INABILITY TO GET "HARD"

Dr.Joe's Data Base

Worry is the first time you can't do it a second time;
panic is the second time you can't do it the first
time.

Although many sexual topics are now "out of the
closet," impotence is still a subject that arouses fear
and anxiety in many men and women.

This emotional reaction is further strengthened by the
lack of knowledge on the part of patients, their
partners, and health care professionals. Most people
were never taught about the erection process in school,
let alone given accurate information from other
sources. Much of the knowledge about penile anatomy and
physiology has only become available in the last five
years.

Sometimes impotence is all in the head

Ignorance, fear, a lack of information, embarrassment,
and anxiety provide a fertile breeding ground for
sexual problems. While some problems related to the
ability of the penis to become hard and ready for sex
are tied to physical problems, some cases of impotence
are linked to psychological issues.

Even when impotence is tied to physical problems, there
can be psychological underpinnings that must be
addressed with successful treatment of the physical
causes. For example, many couples have serious
emotional reactions to the loss of erectile ability and
to what they believe it represents, and have adjusted
their relationships to explain and compensate for their
emotional problems. When treatment of the impotence is
successful, there still are the underlying relationship
problems that need attention.

Our goal at the Male Health Center is to restore a
healthy physical and emotional outlook to the patient
and his partner and therefore improve their ultimate
satisfaction with successful treatment of impotence.

In order to achieve this goal, it is important to:

* Educate: explain in detail the mechanism of
erections and the many causes of problems; dispel
any myths that may exist concerning erections.
* Try to get the partner involved in the process.
Such participation enhances communication and can
identify sources of stress and anxiety for
everyone.
* Perform accurate diagnosis of the physical and
emotional aspects of the erection problem.
* Educate partners on alternatives for treatment and
the expected outcome and risks of each treatment.
* Help the couple define a plan for rebuilding their
sexual and emotional relationship based on their
own particular physical and emotional
circumstances.
* Continue to support couples with counseling in
adjusting to their new situations and reevaluate
them in case of future difficulties.
* Prevention: address factors that can either now or
in the future complicate or cause erectile
problems such as smoking or high cholesterol.

What causes an erection?

During an erection blood fills two chambers in the
penis and is trapped there. The erection begins when
the arteries open up as the smooth muscles of the
vessel walls relax.

The veins which drain the blood then close down and
prevent blood from leaking out. A man must have an
adequate blood pressure to carry blood into the penis,
and can have no leaks in the veins of his penis that
will allow the blood to escape.

The nerves are the control mechanism which coordinate
the increase in pressure in the penis as well as the
closing down of the veins. A man needs sufficient
levels of testosterone in order to have the desire,
feel aroused, and to get an erection.

Any physical or emotional factor that affects a man's
arteries, veins, nerves, or hormones can impact his
erections. A man must allow himself to relax in order
for the blood vessels of the penis to also relax so
that he can get and maintain an erection.

A discussion of the problem followed by a physical
examination is the first step toward diagnosing the
cause of the problem.

How does a physician detect what might be going wrong?

The starting points of a workup include the following
steps:

* Assessing nerve function is done by pinprick
* Assessing reflexes and toe position.
* Blood flow is measured by assessing pulse and
penile blood pressure.
* Hormone status is assessed by evaluating testicle
size and inspection of the prostate through a
prostate exam.
* Preliminary screening includes blood tests to
audit male hormone level, thyroid function,
presence of diabetes and a man's cholesterol
level.
* A stress audit involves a questionnaire to be
completed at home.

A man may also apply a simple snap gauge that can
reveal if the penis is becoming erect during the night.
The normal male has about two or three erections a
night. The snap gauge is a painless tool that unsnaps
when the penis becomes erect, revealing that an
erection occurred when the man was asleep. This can
tell the physician that the man's equipment is working,
and that there may be another cause that is
interrupting the natural erection process.

There may be more specific testing required based on
the results of the physical exam and screening tests.

Is impotence just a symptom of old age?

According to Masters and Johnson, at least 25 to 30
percent of people in their 60's have intercourse at
least weekly...and that's not weakly.

There are normal changes in a man's sexual function as
he gets older, but these are not impotence and do not
mean he is going to lose his erectile ability (in other
words, you don't wear out your penis.) These changes
come on slowly and include:

* Taking a longer time to reach an erection.
* The erection being slightly less firm than when he
was younger.
* An increased ease in delaying orgasm and
ejaculation (a positive change for many couples).
* A loss of force in ejaculation.
* A decrease in volume of the fluid ejaculated.
* The erection being lost more readily after orgasm.
* An increase in the amount of time it takes from
orgasm to the time that a man is able to get
another erection.

