Medical options
You want to know how I feel, I'll tell you. I feel like an absolute nothing. I know I can satisfy her in other ways and I do, but that's not the point. I feel like the masculine center has been taken out of me - Man, 51
I'm the one who feels impotent. I feel unattractive and undesirable because I can't arouse the man I love. If this isn't fixed soon, I'm the one who's going to need pills ... maybe Prozac. - Woman, 55
I feel like a new man, better than I have in years. Being able to function again sexually has given me a new outlook on life and made my marriage 100 percent better. - Man, 46
If you have difficulties with erections, you belong to a very large group of men. It is estimated that twenty million to thirty million Americans suffer from some kind of erection difficulty. Although erection problems are found at all ages, they become more common with age. A recent study found that 52 percent of men between the ages of forty and seventy had some degree of erection problem. Knowing these statistics won't fix your problem, but you may feel better knowing you have lots of company.
While any problem with sex is upsetting to a man, nothing generates as much concern, anxiety, shame, and even terror as an inability to get or maintain erections. Nothing except the loss of his job can make a man feel less of a man. The primary meaning of impotence, the term traditionally applied to erection difficulties, is "a lack of power, strength and vigor" - the negation of all that we consider masculine. Men have been taught to tie their self-respect to the upward mobility of their penises, and when their penises don't work they feel lost.
A man in therapy said it like this: "I've never felt like this before. I just don't feel like a whole person, and certainly not like a man." Other men have used terms such as "useless" "hopeless," "fraud" "lost my manhood," and "can't cut it anymore" to describe how they felt when their penises weren't functioning.
Women are often baffled by the agony a man goes through when he fails to get or keep an erection, but they have no parallel experience with which to compare it. A woman can participate in intercourse or any other sexual act without being aroused or even interested. If she does not lubricate sufficiently, artificial lubrication can be brought to the rescue. She may not have an orgasm, of course, but at least she can go through with the act and give her partner pleasure. A man is in a more difficult situation. Because of the incorrect belief that sex demands a rigid penis, he feels that nothing can rescue him. His "failure" is obvious, dangling in full view. There is no way to fake an erection, and it is difficult (though not impossible) to have intercourse without at least a partial erection.
His partner may be sympathetic and supportive, but he may be so consumed with self-loathing that he can't accept what she offers. Many men distance themselves from their partners after such "failures" and engage in much self-flagellation. The result is usually a miserable time for all concerned.
Over time erection problems typically bring about a horrible equality of feelings for the man and his partner. She feels as powerless to remedy the situation as he does and often blames herself, thinking she's not attractive or skilful enough to arouse him. She starts feeling unattractive, undesirable, and unloved. The way out of this mess is for the partners to turn toward each other: to talk about what's going on, to understand and empathize with what the other is going through, and to look together for a solution. But often the partners turn away from one another, alternately blaming themselves and the other. This, of course, tends to make the situation worse instead of better.
Given all the feelings men with erection problems have, clear thinking becomes difficult. Yet such thinking is exactly what's necessary, because you have to make some decisions about how to deal with your situation. It may help you to feel better to realize that given the various treatment options available, there is almost certainly a solution for you. You can further improve your state of mind by focusing on your virtues as a lover and a human being and by reminding yourself that you are still a worthwhile man regardless of how your penis has been acting.
There are a number of ways in which penises disappoint men. Almost all men have had at least a few experiences when they wanted an erection and didn't get one or when they lost an erection at some embarrassing point. Some men have problems with getting or maintaining erections at the beginning of a relationship. Then, after they become more comfortable with their new partners, erections become more reliable. Because these kinds of difficulties are common and transient, it's best to view them as a part of life rather than as problems. A man can explain to a new partner that it takes him a few times to get comfortable enough for his penis to join in the fun or, perhaps better yet, he can put off getting into sex until he feels more comfortable with her. And some men are now taking Viagra to help break the ice with a new partner.
