Which of the following statements are true concerning male impotence?

a. Psychologic factors account for less than half the cases of male impotence

b. Vascular testing for vasculogenic impotence may include Doppler determination of penile systolic blood pressure and super selective pelvic arteriography

d. Impotence associated with abdominal perineal resection is due to direct trauma to pelvic nerves and may be improved with papaverine injection

Erectile dysfunction is a common condition that affects 10 million American men. The incidence increases with age. By age 55 about 8% of men are affected. By the age of 80 years, the incidence is 75%. Impotence ensues from interference with the normal vascular, neurologic, psychological, endothelial, and hormonal mediators of erection. In many cases, the causes are multi-factorial. Psychological factors can inhibit as well as stimulate erection and account for less than half of the cases of impotence. Although a number of systemic diseases can cause impotence, diabetes is the most common. Impotence may also result from systemic neurologic diseases such as multiple sclerosis. Direct trauma to the pelvic nerves by pelvic fractures of radical pelvic surgery (radical prostatectomy, abdominal perineal resection) may also be associated with impotence.

The determination of the effect of vascular disease on impotence can be determined through a number of techniques. An estimate of penile blood flow can be made through Doppler determination of penile systolic blood pressure using a penile cuff. Direct corporal injection with papaverine, a smooth muscle relaxant, bypasses psychogenic and neurologic factors and produces an erection if the blood flow to the penis is normal. If arterial disease is suspected on the basis of poor response, superselective pelvic arteriography with injection of vasoactive agents is necessary to document the nature of the disease. The treatment of impotence depends on both the cause and the patient’s willingness to pursue various therapeutic approaches. Patients with neurogenic impotence, such as following pelvic nerve injury, can experience dramatic results with papaverine injection. Penile implants can be used to treat any type of intractable impotence, but they are usually reserved for patients with diabetes or vascular neurologic dysfunction who do not respond to conservative measures.