Most men and women are able to adjust to these changes
and still have a perfectly satisfactory sexual
relationships. Although a man of 60 may not be able to
run a mile as fast as when he was 18, he should be able
to cover the distance and may even enjoy the scenery
more. The same goes for his wife, especially since she
may appreciate the increased ease with which he can
delay ejaculation.

A few additional important facts are:

* Most men experience erection problems at some
point in their lives due to job, alcohol, stress
or mental problems.
* Past sexual practices, including masturbation, do
NOT cause impotence.
* An occasional problem does not mean a man will
develop a chronic condition.
* Physical factors can directly affect a man's
ability to get and maintain an erection.
* The mind is very powerful and a man with or
without any physical problem can sabotage his
erections just by worrying about his ability to
perform.

The important point to remember is that sexual intimacy
need not end when you become a senior citizen. And,
finally, if you or your partner have an intimacy
problem in this day and time, you need not suffer any
longer as successful treatment is readily available.

What a man thinks when he is unable to "get hard?"

Many men view impotence as a real challenge to their
self-esteem. Furthermore, many men believe a number of
myths surrounding potency problems. Some men may fear
they themselves have caused their erection problem by
past actions such as infidelity or masturbation.

A man may have feelings of guilt because he no longer
fulfills what he views as his role as a man. It is also
common for a man to fear that impotence is the first
sign of his physical decline toward old age and death.
Most men, even when they admit there is a problem, are
reluctant to ask for help.

How some men think about sex:

* Men shouldn't express certain feelings.
* Sex is a performance.
* A man must orchestrate sex.
* A man always wants and is always ready to have
sex.
* All physical contact must lead to sex.
* Sex equals intercourse.
* Sex requires an erection.
* Good sex is increasing excitement terminated only
by orgasm.
* Sex should be natural and spontaneous.

In this enlightened age, the preceding myths no longer
have any influence us.

How does stress relate to impotence?

Stress is defined as any mental or physical demand that
is placed on a person. Stress comes from "good" things
as well as events labeled as "bad." Adrenaline is an
erection buster. Adrenaline is fine when we're cheering
for our favorite team or in the middle of a heated
argument...certainly not when we'd want to get an
erection.

A person's reaction to stressful events is
physiological. Stress can cause a man's heart rate to
increase, and it can elevate blood pressure, increase
muscle tension, and speed breathing. This phenomenon is
called the "fight or flight" response.

What some people don't know is that stress can pile on
and cause a cumulative effect. Constant arousal due to
stress, can affect sleep, energy level, and
concentration, as well as sexual desire and
functioning.

Most patients and their partners are not surprised that
stress can cause an ulcer or a rise in blood pressure.
They are often surprised, however, that these factors
can have an effect on erections. A man's normal
response to stress, such as being afraid or angry, is
for the nervous system to move blood away from
"nonessential" activities and into muscles so that he
can either fight or get away from the situation.

Ironically, fear of not being able to achieve an
erection can actually cause an impotence problem.
That's because if a man thinks that he is not going to
get a erection, his body may respond to this belief by
shunting blood away from his penis, thus making his
erection go away.

How can a man relax and let things happen naturally?

It is a widely accepted fact that for a man to have
sexual desire, to be able to be aroused to erection and
orgasm, he must feel relaxed.

Our emotions about a given situation are determined by
what we think about that situation. This is called the
ABC's of thinking and feeling:

* A The situation.
* B. The thought or label about the situation.
* C. The emotional outcome that results from how one
labels the situation.

For example, if the situation (A) is that a man is
going to have sex, the thought (B) is that he is
worried about being able to function, then the
resulting feeling (C) is that he is anxious.

As a man moves from pleasure and relaxation to
performance and anxiety, the chances of problems
increase. In other words, the concerns or fears of
being able to perform are sufficient to produce anxiety
and result in a lack of ability to attain or maintain
an erection.

All men have a psychological reaction to an erection
problem even if its cause is primarily physical.

What do women think when a man can't get hard?

When a man has an erectile problem, the couple has a
sexual problem.

The women in the relationships frequently have
questions, doubts, resentments, insecurities, and a
need for information, understanding, and reassurance.
Too often the man alone is seen as the patient and his
partner is - at best - barely acknowledged, and - at
worst- merely tolerated or even discouraged.

It is not enough if the partner's participation is
limited only to hearing the patient's interpretations
of the doctor's replies. Filtering information and
questions through the patient to the woman can lead to
misunderstanding and unhappiness. The woman's own
concerns and questions must be addressed. Unlike many
areas of medicine where only the patient is treated,
with erection problems both members of the couple need
to be considered.

