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Male Sexual Dysfunction, Impotence and Penile Implants by Phalloplasty Surgeon E. Douglas Whitehead, M.D.
Phalloplasty Doctor

This article originally appeared in The New York Times on Thursday, February 6, 1997

How One Man Confronted and Conquered Impotence

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.

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