IMPOTENCE

From Big Medical Encyclopedia

IMPOTENCE (Latin. impotentia weakness, powerlessness) — a state, at Krom the man cannot execute sexual intercourse or provide achievement of sexual satisfaction at both partners. The term «impotence» in modern sexological literature goes out of use. It is caused as uncertainty of the term, the Crimea at early stages of formation of sexual pathology designated * a wide range of frustration (from infertility to various forms of sexual disharmonies), and its use in various understanding (as a symptom, a syndrome and even nozol, a form). In domestic sexual pathology the term «impotence» is usually used in syndromologic sense.

Except for rather exceptional cases, in which And. develops at influence of one pathogenic factor (e.g., owing to damage of pelvic bodies), the analysis of the reasons And. allows to speak about its polietiologichnost as separate somatobiologichesky, personal and microsocial influences in itself, as a rule, cannot break the normal course of sexual departures and to be, thus, the prime cause And.

Classification

From various classifications And. the greatest distribution in domestic sexual pathology was gained by pathogenetic classification of the All-Union scientific and methodical center for problems of sexual pathology. This classification (1956) based on fiziol, concepts about stages and components of a copulative cycle and on the theory of functional systems P. To. Anokhina, includes both the main forms of sexual frustration, and syndromes accompanying them; it reflects the complex nature of frustration of a potentiality which in most cases combine defeats of the urogenital device, endocrine system, elementary innervatsionny mechanisms and the highest regulatory mechanisms of a brain. The isolated defeats of one of the specified spheres are observed rather seldom (27,3%) while 72,7% of all frustration of a potentiality are the share of the combined (polysyndromic) defeats. Kliniko-statistical analysis of St. 1000 cases And., carried out by the All-Union scientific and methodical center for problems of sexual pathology, reveals the following distribution of main types of frustration on the leading syndromes: 0 group (pseudo-impotence) — 12,9%; The I group (disturbance of a neurohumoral component of a copulative cycle) — 27,9%; The II group (disturbance of a mental component) — 36,9%; The III group (disturbance of an erektsionny component) — 1%; The IV group (disturbance of an eyakulyatorny component) — 21,3%. Each of these groups includes a specific wedge, forms.

Wrong assessment by the patient of the sexual opportunities which are not going beyond, however, age and constitutional norms is the cornerstone of pseudo-impotence. It can arise in connection with presentation to itself excessive requirements (e.g., at the elderly men complaining of loss of ability to carrying out daily repeated sexual intercourses) or the assumption at itself the imagined defects (e.g., at young people who do not make attempts to intimacy, considering that at them generative organs are underdeveloped though at objective inspection it is not confirmed). In some cases pseudo-impotence is caused by inadequate reaction of the personality on fiziol, fluctuations of sexual manifestations. E.g., fiziol, shortening of duration of frictions after forced sexual abstinence in connection with a long business trip generates a thought of «exhaustion of the sexual centers» and forces the patient to look for medical assistance. Quite often can be the reasons of pseudo-impotence the wrong behavior of partners (non-compliance with elementary psychogienic norms of «equipment» of a coitus, napr, at insufficiency of preliminary caress) or sexual defects of the woman (existence of primary anorgazmiya, etc.). One of options of pseudo-impotence should consider the lack of an orgasm at the woman with the wakened sexuality caused by the fact that by the time of approach at the man of an ejaculation (with the subsequent detumescence, i.e. loss of an erection) neurosexual excitement at the woman does not reach that critical level yet, at Krom there is a summation of stimuli necessary for emergence of an orgasm. Similar disharmony misunderstanding by the man of psychosexual features of the woman, underestimation of preparatory and final phases of a coitus, importance by it for the woman of «music of words» usually is the cornerstone, of the qualitative party of intimate rapprochement.

In group of disturbances of a neurohumoral component of a copulative cycle it is necessary to distinguish multiglandular defeats of which 12,7% of all - sexual frustration are the share (including of disturbance of rate of pubertal development — 2%, of involutional forms — 8,5%, of other forms — 2,2%), and the specific syndromes making 15,2% of sexual frustration (including on diencephalic And. and other defeats of deep structures of a brain — 8,5% and forms with preferential defeat of separate closed glands — 6,7%).

