"How's Your Love Life?"

Male Sexuality and Impotence

Dr.Joe's Data Base

"How's your love life?"
That's a question many of us have heard, often in a casual,
off-handed way. But if we're having problems with sex, it's not a
joking matter. And the fact is, a lot more of us are having
trouble than most people imagine.
The latest statistics suggest that as many as one out
of ten adult American males have problems with sexual inadequacy.
Among certain groups the percentage is even higher. For example,
adult male diabetics may have erection problems up to 50% of the
time. Men with disorders of the arterial system heart disease,
hypertension and vascular disease may have an even higher
likelihood of being unable to function well sexually.
In some men, the problem is a complete inability to get an
erection. The system simply does not work. More often, the
problem is a partial one. A man cannot depend on an erection
each time he wants one, the erection is not hard enough, or the
erection does not last long enough for mutual satisfaction. In
these situations, sexual intercourse can present insurmountable
difficulties, and attempts at it can be the source of anxiety and
unhappiness. Of course, this affects not only the men, but their
partners as well.
What we are talking about here is impotence. Not only is
impotence more common than most of us suppose, but nowadays it is
much more treatable than ever before. The first step is to take a
good look at our own situation. If there's a problem, ignoring it
won't help.
In this section of the book we'll examine how men are able
to achieve erections, and we'll try to shed some light on why
some men cannot function well. We'll discuss what can be done to
correct serious problems and then we'll consider some simple ways
to make sex more exciting, more satisfying and more enjoyable for
both parties.

How does a man have an erection?

In the human body, male or female, there's no other organ
that works the way the penis does. When a man is sexually
aroused, his penis changes from a limp phase to become longer,
wider and heavier. Most importantly, it becomes firm or rigid,
allowing penetration to occur. For both men and women, of course,
this process provides a high degree of pleasure.

First, let's take a look at how the penis functions when we
are not sexually aroused.
In this state, a small amount of blood trickles into the
penis, bathing the spongy tissues in the two erectile chambers of
the penis, which are called the corpora cavernosa (literally,
"spacious bodies.") There is just enough blood flow to furnish
oxygen and nutrients to the tissues. The blood then readily
leaves the corpora through tiny veins, and returns to general
circulation. Since there is little pressure in the spongy
tissues, the corpora are not filled out, and the penis is limp.

The process by which a man gets an erection depends on
increasing the blood flow into the chambers of the penis, and
then trapping the blood inside. This fills and expands the spongy
tissues and causes the entire penis to become firm.

But what makes more blood flow in? This is the role of
sexual stimulation or "arousal." All forms of sexual stimuli work
through the nervous system, and they depend to some degree on
testosterone, the principal hormone made by the testicles.
Testosterone is necessary for male sexual functioning. Without
sufficient quantities of this hormone, men cannot be sexually
stimulated, nor can the internal structures of the penis function
properly.
So, when testosterone is present in sufficient quantity, a
man can be "turned on" by any number of stimuli. For example, the
stimuli can be visual, they can be tactile (touch), they can be
sheer fantasy or even certain fragrances. The brain sends a
series of nerve signals to the penis and, under ordinary
conditions, an erection develops.
The proper nerve signals cause the tiny arteries bringing
blood to the penis to widen, allowing more blood to enter. These
same nerve signals also cause the muscular walls of the spongy
tissues to relax. Then, as the spongy tissue fills with more
blood under pressure, the tiny thin-walled veins leading blood
out of the penis are squeezed shut. The spongy tissue and the
corpora cavernose actually beings to trap blood inside itself.
To bring about real rigidity, we require one more anatomical
component, the muscles located at the base of the penis. When the
penis is stimulated during sexual activity, these muscles
contract. They squeeze the corpora and raise the pressure inside
to the point of rigidness.

What causes erection problems?

Even from that simple overview, you can see that for the
penis to do its job, a lot must happen. We need the proper
stimulation from the brain and nervous system. Male hormones must
be secreted in the right way and in the correct amount. Most
importantly, the heart must pump blood through the arteries to
the penis and certain muscles and tissues must respond in very
precise ways to make certain that blood does not escape too
readily.
With all these physical factors at work, it may seem odd
that until fairly recently, many doctors believed that impotence
was all or mostly "in the mind." A popular home medical guide
published in 1973 deals with impotence under "Emotional and
Mental Illness" and mentions only "counseling or psychiatric
help" as treatment.
Today we have a better understanding of the physiology
involved. We find that although psychological factors often come
into play, by far the most common causes of impotence are
physical parts of our body are not working the way they should
be. Nowadays there are specialists, usually urologists, who can
treat many of these conditions. The majority of patients can be
restored to sexual potency. The type of treatment, of course,
depends on the precise cause of the problem and on the motivation
of the patient.

