Evaluation and Treatment of Patients with Impotence Shailendra Kumar, MD Washington, DC
Impotence is a common problem of adult males. Thorough history from both partners, physical examination, and laboratory work uncover a small minority who are suffering from an organic cause. The majority of such patients have a psychological basis for the condition. In the absence of demonstrated organic disease, psychiatric consultation is indicated. Surgery is helpful in erectile impotence. Potency is the ability to initiate, sustain, and successfully conclude the act of coitus.' Various degrees of impotence in men are common, but it is rare to find a defmite organic cause. Impotence is the inability to gain an erection, weak erection, nonemissive erection (failure of ejaculation), premature ejaculation, and loss of libido. Psychosexual problems in men can cause varying difficulties with potency. If a male can obtain an erection and experience orgasm with ejaculation a minimum of once a year, he is, according to an accepted classification, potent.' This impression is based on the fact that to have one erection, the basic mechanism must be intact. An intact nerve and blood supply are essential to achieve an erection; thus, if a rare erection is had, the patient's problem can be considered psychic in origin.
Requests for reprints should be addressed to Dr. Shailendra Kumar, Division of Urology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060.
Mechanism of Erection and Ejaculation There are three responses to erotic stimuli: (1) a general response mediated by the autonomic nervous system evidenced by an increase in pulse rate and blood pressure with a diminution of auditory and visual senses; (2) an erectile response initiated by psychic or local influences; and (3) ejaculation.' A fourth response, resolution, has also been described.2 Actually, there is one smooth, unitary response, the stages flowing into one another in the properly functioning individual. Sexual stimulation can originate in the cerebral center as a result of visual, auditory, or olfactory sensations. Also, tactile stimuli are mediated over the internal pudendal nerve synapse in the erectile center. This is located in sacral cord segments 2, 3, and 4. From there they pass as efferent stimuli over the pelvic nerves, ie, nervi erigentes to the parasympathetic plexuses. There, impulses produce relaxation of arterioles to the corpora of the penis, and the arterial-venous shunts, which permit arterial bypass of the corpora in the flaccid state, are closed. Erection can also occur without any venous closing mechanism; this has been demonstrated experimentally by
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 9, 1978
Newman, Northrop, and Devlin3 in cadavers and human volunteers. Lack of psychic stimulus or interruption of these nerves can impair erection. Continued stimulation of the glans results in a summation of stimuli which, on reaching a certain threshold, call for smooth muscle activity, with first the elevation and closure of the internal vesical sphincter followed by the expulsion of secretions from the prostate, vas deferens, and seminal vesicles. The presence of this ejaculatory fluid in the posterior urethra promotes still another reflex via the pudendal nerve which causes contraction of the striated perineal musculature at the base of the penis and expulsion of the semen through the urethra. Orgasm is composed of all the sensations resulting from the above mentioned activity.
Causative Factors ejaculatory and erectile disorders are clearly separate, although as late as 1960 they were regarded as one symptom and treated the same.4 It must be noted that the ejaculatory response appears to be a function of the sympathetic nervous system, whereas erection is dependent on the parasympathetic nervous system. Thus, it is obvious that neurological lesions, especially those of the sacral cord, can result in organic impotence and lumbar sympathectomy, and that excision of the hypogastric plexus results in disturbance of ejaculation (dry ejaculation). An impotent man can still ejaculate. Most men who do not have erections get so discouraged that they do not continue stimulating: if they did, they would probably have an orgasm. 671
Nearly 85-90 percent of impotence patients have psychological problems and obvious emotional involvement. However, organic causes must be suspected and ruled out. Atherosclerosis of the lower extremities, resulting in claudication (eg, Leriche's syndrome) causes diminished arterial flow to the corpora. This has been shown experimentally by ligation of hypogastric vessels in patients undergoing cystectomy for bladder cancer (Kumar S, Watson R, Whitmore WF, unpublished data). Abdominoperineal resection, total prostatectomy, and cystectomy may interfere with pelvic nerves. Direct damage to the corpora is rarely so extensive as to result in organic impotence. Endocrine disorders, such as androgen or pituitary insufficiency with hypogonadism, severe hypothyroidism, or excess estrogen (eg, prostatic carcionma) may cause impotence. The diagnosis of these conditions is usually quite obvious but may require extensive endocrinologic evaluation. Diabetes, even without advanced neuropathy, may cause problems. Good control of diabetes by medical management may not improve the situation when there is associated neuropathy. In early diabetes, there may be retrograde ejaculation before total erectile impotence. Prostatitis