Impotency is nothing to be ashamed of. Most recent research indicates that one in five men between the ages of 30 and 60 has some degree of recurring impotence, while this condition affects nearly half of all men over 60 years old. In the United States there are approximately 30 million men with impotence, but only 500,000 have sought or will seek help. There is hardly a man who has not experienced erectile dysfunction at some time, and has some anxiety about being able to "perform" on demand.

Loss of sexual potency can have a profound effect on a man's self-image. Some men see themselves as failing both as a lover and as an individual when they can no longer sexually satisfy their partner in this particular way. They may avoid sexual situations and make excuses because sexual problems are often difficult to talk about. Impotency becomes a relationship issue. The partner frequently blames herself and sometimes feels inadequate and unattractive. Anxiety, frustration, and anger often follow.

Many physicians have made this situation worse by assuring that their older patients are not or should not be interested in sex, and they often tell men that impotence is to be expected after the age of 50 or 60. Some doctors even reprimand their patients for wanting to regain sexual potency.

It is a myth that "real men" always want sex, are always "ready" and know how to please a woman. Skills and sensitivity need to be learned and becoming a good lover requires practice and communication. An understanding and supportive sex partner's help in overcoming impotence is invaluable. This is best achieved with good communication, love and affection.

Almost every man, regardless of age, can be helped and can obtain penetration after treatment. Safe, effective treatments are available in almost every case. These treatments could be as simple as changing medication, stopping smoking, eating differently or changing the saddle on a bicycle. Or it could be helped with an insert, pills, patches, injections or a pump. Some patients need a surgical procedure such as a penile implant or repair of blood vessels.

The information in this series is intended to inform you of the causes and of treatments that are available to help regain the ability to have sexual intercourse. Impotency is not a disease in itself, but a symptom of other problems, and it is therefore often necessary to understand and treat the causes.

We will discuss the simple steps that can be taken without ever having to visit a doctor and how to choose a physician who specializes in sexual issues and what to expect on your visit.

Medical treatments, including surgery and alternatives, are discussed in detail together with medicines which are likely to become available within the next few years.

THE CAUSES OF IMPOTENCY

Damage to the blood vessels is frequently the cause of impotency. About 80% of men who are suffering the symptom of impotency have problems with blood flow to the penile arteries and/or problems with the erectile chambers. This can be due to blockages, leakage from the penile veins or problems with the relaxation of the muscles within the penis.

Men who are in this category are the same as those at risk for heart disease; men who smoke, eat a diet high in fat or cholesterol, or those who have high blood pressure. In many instances, these issues should be addressed through diet, exercise and overcoming bad habits, rather than with medications.

Many men have impotence caused by diabetes. As many as three out of four diabetic patients will become impotent. This is a serious medical issue. For answers, please talk to a urologist that has special training in impotency issues.

Medications may cause problems with erections, ejaculation and libido. There are more than 200 prescribed and over-the-counter medications that may cause impotency and other sexual dysfunction problems. About 2% of all impotency is caused by medication. These medications may be those prescribed for high blood pressure or depression. Cold medications, antihistamines, diuretics, hormones such as estrogen, antiandrogens, beta-blockers and tranquilizers can also be a problem. To correct problems with medications, talk to the doctor who prescribed the medicine for your problem. The dosage may then be safely lowered or the medication changed.

Approximately 10% of impotency is caused by damage to nerves or blood vessels from falls, accidents, constantly recurring trauma; and from surgery or radiation treatment for problems such as prostate cancer or bladder cancer. Men who have surgery for bladder or prostate cancer frequently have injury to the nerves that cause erection, even with the so called "nerve sparing" operations. Surgery for certain other abdominal conditions can also cause injury to nerves or restrict blood flow to the penis.

Bodily injury can occur from bike riding or other physical activity. Because the nerves damaged from injury cannot be repaired, medical devices and medicines that will induce an erection are used.

Hormonal and thyroid problems account for about 2 to 3% of impotency. These issues will need to be resolved with help from a medical specialist.

Some men have a combination of these physical causes and psychological causes, such as poor body image, self-doubt and performance anxiety, which will tend to make the impotency worse.

Psychological problems such as relationship issues, depression and poor self-image can be helped with counseling, sex therapy or psychotherapy, and in some cases, medication. Even overwork, fear and stress can cause impotence.

Three other problems that can cause impotency are: Prostatitis, Priapism and Peyronie's disease.

Prostatitis is an inflammation of the prostate that may be effectively treated with antibiotics. However, sometimes this is very difficult to treat.

Priapism is a condition which causes the penis to stay hard and not go down. If left untreated, this can cause internal damage to the erectile chambers. It can be treated if medical attention is sought early, but if irreparable damage has already been done the resulting impotency can often be helped with surgery.

Peyronie's disease is a condition where scar tissue causes penile deviation, so that an erection comes up with a curve or angulation. This could be up to a 90 degree angle, so that sexual penetration is not possible. If this condition persists for more than one year, the treatment is surgery.

IF YOU HAVE ERECTILE DYSFUNCTION
WHAT YOU CAN DO TO HELP WITHOUT HAVING TO VISIT A DOCTOR

The following steps can help, not only with impotence, but also to improve overall quality of life.

