Sexual problems | Ayurvedic and modern treatment modalities

Dr. Vijay Singh Chauhan, M.D. (Ayu)

Dr. H.S. Parikh, M.D. (Pharmacology)

The success of happy sex life in males depends on a desire to indulge into an act that culminates into sexual arousal, penile erection and effective foreplay, followed by the sexual congress for a considerably long/satisfactory duration. All sequenced well, the act ultimately results in the ejaculation coupled with an orgasm that gives an individual a sense of physical as well as emotional well being.

Successful sexual functioning is a complex process and involves psychological and social responses, as well as neurological biochemical and vascular processes.

The problems of low sexual desire, erectile failure or premature ejaculation, which could be because of physiological, psychogenic and/or organic cause may disturb the entire rhythm of life, hence, need to be addressed to, seriously.

Major Sexual Inadequacies

Inhibited Sexual Desire (ISD) or Sex Fatigue

Desynchronisation of sexual aspiration and motivation components results in ISD. It is mainly caused by physical or emotional stress, monotony in the relationship, depression, psycho-active drugs, anti-hypertensive medication, and hormonal deficiencies. ISD starts effecting men any time after 35-40 years of age and its severity depends on general fitness, amount of stress and exertion, work and home environment, socio-economic status and so on.

The patient complained of a lack of interest in sex, even in ordinarily erotic situations. The disorder is associated with infrequent sexual activity, often causing serious marital conflict.

Erectile Dysfunction (The Major Factor Leading To Impotence)

Physiology of Erection

The Penis and Erectile Function

The penis is composed of the corpus cavernosum, two parallel spongy columns of erectile tissue, and corpus spongiosum, which is also composed of erectile tissue and contains the urethra, the tube that carries urine from the body. Erectile tissue is rich in tiny pool-shaped blood vessels called cavernous sinuses, which are surrounded by smooth muscles and supported by elastic fibrous tissue composed of collagen. In the flaccid, or unerect, state of the normal penis, the small arteries leading to the cavernous sinuses contract, reducing the inflow of blood. The smooth muscles of the many tiny blood vessels within the penis are also contracted, and the blood they contain leaks out of the surrounding spongy tissue. When a man becomes aroused, his central nervous system stimulates the release of a number of chemicals, including acetylcholine and nitric oxide, which relax the smooth muscles in the penis, allowing blood to flow into the tiny pool-like sinuses and flood the penis. The spongy chambers almost double in diameter due to the increase in blood flow. The veins surrounding the corpus cavernosum and corpus spongiosum are squeezed almost completely shut by the pressure of the erectile tissue; they are unable to drain blood, causing the penis to become rigid.

During sleep, for instance, oxygen levels are high and a man can normally have three to five erections per night, each one lasting from 20 to 40

Oxygen-rich blood is critical for erectile health Oxygen itself affects two substances that are important in achieving erection: it suppresses transforming growth factor-beta 1 (TGF-B1) and enhances prostaglandin E1. The smooth muscles produce TGF-B1, which is a component of the immune system, and one of its roles is to produce collagen. Collagen contributes not only to structural tissue in the body but is also the material that comprises scar tissue. Prostaglandin E1 is produced during erection by the muscle cells in the penis; it activates an enzyme that results in calcium release by the smooth muscle cells, which, in turn, relaxes them and allows blood flow.

Prostaglandin E1 also suppresses collagen production. Oxygen levels vary widely from reduced levels in the flaccid state to very high in the erect state. During sleep, for instance, oxygen levels are high and a man can normally have three to five erections per night, each one lasting from 20 to 40 minutes.

Pathophysiology of Erectile Dysfunction (Impotence)

Impotence or erectile dysfunction is the inability to achieve or maintain an erection sufficiently rigid for intercourse, ejaculation or both. It does not affect sexual drive or the ability to have an orgasm. Rarely does erectile dysfunction signify a chronic problem? When a consistent pattern of sexual dysfunction extends over a prolonged period of time, however, a physical or serious emotional disorder may be indicated. Impotence is not new in the medical texts or in human experience. It is not easily or openly discussed, however. Our cultural expectations of male sexuality have forced many men to refrain from seeking help for a disorder that can, in most cases, benefit from medical treatment.

Medically speaking, impotence is defined as the inability to sustain an erection sufficient for intercourse on at least 25% of attempts. One major hospital reported that one-third of men coming in for examinations complained of erectile dysfunction.