may result in impotence and impaired sexual performance. Lumbar disc disease may be characterized by impotence and low back pairn. Brain and spinal cord tumors or injuries and their sequelae may be associated with impotence.5 Severe systemic disease (eg, chronic renal failure, hemodialysis) of any nature with weakness and priapism, commonly associated with sickle cell disease and leukemia, are other causes of the flaccid penis, incapable of erection. Various medications may also cause impotence. For instance, the chronic morphine or heroin addict frequently suffers from an absolute impotence with little or no libido. Alcoholism may produce impotence. However, small amounts of alcohol, by releasing inhibitions, may stimulate libido and potency. Chronic barbiturate intoxication and long term use of anticholinergic agents may interfere with sexual function. There have been a number of reports of impotence with loss of ejaculation with use of tranquilizers derived from phenothiazine, eg, chlorproma672
zine, HCI, prochlorperazine, thioridazine, promethazine HCl, promazine HCl, and perphenazine. The monoamine oxidase inhibitors, such as phenelzine, isocarboxazid, and tranylcypromine may produce impotence. Some antihypertensive blocking agents, guanethidine, guanethidine sulfate, and guanethidine monosulfate plus hydrochlorothiazide may produce impotence, probably by sympathetic blockade.
Management Management is primarily a problem of recognition by both the physician and patient. A good history and frank discussion of the problem with the husband and wife, in combined and separate sessions, are important. Sometimes these interviews are very revealing. Separate discussions might reveal the degree of validity of the patient's responses to the physician's questions. There may be a considerable difference between truth and expectation. Many times, a husband gives a story which is quite different from the one given by his wife. Because of the lack of real training and a formalized curriculum in human sexuality in medical schools, asking such questions may, at times, be embarrassing to the physician. However, he/she must face this problem with confidence and without hesitation, and use language which is understandable to the patient. Many times patients do not understand words like "erection." But if he is asked in common language, he will understand it well. So one should be frank, even blunt if necessary, and seek the level of the patient. Inquiry should also be made about morning erection. If he has this, neural arc is intact and only reassurance can be curative. It is important for the patient to realize that in over 75 percent of normal men ejaculation occurs within two minutes after entrance to the vagina or after 50 strokes. One should try to impress upon the patient that he has been studied completely. During physical examination, femoral pulsation, atrophic testis, and a boggy and tender prostate gland should be checked. Laboratory work should include a glucose tolerance test, to rule out diabetes, and serum testosterone levels to detect a hormone deficiency. Complete blood count and SMA-12 may be helpful. A liver profile could be revealing. Hormone replacement with
testosterone may be indicated in Kleinfelter's, testicular feminization, and male climacteric syndromes. The male climacteric syndrome is a disputed entity, however. Laboratory tests rarely confirm changes in the male, unlike the female. Results of therapeutic tests of the clinical effectiveness of hormonal therapy are usually badly distorted by subjective beliefs concerning the injection procedure and the reputation that hormones contain such vital life-giving properties.6 When the laboratory does verify the climacteric syndrome, there is a demonstrable decline in excretion of 17ketosteroids. The administration of testosterone has been of value, but often it has a placebo effect. Until some method enables us to determine more frequently that gonadal insufficiency, if any, in a man between 40 and 65 is producing any symptoms similar to those of the menopause in women, one should rely upon competent psychotherapy rather than trials at organotherapy based on wishful thinking, hope, and suggestion. Although the administration of male sex hormone temporarily produces a period of sexual rejuvenation, it becomes evident that the patient's most effective psychic equilibrium is maintained after the discontinuance of hormone therapy.7 Sexual activity in the aging male should continue, although reduction in frequency and performance might be expected. It is estimated that over 60 percent of married men in their 60s continue to function sexually in a satisfactory manner. This percentage is reduced in males who have lost their spouses, and this may be accounted for by the difficulty in securing a willing partner.8 Chronic prostatitis and prostatosis have been blamed for impotence and premature ejaculation. This condition can be present with or without evidence of infection. Treatment with antibiotics and massage has been helpful. However, there is a feeling that massage is actually a form of psychotherapy. Certainly, sexual intercourse or masturbation two to three times a week is a far more effective way of emptying the prostate and more pleasurable than pressure by the urologist's finger. It may be stated that masturbation is practiced by many healthy individuals. Premature ejaculation is the most common of male sex dysfunctions and
