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Psychological impotence: Psychological erectile dysfunction and erectile

dysfunction causes, diagnostic methods and management options

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DOI: 10.5897/SRE11.1065

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Scientific Research and Essays Vol. 7(4), pp. 446-452, 30 January, 2012
Available online at [Link]
DOI: 10.5897/SRE11.1065
ISSN 1992-2248 ©2012 Academic Journals

Full Length Research Paper

Psychological impotence: Psychological erectile

dysfunction and erectile dysfunction causes,
diagnostic methods and management options
Kingston Rajiah1*, Sajesh K Veettil1, Suresh Kumar1 and Elizabeth M. Mathew2
1
International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000 Kuala Lumpur, Malaysia.
2
Mallige College of Pharmacy, No. 71, Silvepura, Bangalore, 560090 Karnataka, India.
Accepted 6 January, 2012

Psychological impotence or erectile dysfunction is nowadays a pretty common yet misunderstood

disorder. People often cannot detect it properly and misunderstood it for physical impotence.
Psychological impotence is basically caused by psychological problems. Most of the times, this kind of
impotence are curable. Recent study has shown that most of the cases of impotence are basically of
this nature. Numbers of sexual problems were found to be frequent. Physical, social/emotional, and
relationship factors were all found to have a significant impact on the prevalence of one or more sexual
problems. In addition, we observed an important gender difference: increasing age was more
consistently associated with sexual problems among men. Thus, sexual problems among women and
men appear to share similar correlates, but physical factors may play a larger role among men.
However, as men age, there may be more psychological and relationship issues as well that influence
their sexual satisfaction and performance.

Key words: Psychological erectile dysfunction, psychological impotence, erectile dysfunction.

INTRODUCTION

Psychological impotence or erectile dysfunction is cervical or thoracic spinal cord (paraplegics) are still able
nowadays a pretty common yet misunderstood disorder. to have this type of erection. A small number of men with
People often cannot detect it properly and misunderstood complete transection of the spinal cord can also have
it for physical impotence. There are clear and distinct erections which are psychogenically induced.
differences between these two. But before jumping into 2. Psychogenic erections are induced by visual or
the differentiation of these two, it is advisable to have a memory associations.
clear concept in erectile dysfunction or impotence. 3. Nocturnal erections occur during rapid eye movement
(REM) sleep and may take place anywhere from three to
six times a night, lasting from 20 to 40 minutes.
ERECTION Generally, nocturnal erections begin with the onset of
puberty and diminish in intensity, duration and frequency
Men experience three types of erections: later in life (Ackerman, 1994).

1. Reflexogenic erections are induced by tactile Erections during arousal and intercourse are often
stimulation of the genitals. Men with lesions of the achieved as a combination of reflexogenic and
psychogenic and a deficit in one or both areas can lead
to impotency. When an individual is sexually aroused, a
message from the brain travels down nerves to the penis
*Corresponding author. E-mail: kingrajiah@[Link]. Tel: (Mulligan, 1990). Chemicals called neurotransmitters are
0060146400547. then released from the ends of the nerves in the penis.
 Rajiah et al. 447

Table 1. Factors and causes of erectile dysfunction.

Causes Factors
Narrowing of the arteries. These include: getting older; high blood pressure; high cholesterol;
Reduced blood flow to the penis.
smoking; diabetes.
Diseases which affect the nerves going to
Multiple sclerosis, a stroke, Parkinson's disease
the penis
spinal injury, following surgery to nearby structures, fractured pelvis, radiotherapy to the
Injury to the nerves going to the penis
genital area
Side-effect of certain medicines antidepressants; beta blockers and some diuretics
probably due to pressure on the nerves going to the penis, from sitting on the saddle for long
Mechanical factors
periods (especially during cycling)
Hormones lack of a hormone called testosterone which is made in the testes
Stress. For example, due to a difficult work or home situation, Anxiety, Relationship difficulties,
Mental health (psychological)
Depression