Who Becomes Impotent?

It is safe to say that every man experiences erectile dysfunction from time to time. Medically speaking, impotence is defined as the inability to sustain an erection sufficient for intercourse on at least 25% of attempts. One major hospital reported that one-third of men coming in for examinations complained of erectile dysfunction.

Ageing is most often associated with impotence. About 5% of men at 40 reports complete erectile dysfunction; by age 65, 15% to 25% of men are troubled by this problem, and over age 75, about 55% of men report being chronically impotent. Severe erectile dysfunction in elderly men often has more to do with disease than age itself. Atherosclerosis, heart disease, and hypertension are some conditions that can afflict the older male and cause sexual dysfunction [see What Causes Impotence, below].

What Causes Impotence?

Over the past decades, the medical perspective on the causes of impotence has shifted. Common wisdom used to attribute almost all cases of impotence to psychological factors. Now, investigators estimate that between 70% and 80% of impotence cases are atherosclerosis (hardening of the arteries); complications of diabetes; prostatectomy (surgical removal of the prostate); and medications. Many experts believe that negative emotional states occurring with the condition are more likely to be a reaction to the experience of impotence than its causes. Psychological problems are more apt to be the causes of erectile dysfunction in younger men, however, while physical problems are usually the cause in older men. So many physical and psychological situations can bring about erectile dysfunction, in fact, that a man should consider brief periods of impotence to be as normal as having a cold (Even a cold can, in fact, cause temporary impotence.). Oxygen deprivation is the most common cause of impotence and can occur from numerous conditions that deprive the penis of blood. Nerve damage in the penis or the pelvic area and deficient levels of important hormones can also be responsible for erectile dysfunction.

Deprivation of Oxygen-Rich Blood Supply

Erectile dysfunction most commonly occurs when the penis is deprived of oxygen-rich blood. There is some evidence that when oxygen levels to the penis are low, TGF-B1 production increases and prostaglandin E1 production decreases. TGF-B1 produces collagen, which forms hard structural tissue, including scar tissue; prostaglandin E1 suppresses collagen production and relaxes the smooth muscles that allow blood flow resulting in an erection. When TGF-B1 levels increase and prostaglandin E1 levels decrease, smooth muscles waste away and collagen is overproduced, causing scarring, loss of elasticity, and reduced blood flow to the penis. A number of conditions can deprive the penis of oxygen-rich blood.

Ischemia

The primary cause of oxygen deprivation is ischemia—the blockage of blood vessels. The same conditions, such as unhealthy cholesterol levels, that cause blockage in the blood vessels leading to heart problems may also contribute to erectile dysfunction. When cholesterol and other factors are imbalanced, a fatty substance called plaque forms on artery walls. As the plaque builds up, the arterial walls slowly constrict reducing blood flow; this process, known as atherosclerosis, is the major contributor to the development of coronary heart disease. It may also play a role in the development of coronary heart disease. It may also play a role in the development of erectile dysfunction.

Lack of Frequent Erections

Infrequent erections deprive the penis of oxygen-rich blood. Without daily erections, collagen production increases and eventually may form a tough tissue that interferes with blood flow. The spontaneous erections men experience while sleeping or during the day may be a natural protection against this process.

To summarize, normal levels of hormones, especially testosterone, are essential for erectile function, though it is not clear what their role is in potency.

Factors Causing Erectile Dysfunction

Physical factors responsible for erectile dysfunction are systemic diseases (e.g. diabetes mellitus, syphilis, multiple sclerosis, alcoholism, heavy smoking, drug dependency, hypopituitarism, hypothyroidism, inflammatory diseases of the genitalia, ageing) and drugs such as anti-hypertensives, sedatives, tranquillizers, and amphetamines.

Specific Medical/Physical conditions contributing to Erectile Dysfunction

Diabetes

Diabetes may contribute to as many as 40% of impotence cases. Between one third and one-half of all diabetic men report some form of sexual difficulty. Diabetics often develop atherosclerosis and nerve damage; when the blood vessels or nerves of the penis are involved, erectile dysfunction can result. (It should be noted that women with diabetes also suffer from sexual dysfunction due to damaged circulation and can also be helped by some of the drugs given to men for impotence.)

High Blood Pressure

In one study, 17% of men with high blood pressure experienced erectile dysfunction even before being treated. Many of the drugs used to treat hypertension cause impotence as a side effect, although it is reversible when the drugs are stopped. Newer drugs, such as ACE inhibitors, may be less likely to cause erectile dysfunction.