We have seen how an erection depends on the flow of blood.
Consequently, it is easy to understand how any problems with the
blood flow not enough blood entering the penis or blood flowing
out too quickly can seriously affect our ability to achieve and
sustain an erection.

Why do diabetics suffer from impotence?

Just one year after Sidney M. found out he was diabetic, he
began having difficulties in sexual intercourse. At first, he
noticed that his erections were less firm. Soon he could not
maintain an erection long enough to satisfy himself or, for that
matter, his wife June. Eventually, both husband and wife realized
that Sidney had become impotent.
At this point, they sought help from a urologist
specializing in sexual dysfunction. When the evaluation was
completed, the doctor determined that the cause of Sidney's
impotence was his diabetes.
Men with diabetes often have a malfunction of both the
nerves and the blood vessels involved in the erection process.
Not only may the signals that stimulate the penis not arrive
properly, but the blood vessels bringing blood to the male sexual
organs may be blocked. In addition, current research shows that
the trapping mechanism which keeps the blood from leaving the
penis too quickly is very sensitive to blood vessel damage of the
type found among diabetics.

What drugs are available to treat impotence?

Papaverine is a medication commonly used by vascular
surgeons to prevent spasm in tiny blood vessels. It has also
become a common treatment for impotence. Papaverine increases
blood flow in the penis and helps to trap blood inside the
erection chambers. Self-injection therapy with this drug (and
with Prostaglandin-caverject) has revolutionized the treatment of impotence for
men with diabetes as well as a variety of other physical
disorders.
This new form of treatment, Pharmacologic Erection Therapy,
was selected by Sidney and his wife in consultation with the
urologist. Just before having sex, Sidney injects himself with a
dose of the medication directly into the penis. With sexual
stimulation, he is able to achieve a quite normal and satisfying
erection, and he becomes capable of having intercourse. Sidney
and June are often able to achieve a satisfying climax together
because Sidney's erection lasts until the medication's effect
wears off, usually up to a half hour. Since he had already
learned to use insulin to treat his diabetes, Sidney was easily
able to adapt a very similar technique to administering
Papaverine. He and June now have intercourse on average once or
twice weekly. In his words, "Sex has not been this satisfying
for either of us in ten years!"

Sexual dysfunction in men may also be caused by cardiac and
peripheral vascular disorders, high blood pressure and its
treatment, hormone imbalances and emotional difficulties. These,
in turn, may accompany diabetes.
Despite Sidney's success, not every man is a suitable
candidate for self-injection therapy. The treatment demands
motivation and careful attention to injection technique. There
are potential side effects, which include infection, scarring of
the penile chambers, and even a painful prolonged erection. In
addition, Pharmacologic Erection Therapy will not work in all
cases. There are also many individuals and couples who feel that
this technique is not spontaneous enough for their needs and
desire a more permanent means of overcoming impotence. Medical
science is constantly exploring new treatments for impotence and
your doctor may be aware of some of the medications which can be
effective in treating this condition.
The bark of a tropical tree yields a drug called Yohimbine,
which can also help certain men by increasing penile blood flow
and improving the "venous trapping mechanism". Yohimbine tablets
have improved sexual functioning in many men, usually in
situations where the loss of sexual function is only partial.
In a few cases, hormone therapy may be advised. If blood
tests show elevated levels of prolactin, there is medication to
control this erection-inhibiting hormone. For those with low
testosterone levels, supplemental injections may be considered.
However, the potential of harmful effects is considerable, so
testosterone therapy is only rarely recommended.

Is there an external therapy for impotence?

One of the more recent and popular methods of dealing with
an erection problem is with an External Vacuum Device. Quite
simply, this is a plastic cylinder with a hand pump attached. The
limp penis is placed inside the tube, then air is drawn out
through the pump. Creation of a vacuum outside the penis allows
blood to rush in and fill the corpora cavernosa. A tension ring
is placed around the base of the penis to maintain rigidity for
up to 30 minutes.
Thousands of men have used external vacuum devices, and many
with good success. But, they are not suitable for everyone. For
example, this technique is not recommended for men who have had
injuries to the penis, sickle cell disease, leukemia, pelvic
infections or blood clotting difficulties. Some men as well as
their partners object to the limits it may place on foreplay and
romance. Still, external vacuum devices are usually safe,
relatively inexpensive and simple to use.

Are there permanent solutions to impotence?