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 9, 1978
can be treated by explanation of the problem and reassurance. The following recommendations could be helpful: (1) earlier stimulation of the female, (2) change in position during intercourse, (3) reduction in number and vigor of thrusts, and (4) use of a condom, tranquilizers, or local anesthetics.1 The techniques used by Kaplan9 are: 1. the stop-start technique, and, 2. the squeeze technique. In the first method, the man lies back and just concentrates on his sensations while the woman stimulates him manually. When he is near ejaculation, stimulation is discontinued for a few seconds for the feeling to abate; then the woman begins to stimulate him again, and so on. During the fourth cycle he usually ejaculates. When the couple can do that, they go through the same procedure using petroleum jelly to produce a more intense stimulation similar to that felt with the penis inside a vagina. When he feels confident about this, they proceed to the female superior intercourse, with the man regulating the woman up and down, using the same stop-start technique. The squeeze technique differs in
that when the point of ejaculation is reached, the woman squeezes the penis immediately below the frenulum, which makes the man lose about a third of his erection. It is uncomfortable sometimes. Many women object to it and the first technique mentioned works equally well. In any case, if a couple uses squeezing most men will acquire very good ejaculatory control within a few weeks. Some of the conditions which lead to premature ejaculation are: hyperirritable glans penis, hyperirritable verumontanum, and chronic congested prostate. Another sexual dysfunction is retarded ejaculation (ejaculatory incompetence). Here the man has no orgasm or takes on excessive amount of stimulation before he does. This is due to an involuntary inhibition of the orgastic reflex seen commonly in very religious men. Retrograde ejaculation may be encountered in diabetics, following sympathectomy, transurethral resections of bladder neck, and following prostatectomy. A recently developed surgical procedure on bladder neck offers some hope for such patients.
Finally, surgery has a role in cases of erectile impotence. If a patient has good libido, a willing partner, and no psychiatric problem (clearance), placement of an intrapenile plastic prosthesis, eg, Small-Carrion,10 Scott," should be considered. Literature Cited 1. Karafin L, Kendall AR: Psychosomatic problems in urology. In Karafin L, Kendall AR (eds): Urology, vol 2. Hagerstown, Md, Harper and Row, 1975, p 6 2. Masters W/H, Johnson VE: Human Sexual Inadequacy. Boston, Little, Brown, 1970 3. Newman HF, Northrop JD, Devlin J: Mechanism of human penile erection. Invest Urol 1:350-353, 1964 4. Kaplan HS: Sexual medicine. Hospital Tribune, March 15, 1975 5. Amelar RD, Dubin L: Infertility in the male. In Karafin L, Kendall AR (eds): Urology, vol 2. Hagerstown, Md, Harper and Row, 1975, p 16 6. English OS: The psychosomatic approach in urology. In Campbell MF, Harrison JH (eds): Urology, vol 3. Philadelphia, WB Saunders, 1970, p 2047 7. Tauber ES, Daniels GE: Hormone Therapy in Climacteric Men. Psychosom Med 3:72, 1941 8. Finkle AL: Sexual function during advancing age. In Textbook of Geriatrics, Philadelphia, JB Lippincott, 1969 9. Kaplan HS: Sexual medicine. Hospital Tribune, March 18, 1975 10. Small MP, Carrion HM: Small-carrion prosthesis: A new implant for management of impotence. Urology 5:479-486, 1975 1 1. Scott FB, Bradley WE, Timm GW: Management of erectile impotence: Use of an inflatable prosthesis. Urology 2:80-82, 1973
Notional *u1979 NMA Convention The 84th annual convention and scientific assembly of the National Medical Association will be held in Detroit, Michigan from July 29-August 2, 1979. The scientific program will include Aerospace and Military Medicine, Anesthesiology, Basic Science,
Community Medicine, Dermatology, Family Practice, Internal Medicine, Neurology and Psychiatry, Obstetrics and Gynecology,
Ophthalmology, Orthopedics, Otolaryngology, Pediatrics, Physical Medicine and Rehabilitation, Radiology, Surgery, and Urology. T N IONCE A
1895
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 9, 1978
673
Impotence is a common problem of adult males. Thorough history from both partners, physical examination, and laboratory work uncover a small minority who are suffering from an organic cause. The majority of such patients have a psychological basis for the condition. In the absence of demonstrated organic disease, psychiatric consultation is indicated. Surgery is helpful in erectile impotence. Potency is the ability to initiate, sustain, and successfully conclude the act of coitus.' Various degrees of impotence in men are common, but it is rare to find a defmite organic cause. Impotence is the inability to gain an erection, weak erection, nonemissive erection (failure of ejaculation), premature ejaculation, and loss of libido. Psychosexual problems in men can cause varying difficulties with potency. If a male can obtain an erection and experience orgasm with ejaculation a minimum of once a year, he is, according to an accepted classification, potent.' This impression is based on the fact that to have one erection, the basic mechanism must be intact. An intact nerve and blood supply are essential to achieve an erection; thus, if a rare erection is had, the patient's problem can be considered psychic in origin.