Multiple Sclerosis

Multiple sclerosis (MS), which affects the central nervous system, also precipitates sexual dysfunction in as many as 78% of male patients. (Corticosteroids, which are common treatments for MS may improve sexual function.)

How does age affect sexuality?

Sexuality implies the desire and capability for sexual activity. Sexuality remains with us as we get older. Women retain their capacity for orgasm and men retain their capacity for penile erection, ejaculation, and orgasm. Sexual behaviour many changes, of necessity, due to changing circumstances but the basic sex drive remains.

The relationship between ageing, hormones, and erectile dysfunction is controversial. In one survey, about half of all men believed that impotence is an inevitable consequence of ageing. As a man ages, blood flow through the penis slows down, causing an increased refractory period (the amount of time it takes for the penis to become erect again after an orgasm). Age also seems to affect the time it takes for ejaculation to occur. It is important to note that these changes are generally thought to be a normal and inevitable part of the ageing process.

Male hormone (testosterone) levels decrease with age. Levels of testosterone, the primary male hormone, decline gradually after ages 40 to 50; by 70 they have declined by about 30%; it should be noted that these levels would still be considered within the normal range, although low, in a younger man.

About a quarter of all cases of impotence can be attributed to medications. Many drugs pose a risk for

Older men may take a longer time to attain an erection. Also, the erection may be smaller and less firm and ejaculation less forceful. Many sexual problems in older people are caused by worry about changing circumstances, about their own health, or that of their partner. In men, fear of impotence (the inability to achieve or maintain a penile erection that is hard enough for sexual intercourse) may create sexual problems. Counselling can be very helpful in these circumstances.

Prostate Cancer and Its Management

Advanced prostate cancer can damage the nerves needed for erectile function. Prostate surgery and surgical and radiation treatments for prostate and colorectal cancers can also cause impotence. Surgery and drug treatments, for benign prostatic hyperplasia (BPH), can also increase the risk for impotence, although to a much lesser degree. Vasectomy does not cause erectile dysfunction; if impotence occurs after this sterilization procedure, it is often in men whose female partners were unable to accept the operation.

Drugs

About a quarter of all cases of impotence can be attributed to medications. Many drugs pose a risk for erectile dysfunction. Fortunately, the condition is always resolved when the medication is changed. Among the drugs that can cause impotence are many of those taken for high blood pressure (particularly diuretics and beta-blockers), anti-ulcer medication, drugs used in chemotherapy, and most drugs that are used for

Among the drugs that can cause impotence are many of those taken for high blood pressure (particularly diuretics and beta-blockers), anti-ulcer medications, drugs used in chemotherapy, and most drugs that are used for psychological disorders, including antidepressants, anti-anxiety, and anti-psychotic drugs.

Psychological disorders, including antidepressants, anti-anxiety, and anti-psychotic drugs. Other drugs that sometimes cause impotence include the antifungal drug ketoconazole, antihistamines, anticholinergic drugs, and drugs that block male hormones. Some authorities go so far as to say that nearly every drug prescription or nonprescription can be a cause of temporary erectile dysfunction.

Physical Injuries

Spinal cord injury and pelvic trauma, such as fracture, can cause nerve damage that frequently results in impotence.

Smoking and Alcohol

Heavy smoking is frequently cited as a contributory factor in the development of impotence, mainly because it accentuates the actions of other disorders of the blood vessels, including high blood pressure and atherosclerosis. Alcohol has also been implicated in causing impotence. In small doses, alcohol releases inhibitions, but in doses larger than one drink, it can depress the central nervous system and impair sexual function.

Psychological Factors

In virtually every case of inadequacy, there appear to be emotional issues that may seriously affect both an individual’s self-esteem and relationship. It may even cause or perpetuate erectile dysfunction. Many men tend to fault themselves for their impotence even if it is clearly caused by physical problems over which they have little control.

Anxiety, stress, and depression are among the most frequently cited contributors to psychological impotence. For many reasons, cultural as well as situational anxiety over sexual performance may provoke an intense fear of failure and self-doubt on the part of the individual. Often called performance anxiety, these feelings can sometimes set off a cycle of chronic anxiety-induced failure. In all these conditions, the brain releases chemicals known as neurotransmitters that constrict the smooth muscles of the penis and its arteries. This constriction decreases the blood flow into and increases the blood flow out of the penis, resulting in erectile dysfunction.