Sometimes simple treatments are unsuccessful. At other
times, men are dissatisfied with non-surgical solutions. In such
cases, the best course is usually a Penile Implant.
Also called a penile prosthesis, an implant is surgically
placed into the corpora chambers of the penis. It provides enough
firmness and substance to the penis so that a man can engage in
satisfactory sexual intercourse. In general, the sensations sur-
rounding sexual activity do not change after an implant, nor does
a man's ability to achieve climax and ejaculation. The erection
resulting from an implant is very similar to a natural one, and
the devices are not visible at all from the outside.
Most penile implant surgery is now done on an outpatient
basis, though some may require a day or two in the hospital. The
recovery period until a man can resume sexual relations is
usually about six weeks. Currently available devices have been
found to be quite safe and reliable. Urologists who specialize in
this form of therapy can provide guidance in choosing the type
that will be best for a particular individual. More than a dozen
different penile prosthetic devices are available, falling into
four general types.
Fully Inflatable Implants have an action that most closely
mimics normal sexual activity. They provide the best overall
results and the greatest degree of patient satisfaction.
However, they are slightly more complicated and more difficult to
install.

The surgeon places two balloon cylinders within the penis
and a small pumping mechanism inside the scrotum. In addition, a
fluid reservoir must be implanted, either in the abdomen or the
scrotum, and these units must be connected by tubing.
To achieve an erection, the man squeezes the pump, which
sends fluid from the reservoir into the balloon cylinders. The
cylinders expand within the corpora, and the penis becomes erect.
At the end of sexual activity, the pump is activated again and
the fluid returns to the reservoir, returning the penis to its
limp state.
The Self-Contained Inflatable Implant works more or less the
same way, except that all the parts are contained in one unit.
One device is implanted into each corpora cavernosa. When the
pump is squeezed, the unit becomes rigid. Pressing the release
valve returns the fluid to its reservoir and the penis once again
becomes flaccid.
Unlike the fully inflatable implant, the self-contained unit
will not expand the girth (width) of the penis. However, its
rigidity is quite sufficient for effective intercourse. The
surgery is slightly less extensive and patient satisfaction is
excellent.
Finally, the most simple and least expensive prosthesis is
the Semi-Rigid Implant. These devices are non-inflatable and non-
expandable, and easiest to implant. They produce a satisfactory
erection and most patients are very pleased with the result.

Implant therapy is usually covered by insurance plans and
Medicare as long as an underlying physical cause of impotence can
be demonstrated. The overall success rate for implants is well
over 90 percent, and most men have no change in sensation, orgasm
or ejaculation. Men are usually able to resume intercourse four
to six weeks after surgery.

A newly developing area for treatment of impotence is Penile
Vascular Surgery. In carefully selected individuals, it may be
possible to actually increase the amount of blood flowing into
the penis, bypassing obstructions in the arteries. In other
cases, the goal of surgery is to decrease the flow of blood
leaving the penis by tying off certain veins. These two surgical
procedures are the subject of much current research and may hold
a good deal of hope for the future.

What can I do to make sex better?

Men who are even slightly impotent want to improve their
sexual function. This can lead to fear of failure. Sometimes
their partners' expectations create tension or anxiety.
Depression, stress and marital problems all can affect our
ability to perform sexually. While most impotence is caused by
physical factors, psychological factors almost always come into
play, sooner or later.
For that reason, whether or not we require medical
treatment, we need to examine the way we approach sex and whether
our lifestyles should be changed to improve our sex lives.
Especially for men and women over 40, these are vital steps to
achieving satisfying sex and improved relationships.
Cut out smoking. Tobacco constricts blood vessels and the
long-term affects of smoking affect all of the tiny blood vessels
in the body. An unusually high percentage of men seeking treat-
ment for impotency are smokers.
Drink less alcohol. Heavy drinking is likely to produce
impotence, sterility or loss of sexual desire in men. Alcohol
does not improve an erection, it prevents one. With increasing
age, it takes smaller amounts to affect us.
Look into the prescription and non-prescription drugs you
may be taking. Blood pressure medications are particularly prone
to reducing our ability to have an erection. Antidepressants,
antihistamines and some ulcer medications also inhibit erections.
In most cases, doctors can prescribe alternative medications that
will improve your sexual functioning.
Relax and have fun with sex. Take a warm bath, maybe with
your partner. Try different positions for sex and you'll find
that some lead to better erections. Ask your wife or lover for
more stimulation, something that older men naturally require for
an erection. Avoid sex when you're tired or tense. Try different
times (especially mornings) and places for sex. Get in the mood
by combining relaxation and stimulation. Get regular exercise.

Urologists are all-too-often consulted by patients who feel
despondent because they've been unable to have intercourse for
years. They've been too embarrassed or afraid to discuss their
impotence. But thanks to recent medical progress there are ways
to treat almost every erection problem, no matter how long it's
been present. With the wide range of treatments available to us
now, it's almost a sure bet that a man's sexual function can be
restored.
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