By Robert Stock
My new doctor told me he was sending over a questionnaire before
my appointment. The first page turned out to be a snap: marital
status, date of birth, education. The next few pages were something
else again: During sexual activity are you preoccupied about
getting and maintaining an erection? How often do you have sexual
intercourse or attempt to have sexual intercourse? Are your
erections straight?
Seeing those questions there in black and white gave me pause:
What had I let myself in for?
I had called the doctor because I hoped he could help me with
a case of creeping impotence. My erections were getting smaller,
softer, and less reliable. I had seen ads for gadgets that promised
to make everything right again and read articles about testosterone
patches that supposedly did wonders for one's libido. I had
my doubts, but I was determined to stop the creep, and that
was how I ended up on the doorstep of Dr.
E. Douglas Whitehead a Manhattan urologist.
He has no lack of potential patients. Some 30 million American
men suffer from partial or chronic erectile dysfunction, as
the doctors call it, and the majority are older than 65. But
only 10 percent of impotent men seek medical help. Many assume
nothing can or should be done; older men often accept impotence
as an inevitable part of aging, which it is not, and buy into
the widespread notion that sexuality in the old is distasteful
and unnatural. Doctors tend not to take the problem seriously.
Most older men don't know what to expect if they seek treatment
or are afraid of the treatment itself. They are often ashamed
to even consider exposing their weakness to strangers.
My generation - I'm 67 - was raised to believe that the performance
aspect of sex defined our manhood. Failure would be crushing,
unthinkable. We were also told that 90 percent of impotence
was psychological.
Somehow, the thought that the problem could be psychological
made it more of a personal failure, something you should be
able to control. Today, the experts say that the vast majority
of impotence in men of any age is organic in nature -- a problem
with blood vessels or the nervous system. When I decided to
seek treatment, I prayed for a physical diagnosis. It would
be like having arthritis or a toothache -- it would mean I was
not to blame.
In men over 65, physical causes are the chief culprit 90 percent
of the time. And once the particular physical problem is determined,
there are effective treatments available -- from vacuum pump
devices to self-administered medications. Several more treatments,
including pills to be taken shortly before sex, are on the way.
The pills, which are still experimental, are likely to change
the whole treatment of impotence. They include one that blocks
the action of an enzyme that prevents erections. Another pill
combats the restriction of blood vessels caused by adrenaline,
and yet another under the tongue, stimulates the center in the
brain that signals for an erection.
But before I could be treated, there had to be a diagnosis.
Impotence has a host of possible causes, including high blood
pressure, diabetes and prostate cancer, and many of the medications
used to treat them.
The urologist's office is a great leveler of men. My first
visits to Dr. Whitehead made it clear, for example, that he
and his staff did not attach the same significance to my penis
that I did. It was merely an object of professional interest,
like a foot or a shoulder -- something to be examined, tested,
its performance noted. Dr. Whitehead, a tall, patrician-looking,
57-year-old, whose surgical career included a tour in Vietnam,
is courteous, concerned and businesslike. Impotence treatment
makes up about 80 percent of his practice; he is also an associate
clinical professor of urology at the Albert Einstein College
of Medicine, and the director of the Association
for Male Sexual Dysfunction, a medical group that includes
physicians, sex therapists and psychiatrists.
Dr. Whitehead started me off with a physical exam and blood
tests, which eventually showed that my testosterone levels were
normal. No patch for me.
Next came a test called the Rigiscan. For three nights in a
row, I went to bed wearing a heavy, battery-laden monitoring
device strapped to my left leg. Two wires emerged from the monitor,
each ending in a loop. I attached the loops to my penis, one
at the base, the other at the tip, and then I tried to sleep.
Men of all ages have erections during the rapid-eye movement
stages of sleep. If mine were measured at the normal frequency,
duration, and rigidity, it would mean my main problem was not
organic but psychological -- something in my head was overriding
my body's normal sexual reactions. For the first time that I
can remember, I prayed to fail a test.
A few days later in his office, Dr. Whitehead took a gulp from
a can of Diet Black Cherry and delivered the verdict. "I'm afraid
you had only infrequent erections, and they were poorly maintained,"
he said.
I was delighted -- even though I knew it meant something physical
was wrong.
Then the nerves in my penis were tested. An aide touched me
here and there with a mechanical wand and asked if I could feel
any vibration. I did, and she pronounced my nerves normal.
The next test called for the penile injection of a drug called
alprostadil, which is supposed to stimulate an erection. Sitting
alone in an antiseptic waiting room, I waited, and eventually
the drug did its job. Then a technician used an ultrasound machine
to check the state of arterial blood flow in my penis. The report:
"A certain degree of impairment."
Difficulty with penile blood flow is the most common cause
of impotence, Dr. Whitehead said. Then, with plastic models
and full-color drawings, he proceeded to explain my options.
Last November, a panel of the American Urological Association
listed five potential therapies. The three it recommended --
and which Dr. Whitehead suggested I consider -- are all covered
by Medicare and medical insurers. The two that failed to pass
muster or had very limited benefits were yohimbine, a drug that
can be taken orally, and surgery to correct defective penile
veins or arteries.
One approved treatment is a vacuum device that consists of
a plastic cylinder that looks like a test tube with a pump attached.
The patient places the cylinder over his penis and pumps the
air out, drawing blood into the penis an creating a erection.
An elastic band is then placed around the base of the penis
to maintain the erection.
Surgical implants are another option. One kind is a pliant
rod that keeps the penis somewhat distended and can be raised
or lowered at will. Another kind is more complicated: two inflatable
cylinders are set in the penis, a reservoir of liquid is implanted
in the abdomen or scrotum, and a pump is placed in the scrotum.
When the pump is squeezed, the liquid from the reservoir fills
the cylinders, and the penis becomes erect. Squeezing a release
bar near the pump returns the fluid to the reservoir.
The third approved treatment is the penile injection called
Caverject, which was used as part of my ultrasound test. The
self-injected alprostadil relaxes the smooth muscles in the
penis and expands the arteries to improve blood flow.
I considered the advantages and disadvantages of each treatment.
The surgical implants require no rigmarole -- no pumping or
injecting. The inflatable version provides a natural looking
erection. But implants are invasive and subject to mechanical
failure (though it is rare). And surgery was more than I was
ready to think about.
The vacuum pump is simple to use and noninvasive, but it is
cumbersome and provides a wobbly erection because the vacuum
does not affect the half of the penis within the body. And the
band should be left on for no more than 30 minutes at a time.
I finally chose the Caverject. There are needles, of course,
but they are short and fine, and virtually painless. Erection
occurs within a few minutes and lasts an hour or so. I am more
than content.
Last month, a new therapy called Muse entered the market. It,
too, is self-administered and relies on alprostadil, but instead
of being injected through a needle, the drug is delivered by
a tiny plunger that is slid an inch or so down the urethra.
The development of tests and treatments, as well as the growing
number of sexually active older people, has spurred the establishment
of hundreds of impotence clinics around the country, as well
as 55 chapters of the support groups Impotence Anonymous and
I-Anon, for their partners; information on nearby chapters of
either group is available by calling (800) 669-1603.
The availability of more clinics and programs to aid the impotent
is having a positive effect on public attitudes, said Dr. Troy
A. Burns, the medical director for the Diagnostic Center for
Men, based in Kansas City, Kan.
These clinics are mainly staffed with primary-care physicians.
Dr. Burns says that the Kansas center is the largest in the
field, with 30 clinics in 18 states.
"People are beginning to understand," he said, "that impotence
in the old is not automatic, something they should expect and
accept. Much can be done."
I can vouch for that.