Problems in relationships often have a direct impact on sexual functioning. Partners of men with erectile dysfunction may feel rejected and resentful, particularly if the affected man does not confide his own anxieties or depression. Both partners commonly experience guilt for what they each perceive as a personal failure. Tension and anger frequently arise between people who are unable to discuss sexual or emotional issues with each other. It can be very difficult for the man to perform sexually when both partners harbour negative feeling.

How Is Impotence Diagnosed?

Medical and Personal History:

There are several tests available to assist physicians in diagnosing impotence and its causes. The first step is, of course, talking openly the patient must be as frank as possible in order to assist his physician in making a diagnosis. In addition to reporting any past and present medical problems, the patient should report any medications or drugs he is taking and any history of psychological problems, including stress, anxiety, or depression. The physician also requires a sexual history. This should include the nature of the onset of dysfunction, and the frequency, quality, and duration of any erections, and whether they occur at night or in the morning. The physician might also ask about the specific circumstances when erectile dysfunction occurred, details of the technique, the man’s motivation for and expectations of treatment, and whether problems exist in the current relationship. The man should not interpret these questions as intrusive or too personal if he expects to obtain help; they are very relevant and important for determining the proper approach to the problem. If appropriate, the physician might also interview the sexual partner.

Apart from this, a Physician may use a battery of tests, both laboratory and invasive along with a detailed examination to diagnose impotence.

Premature ejaculation

Ejaculation is commonly called premature if a man climaxes and releases his semen before or within a few minutes after entering his partner’s vagina and before his partner has an orgasm. Premature ejaculation is a problem only if it prevents a couple from having sexual experiences that are satisfying for both partners.

The human experience of orgasm is a complex interplay of psychological, physical, and physiological factors. To control the timing of ejaculation a man must learn to exercise some control over these factors. Premature ejaculation is rarely caused by a medical condition.

Premature ejaculation can occur when a man has not had sexual intercourse for a long period of time. Other situations in which there is unusually heightened sexual arousal and excitement may also promote early ejaculation.

Premature ejaculation may happen in a new relationship because the partners have not yet learned each other’s stimulation needs for arousal and orgasm.

TREATMENT OF SEXUAL INADEQUACIES

General Considerations:

Maintaining General Health

Because many causes of impotence are due to reduced blood flow from blocked arteries, it is important to maintain the same lifestyle habits as those who face an increased risk for heart disease. Such good habits include a diet rich in fresh fruits and vegetables, whole grains, and fibre and low in saturated fats and sodium. Men who drink alcohol should do so in moderation. A regular exercise program is extremely important. Quitting smoking is essential.

Frequent Erections

Staying sexually active can help prevent impotence. Frequent erections stimulate blood flow to the penis. It may be helpful to note that erections are firmest during deep sleep right before waking up. Autumn is the time of the year when male hormone levels are highest and sexual activity is most frequent.

Kegel Exercises

The Kegel exercise is a simple exercise commonly used by people who have urinary incontinence and by pregnant women. It may also be helpful for men whose erectile dysfunction is caused by impaired blood circulation. The basic technique consists of tightening and releasing of pelvic muscle that controls urination. Since muscle is internal and is sometimes difficult to isolate, doctors often recommend practising while urinating on the toilet. The patient tries to contract the muscle until the flow of urine is slowed and stopped and then releases it. People should perform 5 to 15 contractions, attempting to hold each contraction for 10 seconds, three to five times daily.

Changing or reducing medications causing impotence

If medications are causing the problem, the patient and the physician should discuss alternatives or reduced dosages. In treating high blood pressure, for instance, ACE inhibitors are less likely to cause sexual dysfunction than many other medications.

Psychotherapy and behavioural Therapy

Some form of psychological, behavioural, sexual, or combination therapy is often recommended for individuals suffering from impotence, regardless of cause. In such cases, it is beneficial to have the partner involved in this process whether sexual therapy is part of the treatment or not. The value of sex therapy is questionable.

A look into Drug or Drugless Options

A European survey reported that less than 20% of men would seek help for impotence if they experienced it, although this may change with the introduction of successful oral treatments. The specific problem causing the impotence dictates the mode of treatment. The first step is to define the cause, if possible, and then try the simplest and least risky solution.