Requests for reprints should be addressed to Dr. Shailendra Kumar, Division of Urology, Howard University Hospital, 2041 Georgia Avenue NW, Washington, DC 20060.
Mechanism of Erection and Ejaculation There are three responses to erotic stimuli: (1) a general response mediated by the autonomic nervous system evidenced by an increase in pulse rate and blood pressure with a diminution of auditory and visual senses; (2) an erectile response initiated by psychic or local influences; and (3) ejaculation.' A fourth response, resolution, has also been described.2 Actually, there is one smooth, unitary response, the stages flowing into one another in the properly functioning individual. Sexual stimulation can originate in the cerebral center as a result of visual, auditory, or olfactory sensations. Also, tactile stimuli are mediated over the internal pudendal nerve synapse in the erectile center. This is located in sacral cord segments 2, 3, and 4. From there they pass as efferent stimuli over the pelvic nerves, ie, nervi erigentes to the parasympathetic plexuses. There, impulses produce relaxation of arterioles to the corpora of the penis, and the arterial-venous shunts, which permit arterial bypass of the corpora in the flaccid state, are closed. Erection can also occur without any venous closing mechanism; this has been demonstrated experimentally by
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 9, 1978
Newman, Northrop, and Devlin3 in cadavers and human volunteers. Lack of psychic stimulus or interruption of these nerves can impair erection. Continued stimulation of the glans results in a summation of stimuli which, on reaching a certain threshold, call for smooth muscle activity, with first the elevation and closure of the internal vesical sphincter followed by the expulsion of secretions from the prostate, vas deferens, and seminal vesicles. The presence of this ejaculatory fluid in the posterior urethra promotes still another reflex via the pudendal nerve which causes contraction of the striated perineal musculature at the base of the penis and expulsion of the semen through the urethra. Orgasm is composed of all the sensations resulting from the above mentioned activity.
Causative Factors ejaculatory and erectile disorders are clearly separate, although as late as 1960 they were regarded as one symptom and treated the same.4 It must be noted that the ejaculatory response appears to be a function of the sympathetic nervous system, whereas erection is dependent on the parasympathetic nervous system. Thus, it is obvious that neurological lesions, especially those of the sacral cord, can result in organic impotence and lumbar sympathectomy, and that excision of the hypogastric plexus results in disturbance of ejaculation (dry ejaculation). An impotent man can still ejaculate. Most men who do not have erections get so discouraged that they do not continue stimulating: if they did, they would probably have an orgasm. 671
Nearly 85-90 percent of impotence patients have psychological problems and obvious emotional involvement. However, organic causes must be suspected and ruled out. Atherosclerosis of the lower extremities, resulting in claudication (eg, Leriche's syndrome) causes diminished arterial flow to the corpora. This has been shown experimentally by ligation of hypogastric vessels in patients undergoing cystectomy for bladder cancer (Kumar S, Watson R, Whitmore WF, unpublished data). Abdominoperineal resection, total prostatectomy, and cystectomy may interfere with pelvic nerves. Direct damage to the corpora is rarely so extensive as to result in organic impotence. Endocrine disorders, such as androgen or pituitary insufficiency with hypogonadism, severe hypothyroidism, or excess estrogen (eg, prostatic carcionma) may cause impotence. The diagnosis of these conditions is usually quite obvious but may require extensive endocrinologic evaluation. Diabetes, even without advanced neuropathy, may cause problems. Good control of diabetes by medical management may not improve the situation when there is associated neuropathy. In early diabetes, there may be retrograde ejaculation before total erectile impotence. Prostatitis may result in impotence and impaired sexual performance. Lumbar disc disease may be characterized by impotence and low back pairn. Brain and spinal cord tumors or injuries and their sequelae may be associated with impotence.5 Severe systemic disease (eg, chronic renal failure, hemodialysis) of any nature with weakness and priapism, commonly associated with sickle cell disease and leukemia, are other causes of the flaccid penis, incapable of erection. Various medications may also cause impotence. For instance, the chronic morphine or heroin addict frequently suffers from an absolute impotence with little or no libido. Alcoholism may produce impotence. However, small amounts of alcohol, by releasing inhibitions, may stimulate libido and potency. Chronic barbiturate intoxication and long term use of anticholinergic agents may interfere with sexual function. There have been a number of reports of impotence with loss of ejaculation with use of tranquilizers derived from phenothiazine, eg, chlorproma672
