Impotency in Diabetes

About 50% of diabetic patients with high blood sugar ultimately become impotent. It can occur at young age or old age. It occurs more frequently at older age & after many years of uncontrolled high blood sugar, but in some it can occur at younger age also. It is more common in patients with other associated complications as Nerve, Kidney or Heart involvement. In those in whom sugar is not well-controlled chances of developing impotency is more. It is also more in those who have hypertension & taking medicines for that & also in alcoholics & smokers

The causes for impotency in diabetes are as follows: - 

(i) Hormones Disorder (Deficiency of male hormones or increase in some inhibitory hormone as high prolactin & disorders of Thyroids can cause dysfunctions.
(ii) Decreased penile blood supply due to deposition of cholesterol in penile blood circulation or in arteries supplying blood to pennis.
(iii) Endothelial & smooth muscle disorders leads to decreased dilatation of penile vessels on genital stimulation so that blood is unable to reach in pennis thus full hardness is not achieved.
(iv) Involvement of penile nerve i.e. penile neuropathy. 
(v) Psychogenic factors as presence of depression or other psychiatric illness.
For detail investigation to diagnose the cause of disorder

DIAGNOSIS OF CAUSE OF IMPOTENCY

First step in proper treatment of  Dysfunctions (impotency) is accurate diagnosis of cause. So we first try to find out cause. We take detailed history, thorough  counseling, physical examination, examination of nerves and penile arterial examination. After that depending on likelihood of particular, cause relevant tests are done. All testing facilities are available at our centre. Thus you may consult us at our centre & at same time you may get all tests done. The time taken in getting all the reports ready is 36 hours. So if you are from out of Delhi, you may come here for two days.

DETAILED HISTORY: We take detail history about the onset of dysfunction i.e. whether it started Sudden or gradual, Primary or Secondary, Erections at other occasions, Response to previous therapy, Libido, Stress (physical or mental), H/O precipitation by some drugs, presence of Hypertension, Ischemic Heart Disease, claudication, trauma, DM, Sec. Genital Characters, Hypothyroidisms,  Hyperthyroidisms & Galactorrhoeas, Symptoms of sensory loss, epilepsy, Liver/Renal failure. 

EXAMINATION OF GENITALS:
We examine whether Genital Development is adequate or subnormal. For this testis size is measured by orchidometer (if patient is outstation then by ultrasound of testis), Pennis Length & girth is measured by phallometer. Galactorrhoea & features of other hormone disorder are checked up. Blood supply of pennis is assessed by, palpating dorsal penile artery of pennis. Nerves of pennis examined by V. P. sensation testing, Deep Tendon reflexes & Bulbocavernosal reflexes. Then other systems are examined. 

INVESTIGATIONS i.e. DIAGNOSTIC TESTS:

At our centre we have all the facility for complete investigation of various causes of Erection difficulties & other  problems. So we perform following tests, step by step depending on their need based on history & examination. 

The various diagnostic tests needed/performed are as follows: - 

Step- I: Hormone Testing: There are two types of hormones in body some stimulates penile hardness whereas there are other hormones which inhibit penile stiffness. 
Male & Female  hormones & other associated Hormones are tested by latest-immunoassay techniques. These hormones includes total Testosterones, free testosterones, Prolactins, LH, FSH, T3, T4, TSH others as Cortical, E2, Free testosterones SHBG etc.. Among above tests relevant hormones are tested in that particular patient. Results are available in 36 hours. In the hormone testing either stimulatory  hormones may be low leading to less erection or those hormones which are inhibitory may be high leading toi inhibition of penile erection. These hormones are tested by taking blood sample from forearm. When we find out any of above hormone disorder simply correction of these hormone disorders corrects the dysfunctions in two months time. 
Blood glucose & other systemic test may be required depending on the need.

Step I1: Penile Blood Supply Testing: 
This test is done to decide whether impotency is due to decreased blood supply to pennis or disorders of nerves or due to some other causes. This test is also called PIPE (Pharmacological induced penile erection) test.
In this test we examine the dorsal pennis artery & veins after giving the various Vasodilators either orally or as injectable, also we asses whether pennis is getting full hard or not after vasodilator use, how long hardness is persisting in response to theses vasodilators. If pennis is not becoming fully hard or not staying hard for at least fifteen minutes even after adequate dose of vasodilators then cause of impotency is inadequate blood supply to pennis or due to leakage of blood out of pennis due to venous leak. If pennis is getting full hard and staying longer than fifteen minutes then cause is nerves of pennis are not functioning or some other cause. There are two types of blood supply disorders are found on blood supply testing.

