood pressure (Leriche syndrome, arteriosclerosis)
- Spinal tap (multiple sclerosis, neurosyphilis)
- CT scan of the brain (pituitary tumor)
- Testicular biopsy (testicular atrophy)
- Cystometric studies (neurogenic bladder)
- Doppler sonogram of dorsalis penis artery (arteriosclerosis)
- Drug screen (drug abuse)
- Interview of spouse
- NCV and EMG (peripheral neuropathy)
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Vaginal Discharge
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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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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