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    1. Loss of sex drive and impotence

Although male fertility may remain normal with kidney disease, loss of sex drive and impotence (not being able to raise an erection) are very common. There are a number of causes for this, including anaemia and testosterone deficiency. These can be tested for, and in many cases treated.

Men with kidney failure have a variety of sexual problems. These include having sex less often, loss of interest in sex (sometimes called loss of libido), and being unable to ejaculate (come). However, the most common sexual problem – and usually the most worrying for the man – is difficulty in getting or keeping a hard penis (erection problems). This is usually called impotence. Erectile dysfunction (ED) is an alternative name.

What normally happens first in men with kidney failure is that they become less able to keep an erection for as long as usual, although they are still able to ejaculate. Eventually, many kidney patients lose the ability to get a hard penis at all. This can obviously lead to frustration, particularly if the sex drive is unchanged. The situation can be even more upsetting if the man’s partner interprets the problem as a loss of interest in them personally.

What causes impotence?

Impotence has many possible causes. In most men with kidney failure, sexual problems do not have just one cause, but are usually due to a combination of:

  1. Poor blood supply. In order to make the penis hard, extra blood enters the penis and is then prevented from leaving it. Many kidney patients have narrowed blood vessels all over their body, including those vessels that supply the penis. This reduces the blood supply to the penis, and makes it difficult to get an erection. It is not just kidney patients who have this problem. It also occurs as part of the natural ageing process and is commoner in older men, as well as in men with diabetes.
  2. Leaky blood vessels. To keep the penis hard, the extra blood that has entered the penis must stay inside it. In men with kidney failure, the extra blood sometimes leaks back out of the penis, and so the erection is lost.
  3. Hormonal disturbances. Hormones are chemical messengers that control many body functions. They are carried around the body in the blood. Some hormones are specifically designed to control sexual urges. The levels of these sex hormones can be either higher or lower than normal in people with kidney failure. In particular, the testicles may produce less of the male sex hormone, testosterone.
  4. Nerve damage. The nerves that supply the penis are also involved in getting an erection. When someone has kidney failure, nerve damage may prevent the nerves from working properly.
  5. Tablets. Most tablets do not cause impotence on their own. However, a few drugs can contribute to sexual problems. The biggest culprits are the blood pressure tablets called beta blockers, such as atenolol, propanolol, metoprolol and bisoprolol.
  6. Tiredness. Tiredness can affect sexual performance. Tiredness in kidney patient may be caused by anaemia, by not receiving enough dialysis, or by other medical problems, such as heart disease.
  7. Psychological problems. When a kidney patient starts dialysis there are many stresses to deal with. Not surprisingly, some patients feel quite depressed. If so, they may not feel like having sex.
  8. Relationship difficulties. The illness of one partner naturally causes stresses in a relationship. For instance, household jobs, such a decorating or washing-up, which used to be done by the patient may now sometimes have to be done by the partner. This can lead to arguments or resentment on either side of the relationship.

How is impotence investigated?

The first and most important step is for the subject to be raised. There is often a lot of unnecessary suffering due to either denial of the problem or fear of embarrassment. Some kidney doctors and nurses have no experience of treating sexual problems in people with kidney failure, or are embarrassed themselves. If this is the case, patients should ask to see an expert in sexual problems. Sadly, few kidney units have such an expert at present.

Once the problem of impotence has been recognised, the following should take place:

  1. A general health check. This will include an assessment of the distance a person can walk on level ground without having to stop, which is a useful guide to general health.
  2. Physical examination. This will include an examination of the genitals. The doctor will also feel for a pulse at various points in the legs. If the pulses are weak, this means that the blood vessels in the legs have narrowed, reducing the blood supply. Then there will usually also be narrowing of the blood vessels supplying the penis, reducing its blood supply.
  3. Blood tests. In addition to the usual blood tests, there will be tests to measure the blood levels of various hormones. These include testosterone, and also luteinising hormone (LH), follicle stimulating hormone (FSH) and prolactin. LH and FSH are hormones that regulate the testicles. Prolactin’s usual role is to produce milk in females, but it is often present in larger than normal amounts in male dialysis patients with impotence.

  4. Review of medication. The doctor should review the various tablets that the patient is taking. Some types of tablets may contribute to a patient's sexual difficulties. Alternative medication is sometimes available.
  5. Investigation of psycho-sexual problems. The patient will be asked to consider whether psychological or relationship difficulties may be contributing to the physical problem of impotence.

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.