The first pattern is suggestive of penile arterial blockade in which blood does not flows in pennis from blood circulation due to block in arterial supply of pennis. This obstruction in vascular supply is diagnosed by above mentioned blood supply test in which after giving blood flow medicine we find that there is increase in blood flow in arteries of pennis is less than normal with resultant absence of achievement of full hardness of pennis for sufficient time. This test is very simple to perform if the concerned doctor is well trained & experienced. This is an O. P. D. procedure & takes approximately 30 minutes to perform the test. We do these tests daily at our centre as we have all the required instruments to do these tests. Once we diagnose that there is decreased blood supply to pennis then we find out the cause of this inadequate blood flow. 
Once the cause of decreased blood supply is diagnosed then treatment becomes very easy with virtually full chances of permanent cure.

Second pattern found on blood supply testing is Leakage of blood out of pennis back into circulation after initial full erection (also known as Veno-occlusive dysfunction): In this defect, blood flows from circulation to pennis normally but due to continuous leak of blood out of pennis due to defect in penile valves whose job is to stop the leakage of blood out of pennis, enough pennis hardness is either not achieved or even if pennis becomes fully hard it become loose there after due to leakage of blood out of it. When we do blood supply testing, in this disorder there is good blood flow in arteries of pennis through out study, but there is continuous leakage of blood is seen through valves of penile veins. 

Step-3: N.P.T. MONITORING: Penile Erection assessment at night (called as nocturnal penile tumescence) is done by Rigiscan device (it measures penile rigidity & diameter) to differentiate between impotency of psychogenic origin or due to some internal cause. If N.P.T. monitoring shows Normal results it means impotency is Psychogenic, if results are impaired means impotency is due to some internal cause. 

Step 4: DUPLEX SCANNING: (Doppler & ultrasound scanning before & after vasodilator use) In this Testing with use of vasodilator drugs/Duplex vascular scanning is done to decide which type of problem patient is suffering, accordingly treatment is prescribed. It assesses arterial diameter & blood flow status. It helps in differentiating & pinpointing the cause of impotency i.e. whether it is arterial or venous cause & what is the specific cause, of that problem so that it can be treated properly.

Step 5:  Counseling: After detail discussion with our male & female  therapist, we try to finds out the root cause of  problem then we treat accordingly. For counseling we take detail history of Genital development, his thoughts, his misconception about , his old experience in , his unconscious fears about . This counseling session unravels all the hidden psychological causes of Genital inadequacy.

Step 6: Other tests (If required)

1) Penile Nerve Testing: By conduction and sensory testing (NCV, EMG & VPT). 
2) Psychoanalysis: To find different factor leading to psychogenic impotency.
3) Functional Studies: To see the penile response in provocation to various drugs.
5) Arteriography:  It is a Specialized X-Ray of pennis before arterial opening i.e. opening of the blockade surgery. In this test a drug (dye) is infused which detects whether block is situated , whether it is localized or diffused. Once we localized the obstruction & its cause, then we decide whether it can be cured through medicine or surgery. 
6) Cavernosometry & cavernosography (before venous leak surgery).
 

TREATMENT OF DYSFUNCTIONS

After diagnosing the cause of impotency, we prescribe medicines that patient has to purchase himself from any medical store The success of various drugs we use in dysfunction depends on accurate diagnosis of cause. If empirical treatment is prescribed as most doctors do, it often does not achieves permanent cure. These  tonics & ayurvedic medicines can improve your Genital life temporarily but they cannot give permanent cure. Thus please get yourself fully investigated before starting treatment. 

The various treatment option for patient with impotency are:

1) Hormone Therapy
2) Medicines to increase blood supply to pennis (Oral & Local Gels)
3) Viagra & like drugs
4) Therapy 
5) Vacuum Erection Pumps 
6) Injection therapy
7) Penile Blood Supply increasing Surgery
8) Penile Hardness Increasing Implants (Penile prosthesis)

(1) Hormone Therapy:

Hormone therapy is given to cure the problem whatever defect is found.

Hormones Therapy: Depending on the type of hormone disorder i.e. whether male  hormones decreased or inhibitory hormones has increased, Hormone therapy is directed towards that. Hormone therapy usually cures the Hormone problem in 2 to 3 months time and they do not have any adverse effects as they given to only those patients in whom some hormone disorder is found.
The various hormone preparations & their route of administration are: 
1. Oral testosterone preparations that is available in capsule form. It needs to be given one to three capsules daily. These have no side effects. 