Alprostadil: Injection and Transurethral Therapy

Although the new oral drug is proving to be popular, it may not be appropriate for certain men. Administration of the drug alprostadil through injections or through the urethra is an effective alternative treatment. Alprostadil is a form of a natural substance, prostaglandin E1, which serves to open blood vessels. It is effective in men with a wide range of medical disorders, including diabetes, surgery and injury. Men who are at high risk for blood clots should not use alprostadil. The drug may have toxic effects if it reaches the foetus in pregnant women; men should not use alprostadil, then, for intercourse with pregnant women without the use of a condom or other barrier contraceptive device. Women partners may experience vaginal burning or itching.

Sildenafil

Sildenafil was originally developed for heart disease but was found to have a unique mechanism of action in the penis, even though it is taken orally. The drug blocks the enzyme phosphodiesterase-5. This action maintains persistent levels of cyclic GMP, a chemical that is produced in the penis during sexual arousal and which is the primary chemical that relaxes smooth muscles and increases blood flow. Sildenafil is effective within 20 to 40 minutes. One study reported that it was successful in achieving erections in almost two-thirds of patients with severe erectile dysfunction due to medical conditions that included high blood pressure, impotence after prostate surgery, and diabetes. The study did not include men with uncontrolled diabetes, psychiatric disorders, or those with a history of drug or alcohol abuse. The drug works only when the man experiences some sexual arousal. Side effects reported to date are minor and temporary; they include gastrointestinal distress, nasal congestion, headache, and muscle aches. An uncommon but odd side effect is visual effects that include seeing a blue haze and temporary increased brightness. It should not be used more than once a day. Deaths have been reported in a few men taking nitrates (such as nitroglycerine) along with sildenafil. No one taking nitrates, such as nitroglycerin, should take it. It is important to note that few studies have been conducted with this drug and none have been long-term. Men should discuss the drug carefully with their physician, and those who choose to use it must do so responsibly.

Experimental Oral Drugs

Phentolamine. Phentolamine has been given intravenously to prevent episodes of high blood pressure in certain conditions. Currently, an oral form is being investigated for impotence. The drug blocks adrenaline (epinephrine), which in turn, dilates blood vessels. In some studies, it was effective in producing erections within 20 to 40 minutes in 40% to 50% of men with mild to moderate erectile dysfunction. Side effects include nasal congestion, light-headedness, and low blood pressure.

Apomorphine

Apomorphine is an old drug used in some situations for Parkinson’s disease. When used for erectile dysfunction, it causes a sexual signal in the brain to trigger an erection, although it is not an aphrodisiac. It is placed orally under the tongue. Early studies show that it is effective in 70% of men without organically caused impotence, but some experts believe it may prove beneficial for some men with significant medical problems associated with erectile dysfunction, including nerve-sparing radical prostatectomy. Side effects include nausea, yawning, fatigue, dizziness, excitability, and aggression.

Other Drugs

Pentoxifylline improves oxygen delivery to the penis by reducing the “sticky” quality of red blood cells. In a small test, it was effective for many men with mild to moderate dysfunction, although it does not seem to be beneficial for men with diabetes. A German study using naltrexone, a medication currently used for drug abuse, reported increased early-morning erections but no increase in sex drive or frequency of intercourse.

Hormone Replacement

Testosterone therapy is usually limited to men with hypogonadism and not recommended for men with natural testosterone levels normal for their age group. Recently, however, some experts believe it may be helpful for older men whose testosterone levels are deficient It may improve sexual drive but is very risky. The hormone can worsen prostate problems, high, prolonged levels of testosterone may actually trigger prostate enlargement or even cancer. In addition, testosterone causes a drop in the beneficial HDL cholesterol, which could increase the risk for atherosclerosis.

Topical Medications

To date, medications delivered topically (through skin patches, ointments, or sprays) have not been very successful, but research is ongoing for effective drugs that can be applied to the skin of the penis rather than administered by injections or orally. In one study, a cream containing prostaglandin E2 resulted in erections in 30% of subjects. An aerosol spray made from minoxidil, a drug that relaxes smooth muscles and helps open up blood vessels, has been beneficial in 25% of a very small group of men whose dysfunction was caused by spinal cord injury. Also of some future interest is an ointment called SS-Cream, which is made from nine oriental herbs; in one uncontrolled Korean study of men with premature ejaculation, 89% achieved erections that had an extended time of an average of 11.5 minutes.