zine, HCI, prochlorperazine, thioridazine, promethazine HCl, promazine HCl, and perphenazine. The monoamine oxidase inhibitors, such as phenelzine, isocarboxazid, and tranylcypromine may produce impotence. Some antihypertensive blocking agents, guanethidine, guanethidine sulfate, and guanethidine monosulfate plus hydrochlorothiazide may produce impotence, probably by sympathetic blockade.
Management Management is primarily a problem of recognition by both the physician and patient. A good history and frank discussion of the problem with the husband and wife, in combined and separate sessions, are important. Sometimes these interviews are very revealing. Separate discussions might reveal the degree of validity of the patient's responses to the physician's questions. There may be a considerable difference between truth and expectation. Many times, a husband gives a story which is quite different from the one given by his wife. Because of the lack of real training and a formalized curriculum in human sexuality in medical schools, asking such questions may, at times, be embarrassing to the physician. However, he/she must face this problem with confidence and without hesitation, and use language which is understandable to the patient. Many times patients do not understand words like "erection." But if he is asked in common language, he will understand it well. So one should be frank, even blunt if necessary, and seek the level of the patient. Inquiry should also be made about morning erection. If he has this, neural arc is intact and only reassurance can be curative. It is important for the patient to realize that in over 75 percent of normal men ejaculation occurs within two minutes after entrance to the vagina or after 50 strokes. One should try to impress upon the patient that he has been studied completely. During physical examination, femoral pulsation, atrophic testis, and a boggy and tender prostate gland should be checked. Laboratory work should include a glucose tolerance test, to rule out diabetes, and serum testosterone levels to detect a hormone deficiency. Complete blood count and SMA-12 may be helpful. A liver profile could be revealing. Hormone replacement with
testosterone may be indicated in Kleinfelter's, testicular feminization, and male climacteric syndromes. The male climacteric syndrome is a disputed entity, however. Laboratory tests rarely confirm changes in the male, unlike the female. Results of therapeutic tests of the clinical effectiveness of hormonal therapy are usually badly distorted by subjective beliefs concerning the injection procedure and the reputation that hormones contain such vital life-giving properties.6 When the laboratory does verify the climacteric syndrome, there is a demonstrable decline in excretion of 17ketosteroids. The administration of testosterone has been of value, but often it has a placebo effect. Until some method enables us to determine more frequently that gonadal insufficiency, if any, in a man between 40 and 65 is producing any symptoms similar to those of the menopause in women, one should rely upon competent psychotherapy rather than trials at organotherapy based on wishful thinking, hope, and suggestion. Although the administration of male sex hormone temporarily produces a period of sexual rejuvenation, it becomes evident that the patient's most effective psychic equilibrium is maintained after the discontinuance of hormone therapy.7 Sexual activity in the aging male should continue, although reduction in frequency and performance might be expected. It is estimated that over 60 percent of married men in their 60s continue to function sexually in a satisfactory manner. This percentage is reduced in males who have lost their spouses, and this may be accounted for by the difficulty in securing a willing partner.8 Chronic prostatitis and prostatosis have been blamed for impotence and premature ejaculation. This condition can be present with or without evidence of infection. Treatment with antibiotics and massage has been helpful. However, there is a feeling that massage is actually a form of psychotherapy. Certainly, sexual intercourse or masturbation two to three times a week is a far more effective way of emptying the prostate and more pleasurable than pressure by the urologist's finger. It may be stated that masturbation is practiced by many healthy individuals. Premature ejaculation is the most common of male sex dysfunctions and