Stimulation of the penis can also cause local nerve most of the cases of impotence are basically of this
endings to release neurotransmitter chemicals. The nature (Mulligan, 1990; Wei, 1994). It may occur in a
neurotransmitters which are released in the penis cause certain situation due to some specific reason or may be
another chemical to be made called cyclic guanosine an effect of a particular incident. Most of the times, these
monophosphate (cGMP). An increase of cGMP causes incidents are related to emotion of an individual.
the arteries in the penis to dilate (widen) (Kahn, 1995). Bereavement of your loved ones can cause you a
This allows extra blood to flow into the penis. The rapid temporary impotence. On the other hand, guilt arise from
inflow of blood causes the penis to swell into an erection. extra marital affairs can be cause of psychological
The swollen inner part of the penis also presses on the impotence. Sometimes the impotence or erectile
veins nearer to the skin surface of the penis. These veins dysfunction caused by particular incident heals
normally drain the penis of blood. Such that the flow of automatically in due course of time (Yoshikawa, 1993;
blood out of the penis is also restricted, this enhances the Wei, 1994; Mbizvo, 1997). It can happen to every man.
erection (Yoshikawa, 1993). The cGMP is soon People from different age groups can be victims of this
converted into another inactive chemical. But, remaining disorder. Increasing pressure and stress of modern life
sexually aroused whilst having sex, the brain keeps are acting as impetus to this disease. Our complex
sending nerve messages to the penis which makes more lifestyle and critical socio economic condition are making
cGMP to maintain the erection. When the level of cGMP us vulnerable to this disorder. From a school going
falls, the blood flow to the penis returns to normal, and teenager to a super annuated person, every fertile male
the penis gradually returns to the non-erect state (Wei, can be a victim of this disease (Yoshikawa, 1993).
1994).

Age groups
IMPOTENCE OR ERECTILE DYSFUNCTION
School going teenagers and young men: More than
1.) When due to some reason, during the time of sexual ninety percent impotence of this age group is basically
stimulation the pump of extra flood is hampered, then psychological impotence. Nervousness and anxiety are
impotence or erectile dysfunction occurs. The cause may the main reasons behind this kind of erectile dysfunction.
be physical, psychological or combination of both (Table Fear from having sex cause anxiety among this age
1). At times it becomes problematic to point out the group. Most of the cases are ephemeral in nature
reason of impotence (Kahn, 1995). (Halliwell, 1994).
Middle aged men: The main reason of erectile
dysfunction of this age group is personal and professional
stress. Unfaithful partner or unhappy married life can
Psychological impotence or psychological erectile cause impotence too (Halliwell, 1994).
dysfunction Old age group: This age group is mainly vulnerable to
physical impotence. But psychological erectile
Psychological impotence is basically caused by dysfunction also may happen at this mature age.
psychological problems. Most of the times, this kind of Bereavement of partner, loneliness can be the cause of
impotence are curable. Recent study has shown that impotence (Halliwell, 1994).
448 Sci. Res. Essays

Psychological or physical? cholesterol and triglycerides, and testosterone. If the

