Impotence, or erectile dysfunction, is associated with the following risk factors: 

Age. 
Smoking. 
Alcohol abuse.
Obesity. 
Diabetes. 
Hormonal imbalance. 
Hypertension. 
Medications. 
Neurologic problems. 
Radical pelvic surgery. 
Peripheral vascular disease. 
Priapism. 
Surgical or pelvic trauma.

In addition to the risk factors above, many patients will have an isolated or co-existent psychological component to their erectile dysfunction.

TREATMENT OPTIONS 

1. Oral. 

A. Yohimbine. 

This may be useful, particularly in patients with psychogenic erectile dysfunction. 

B. Viagra. 

C. Testosterone. 

Supplemental androgens, whatever the route of administration (oral, injectable or transdermal), should be administered exclusively to individuals who have a low testosterone count. Liver function levels need to be monitored, as supplemental testosterone may cause liver problems. 

In addition, the serum PSA should be monitored, as an elevation may reflect an occult co-existing prostate cancer. The administration of testosterone would then enhance the prostate cancer growth. 

D. Herbal. 

DHEA and Yohiminex may be helpful. 

2. Transdermal testosterone patch. 

3. Injectable 

A. Intramuscular 

- testosterone. 

B. Intracorporeal 

- Papaverine. 
- Prostaglandin E

4. Transurethral: 

Prostaglandin pellet (MUSE). 

5. Vacuum device. 

This treatment involves the use of an external vacuum device with a tension ring placed at the base of the penis to maintain the erection, and then the vacuum device can be removed. 

6. Surgical treatment. 

This form of treatment is reserved for those who have failed one or more of the conservative treatments listed above.

A. Arterial impotence treated with revascularization. 

B. Venous leak impotence may be treated with ligation of the penile veins. 

C. Penile prosthesis. This treatment option should be reserved for those men in whom all other treatment options have failed. Basically, the implants come in two forms, a non-inflatable device using semi-rigid rods or alternatively, a more complicated inflatable device. 

PREMATURE EJACULATION 

Currently, the first line of treatment for premature ejaculation is either Prozac or Zoloft. These medications help desensitize the ejaculatory reflex. Alternatively, behavioral modification through the squeeze technique advocated by Masters and Johnson can be used, or an anesthetic jelly may be applied to the glans to diminish sensitivity. 

RETROGRADE EJACULATION 

This may occur after various surgical procedures in the retroperitoneum or bladder neck. Alternatively, it may be due to autonomic neuropathy of diabetes or associated with alpha block medication and may sometimes be treated with Ephedrine or Ornade, as previously discussed in the infertility section.