Defeats of a mental component of a copulative cycle represent the most frequent form I. They are subdivided into syndromes with dominance endogenous (inborn, constitutional) factors, observed at a psychopathia, endogenous psychoses, an oligophrenia, and also at persons with accentuation separate harakterol. properties, and syndromes with dominance exogenous (reactive, situational) factors. In this group of syndromes it is possible to allocate the options with primary, direct injury of the sexual sphere presented by cases of «neurosis of expectation of failure», transformations of natural sexual irritants into a conditional brake, disturbances of psychosexual orientation owing to wrong definition of a passport floor, etc. and options with secondary involvement of the sexual sphere in a picture of neurosis (e.g., a neurasthenia), somatogenic asthenic and depressions, exogenous psychoses. At psychogenic forms with primary involvement of the sexual sphere the mental injury, deeply hurting vanity and mentioning especially sensitive parties of the personality, precedes development of frustration and is the basic etiol, a factor which defines all a wedge, a picture. Within the «general» neurosis sexual disturbances, in particular frustration of an ejaculation, are caused by the factors which are not connected directly with the sexual sphere (a sleep debt, overfatigue, the conflicts to work, etc.), and they are usually preceded by all-neurotic symptoms (irritability, fatigue, difficulty of concentration, headaches, frustration of a dream etc.).

The wedge, options I belong to syndromes of defeat of an erektsionny component of a copulative cycle (apprx. 1%)., which are characterized by spinal localization patol, the center (a myelitis, multiple sclerosis, tumors, injuries of a spinal cord, etc.), nek-ry ekstraspinalny defeats (kaudit, a plexitis, neuritis, tumors, etc.) or are caused by diseases and injuries of a penis.

Disturbances of an eyakulyatorny component of a copulative cycle (21,3%) cover the syndromes caused primary the Urals, a disease, secondary pathogenetic disintegration (the change of the relations between nerve centers remaining after elimination the Urals, diseases) and primary pathogenetic disintegration, the cut is the cornerstone defeat of the highest cortical centers of regulation of function of a bladder and sexual functions (a syndrome of paracentral segments). A syndrome of paracentral segments (see. Paracentral segments syndrome ) thus, enters into group of cortical frustration of an ejaculation which specific weight, in view of similar frustration at psychogenic, reactive states (first of all neurotic), is the highest in comparison with defeat of other levels.

Classification And., the offered I. M. On rudominsky (1957), has anatomo-phenomenological character. It includes the following forms P.: cortical (34,7%), spinal (54,2%), neuroreceptor (3,5%), endocrine (2,3%), other (subcortical, inborn — 2,2%) and forms with an unknown etiology (3,1%). According to this classification in an origin And. a smaller role is played by defeats of the urogenital device, and also disturbance of neuroendocrinal ensuring sexual functions and considerably primary defeats of the spinal sexual centers prevail.

Clinical manifestations

From manifestations of sexual activity at the man which disorder can cause development And., most often suffer erection (see), ejaculation (see) and sexual desire (see). According to the Moscow scientific research institute of psychiatry M3 of RSFSR, from 600 patients inspected in department of sexual pathology ejaculations — 313 and on patol, change of sexual desire — the 175th persons complained of frustration of an erection 453. As the earliest symptom And. most often frustration of an ejaculation act; they can be subdivided on quantitative, qualitative and atonic.

Quantitative changes are shown by the following frustration: 1) relative acceleration of an ejaculation (ejaculatio praecox relativa — E PR) — approach of an ejaculation before emergence of an orgasm in the woman, at the same time from the moment of introduction of a penis to a vagina to an ejaculation takes place not less than a minute and the man makes 20 — 25 frictions; 2) absolute acceleration of an ejaculation (ejaculatio praecox absoluta — ERA) — a copulative cycle makes less than 20 frictions; 3) ejaculatio ante portas (EAP) — approach of an ejaculation in the conditions of sexual intercourse, but before introduction of a penis to a vagina; 4) the delay of an ejaculation (ejaculatio tarda — ET) — sexual intercourse carries long, sometimes wearisome character; its extreme degree — a functional aspermatism (see) when the ejaculation does not come at all.