2. Transdermal Testosterone given as scrotal patch. It is very effective & has no side effects. It can be also given as Testosterone gel, which can be applied on any part of the skiin. 

3. Sublingual Testosterone cyclodextrin is now available which is very fast acting & very effective is fast & has better effects on  organs. 

4. Local application of D.H.T. gel is new preparation for male hormone replacement. It is very effective without any side effects. 

5. Injection Testosterone esters these includes Testosterone enanthate & testosterone cypionate given intramuscular injections every 10 to 14 days. 
6. New human androgen receptor modulators they increase the effect of male hormone over androgens sensitive organs. 

7) DHEAS tablets are available which are effective & has no side effects.
8)Treatment of hyperprolactinemia with cabergoline & Bromocriptine is done with quick cure of Genital dysfunctions.

(2) Medicines to increase blood supply to pennis: (oral & local gel)

Medical treatment (i.e. prescription of various drugs to increase blood supply to pennis, nerve rejuvenating etc are given to correct the basic cause found on investigations.
These drugs open the blockade of penile arteries so that blood flows into pennis increases and pennis becomes fully hard. The various drugs, which are effective to increase penile blood supply, are as follows. The particular drug needed in particular patient depends on the cause of dysfunctions.
Oral Drugs: The various oral drugs are: 

a. Yohimbine: By acting on alpha-receptors it dilates the penile blood supply. It is one of the common drug used for increasing penile blood supply. It is freely availalable as oral tablet. 
b. Phentolamine: is also a good drug to increase blood flow in the pennis. The effect of this drug increases manifold when it is used along with other commonly used vasodilators. It is used as oral, sublingual tablets. In advance cases it is given as injectable also. 
c. Sublingual apomorphine is very effective in increasing penile blood supply. 
d. Trazadon works on  centre & increase penile blood supply.
e Oral Prostaglandin. 

f Nalaxone
g Gene Therapy: In this modality of treatment blood supply to pennis is increased by gene therapy. By the introduction new genes in body the generation of penile blood increasing substance nitric oxide generation increases in penile blood tissue leading to more blood supply & hardness of pennis. This is a slow process takes longer time to have effect but once the effect starts coming the results are permanent. Thus it achieves the cure of impotency. This is effective & achieves permanent cure of impotency

3) Local Application of Gels / Drugs

a. MUSE is per urethral use of PGE1. In this medicated pellet is inserted into the Urethra. After insertion pennis becomes hard with in 20 minutes. This hardness lasts for up to 60 minutes. 
b. Topical preparations of papaverine 
c. Topical preparations of prostaglandin E1 
d. Vasoactive intestinal peptide
e. Local application of Minoxidil
f. Local application of Nitroglycerine
g. Local application of l-arginic acid

4) Viagra & Like drugs

These drugs are good but temporary method of treatment because it does not treats the basic cause of  problem. These drugs belong to following the groups:

Sildenafil,( Viagra, penegra, caverta) : one tablet works for 4 hours.

Tadalafil (Cialis, tadalis, megalis ) : one tablet works for 24 hours.

Vardenafil (Levitra): one tablet works for 6 hours. 

It is a temporary therapy. After consumption of this tablet, patient gets hardness only temporarily. Once this tablet is consumed, the blood flow into pennis increases & pennis becomes fully hard in many patients. But this is an effective short-term treatment but it does not cures the basic problem. It also has certain side effects & many deaths have been reported after its use if not used with proper precaution. Thus it should not be consumed without the advise of experts. There need to have detailed physical examination before one is prescribed Viagra. So never take it without expert advise.
Dose used is 25 mg to maximum of 100mg. It should be taken 60 minutes before Genital intercourse.
5. Detailed  Education: In this patient is explained in detail about what is normal physiology of erection and what we can do in our daily life to increase strength & staying it hard for longer time. Also we educate the patient how to satisfy the women so that she gets satisfactory orgasm and considers you a wonderful partner.