There are also more chronic difficulties.. Some men usually have difficulty attaining erections, while others have trouble maintaining them. For still other men, the problem is that their erections aren't as hard as they would like. And there are men who don't get erections at all, regardless of the kind of stimulation.
There are basically three ways to resolve erection problems. One consists of various medical, pharmaceutical, or mechanical interventions, the most recent and best-known of which is Viagra. The second is sex therapy, the third is a combination of the first two.
Before getting to these options, however, you need to know more about the nature of the problem. Some erection problems are primarily physical or drug-related in nature, some are primarily psychological, and a majority have both physical and emotional components. The cause does not necessarily dictate the treatment - you can try any treatment you want but this information can be very helpful. For instance, if your problem is due to a medicine you're taking or to not having enough testosterone, going through sex therapy would be a waste of time. So please attend to the following questions.
WHAT CHEMICALS ARE YOU PUTTING INTO YOUR BODY?
This includes any and all chemicals, including prescription and recreational drugs, alcohol, and nicotine. There are a host of drugs that contribute to erection problems. If you are taking any of the suspected drugs, adjusting the dose or switching to another drug is possible. If you're taking a recreational drug on the list, you should consider getting off it and at the same time look at the available medical and therapy interventions.
Don't forget to consider your intake of alcohol. Social drinking or having "just a few drinks to relax" may inflame desire but kill erections. And long-term alcoholism - which can destroy testicular cells, lower testosterone production, and increase the production of female hormones - has serious negative effects on penises and sexual desire.
Smoking tobacco is another risk factor to consider. Studies show that smoking contributes to the hardening and clogging of arteries, including the ones that supply blood to the penis. Smokers have far more potency problems than nonsmokers.
DO YOU DESIRE SEX WITH YOUR PARTNER, YOURSELF, OR ANYONE?
If your appetite for sex is intact, we can assume your hormones are in working order and there is no need to get tested. But if your desire is low or nonexistent - if you don't notice attractive women, don't fantasize about sex, don't want to masturbate or have sex with a partner - it may well be that your testosterone level is deficient. Testosterone is the desire hormone in both men and women. When its level goes below normal, as it can for a number of reasons, desire significantly decreases or disappears. It's difficult to have a functioning penis in the absence of desire.
If your desire and penis are both in the doldrums, you should schedule an appointment with your regular doctor or a urologist to get a blood test to determine your testosterone level.
Unfortunately, different doctors and different laboratories have different criteria for what they consider normal testosterone levels. And because of the risk that supplemental testosterone can hasten the growth of already existing prostate cancer, some doctors are hesitant to give it. You need to talk openly with your doctor about the test results; if you think you're getting a runaround, seek a second opinion. Supplemental testosterone is usually given by injection, typically every two weeks. But patches and gels are now also available.
Although hormonal deficiencies account for only about 5 percent of erection problems, they are often overlooked, especially in young people.
When hormone injections or patches are used, the results are often quick and dramatic. "The difference between day and night" was how the wife of a client who previously had no interest or erections put it after his first testosterone injection. "In the past I couldn't get him to have sex no matter what I did," she continued. "Now he's the one who says we can be late to work because we have better things to do first. I love it."
Advantage
If low testosterone production is the cause of your desire and erection difficulties, testosterone is exactly what you need and will probably resolve the problem.
Disadvantage.
Although there is no evidence that testosterone injections cause prostate cancer, they can speed the growth of a cancer that's already present, especially in men who do not suffer from testosterone deficiency.
A relative lack of desire and trouble with erections can also be the result of depression. By depression I mean a definite sense over a period of at least several weeks that life isn't worth living and things aren't going to get any better (other possible signs are increased irritability, diminished pleasure in activities that once were fun, increased or decreased appetite, decreased ability to concentrate on what you are doing, and any kind of sleep problem). One of the signature attributes of depression is a loss of interest in sex and usually other things as well. If you or your partner think you are depressed, you should get yourself to a physician or therapist as quickly as possible. When the depression is treated with therapy or drugs, chance, are good your sexual desire and erections will return.