Qualitative changes of an ejaculation are expressed in day emissions (see), i.e. the ejaculations arising at a usual condition of consciousness and out of a situation of sexual intercourse. They are subdivided on adequate and inadequate. Adequate day emissions (pollutio diurna adaequata — PDA) are understood as the ejaculations caused by action of sexual irritants in an inappropriate situation (in other words, these ejaculations are adequate to an irritant, but not time and the place). Most often such emissions come owing to intensive caress, is more rare — under the influence of the influences which are not bearing sexual coloring for the woman, but perceived in the sexual plan by the man (e.g., approach of an ejaculation in hairdressing salon under the influence of a touch of hands of the female master to the person, and also the visual and olfactory feelings received at the same time). In other cases for emergence of an ejaculation of rather simple handshake, a sound of a voice or only one type of the woman causing erotic excitement. At inadequate day emissions (pollutio diurna inadaequata — PDI) of an ejaculation are observed at the influences which do not have sexual and erotic character, napr, at transport vibrations (it is characteristic that ejaculations at the same time come only when the patient is a passenger, but not the driver). However, as a rule, the irritants provoking inadequate day emissions have mental character; usually it is emotions as positive (e.g., laughter during execution by the male actor of comic number), and (more often) negative: anger, fear, despair at the sight of the moving-off train for which the patient was late, shame from consciousness that people around are witnesses of its insolvency in any relation. At atonic forms (a spermatorrhea and a prostatorrhea) of ejaculation per se is not present, and instead of vigorous eruption of semen there is its passive expiration, hl. obr. at a natuzhivaniye during defecation.

In dynamics of development And. the frustration of an ejaculation most often arising as the earliest manifestations of sexual frustration in the absence of the timely help are complicated by accession of other symptoms that gives the chance to characterize each frustration of an ejaculation not only on intensity, but also on extensiveness. The data on percentage distribution of frustration of an ejaculation on their intensity and extensiveness received on the basis of inspection of 330 patients are presented in the table. A wedge, manifestations of frustration of an erection and sexual desire — see in the relevant articles.

Diagnosis of separate forms of sexual frustration is carried out by means of the corresponding criteria which can conditionally be subdivided into the general (the used hl. obr. for establishment of the fact of disturbance of a certain component of a copulative cycle) and specific (allowing to identify specific seksol. syndromes).

Treatment

In treatment And. it is necessary to consider all structure of a disease and to influence not only the leading syndrome, but also on accompanying without what it is usually impossible to achieve normalization of sexual functions. Treatment And. shall be pathogenetic, constructed on the accounting of specifics of syndromes, mechanisms of their interaction and dynamics of development. According to dynamics of manifestations And. treatment usually consists of several stages. E.g., in case of the pseudo-impotence which is combined with primary anorgazmiya at the woman to lay down. tactics demands elimination of an anorgazmiya at the first stage and corrective psychotherapy on the second. The disharmony caused by hl. obr. with insufficiency of preliminary caress and the cornerstone of one of options of pseudo-impotence, is eliminated by means of the corresponding instructing. At the true acceleration of an ejaculation arising after the periods of forced abstention it is also necessary to assume existence of the pseudo-impotence caused by discrepancy of long intervals between the intercourses and high individual requirement of inspected. Rather high level of sexual activity usually normalizes duration of the intercourse that validates diagnosis in similar cases. If increase in sexual activity does not eliminate true acceleration of an ejaculation, then it is obvious that the arisen frustration is beyond pseudo-impotence. Existence in the anamnesis of such factors as sexual frustrations (sexual excitement, a cut does not come to an end with an ejaculation), a petting — one of substitute forms of sexual satisfaction (see. Sex life ), coitus interruptus, etc., gives the grounds even in the absence of the objective data obtained at a rectal or laboratory research to assume existence of urogenital frustration (e.g., so-called congestive prostatitis). In these cases it is necessary the Urals, treatment, a basic element to-rogo — massage of a prostate. Timeliness and sufficient duration of treatment usually allow to prevent transition of the specified form I. (caused the Urals, suffering) in its more severe form connected with so-called secondary pathogenetic disintegration.