(5)  Therapy: 

Once we found out the cause we treat internal causes like hormone disorder & decrease penile blood supply. But even after treating above basic primary causes of impotency, Many times patients still do not recovers fully because of his fear of failure, Genital performance anxiety and spectatoring attitude. These secondary factors do not allow him to function normally. For cure of these secondary problem patient needs details  therapy. Basic purpose of this exercise is to make patient free of any fear of Genital performance. After this exercises all performance anxiety disappears. In  therapy the patient is taught various exercises & how to use various body part in particular way so that erection become good, sustained & patient does not have any fear. Normally in six to eight sittings patient's all fear disappears.  therapy is a very effective in impotency, premature ejaculation. Thus we advise all of our patients not to hurry, and take few sessions of  therapy sittings for permanent cure.

(6) Vacuum Pump Devices 

Vacuum Pump Devices is a small instrument, application of it on pennis, makes pennis fully hard within three minutes. With this instrument patient does not have to consume any medicine. So it has no side effect.
(By this device a vacuum of > 100 mm of Hg is created around pennis leading to Pooling of blood in pennis resulting in full hardness).
Efficacy: Approximately 80% of patients get full erection & satisfied. 

(7) Injection Therapy

The various drugs used as injections are 
Injection of papaverine, ProstaglandinE1, & Phentolamine is used alone or in combination (bimix or trimix). This is a very effective mode of treatment of impotency. The dose of papaverine is 5mg. to 60mg. at one time. It work in 15 minutes & patient gets very hard erection, which lasts for at least thirty minutes. It is very good especially for those who fear that they may fail during . So that by taking this injection they can perform without fear & with hundred percent guarantee of success. It is a quiet popular form of treatment among boys & young adults. Especially for those, who have severe fear for failure for the first night or when expecting Genital encounter with a new partner. 
Response - Success is achieved in approximately 90% patients. 
Injection of ProstaglandinE1: dose used is 10 to 20 mg at one time .It is very effective with virtually no side effects.
Injection of Phentolamine normally it is used in combination with papaverine or Phentolamine.
Inj. Of Moxisylyte: available by the name of injection Erecnos.
Inj. of Vasoactive Intestinal Polypeptide: available by the name of injection Invicorp.

Treatment of underlying cause: When some underlying cause as diabetics, depression, high blood pressure (hypertension), or use of drug is diagnosed is treated accordingly. 

(8) Surgical Treatment 

Surgical treatment is suggested only when all the above mode of therapy namely hormone therapy, blood supply increasing tablets, Viagra like drugs, &  therapy has failed.

(9) Penile blood supply increasing surgery:

After investigations when it is diagnosed that blood supply is decreased. In majority of patient's blood supply can be normalized by many of the medicines as mentioned above, which have capacity to correct the vascular disorders. But in some cases surgery is required.
Before surgery for vascculogenic impotency, exact site of blockade is localized by Arteriography.
The various surgeries are as follows: 
a) Arterial Recanalization surgery: After localizing the block, we open the blocked part of artery by vascular microsurgery, this is called recanalization vascular surgery. This is commonly done in younger patients.
b) Arterial bypass surgery: When we find that there is blockade in broad segment of dorsal penile artery then such a long segment can not be recanalized. In such cases we bypass the blocked portion of the artery by use of other inferior epigastric artery. In this normal artery is connected with pennis artery distal to blocked artery so that blood flow normalizes.
c) Venous leak surgery: As we have mentioned above leakage of blood from pennis to back into body in mid of erection is one of the cause of impotency. In this surgery the leaking veins is localized first by venography (cavernasometry & cavernosography). After localization of those veins through which blood is leaking are ligated i.e. tied. Thus venous leak stops & pennis starts becoming full rock like hard & patient Genital problem normalizes. For this surgery we keep patient admitted for one day only. 
At our centre our micro vascular surgeon is very expert in doing all above surgeries. In this surgery artery in which blockade is present is either opened or blocked area is bypassed by use of other artery so that blood Supply to pennis is established. Result is very good when candidate for surgery is properly selected. This operation needs expertise. It is done under the guidance of operating microscopes. 

(10) Penile Hardness Increasing Implants (Penile prosthesis): 

There are some patients in whom blood supply increasing surgery is not possible. Thus penile implant is a good treatment in all those patients in whom cure is not possible inspite of all above treatments. In such cases we put intrapenile implants. After these surgery patient can resume his normal Genital functions.
There are two kinds of implants:
a) Malleable i.e. semi rigid implants:
b) Inflatable implants: Now days this implant is more in use as penile hardness is very good above all it may remain erect for longer time. This surgery takes approximately 30 minute by our surgeon. 

There are certain penile implants which when applied into pennis then its hardness become very hard.