ARE YOU GETTING AND KEEPING ERECTIONS UNDER SOME CONDITIONS BUT NOT OTHERS?
If you have erections (firm enough for vaginal insertion but not necessarily hard as a rock) by yourself but not with a long term sexual partner, or with one partner but not another, or on vacation but not at home, this strongly suggests that the problem is not primarily physical in nature but instead has more to do with your feelings about one or all partners or your level of stress. This means you can choose any treatment option that you, your partner, your physician or therapist agree on.
DO YOU NEVER GET OR KEEP ERECTIONS UNDER ANY CIRCUMSTANCES?
If you don't get erections at all - while you sleep or on awakening, with your own or a partner's stimulation - this strongly suggests a physical cause or medication side effect. It would probably be a waste of time to try the exercises. As soon as possible, set up an appointment for you and your partner with your regular physician or a urologist.
If you have already tried one or more self-help programs or courses of sex therapy without substantial improvement, you should also see a urologist.
DO YOU GET ERECTIONS BUT USUALLY CAN'T MAINTAIN THEM?
This could mean the problem is either psychological or physical. One of my clients started losing erections in his early sixties. No matter what the activity, he would get an erection and lose it within a few moments. He and his wife of thirty-five years were both puzzled because nothing else had changed in their relationship or sex life. Medical tests demonstrated that although blood was getting into his penis - hence the erections - it was leaking out faster than it could be replaced. He needed a medical solution.
Another client had a different situation. With masturbation or hand or mouth stimulation from his girlfriend, maintaining an erection was easy. It was only when they attempted vaginal insertion that his erection would disappear. This clearly was not a physical or drug-related problem. The real issue, it turned out, was that Larry had serious concerns about commitment, and for him intercourse was the defining act. As long as he didn't have intercourse with Joan, he didn't feel trapped. But deep down he believed that if he had intercourse with her, he would have to marry her. It took several months of therapy before we resolved his fears of commitment. After that, erections were no longer a problem.
BE A WISE CONSUMER
If you're going to see a physician or a therapist, it's important to be a smart consumer. Among other things, this means that you should see the right kind of person. Sad to say, many physicians and therapists have little or no training in sexuality and not much skill with sexual and relationship problems. You want to find someone who is comfortable dealing with sexuality and knows what he or she is doing. Your family physician may or may not be that person; the psychotherapist you're seeing or have seen for another matter may or may not be that person.
Whoever you see, you should review your sexual history, or at least the history of the problem, before seeing the doctor so you can present an accurate and comprehensive picture. And make a list of questions you want answered. Don't let your fear of looking stupid prevent you from asking all the questions you want. The only stupid questions are the ones you don't ask. If the doctor doesn't seem comfortable dealing with you and your situation, isn't willing to take the time you want to discuss your case with you, won't talk to you in language you can understand, or won't answer your questions, go elsewhere.
Whether you see a physician or a sex therapist, I strongly suggest bringing your partner with you. Even though it's your penis, your partner is an integral part of your sex life, has important information to contribute, and should be there to hear the pros and cons of various treatments and to ask any questions she has. Another advantage to having her with you is that she can later help you evaluate the doctor's competence and suggestions.
While you should listen carefully to the doctor's recommendations, they are only suggestions. Every treatment costs money and it's you who will have to live with the consequences. You should get the best therapeutic and medical advice you can, and then determine with your partner what course of action makes the most sense.
It's a good idea to get copies of your test results from your doctor. These can then be shown to any other doctors or therapists you consult. This can save time and sometimes money as well.
DIAGNOSTIC TESTS
If you see a physician, there are a number of procedures that may be employed to determine the exact nature of your problem. First a complete history of the problem should be taken. Some of the important questions are: Exactly what is the problem (don't get erections, get them but lose them quickly, penis is full but not rigid)? Under what circumstances do you get and not get erections? When did the problem start, and how has it changed since then? How is your general health, and what medications are you taking? What about alcohol, nicotine, and recreational drugs? Have you ever had pelvic trauma (being kicked in the balls, falling on the top tube of your bicycle)? These questions are the ones you should address yourself before seeing the doctor or therapist.
