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Few men bring up this issue with their doctors, and few doctors ask about it. This doesn't mean it's unimportant. The ability to achieve and maintain an erection is frustrating, embarrassing, and distressing to you and your partner. Achieving and maintaining an erection results from the successful interplay of several different physical and psychological processes. One or more of these may be impaired in PD. Thus, anxiety and or depression may result in a loss of a desire to have or think about sex. The desire to have sex or think about sex is called libido. A loss of libido results in impotence. Most men with PD, however, retain their desire for sex, and this coupled with impotence, heightens frustration, results in abstinence, and deepens social isolation.

PD usually begins at age 60, a time when many men experience impotence related to vascular disease, diabetes, an enlarged prostrate, or depression. Thus, impotence should not automatically be attributed to PD. Diabetes, an underactive or overactive thyroid, adrenal, or pituitary gland, or a deficiency of testosterone may cause impotence. Disease of the arteries and veins may cause impotence. Smoking, diabetes, high blood pressure, and high cholesterol promote disease of the arteries. Men with arterial disease may have difficulty in attaining an erection, whereas men with disease of the veins may have difficulty in maintaining an erection. Disease of the veins results in impotence because the veins are unable to constrict. After an erection is attained, blood normally leaks from the penis back into the veins, causing the penis to soften. After an erection is attained, the veins constrict, preventing leakage of blood from the penis maintaining the erection.

Some features of your appearance such as tremor may cause you to lose self-esteem. Other features such as drooling may make you think that you're unattractive to your partner. These features, if relevant, must be discussed and resolved. Some men (and women) because of their physical limitations no longer maintain proper grooming. Thus, hair may grow from their nose or ears, or their teeth may be dirty. If relevant, these features should be remedied. Some people because they move slowly and cannot turn in bed become unduly anxious and cannot perform sexually. For them, taking Sinemet or a dopamine agonist (Mirapex, Requip) an hour before intercourse is helpful.

Alcohol, in moderation (because it represses social inhibitions), may promote sexual activity. In excess, alcohol depresses the brain and can temporarily result in impotence. Antihistamines, cocaine, marijuana, major tranquilizers, sedatives, and some anti-depression drugs may aggravate or cause impotence by depressing the brain. Some of these drugs may block ejaculation. Some drugs that lower high blood pressure may cause impotence. This may be related to the drop in blood pressure. Drugs that regulate blood pressure by regulating the ANS are more likely to cause impotence. The commonly used PD drugs rarely cause impotence. Impotence associated with their use invariably results from PD. As a rule, if impotence occurs within a few days or a month of starting a drug, the drug should be considered to be a potential cause of the impotence. If a drug aggravates or causes impotence, stopping the drug restores potency.

In PD, the main cause of impotence is ANS insufficiency. Impotence is usually, but not always, associated with other symptoms of ANS insufficiency. The ANS sends messages to the lower spinal cord, the parts involved in sexual function. The lower spinal cord sends messages through nerves to the penis and testes. If you are able to achieve and maintain an erection, this reflects adequate blood flow through the arteries to the penis, with appropriate filling and hardening of the penis. If you are unable to achieve or maintain an erection, this reflects a failure of the ANS system to constrict the veins surrounding the penis, resulting in softening.

Impotence must be acknowledged. You, or your partner, must bring up the issue and want to resolve it. Many men are reluctant to admit that they are impotent. If they do confess impotence, they do it at the end of their consultation—as an afterthought. This reflects their ambiguity and leaves no time for a frank discussion of a sensitive problem. If impotence is important, it alone should be the subject of your doctor's visit, and both you and your partner should attend. If discussing impotence in the presence of your partner is difficult, then you should go alone. You and your partner should recognize that your inability to talk as a couple may be part of the problem. Some men become obsessed with impotence. This, when it becomes all encompassing, can turn off even a sympathetic partner. The main ingredients to success in treating impotence are a willingness to seek help, to discuss everything openly, and to respect each other's needs.

Keep in mind that desire precedes arousal. Your partner should be aware of the problems that are unique to you. This includes a decreased sense of smell, resulting in an inability to be aroused by provocative odors, including perfumes, hair lotions, and body parts. Visual stimuli may be better: anything that works. Viagra, taken orally, is a potent blocker of an enzyme in the penis. Viagra increases the concentration of a naturally occurring compound, nitrous oxide, which allows blood to enter the penis. Studies indicate that Viagra is effective in many men with PD. Because blood pressure in PD patients may drop upon standing, you must consult with your doctor before using Viagra.

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