IMPOTLENCE: I

Abstract

Mr. X is a 49‐year‐old black male with end‐stage renal disease (ESRD) secondary to long‐standing insulin‐dependent diabetes and hypertension. He currently is on hemodialysis three times per week via a left forearm prosthetic A‐V graft, and is on the renal transplant waiting list. He is on insulin as well as the standard regimen of vitamins, antacids, erythrogenic agents and antihypertensives. Mr. X has noted a slow progressive loss in his ability to attain an erection over the past four to five years and, even after attaining an erection, he notes that he can only maintain it for a few moments. On occasion his erection is firm enough for vaginal intercourse, but he loses it soon after penetration. In most instances, his erection is not firm enough for vaginal penetration, and he achieves vaginal penetration by “stuffing” the penis into the vagina. At peak, he was having intercourse three times per week, but now it is only once a month. He masturbates only on occasion. He is able to ejaculate, and reaches orgasm with seminal expulsion, but the ejaculate volume is markedly diminished compared to that seen in his youth. Occasionally, he gets a morning erection, which is “five” on a scale of one to 10, with 10 the maximal erection he achieved during his peak years. With masturbation or with sexual stimulation he describes his erection as a “four of 10.” He denies trauma to the erect or flaccid penis. He claims to have had a gradual change in his penile sensitivity over the past three years. He denies radiation to his pelvic area, recreational drug use, and does not use alcohol. He has no drug allergies. His surgical history is noncontributory. He denies neurologic disease, hypercholesterolemia, heart disehse, and claudication, and had smoked 2 packs of cigarettes per day for 20 years, quitting seven years ago. Mr. X is currently separated from his wife; however, the same erectile dysfunction occurs, even with his new sexual partner. Physical examination was unremarkable. The penis was circumcised with no lesions or plaques. The testes were descended and normal. There were no hernias. The bulbocavernosus reflex was absent. The penile‐brachial index was 0.40 on the left and 0.52 on the right. Penile biothesiometry was abnormal on the penile shaft as well as the glans. The hormonal profile, including prolactin and testosterone were normal. The patient underwent a nocturnal penile tumescence (NPT) evaluation which confirmed the organicity of his disease. It demonstrated three short‐lived REM‐associated erections of poor quality. He opted for penile seif‐injection therapy, which he uses only on nondialysis days, combined with prophylactic oral antibiotics. This therapy, along with psychologic counseling has worked well, with return of a full rigid erection of 1/2 hr in duration. He is now quite satisfied, and has vaginal intercourse with his new partner two times per week.