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How is impotence treated?


How is impotence treated?

The doctor will begin by looking at any more general problems that may be contributing to a patient’s impotence. These may include: treating anaemia; increasing the amount of dialysis; changing the patient’s tablets.

More specific physical treatments for impotence will then be considered. These may include: medication such as Viagra; hormone injections; use of a vacuum device; penile injection therapy; penile insertion therapy (transurethral therapy); penile implants.

In addition to the various physical treatment options (see below for more details), patients may be recommended to seek help for emotional problems relating to impotence.

Hormone Injections

Most male dialysis patients with sexual problems have low testosterone levels. This deficiency can be treated by an injection of testosterone every three to four weeks. Although testosterone injections replace the hormone that is lacking, they are not always very effective in treating impotence. This is probably because impotence in men with kidney failure is not usually due only to low testosterone levels.

Many other hormones are also often found to be at the wrong level, but correcting them rarely makes much difference to sexual difficulties. If the prolactin level is too high, a tablet called bromocriptine (or sometimes one of the newer alternative drugs, such as cabergoline) may be given.

Viagra (sildenafil)

Viagra is a tablet treatment for impotence, which has been widely reported in the media since its US launch in April 1998. Viagra acts by enhancing the action of a compound called nitric oxide, which opens wide the blood vessels of the penis, leading to an erection. Other drugs with a similar mechanism of action, called vardenafil and tadalfil, are undergoing trials.

Research with Viagra in men on dialysis has shown that about 3 in 4 men who used the drug found they developed erections. The success rate may be a little lower in men who have diabetes as well as kidney failure. Side effects such as headaches and low blood pressure occurred in 1 in 4 men, with some having to stop using the drug. Men who are taking nitrate drugs (isisorbide mononitrate or isisorbide dinitrate) should not take Viagra within a week of using the nitrate, and nitrates that are used under the tongue or as a spray should not be used for 24 hours before or after Viagra. Nitrates plus Viagra can cause a dangerous fall in blood pressure.

Anyone with heart disease should have a careful assessment to see if Viagra is safe in his or her case, as the low blood pressure that Viagra can cause could be dangerous in the presence of serious heart disease.

Viagra can be prescribed to people with kidney failure on the National Health Service and many doctors interpret this as including men with advanced kidney failure not yet receiving dialysis.

Vacuum devices

Many kidney patients with impotence require therapies which act directly on the penis, helping them to get and keep an erection. One of these is called vacuum tumescence therapy, which uses a mechanical device (such as the ErecAid) to produce a hard penis. Nearly three quarters of the male dialysis patients who use a vacuum device are able to have full penile erections.

To use the vacuum device, the man first inserts his penis into the clear plastic cylinder. He then holds the device against his body so that the chamber is closed with an air-tight seal. Using either a hand or battery operated pump, the man then withdraws air from the cylinder to form a vacuum. This causes the penis to enlarge in a way that is similar to a natural erection. However, to maintain the erection, the man must then push a tension ring (resembling an elastic band) from the outside of the cylinder onto the base of the penis. The seal of the vacuum is broken, and the cylinder and pump are removed. With the tension ring in place, the erection can be maintained for up to 30 minutes.

The erections may be longer lasting than natural ones, and do not usually disappear after an orgasm. The most common complaints are mild discomfort and ‘timing difficulties’ (such as pumping too rapidly with the hand pump) when the device is first used. Occasionally, harmless, tiny reddish spots (called petechiae) may appear on the penis.

The main advantages of vacuum therapy are that it is safe and does not require an operation, can be used as often as desired, and works well for most male dialysis patients. Its suppliers also claim that it may improve blood flow to the penis and result in occasional natural erections.

The disadvantages of vacuum therapy are that it involves a loss of spontaneity in lovemaking, it requires some skill to use, and it can cause mild bruising. It is also not available on the NHS. The current cost is over GBP £200, but only the initial outlay is usually required.

Penile injection therapy

Penile injection therapy is another non surgical technique used to treat impotence. The man injects medication (usually alprostadil) into the base of his penis. This causes the penis to become hard almost immediately. The erection then lasts for up to one to two hours. Use of the injections is limited to not more than once a day and three times a week. Several clinic visits are usually needed to establish the dose of medication required. Treatment is available on the NHS.

Penile injections have the advantage of not involving surgery. They are also effective in many dialysis patients. It is not known, however, whether the success rate for these injections in kidney patients is as high as 70%.

The main problems with this technique are pain in the penis, and a condition called priapism, which is an unwanted erection that goes on too long. There may also be bleeding, bruising or scarring (fibrosis) at the injection site. Because of the risk of bleeding, patients on haemodialysis are advised not to have the injection on a dialysis day. Another problem is that the penis may become misshapen. After a while, some patients get fed up with this treatment, but it is usually possible for them to change to a different therapy option.

Penile insertion therapy

This treatment has been available since early 1998 and is proving popular as it is less intrusive than injections. As yet, it has been used by only a small number of kidney patients. For penile insertion therapy, such as MUSE (Medicated Urethral System for Erection), the patient slowly inserts an applicator into the end of his penis. A button on the applicator is then pressed to release a tiny pellet of medication (alprostadil). Once the pellet has been released, the applicator is removed and an erection develops over the next 10 to 30 minutes.

Penile insertion therapy has been shown to be successful in just over half the men treated in the general population. The most common side effects are penile discomfort and burning, and light-headedness. Female partners have occasionally reported vaginal burning or itching.

Penile insertion therapy is likely to have a slightly higher failure rate than vacuum devices and penile injections. Nevertheless it is a safe and well tolerated treatment option. It is available on the NHS.

Alprostadil cream

Trials are under way to investigate the administration of a drug called alporstadil as a cream directly onto the penis. Alprostadil is the same drug as used in injection and insertion therapies. If it works, this method of administration may be preferable to injections or insertion methods for many men.

Penile implants

The decision to have a penile implant should be made only after very careful consideration. This surgical treatment for impotence is usually effective, but it does have disadvantages (see below). The implant is inserted during an operation performed under a general anaesthetic. There are various different types available. Typically, a cylinder implanted in the penis is connected by a tube to a pump in the scrotum. This pump is connected by another tube to a fluid containing reservoir in the abdomen. Squeezing the pump with the fingers causes fluid to pass from the reservoir into the cylinder, so simulating an erection. The main disadvantage is that the operation to insert the implant alters the penis permanently, ending all hope of natural erections. There is also a risk of infection, and a possibility that the implant will be rejected by the immune system (the body’s defence system). Another problem is that an implant can be difficult to conceal.

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The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.

NKF Controlled Document No. 210: How is impotence treated? written: 15/12/2002 last reviewed: 13/03/2019