man’s testosterone concentration is low, serum free (or
The best and safest way to know whether it is bioavailable) testosterone, prolactin, and lutenizing
psychological or physical impotence is to a consult a hormone should be measured (Mbizvo, 1997).
physician. Through medical test, the doctor will be able to
point out the reason of erectile dysfunction. But, before
consulting physician you are advised to follow few simple Trials using treatments for erectile function
steps to know the reason. Morning erection and
masturbating are two easy ways to know whether it is A useful approach is to administer a treatment for erectile
psychological or physical. If your penny erects normally dysfunction and then observe the response: Physicians
during these two phases, then you can be sure that you now usually recommend a trial of sildenafil to test for an
do not have a physical problem (Wei, 1994; Mbizvo, erection response after 30 to 60 min. This drug is
1997; Halliwell, 1994; Schmid, 1997). replacing more invasive and expensive tests, such as an
injection of papaverine or prostaglandin E1, medications
Psychological erectile dysfunction is often temporary in that dilate blood vessels in the penis. They produce an
nature. It heals automatically in due course. As, the time erection in about 15 min. After administering the
passes, the importance of an incident alleviate and thus treatment and waiting the appropriate amount of time, the
help the patient to come back in normal state. So, it is physician then observes the erectile response, curvature
advisable to not force a person who has gone through a of the penis, and response after erection, sometimes
hard phase of life to consult a doctor for treatment of using an ultrasound scanner to assess blood flow
psychological erectile dysfunction. Patience and effort of (Sikora, 1995).
partner can create a magic in treating this disorder. If in
due course the problem is not cured, then you can apply
several therapies. Proper treatment can cure even the Monitoring night time erections
hardest of psychological impotence disorder (Schmid,
1997). Tests that monitor nighttime erections may be used to
determine if the causes of erectile dysfunction are more
likely to be psychological. Neither of the following
Diagnostic methods methods is helpful in determining a physical cause for
erectile dysfunction:
Physician interview
Snap-gauge test: The snap-gauge test monitors the
1. The physician typically interviews the patient about man's ability to achieve an erection during sleep. It is a
many physical and psychological factors. The patient very simple test. When the man goes to bed, he places
must be as frank as possible for his physician to make a bands around the shaft of his penis. If one or more
diagnosis. He should not interpret these questions as breaks during the course of the night, it provides
intrusive or too personal if he expects to obtain help. evidence of an erection. In this case, a psychological
These questions are very relevant and important for basis for the erectile dysfunction is likely (Sikora, 1995).
determining the proper approach. Even when erectile Rigi scan monitor: A more sophisticated and more
dysfunction has a clear physical cause, relationships and expensive device is the Rigi Scan monitor, which makes
psychological factors can also have an effect (Brown, repetitive measurements of rigidity around the base and
1995). tip of the penis. This test is quite accurate but may fail to
detect mild cases of erectile dysfunction (Sikora, 1995).

Physical examination
Penile brachial index
The physician should perform a careful physical exam,
including examination of the genital area and a digital The penile brachial index is a measurement that
rectal examination (the doctor inserts a gloved and compares blood pressure in the penis with the blood
lubricated finger into the patient's rectum) to check for pressure taken in the arm. Problems with the arterial flow
prostate abnormalities (Brown, 1995). to the penis can be detected using this method (Schmid,
1997).

Laboratory tests
Imaging techniques
These include urinalysis, complete blood count, and
measurement of fasting blood glucose, creatinine, Imaging tests may be used in certain cases, but they are
 Rajiah et al. 449

expensive and often limited to younger men. Anyone (Morales, 1995).