Typically a physical examination is also done. This usually includes tests to determine the state of your arteries and blood pressure, since blood flow difficulties may well be responsible for your erection complaints. The physician may conduct a rectal exam to check your prostate gland, since an inflamed or painful prostate can disrupt blood flow or sensation in the penis; a check for anatomical abnormalities of the penis, such as Peyronie's disease (a curved and sometimes painful erection), that can impede blood flow; and a determination of whether the nerves in the penis are functioning normally.
Blood tests are usually taken to determine your level of testosterone. Your blood sugar may also be checked for diabetes, a frequent contributor to erection problems.
Several other tests may be given. One of them is the RigiScan, a device attached to your penis that records its activity while you sleep. Since men usually have erections during rapid eye movement sleep, the stage of sleep when we dream, this is a way of determining if the problem is physical or not. The RigiScan is painless and typically done for two consecutive nights either at home or at a sleep laboratory. Most other tests have the goal of determining if enough blood is getting into the penis require the doctor to inject your penis with a drug, usually prostaglandin, that causes the smooth muscles to relax and the arteries to open, thereby allowing increased blood flow into the penis. (Giving yourself such injections is also used as a treatment.) By using X rays, blood pressure cuffs, and ultrasound, important information is collected about what might be getting in the way of you getting and keeping erections. If these tests don't reveal significant pathology, the problem clearly lies elsewhere.
WHAT MEDICAL OPTIONS CAN AND CANNOT DO
Each of the medical interventions that I describe below can do one thing and one thing only: give you a usable erection when you want it. That's it - nothing more. Compared to what was available twenty-five years ago, that's miraculous enough, but some people have let their expectations get out of control. The resources we have - Viagra, penile injections, penile implants, vacuum devices, and so on - will change only the stiffness of your penis, but not your personality, behavior, or lovemaking positions or techniques.
Some couples are doing fine even without an erection but would like to have intercourse. All they want from the medical tool is what it can offer. Simone and Paul were such a couple. Even though Paul had developed an erection problem, they still had a wonderful relationship and sex life, with Paul able to satisfy his partner in bed. They had sex frequently and did all sorts of lovely things with their hands and mouths and a vibrator. Nonetheless, they both missed intercourse. After a few sessions with me and some medical tests, it seemed to be the case that Paul's problem with erections was caused by his long-standing diabetes. They tried a vacuum device for several weeks before deciding it wasn't for them. The penile injections they tried next worked very well for them. They tried Viagra as soon as it came on the market, but it was not as reliable as the shots, to which they returned. Because Simone and Paul only needed erections and found a medical tool that provided that for them, they are doing very well.
The situation for some other couples is different. Yes, there's an erection problem, but there are also other issues. Despite what many people think, these resources are not aphrodisiacs and in themselves will not make you desire sex more. (There is one exception. There are some men who have turned away from sex because of their erection problems. Because of the problem, sex was so full of tension and humiliation that they suppressed their desire. With the erection problem resolved, these men become more willing to have sex. But this is the only way in which it can be said that using any of the following tools creates more desire for sex.)
