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All diagnostic procedures are aimed at establishing the cause of impotence, which means the possibility of restoring erectile function and eliminating emotional distress. For this, first of all, it is necessary to differentiate psychogenic and organic impotence. Monitoring of nocturnal erections and intracavernous injection test (caverject test) is a simple and reliable method. If, according to these methods, the organic nature of impotence is confirmed, then a number of additional examinations are carried out to identify the root cause.
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Cavernous insufficiency or dysfunction of the cavernous tissue can also lead to impotence. In the pathogenesis of this type of impotence, there are changes in the cavernous bodies, blood vessels and nerve endings that disrupt the work of the erector mechanism.
In patients with bronchial asthma, in a postinfarction state, impotence is due to the fear of exacerbation of the disease during intercourse. Prostatitis is not the main cause of impotence, it can only aggravate its course, this should be borne in mind, since most men believe that only prostatitis can cause erectile dysfunction.
Kidney diseases, in which patients are shown extracorporeal dialysis, are combined with erectile dysfunction in half of the cases, while after kidney transplantation, two-thirds of patients recover their erectile ability. Prostatitis can cause impotence both due to insufficient testosterone in the blood serum and due to circulatory psychogenic disorders: soreness during ejaculation, premature ejaculation and iatrogenic conditions in which the syndrome of failure is formed.
Hormonal impotence most often develops against the background of diabetes mellitus, since in diabetes mellitus, changes in the penile vessels and cavernous tissue are quite serious. But at the same time, the cause of hormonal impotence is not so much a decrease in testosterone levels, but in a violation of its assimilation, because in persons with hypogonadism, when stimulating erection problems, no problems with erection were observed. But with hypogonadism and male menopause, hormone replacement therapy is performed as the main treatment for erectile dysfunction.
The pathogenesis of venogenic impotence has not been studied enough, but its development is facilitated by disorders in the venous bloodstream, in which the lumen of the veins increases. This happens with ectopic drainage of the corpora cavernosa through the venous vessels of the penis, with traumatic ruptures of the tunica albuginea, as a result of which its insufficiency develops. Venogenic impotence often accompanies Peyronie's disease and functional insufficiency of the cavernous erectile tissue. Smoking and alcohol abuse aggravate symptoms of venogenic impotence.
Neurogenic impotence occurs against the background of injuries and diseases of the central nervous system and peripheral nerves. The pathogenetic link is the difficulty or complete absence of the passage of nerve impulses into the corpora cavernosa. In 75% of cases, the cause of neurogenic impotence is spinal cord injury. The remaining 25% are neoplasms, cerebrovascular pathologies, intervertebral hernia, multiple sclerosis, syringomyelia and other neurogenic diseases.
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Arteriogenic impotence is an age-related pathology, since atherosclerotic changes in the coronary and penile vessels are identical. At an early age, arteriogenic impotence can occur due to congenital vascular anomalies, smoking, hypertension, diabetes mellitus, or trauma. Insufficient arterial blood flow is not able to fully nourish the cavernous tissues and vascular endothelium, local metabolism is disturbed, which can lead to irreversible dysfunctional disorders of the cavernous tissue.
Temporary psychogenic impotence disappears after the normalization of the lifestyle.
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Psychogenic impotence, the pathogenesis of which is a decrease in the sensitivity of the cavernous tissue to neurotransmitters due to the suppressive effect of the cerebral cortex or due to an indirect influence through the spinal centers, can occur against a background of sexual phobias and deviations, associative psychotrauma and religious prejudices. Today, thanks to the development of diagnostics between true and psychogenic erectile dysfunction, psychogenic impotence in its pure form, as for example, happens with serious sexual deviations (pedophilia, bestiality), is diagnosed less often.
Both of these processes are controlled by the middle preoptic area of the cerebral cortex, but in general, the sexual activity and sexual behavior of a man depends on the concentration of dopamine-like substances that have a stimulating effect, and serotonin-like substances that have a suppressive effect. Violations in any part of the whole process can lead to impotence.