Vacuum Devices

Vacuum devices or external management systems are effective, safe, and simple to use for all forms of impotence except when severe scarring has occurred. Studies have found that success with the vacuum device is equal to other methods, including injection therapy. Between 56% and 67% of men using it reported the device to be effective. The penis is placed inside a plastic cylinder; a vacuum is created, which causes blood to flow into the penis, thereby creating an erection. The cylinder is removed after a band has been tightly secured around the base of the penis, which retains the erection. Side effects include blocked ejaculation and some discomfort during pumping and from the use of the band. Minor bruising may occur, although infrequently.

Penile Implants

Three types of surgical implants are currently being used for the treatment of erectile dysfunction. One device, known as a hydraulic implant, uses two cylinders and a pump placed within the erection chambers of the penis. The pump releases a saline solution into the chambers, thereby causing an erection; it also removes the solution from the chambers, thereby deflating the penis. The second type of implant, also known as prosthesis is composed of two semi-rigid, but bendable, rods, which are placed inside the erection chambers of the penis. The penis can then be manipulated to an erect or non-erect position. A third implant uses interlocking soft plastic blocks that can be inflated or deflated using a cable that passes through them.

Though many patients benefit from implant surgery, it is an irreversible procedure. Erectile tissue is permanently damaged when these devices are implanted. A mechanical breakdown can occur, and a less than optimal quality of erection may result. Infection may be the major cause of penile implant failure.

Vascular Surgery

For men whose impotence is caused by damage to arteries or blood vessels, vascular surgery might be an option. Two types of operations are available revascularization (or bypass) surgery and venous ligation. The revascularization procedure is effected by taking an artery from a leg and then surgically connected it to the arteries at the back of the penis, bypassing the blockages and restoring blood flow. Young men with local sites of arterial blockage generally achieve the best results.

Venous ligation is performed when the penis is unable to store a sufficient amount of blood to maintain an erection. This operation ties off or removes veins that are causing an excessive amount of blood to drain from the erection chambers. Success rate is estimated at between 40% and 50% initially but drops to 15% over the long term. It is, of course, important to find a surgeon experienced in this surgery.

Alternative Treatments and aphrodisiacs

Yohimbine. Yohimbine has been used as a folk medicine for years; it appears to improve blood flow. Studies have been inconclusive about its benefits, but a recent analysis of seven trials reported that between 34% and 75% of men achieved favourable results when taking 5 mg to 10 mg. Side effects include nausea, insomnia, nervousness, and dizziness. Large doses can increase blood pressure and heart rate.

Other Herbal Treatments

Ginkgo improves blood flow in the brain and in one small study 78% of men who had impotence caused by impaired blood flow regained erections. More research is needed. Ginseng root is a traditional Asian remedy for stimulating sexual function, although no studies have been conducted on its efficacy.

Aphrodisiacs

Aphrodisiacs are substances that are supposed to increase sexual drive, performance, or desire. Food that some people claim has aphrodisiacal qualities include chillies, chocolate, liquorice, lard, scallops, oysters, and anchovies. No evidence exists for these claims and certainly, no one would ever advocate eating large amounts of such foods, which, in cases such as licorice and lard, can be dangerous. Spanish fly, or cantharides, made from dried beetles is the most widely-touted aphrodisiac and is particularly harmful. It irritates the urinary and genital tract and can cause infection, scarring, and burning of the mouth and throat; in some cases, this substance can be life-threatening.

LIMITATIONS OF MODERN THERAPIES

Modern medicine has hardly any drugs or therapy to offer to benefit patients with Inhibited Sexual Desire (ISD).

One’s sexual functioning is not only an expression of reproductive capacity and gender identity but also serves a major role in cementing the emotional bond with the primary partner. When this capacity is diminished or disrupted, the psychological implications can range from minor to catastrophic, depending on the individual history and situation. Therefore treatment of sexual dysfunction is imperative as it can have a profound effect on the

Field of erectile dysfunction was sort of a neglected branch of medicine, to which very little attention was focused till date. Lately, there has been an enhanced focus on this dysfunction to understand its aetiology and evaluate various remedies available for the same. There has been an increase in the quantum of research in this field, which will lead to more drugs being made available to those patients who have erectile dysfunction. Recently Sildenafil has been made available but has shown to provide benefit only to those patients who have erectile dysfunction. It does not have any effect on sexual desire and it is contraindicated in patients with heart ailments.