These tools will not help you to talk or listen to your partner or be more sensitive, will not make you a better lover, will not improve sensation or give you a better orgasm, will not resolve relationship tension, and most certainly will not save a failing relationship. All of these considerations may seem too obvious to be worth stating, but strange things happen. A client of mine in his fifties got Viagra, tried it by himself, and found that it worked. His wife was very angry that in the weeks after that discovery he didn't approach her. So he agreed that he would take a pill immediately after our session and make love with her that night. But he didn't. After he took the pill, they made out on the couch, but before things got too interesting he told her he wanted to watch "a few minutes" of the first game of the 1998 NBA playoffs. She went into the bedroom, and two hours later when he had still not come to bed she called me in a state of great distress. We interrupted his game watching and got him on the phone as well. He didn't have an explanation for what had happened, but it was clear that despite knowing that the Viagra he had taken would give him a good erection, despite knowing that his wife was expecting and wanting to make love with him, he chose Michael Jordan over his wife. Urologists and sex therapists, including myself, have talked with men, who have gotten prescriptions for Viagra or vacuum devices which they never filled; others got the drug or pump and never used it. Some men have had surgery to have a penile prosthesis implanted and then never again had sex; some men have had sex only a few times in the years after surgery. Obviously, there is more to many men's "erection problems" than simply not having erections.
There is another issue to consider as well. In some relationships the woman likes not having sex and is actually grateful for the erection problem) perhaps because she didn't get much out of sex when they had it or because she feels estranged from her partner. So she isn't receptive, and may even be horrified, when he presents himself ready for action.
Unless your problem is a very simple one, like Simone and Paul's, consider a few sessions of sex therapy along with your new medical erection helper.
If you have refrained from sex for a long time because of
your problem, it may be difficult to get started again after you have the pill,
pump, or injection. Even though you know you can now get erect, there may be
some shyness or hesitation on your part and perhaps your partner's as well. This
is especially true if there were bad feelings and ugly words exchanged about not
having sex. You may need professional help to get past the bad feelings and deal
with the anxieties and hesitations still present. Start with the simpler and
more familiar with the best sexual positions such as man on top; move on to more complicated sex as your confidence returns.
Another reason to see a sex therapist - get advice and information here -
www.aasect.org - is that most doctors today simply don't
have the time to deal with all the concerns you may have. They may also lack the
training or skill to deal with the relationship issues, anxiety, and other
feelings that accompany erection difficulties. In addition, the female partner
may need to spend anywhere from a few minutes to several hours expressing
how ED affects the female partner - and, more specifically, how angry she is about all the rejections she endured before her man
became willing to deal with his erectile dysfunction. Remember that sex is a
barometer of the health of a relationship: the first thing that disappears when
a couple's relationship begins to fracture is sexual intimacy. And because
co-operation from the partner is essential, the partner is
typically the key to whether any psychological or therapeutic intervention will succeed. If your partner
continually complains about the medical option the two of you have selected - it
doesn't feel natural, it interferes with spontaneity, why can't you get erect
without it, and so on - chances are good that there are still feelings of hurt
and anger that need to be dealt with, in which case, you may wish to make an
appointment to see a psychosexual therapist. if you're in the UK, see
The United Kingdom Council for
Psychotherapy. In America, see
www.aasect.org.
MEDICAL TREATMENTS
I start with the options available before the advent of Viagra that are still useful today, and then take a detailed look at the drug we've heard so much about. All of these therapies are FDA approved, but of course this discussion is not intended as a substitute for an in-depth conversation with your physician.
Yohimbine
A drug in pill form that comes from the bark of an African tree, Yohimbine was, until recently, often the first intervention suggested by physicians for erection problems. It is being used less frequently now because its results have not been impressive: Only about 20 percent of patients received significant benefit. However, side effects - anxiety, headache, and a small increase in blood pressure - are infrequent and generally mild, Yohimbine may be worth a trial if your doctor suggests it.
Advantage.
Yohimbine is safe, relatively inexpensive, and noninvasive.
Disadvantage
It is effective for only a small number of men.
Vacuum Devices
Vacuum pump devices and constriction rings consist of a plastic cylinder that
fits over the penis. You then repeatedly press a lever that pumps the air out of
the cylinder. This creates a vacuum, which draws blood into the penis, resulting
in an erection. When you have a satisfactory erection, you remove the cylinder
after placing a specially designed constrictor band at the base of your penis;
this holds the blood in and keeps the penis erect during sex. The constrictor
band should not be kept in place, longer than thirty minutes. Vacuum devices
work well almost regardless of the cause of the erection problems. A plus for
some men is that they are entirely mechanical and noninvasive. Surveys indicate
that the majority of men who've tried these devices like them and so do their
partners, especially in established relationships. They are a bit cumbersome for
the dating game.