considering these tests should have them done in a
specialized setting by professionals experienced in their
use. Dynamic infusion cavernosometry and Testosterone replacement therapy
cavernosography (DICC) is usually only given to young
men in whom some blockage of the penis or physical Replacement therapy for hypogonadism: Testosterone
injury of the pelvic area is suspected. After an erection is replacement therapy may be effective in inducing puberty
induced with drugs, the following four steps are taken: in adolescent boys with hypogonadism and may also be
helpful for some adult patients with the condition. Some
1. The penile brachial index is taken. experts believe testosterone replacement therapy also
2. The storage ability of the penis is gauged. may be helpful for older men whose testosterone levels
3. An ultrasound of the penile arteries is performed. are deficient. Over the course of about three months, it
4. An x-ray of the erect penis is taken. may gradually heighten sexual interest. It can also
improve bone density, boost energy and mood, and
Duplex doppler ultrasound: An ultrasound technique increase muscle mass and weight (Morales, 1995).
called duplex Doppler ultrasound may be useful alone or Forms of testosterone therapy include the following:
with sildenafil in detecting some causes of erectile
dysfunction, such as leakage from blood vessels 1. Muscle injections using testosterone enanthate
(Schmid, 1997; Brown, 1995; Sikora, 1995). (Andryl, Delatestryl) or cypionate (Andro- Cyp, Depo-
Testosterone, and Virion) has been the standard
administration.
Treatment options 2. Skin patch (Testoderm, Testoderm TTS, and
Androderm): Depending on the brand, patches may be
Dietary treatment applied to the skin of the scrotum every 24 h or to the
abdomen, back, thighs, or upper arm. In the latter case,
The best way to correct impotency is to treat its primary two patches are required every 24 h. Testoderm and
cause and vitamins, minerals, herbal and homeopathic Testoderm TTS may cause less skin irritation than
medicines can help. Which remedies to use and how long Androderm. The skin patch achieves normal testosterone
they will take to work depends on the type of dysfunction, levels in between 67 and 90% of men.
so therefore a diagnosis of the cause of the dysfunction is 3. Skin gel (Androgel): At this time, the gel is applied only
needed (Reid, 1996). As with any genital-urinary tract to the same parts of the body as the patch. In one study
condition, a good nutritional program is a must. Most the gel produced normal testosterone levels in 87% of
impotency problems respond to nutritional therapy, men. A gel applied to the penile skin is being investigated
whether they are of a psychological or physiological for men with hypogonadism and erectile dysfunction.
nature. For instance, caffeine and tobacco are stimulants, Pregnant women must avoid contact with the gel
yet both also relax muscles and deplete nerve endings of because theoretically the testosterone could harm the
neurotransmitters, making it more difficult to maintain an fetus (Morales, 1995).
erection. Alcohol and recreational drugs have similar
effects and ultimately promote impotency (Reid, 1996;
Morales, 1995). Prolonged use of drugs and alcohol can Yohimbine
lead to depression as well as, be a sign that it is present.
Vitamins and minerals, which are essential for erections Yohimbine (Yocon, Yohimex) is derived from an herbal
to occur, are depleted with extended use of tobacco, remedy. It appears to boost erectile function by improving
caffeine, sugar, alcohol and recreational drugs. Allergies blood flow. Studies have been inconclusive about its
to food and other substances rarely lead to impotency benefits, but a recent analysis of seven trials reported
unless they cause discomfort in the genital or lower that between 34 and 75% of men achieved favorable
urinary tract and thus interrupt normal function. Allergies results when taking 5 to 10 mg. Side effects include
should be considered only as a last resort when all other nausea, insomnia, nervousness, and dizziness. Large
possible causes are ruled out (Reid, 1996). doses of yohimbine can increase blood pressure and
Studies show that high cholesterol also contributes to heart rate. One death has been reported from taking
impotency. An increase in erectile dysfunction was noted tablets of the standard dosage (5.4 mg). More rigorous
in a group of 3,250 men ages 26 to 85 years in studies are needed to confirm its effectiveness, and men
relationship to their serum cholesterol. For every mmol/l suffering from anxiety or hypertension are cautioned
of cholesterol increase above the normal range (normal = against its use (Reid, 1996).
3.63 to 5.18), a greater risk of impotency has been shown To boost success rates, some doctors suggest
(Wei, 1994). The authors concluded that high levels of combining it with the antidepressant drug trazodone if a
cholesterol and low levels of HDL cholesterol were patient is also depressed. The American Urologic
important risk factors for the development of impotency Association does not recommend yohimbine for treating
450 Sci. Res. Essays