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 9, 1978
can be treated by explanation of the problem and reassurance. The following recommendations could be helpful: (1) earlier stimulation of the female, (2) change in position during intercourse, (3) reduction in number and vigor of thrusts, and (4) use of a condom, tranquilizers, or local anesthetics.1 The techniques used by Kaplan9 are: 1. the stop-start technique, and, 2. the squeeze technique. In the first method, the man lies back and just concentrates on his sensations while the woman stimulates him manually. When he is near ejaculation, stimulation is discontinued for a few seconds for the feeling to abate; then the woman begins to stimulate him again, and so on. During the fourth cycle he usually ejaculates. When the couple can do that, they go through the same procedure using petroleum jelly to produce a more intense stimulation similar to that felt with the penis inside a vagina. When he feels confident about this, they proceed to the female superior intercourse, with the man regulating the woman up and down, using the same stop-start technique. The squeeze technique differs in
that when the point of ejaculation is reached, the woman squeezes the penis immediately below the frenulum, which makes the man lose about a third of his erection. It is uncomfortable sometimes. Many women object to it and the first technique mentioned works equally well. In any case, if a couple uses squeezing most men will acquire very good ejaculatory control within a few weeks. Some of the conditions which lead to premature ejaculation are: hyperirritable glans penis, hyperirritable verumontanum, and chronic congested prostate. Another sexual dysfunction is retarded ejaculation (ejaculatory incompetence). Here the man has no orgasm or takes on excessive amount of stimulation before he does. This is due to an involuntary inhibition of the orgastic reflex seen commonly in very religious men. Retrograde ejaculation may be encountered in diabetics, following sympathectomy, transurethral resections of bladder neck, and following prostatectomy. A recently developed surgical procedure on bladder neck offers some hope for such patients.
Finally, surgery has a role in cases of erectile impotence. If a patient has good libido, a willing partner, and no psychiatric problem (clearance), placement of an intrapenile plastic prosthesis, eg, Small-Carrion,10 Scott," should be considered. Literature Cited 1. Karafin L, Kendall AR: Psychosomatic problems in urology. In Karafin L, Kendall AR (eds): Urology, vol 2. Hagerstown, Md, Harper and Row, 1975, p 6 2. Masters W/H, Johnson VE: Human Sexual Inadequacy. Boston, Little, Brown, 1970 3. Newman HF, Northrop JD, Devlin J: Mechanism of human penile erection. Invest Urol 1:350-353, 1964 4. Kaplan HS: Sexual medicine. Hospital Tribune, March 15, 1975 5. Amelar RD, Dubin L: Infertility in the male. In Karafin L, Kendall AR (eds): Urology, vol 2. Hagerstown, Md, Harper and Row, 1975, p 16 6. English OS: The psychosomatic approach in urology. In Campbell MF, Harrison JH (eds): Urology, vol 3. Philadelphia, WB Saunders, 1970, p 2047 7. Tauber ES, Daniels GE: Hormone Therapy in Climacteric Men. Psychosom Med 3:72, 1941 8. Finkle AL: Sexual function during advancing age. In Textbook of Geriatrics, Philadelphia, JB Lippincott, 1969 9. Kaplan HS: Sexual medicine. Hospital Tribune, March 18, 1975 10. Small MP, Carrion HM: Small-carrion prosthesis: A new implant for management of impotence. Urology 5:479-486, 1975 1 1. Scott FB, Bradley WE, Timm GW: Management of erectile impotence: Use of an inflatable prosthesis. Urology 2:80-82, 1973
Notional *u1979 NMA Convention The 84th annual convention and scientific assembly of the National Medical Association will be held in Detroit, Michigan from July 29-August 2, 1979. The scientific program will include Aerospace and Military Medicine, Anesthesiology, Basic Science,
Community Medicine, Dermatology, Family Practice, Internal Medicine, Neurology and Psychiatry, Obstetrics and Gynecology,
Ophthalmology, Orthopedics, Otolaryngology, Pediatrics, Physical Medicine and Rehabilitation, Radiology, Surgery, and Urology. T N IONCE A
1895
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 9, 1978
673