Advantages:
These devices, which can be used effectively by most men with erection difficulties, produce serviceable erections when you want them.
Vacuum devices are inexpensive - a one-time fee of $150 to $450 - and have few side effects.
Disadvantages:
Some users complain that their erections are not as rigid as they want and somewhat wobbly at the base.
Some men experience side effects because of the constrictor band: pain in the penis, numbness and bruising, and painful ejaculation.
You can cause serious damage to the penis if you leave the band on for more than thirty minutes.
Injections of Prostaglandin and Other Drugs
The procedure consists of injecting one or more drugs into the shaft of your penis, just as in the diagnostic test mentioned earlier. These drugs relax the smooth muscles and arteries in the penis, thereby increasing bloodflow. I realize putting a needle into your penis sounds painful, but it usually is not. A very fine needle is used. In some men, however, the medicine itself, not the shot, does cause pain. This method requires a prescription after your doctor determines the correct dose and teaches you how to inject yourself. Within five to thirty minutes after giving yourself a shot, you'll have a very stiff erection that will last from thirty minutes to an hour or longer. Injections have a very high success rate, higher even than Viagra, and often work for men for whom Viagra doesn't. They work with many cases of performance anxiety and also with problems based on physical causes that in the past would have required a penile implant.
The drugs used for the injections can vary. If pure prostaglandin doesn't work or causes pain, your doctor may try what's called a tri-mix, a combination of prostaglandin, papaverine, and phentolamine.
Squeamishness about needles, especially in the penis, has been a tremendous obstacle to the acceptance of this effective therapy. There are two kinds of help available. One is a powerful technique called eye movement desensitization and reprocessing (EMDR). I've used this method with numerous clients to overcome fears of all kinds. Unfortunately, there is no way to do EMDR on yourself; you need a trained therapist.
Other clients have used a little gizmo called a Pen-Inject or Auto-injector. This is a small plastic case in which you insert the syringe after you've loaded it with the dose of medicine you need. You then put the tip of the Autoinjector where you want the injection to go, press a button, and it does the rest. Of course, you're still getting a shot, but it's amazing how much it helps to hide the syringe and needle. One client was so fearful of needles that he started to sweat whenever the topic was broached and was certain that his girlfriend, a nurse, would have to do the injecting. But at the urology consultation the doctor introduced him to the Pen-Inject. My client was so excited, he called me as soon as he got home: "It's not a problem anymore. With this thing, it's not like actually taking a needle. I can do it myself."'
Advantage.
The ability to have good, long-lasting, natural-looking and natural-feeling erections when you want without incurring the cost, pain, and risks of surgery. Injection may work even when Viagra doesn't.
Disadvantages:
Many men don't like to give themselves injections or even think about it. A very high percentage of men who start taking these shots soon discontinue them and seek other treatment. The Auto-Injector can help in this regard.
A small percentage of men experience pain in the penis not from the injection but from the injected agent. This can often be remedied by changing the agent or the mixture of agents used.
There is evidence that over time the injections form scar tissue in the penis in 5 to 10 percent of men, and sometimes cause Peyronie's disease (serious curvature of the penis).
Most men continue to need these shots to get erections. It was once thought that many men would regain confidence after a few shots and be able to have erections without them. Unfortunately, this has proven to be true in less than 10 percent of cases.
Although the risk is small, a few men who inject themselves get priapism, an erection that won't go down, almost always caused by injecting too much medicine. This can necessitate a trip to the doctor's office or a hospital emergency room for treatment. Priapism was more common when papaverine was the drug of choice. With prostaglandin and tri-mix, the incidence of priapism is less than 2 percent.
Although the injections are effective with most cases of performance anxiety, they can be neutralized by massive anxiety.