Earlier investigators have also tried hormone replacement therapy with Testosterone, but it has not shown very encouraging results. Various other devices such as vacuum devices, penile implants (wherein artificial implant has been surgically implanted in the penis so that they can be inflated just prior to sexual intercourse) are also available, but are as radical as vascular surgery, and offer significant benefits only to those patients whose function has been severely impaired.

Modern medicine could not even make a breakthrough in premature ejaculation group of patients. Some investigators recommended the use of topical anaesthetic preparation to treat this problem but, it has not shown encouraging results.

The science of Ayurveda believes that sexual inadequacies may be caused by the following causes:

Psychosomatic – due to suppression of sexual urge again and again; not getting the partner of one’s choice or forcefully engaging with someone who is not liked.

Dietetic – due to excess intake of heavily salty or sour food substances or due to food with extremely low nutritional value.

Over-indulgence – by those who are ageing/exhausted/promiscuous but not resorting to suitable Vajikarana therapies.

STD’s – contracting them, and neglecting for long till complication appears.

Injuries – on testicles or adjacent area severing the spermatic cord and other surrounding structures.

The practice of Celibacy – constant suppression of sexual desires by those who believe in austerity results into the permanent damage of semen producing organs in the body.

Inherent – due to some congenital defect, if there is absence/malfunction/retarded growth of internal genitalia, impotence may be observed.

Old age – i.e., above 70 years of age, all factors basically leading to the weakness in Shukra.

Impotence/Klaibya – (generally applicable to erectile dysfunction) in Ayurveda is classified in the following manner by Acharya Charak. This is four types:

Beejopaghatajanya (Due to defects in spermatogenesis)

Dhwajopaghatajanya (Due to quantitative structural deformity)

Vruddhavasthajanya (Due to old age)

Shukrakshayajanya (Due to diminution of the production/quality of the seminal fluid)

Beejopaghatajanya – Diet containing cold, dry, rotten, incompatible recipes; anxiety; excessive indulgence in carnal pleasure; nutritional deficiencies, suppressing hunger; exertion; improper handling of cleaning manoeuvers; emotional or perusal aversion may lead to a disturbance in the process of spermatogenesis which in turn leads to impotence.

Dhwajopaghatajanya – Excessive intake of sour and salty food, alkaline material; incompatible or non-suitable food recipes; excess intake of water, curd or non-veg soups made up of the meat of those animals which may lead to endotoxicities; excess indulgence in masturbation, anal or any perverted sex; intercourse with a female having chronic infective problems in genitals or, menstruating females; trauma to the penis or improper use of local applications may also lead to a structural deformity in the penis which in turn leads to impotence.

Vruddhavasthajanya (Impotence due to old age) – Ageing of the vital tissues resulting into deficiency of essential hormones due to old age; being deprived of the special nutrients through a decrease in the strength and stamina (aphrodisiacs); in the strength and stamina of the body; functional abnormalities of sensory-motor organs; suppression of hunger; overexertion etc. lead to severe general debility thereby causing impotence in those who are above 50 years of age.

Kshayajanya – Constant exposure to debilitating/invalidating physical or mental circumstances tend to weaken the vital constituents and lead to over-all emaciation/under-nourishment. These could be continuous worries or tension; deep sorrow or shock; bouts of anger; hyper excitement. Physical conditions could be a chronic wasting disease such as Koch’s 1 BD; malnutrition etc. Reportedly, if an individual is not in a position to replenish the draining nutrients or is forced to be on an undernourishing diet, medically his vitality is lost and functional impotence sets in. If not taken seriously, it would flare up into a severe immune-deficiency and result in death.

It is believed that the impotence caused by irreversible damage to phallus or testicles or the one resulting due to severe immune-deficiency (maybe the AIDS in today’s perspective) are incurable.

Charaka has also reported a fifth category of impotence named Janmajata Klaibya the name of which is self-explanatory. It means the impotence which exists since birth and is due to (i) some genetic defect caused by the destruction of internal reproductive organs during pregnancy itself or (ii) some other idiopathic factor. In such case, although the baby boy may be alright externally, becomes unable to perform sex when grows up.

Shukra Dushti Vis-à-vis Male Infertility

Besides the above-mentioned topic of Klaibya which is directly related to impotence and inability to perform the sexual act. Acharya Charak has also described various abnormalities in the constitution of semen under the title of ‘Shukra Dushti’ which are basically the defects leading to infertility but treatment-wise more or less tend to be similar to Klaibya only.