The sexual abstinence generating imaginary acceleration of an ejaculation can lose the reversible character if the periods of abstinence drag on. In similar cases with establishment of the regular sexual intercourses full normalization of sexual functions can not occur since long abstinence promotes development so-called congestive and hron, prostatitis (see). At this stage it is necessary the Urals, treatment, a cut, however, along with normalization of a rhythm of sexual activity also sometimes does not give effect. In such cases it is possible to assume that thanks to extensive nervous bonds of a prostate and prostatic texture with segmented nervous mechanisms of irritation, caused in a prostate and the next bodies by the most insignificant bruises, inflammatory or vascular (e.g., congestive) changes, can exert impact on the cerebral centers which are taking part in regulation of sexual functions. Considered patol, the impulsation from the irritativny centers in a prostate at a certain intensity and duration can be fixed with firmness that influences excitation thresholds of an erection and an ejaculation. The similar fixing of symptoms caused at the first stages patol, changes in generative organs, and then leading to resistant «prints» of these primary and somatogenic irritation in c. the N of page, is designated as a syndrome of secondary pathogenetic disintegration. After its formation elimination of the center on the periphery does not lead to disappearance patol, symptoms any more. For elimination of these secondary, purely nervous changes chlorethyl blockade are required. This method of treatment is pathogenetic and in relation to primary pathogenetic disintegration (a syndrome of paracentral segments).

The main to lay down. a method at the sexual frustration caused preferential by defeat of a mental component of a copulative cycle — psychotherapy (see), and auxiliary — drug treatment. Delay using chlorethyl blockade, napr, at a syndrome of paracentral segments, can promote emergence in the patient of purely psychogenic frustration, is more often in the form of neurosis of the expectation caused by systematic psychosexual traumatization from the woman. In this case treatment is carried out on three stages: on the first — sanitation of a prostate by means of local the Urals, manipulations, use of antibacterial agents and if necessary — the drugs changing local reactivity and also physiotherapeutic actions (a rectal diathermy or mud cure, etc.); on the second — chlorethyl blockade; on the third — psychotherapy (including hypnotherapy and an autogenic training).

Operational methods of treatment can be recommended in cases And., caused by lack of an erection owing to an injury or a disease penis (see) with deformation and its curvature, in connection with priapism (see), etc. Attempts of treatment of the specified options I. by a resection of a back vein of a penis, a sympathectomy, greasing of vessels of a seed cord of 5% solution of phenol, a lumbar gangliectomy, implantation in fabric of a small egg of an epiploon, use of muscles, etc. were ineffective.

the Diagrammatic representation of operation of hypodermic implantation of synthetic prostheses in a penis: and — a synthetic prosthesis (at the left — its cross-section); and in — a vshivaniye of a prosthesis — cross-section of a penis (after operation): 1 — skin, 2 — a fascia, 3 — a prosthesis, 4 — a white, 5 — a cavernous body, 6 — an urethra, 7 — arteries and veins of a dorsum penis.

In 1936 N. A. Bogoraz performed implantation in a penis of a basic prosthesis from the «autokost» afterwards replaced «autokhryashchy». However essential shortcomings of cartilaginous prostheses — their deformation, a curvature, fragmentation, and in certain cases a rassasyvaniye were revealed further. In this regard for basic prostheses began to use inert synthetics [G. I. Goldin, A. M. Dykhno, A. D. Tokhiyan, Heller, Leffler, Morales (E. Heller, R. A. Loeffler, P. A. Morales), etc.]. Originally these prostheses placed in thickness of cavernous bodies or between them. However because during the performance of similar operations quite often there were plentiful bleedings, and further there was a formation of hematomas and gradual substitution of cavernous bodies cicatricial fabric, it was offered to place single [Pirmen (R. Lake of Paerman), 1972] or steam rooms (V. V. Krasulin, V. P. Cockroaches, 1974) prostheses sideways from cavernous bodies, under own fascia of a penis (fig). Such operation of a malotravmatichn, it is carried out under the general anesthesia. Two cross sections on a side surface of a penis at the level of a coronal furrow cut fabrics to a white. Scissors or a Kocher's probe, sliding on a white, do tunnels to the basis and under a balanus. Enter perforated zhelobovaty polyethylene prostheses into tunnels, fixing them to a white under a head 2 — 3 kapron seams. Length of a prosthesis shall correspond to distance from a pubis to a balanus — 12 — 15 cm, thickness of 2,5 — 3 mm. For reduction of hypostasis of a prepuce the penis is bandaged tsirkulyarno on 2 — 3 days. Seams remove on 5 — the 6th days. Complications in the postoperative period (hl. obr. suppuration and formation of purulent fistula), the demanding removals of a prosthesis, are usually connected with errors in technology of operation and violation of the rules of an asepsis.