Sometimes a woman, raised on the myths of men as highly
sexual and always ready, sees her partner's erection as
an emotional lie detector. A woman may view an erection
as proof that a man loves or desires her. Therefore,
she believes the absence of an erection means he
doesn't care, or doesn't find her attractive.

A potency problem can spiral into a major communication
breakdown in a short period of time. A typical scenario
goes like this: a man experiences erection
difficulties, feeling ashamed, embarrassed, and "less
of a man," he withdraws from his partner. With the lack
of ability to perform, it's not uncommon for men to
have a marked drop in their desire or libido. Afterall,
why put yourself in a position where you may not be
able to perform? Over time, he may go so far as to
refuse to kiss her, hug her, even to hold hands with
her, saying, as did one man, " I didn't want to start
anything I couldn't finish." He may start arguments to
avoid sexual encounters. Because he doesn't understand
that he has a health problem, not a character defect,
he may refuse to discuss the issue with anyone
including his partner, his doctor, a friend. Meanwhile,
the partner is feeling rejected, neglected , and full
of self-doubt. She may question her own attractiveness.
She may wonder if her husband still cares for her. She
may even think he is having an affair. She may
withdraw. She is often afraid to bring up the subject
that is so obviously painful for her husband. The
result: each partner is isolated and miserable.
Unfortunately, the Male Health Center has seen
relationships end over this situation.

A number of women whose partners have potency
difficulties feel inadequate. It's not uncommon for a
woman to blame herself. A woman may be fairly open
about her self-blame or she may keep her feelings quite
hidden. A woman may also feel hurt and angry because
her partner has withdrawn from her physically and
emotionally. The relief felt by an insecure partner who
understands she is not to blame can be enormous and can
enable her to more fully participate and support her
partner's diagnosis and treatment.

Medical conditions that may affect sexual intimacy

There are a number of medical conditions that are
associated with impotence. Probably the most common is
the use of certain medications that have side effects
that can affect a man's potency. Examples are drugs
used to treat high blood pressure, sedatives,
tranquilizers, and pain pills. Fortunately, the side
effect of impotence is reversible when the dosage is
altered, or a different medication is prescribed by the
physician.

Medical illnesses that are often associated with
impotence are diabetes, heart conditions and kidney and
liver diseases. There are various surgical procedures
that are often associated with impotence. The most
common are cancer surgery of the colon, rectum,
bladder, and prostate gland.

Most problems of intimacy in the elderly can
successfully be treated. If a woman is suffering from
the problem of estrogen deficiency, then she should
consult with her gynecologist who might prescribe some
form of estrogen replacement therapy. If a man suffers
from impotence, he should contact a urologist who has
sophisticated diagnostic techniques to identify the
cause of the problem and recommend appropriate
treatment.

TREATMENT OPTIONS FOR IMPOTENCE

Oral Medications

Yohimbine is a useful first-line treatment for erection
problems. It appears to help about a quarter of the men
who try it, and side effects are usually minimal.
Currently, medications are being tried in clinical
studies, including a medicine called Sidenafil, which
in Europe has shown excellent preliminary results,
especially in men who have primarily a psychological
cause.

Topical Medications

On the horizon are new methods of applying medicine to
produce erections. Creams rubbed on the skin of the
penis and pellets inserted in the tip of the urethra
are under trial and some show promise.

Injection Therapy

This is a very effective treatment for many men, and
improvement in the drugs have reduced side effects.
Look for prostaglandin E-1 or a combination of several
medications based on prostaglandin.

Vacuum Devices

Devices that produce erection by suction continue to be
safe, effective, and economical.

Penile implants

Penile implants have been successfully used since 1960
to treat over 100,000 impotent men. Surgery, however,
to insert a penile implant should only be performed in
rare situations. When a man can't or won't succeed with
other treatments, an implant is the last resort. Of all
the approaches, this one caries the most irrevocable
consequences. Once you've had an implant, that's it --
the normal spongy tissue has been damaged and
destroyed, and your chances of ever functioning
normally again are gone.

Just because an implant is the last resort doesn't mean
it's not a good one. A modern implant, when properly
installed in the right patient, can work wonders. It
restores a man's ability to enjoy a full relationship
with his partner, making his life whole again.

Just as there are different types of makes and models
of cars, there are also various styles of implants
available. But the three-piece (two cylinders,
reservoir and pump) models tend to produce the happiest
patients. Besides an expensive surgical procedure,
significant side effects are possible. These include
mechanical failure (reportedly five percent), infection
(devastating, but only two percent), erosion,
migration, intractable pain, and autoinflation. While
some question the possibility of reactions similar to
breast implants, since the fluid is saline, there is no
adverse reaction with the leakage. Furthermore, the
body appearrs to form a capsule around the components,
almost in a self-protective manner.