impotence, although some experts believe it is an psychodynamic therapy. Counseling deals with the
inexpensive and reasonable option for some men. It problem in conscious state. It addresses the problem of
should be noted, that Yohimbine is available over the conscious mental state and refurbishes the lost interest in
counter as an herbal remedies. It is not government the mind of patient. On the other hand, according to
regulated and brands vary in effectiveness and quality psychodynamic therapy the root of the cause is hidden
(Morales, 1995). into the subconscious mind. The cause of impotence or
psychological erectile dysfunction is some subconscious
conflict. So it addresses the problem of subconscious
Experimental agents mind and reestablishes the lost interest. It encourages
the patient to come out with his problem frankly. In both
Oral Phentolamine: Phentolamine is an agent that has of these therapies, the partner of a patient has an
been used in injections for achieving erection. The drug important role to play. Without their involvement the
blocks adrenaline (epinephrine), which dilates blood chance of succeeding reduces drastically (Felter, 1998).
vessels. An oral form of phentolamine has been
developed that may be of some benefit for men with mild
impotence. The drug is not as effective as sildenafil Sex therapy for psychological erectile dysfunction or
(Viagra), but it does not interact with nitrates. In some impotence
studies, it was effective in producing erections within 20
to 40 min in 40 to 50% of men with mild to moderate This therapy insists on sensational pleasure rather than
erectile dysfunction. Side effects include nasal hardcore arousal of sex. This therapy basically reduces
congestion, headache, light-headedness, low blood the stress factor involved in a sexual intercourse by
pressure, tachycardia (increased heart rate), and nausea helping normal erection through pleasant touch in
(Farnsworth, 1995). partner’s body. This method is the brainchild of Masters
and Johnsons. They have imposed importance in
Apomorphine: Apomorphine, which is taken as a tablet pleasurable physical contact. This approach instructs a
under the tongue, causes a sexual signal in the brain to couple to concentrate on their thinking instead of activity.
trigger an erection, although it is not an aphrodisiac. According to this therapy, you can easily arouse your
Studies report improved erectile function in 40 to 60% of organ with the pleasant touch of partner’s body (Felter,
men, with the better results occurring at the higher doses. 1998).
High doses, however, also cause severe side effects, Following this process you can avoid the stress
including nausea (in between 15% to a third of patients), associated with erection. After your arousal, you can
yawning, fatigue, dizziness, sweating, excitability, and refrain yourself from the sensational touch and continue
aggression. Apomorphine appears to be safe for men your sex activity as long as you want. This pleasurable
with diabetes or stable heart disease, and is well way of making sex with your partner drives way your
tolerated by men with high blood pressure. It is available negative emotions like fear, stress, guilt etc. In that
in Europe but the manufacturer withdrew the drug fashion this therapy helps you to fight with psychological
application in the US (Ellingwood, 1998). erectile dysfunction. It helps you to build more secure and
reliable sexual life (Lue, 2000).
Alpha-MSH agents: Researchers are investigating drugs
that are derived from a natural substance released in the
brain called alpha-MSH, which increases sexual Surgical treatment
behavior. One agent called Melanotan II is showing
promise in investigative studies. In one study, 60% of Performing a surgery for a penile prosthesis implantation
men achieved erections after injections of Melanotan II, is also a valid option, and it has highly satisfactory results
but up to 20% of men experience severe nausea. It for the solution of erectile dysfunction problems. The use
appears to increase sexual desire and takes over an hour of prostheses began twenty years ago, with a new
to take effect. Another promising agent is a nasal spray technique that consisted in incorporating silicone rods
called PT-141 that may enhance erectile function by inside the corpora cavernosa of the penis in order to
stimulating receptors in the hypothalamus section of the achieve sufficient penile rigidity for sexual intercourse.
brain. This area of the brain is associated with emotions Later, other rigid silicone prostheses were developed,
and sexual arousal (Murray, 1998). which can easily be placed surgically in each corpus
cavernosum. Penile prostheses have been improved and
semi-rigid types have been developed, which are
Psychogenic therapy for psychological erectile malleable and easier to handle by patients. Their
dysfunction malleability is determined by an inner silver wire in the
silicone cylinders (Jackson et al., 2006).
There are namely two kinds of therapy- counseling and Nowadays, these cylinders are quite widely used and
 Rajiah et al. 451