Sex life is resolved in 1,5 — 2 months. By this time around a prosthesis the dense connective tissue capsule burgeoning in perforation openings of a prosthesis forms and thus it is strong it fixing. The long-term results show that, as a rule, the patients who underwent an operation can regularly have sexual intercourse. Many of them married; some have children.

Medicolegal value

By consideration in court of some criminal and civil cases can arise need in court. - medical examination of ability of men to the sexual intercourse. In criminal cases this issue is resolved at charge of sexual crimes (rape, a sodomy, the sexual intercourses with not reached puberty, dissolute actions), and also during the definition of degree of the injuries (generative organs, an urethra, pelvic bones, a backbone, the central and peripheral nervous system) able to cause And. In civil cases establishment of the fact of frustration of a potentiality can be necessary by consideration of alimentary claims, paternity proof, etc.

Establishment of frustration of a potentiality is carried out according to provisions of «Rules of forensic medical examination of sexual conditions of men» (1968). At the same time, except court. - the medical expert, participation of the sexopathologist, and in certain cases — the urologist is necessary. Due to the variety etiol, factors of disturbance of sexual function, and also possible aggravation and simulation establishment And. can be difficult and in certain cases it has to be carried out in the conditions of a hospital. Court. - the medical expert is obliged to study materials of the judicial investigating authorities which appointed examination. Considering special importance of anamnestic data, they should be collected carefully since they can be distorted. At inspection it should be noted a condition of endocrine system, a mental state inspected, existence of spinal defeats, a condition of a penis, testicles, a prostate. The conclusion about disturbance of sexual function shall be carefully reasoned and contain instructions on the reasons and forms I. If at survey it is not established existence And., it also shall find reflection in the expert opinion.

The RATIO of FRUSTRATION of the EJACULATION ON INTENSITY AND EXTENSIVENESS of MANIFESTATIONS (in %) (according to the All-Union methodical center for problems of sexual pathology)

Bibliography: Topical issues of sexual pathology, under the editorship of D. D. Fedotov, M., 1968; B of l yu m and I. G N. Forensic medical examination of sexual conditions of men, M., 1967, bibliogr.; Korik G. G. Sexual frustration at men, L., 1973, bibliogr.; Krasulin V. V. and V. P's Cockroaches. Hypodermic splintage of a penis two side polyethylene prostheses as method of treatment of impotence, Urol, and nefrol., No. 4, page 42, 1974, bibliogr.; The general sexual pathology, under the editorship of G. S. Vasilchenko, M., 1977, bibliogr.; Problems of modern sexual pathology, under the editorship of A. A. Portnov, M., 1972; The Guide to clinical urology, under the editorship of A. Ya. Pytel, page 531, M., 1970, bibliogr.; V. I hares. Surgical treatment of strictures of an urethra and some forms of impotence, Elista, 1970, bibliogr.; Yakobzon L. Ya. Impotence, Pg., 1918; Hastings D. W. Impotence and frigidity, L., 1963; H y-n i e J. Lekarska sexuolOgia, Osveta, 1970, bibliogr.; Masters W. H. a. Johnson Y. E. Human sexual inadequacy, Boston, 1970; M with With an of at J. L. Human sexuality, N.Y., 1973; Schoff ling K. Storungen der Keimdriisenfunktion bei mannlichen Zuckerkranken, Stuttgart, 1960, Bibliogr.

G. S. Vasilchenko; V. V. Zharov (court. medical), V. V. Krasulin (hir.).

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