Types: There are eight types of abnormalities of semen described by Acharya Charak. These are:

Fenila – Vataja (frothy semen)

Tanu – Vataja (low liquefaction time)

Ruksha – Vataja (decreased viscosity)

Vivarna – Pittaja (semen which impaired colour due to infection)

Puti – Tridoshaja (purulent and foul-smelling semen)

Pichchil – Kaphaja (sticky-high viscosity)

Anya dhatu sansrushta (deranged constitution due to infiltration of other tissue-humoral components)

Avasadi – Vataja (causing weakness while ejaculation)

Acharya Charak has described treatment for all these 8 types of Shukra Dushti.

Principles of Treatment:

For all the abnormalities/aberration of semen, the medicinal herbs or herbo-mineral preparations having activities like Shodhana (helpful in the retrieval of the normal constitution), Santarpana (replenishment) and Rasayans (modulating immunity and checking the auto-immune processes) are helpful. This is besides those recipes which are mentioned under the title of ‘Vajikarana chikitsa’. Also, medicines used for some gynaecological diseases (Yoni Rogas) can be employed for seminal abnormalities.

Some food articles like milk, ghrita, meat soups, rice, wheat, etc are considered as having curative properties in minor amounts. Enemata of medicated oils also should be given.

Some Vital Hints:

For the seminal abnormalities caused by vitiated Vata Dosha, treatment with enemata of medicated oils and decoctions should be given.

When ‘Shukra’ is affected by vitiated Pitta Dosha ‘Abhayamalak Rasayan’ should be given (confection containing chebulic and embolic myrobalan as principal ingredients).

When an abnormality is caused by Kapha Dosha, preparations like Pippali rasayan, Amalaki rasayan, Loha rasayan, Triphala rasayan, Bhallatak rasayan etc should be employed. (Main ingredients in these confections are: (i) Long pepper (ii) Embelic myrobalan (iii) Calx of iron (iv) Combination of chebulic/beleric and embolic myrobalan and (iv) Marking nut respectively).

Classification of Ayurvedic Drugs acting in Impotence/Infertility

The Vajikarana drugs are classified into the following:

Shukrajanan

Shukrasrutikara

Shukrastambhan

Herbal Formulations | Ayurvedic medicine for impotence and infertility

Formulations that could be used as a regular nutritional supplement in case of debilitated individuals suffering from Shukradoshas or Klaibya are

Madanananda modaka
Vanari gutika
Narasimha churna
Rativallabha pooga paka
Shatavari ghrita
Mushali paka

Herbo-Mineral Preparations| Ayurvedic medicine for impotence and infertility

In these classical combinations, herbal ingredients or their juices carrying spermatogenic, hormone activating and neurotransmitter regulating activities are processed with detoxicated minerals or their calxes either by grinding them together or subjecting them to sublimation or similar alchemic processes. Such processes leading to strong bio-chemical reaction render their finished products capable of acting fast on body-system due to their Sukshmatwa (micro-particulation ensuring maximum bio-availability), Vyavayi (fast assimilation) and Vikasi (tendency to reach till site of action by way of capacity to pass through capillary permeation). As compared to the powders/decoctions of medicinal herbs, these formulations are fast and specific in action, hence preferred.

A few important ones are:

Makardhwaj Ras: containing calxes of Diamond, Gold, Copper, Mercury, Mica and Iron along with Aloe vera, Silk cotton and some other ingredients.

Dose – 1 gm at night.

Vehicle – 30 gm. of a mixture of powders of long pepper, liquorice and mucuna seeds.

Vehicle- Sugar and Milk

Shilajitu yoga: containing Shilajeet, Embelia Ribes, Calx of Iron, Swarna Makshik and Haritaki (Chebulic myrobalan).

Dose – 250 mg to 500 mg

Vehicle – Honey + Ghee

Swarna Makshikadichurna: containing Swarnamakshik, Calx of Iron, Shilajeet, Haritaki and Embelia Ribes.

Dose – 250 mg to 750 mg at night

Vehicle – Ghee

Duration- For 21 days.

Swalpachandroday Makardhwaj: containing Nutmeg, Clove, Camphor, Pepper, Calx of Gold, Kasturi and Ras sindoor.

Dose – 250mg to 500 mg.

Vehicle – Ghee+Honey+Sugar+Milk

Pushpadhanwa Ras: containing Calxes of Gold, Silver, Copper and Loha, Silk cotton tree and Liquorice.

Dose – 250 mg to 500 mg.