there are different types. Another prosthesis which was caused by impaired blood flow regained erections after
later developed is inflatable, imitating the physiological taking ginkgo. More research is needed.
mechanism of erection. Inflatable prostheses are made 2. Ginseng root is a traditional Asian remedy for
up of two hollow cylinders, a liquid silicone reservoir, a stimulating sexual function, although no studies have
valve, and tubular connections between these elements been conducted on its efficacy.
(Ellingwood, 1998). 3. A dietary liquid supplement called ArginMax is being
The cylinders are introduced in the corpora cavernosa, hailed as a natural sildenafil. The preparation contains a
the spherical reservoir is placed inside the abdomen, and number of vitamins, gingko, ginseng, and arginine, an
the valve is placed in the scrotum. This valve is designed amino acid that increases production of nitric oxide, a
to make the fluid flow from the reservoir to the cylinders substance that relaxes blood vessels and promotes
and, in this way, make them rigid and then flaccid again. erections. As with most alternative remedies, however,
Although, this type of prosthesis is highly physiological, rigorous studies are lacking.
there is a technical problem entailing the possibility of 4. An herbal supplement sold as Vaegra has no
flaws that will necessarily require additional surgeries for association with the prescription drug sildenafil (Viagra).
some patients. Besides, this type of prosthesis is much None of these substances are regulated and their quality
more expensive than the malleable silicone prosthesis, is not controlled. Any substance that can affect the body's
and it involves a surgery that is more invasive than chemistry can, like any drug, produce side effects that
others. All the prostheses show satisfactory results in may be harmful (Sikora, 1995).
relation to the possibility of having sexual intercourse
(Murray, 1998). As in any surgical intervention,
complications, such as infections, pain and/or rejection, Warnings on alternative remedies
may occur.
It should be strongly noted that alternative or natural
remedies are not regulated and their quality is not
Alternative treatments for impotence
publicly controlled. In addition, any substance that can
Many alternative agents are marketed for impotence. affect the body's chemistry can, like any drug, produce
Very few have been studied and some can be harmful. side effects that may be harmful. There have been a
Some, but not all, are discussed in this report. number of reported cases of serious and even lethal side
effects from so-called natural products. For example,
some products marketed for improving sexual function
Aphrodisiacs (Verve, Jolt) contain gamma-butyrolactone (GBL)
(Ellingwood, 1998). This substance can convert to a
Aphrodisiacs are substances that are supposed to chemical that can cause toxic and life-threatening effects,
increase sexual drive, performance, or desire. Some including seizures and even coma. In addition, some so-
examples include the following: called natural remedies have been found to contain
standard prescription medication. Most problems
1. Viramax is a well-marketed product that contains
reported occur in herbal remedies imported from Asia,
yohimbine and three herbal aphrodisiacs: catuaba, muira
with one study reporting a significant percentage of such
puama, and maca. It has not been proven to be either
remedies containing toxic metals. Even if studies report
effective or safe, and interactions with medications are
positive benefits, most, to date, are very small. In
unknown.
addition, the substances used in such studies are, in
2. Foods that some people claim have aphrodisiacal
most cases, not what are being marketed to the public
qualities include chilies, chocolate, licorice, lard, scallops,
(Murray, 1998).
oysters, olives, and anchovies. No evidence exists for
these claims (Farnsworth, 1995) and eating large
amounts of some of these foods, such as licorice and CONCLUSIONS
lard, can be dangerous
Spanish fly, or cantharides, which is made from dried Numbers of sexual problems were found to be frequent.
beetles, is the most widely-touted aphrodisiac but can be Physical, social/emotional, and relationship factors were
particularly harmful. It irritates the urinary and genital tract all found to have a significant impact on the prevalence of
and can cause infection, scarring, and burning of the one or more sexual problems. In addition, we observed
mouth and throat. In some cases, it can be life an important gender difference: increasing age was more
threatening. No one should try any aphrodisiac without consistently associated with sexual problems among
consulting a physician (Brown, 1995). men. Thus, sexual problems among women and men
appear to share similar correlates, but physical factors
Other alternative remedies may play a larger role among men. However, as men
age, there may be more psychological and relationship
1. In one small study, 78% of men who had impotence issues as well that influence their sexual satisfaction and
452 Sci. Res. Essays

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