Masturbation is an important step on the road to a better sex life. Not only to learn your own sexual responsiveness and to find out what pleases you, but as more erections are achieved, more blood is getting to the penis and this keeps erectile tissue healthy.

Since it helps to have an empathic and sympathetic partner, also consider instructional videos, narrated by therapists. These explain sexual function and may stimulate libido and increase erectile performance. In a recent survey, almost 75% of women thought that it would be informative to watch an educational sex video with their partner.

Instructional videos can be obtained from: The Sinclair Institute: 800-995-0888

The Townsend Institute: 800-888-1900

An informative newsletter: "Sex Over Forty" can be subscribed to by calling 800-285-0444. They also provide educational and sexual products by mail order, including books, toys and videos.

Alcohol in a sexual situation may help reduce inhibitions and can help increase desire. However, it frequently reduces performance and when there is abuse it reduces penile sensitivity and performance both physically and psychologically.

Riding a bike, especially an off-road mountain bike, can cause trauma to delicate nerves and blood vessels. It is important to have a "double saddle" to avoid injury to the blood vessels that go to the penis. Any good sporting goods outfitter or large specialty biking outlet will have information about this item.

These next steps, should be taken as necessary:

1. Stop smoking. Nicotine impedes blood flow to the penis.
2. Exercise more to help with overall fitness and increased blood circulation.
3. Lose weight if there are any problems from obesity.
4. Illicit drugs such as marijuana and cocaine, over the long term, gradually decrease desire and cause impotency.
5. If there is alcohol abuse, dealing with this problem may improve potency and will certainly improve relationship problems.

HOW TO SELECT THE RIGHT PROFESSIONAL TO HELP WITH IMPOTENCY

To treat impotence that has physical causes, it is best to look for a board certified urologist who has special training and experience and has attended postgraduate courses on the subject of impotence or, as a second choice, a primary care physician with special interest and knowledge of sexual problems.

If an implant is recommended, the urologist should be proficient with all types of implants; the choice should be up to you.

If medication needs to be changed, it is best to discuss this with your internist, cardiologist or psychiatrist so that dosages can be reduced or medicines changed to allow normal erections.

If the problem is not physical you should see a mental health professional, such as a sex therapist, marital-family therapist, or psychiatrist with a knowledge of sexual dysfunction.

To help find a qualified physician;

• Call your local medical center or hospital and ask for the Department of Urology. Tell them that you are looking for a specialist in impotence.
• Speak with your primary care physician and ask him if he knows a urologist who specializes in impotence. When you call the urologist it is best if you don't immediately say that you are looking for someone to treat impotence, but instead ask what areas the urologist specializes in. If impotence is one of the first three areas mentioned, you may presume that this doctor treats many patients for impotence or sexual dysfunction, and is better trained and has more experience than doctors who do not have this as a specialty. You may wish to ask how many patients with sexual dysfunction the urologist has treated in the last year. If he has treated several hundred patients then he could be considered an expert.

Until recent years, impotence was looked upon as a natural result of the aging process. Men did not want to admit they had a problem, and most physicians knew very little about treatment. However, in today's society it is attitude and not age that decides whether a man wants to regain his capacity for erection.

It should always be the patient and not the doctor who decides what treatments should be employed, and for that reason it is important to know what options are available.

However, there are some important questions to be answered and medical tests to be taken in order to make a diagnosis. The specialist will first want to find out if the erectile dysfunction is physical and/or psychological and this can usually be aided by a medical, sexual and psychological history.

The medical history taken will cover illnesses, family history, past injuries and whether you have taken prescription, over-the-counter medications or legal or illegal recreational drugs such as cigarettes, alcohol, marijuana or cocaine.

Your physician must perform a physical examination with special attention to the sex organs, lower body and pulses to be sure that the blood vessels and nerves are functioning normally, and to the breasts and hair distribution to note if there may be a hormonal problem.

Minimal lab tests on blood and urine are needed to determine testosterone levels, to detect occult diabetes and for general health screening.

To help make a diagnosis, additional tests may be needed that may include a study of your nighttime erections. The doctor may wish to study the blood flow to the penis and the ability of the penis to retain the blood by giving you an injection of a medication such as Prostaglandin E-1.

TREATMENTS AVAILABLE NOW FOR ERECTILE DYSFUNCTION

Medical and surgical treatment should always be discussed with a urologist who specializes in impotence. You should select a board certified urologist who has special training and has taken postgraduate courses on the subject of impotence.

Several different approaches may be necessary before a completely satisfactory solution is found, and the treatment should always be selected by the patient.

At present there are four different options that may be tried with little risk and with very few lab tests required. These are:

1. Pills,
2. Patches and Injections,
3. Urethral Inserts, and
4. Penile Pumps.

Three other options are more costly and will require more lab tests and more thorough understanding by the patient. These are: Penile Injection, Penile Implant, and Penile Artery Bypass Graft Surgery. Each of these treatments will be discussed in this segment.

There are also some treatments which are not yet available, but may soon change the medical answers to these problems in a very dramatic way. Some of these medications will be available within the next year, while some are still over the horizon and may take longer before they are approved by the FDA, even though they have been available in Europe for some years. We will discuss these treatments in this section and tell you why you may want to wait until these new drugs are available before you choose treatment.

PILLS

VIAGRA - also known as SILDENAFIL -This is an FDA approved oral treatment for impotence with an approximate 60% success rate for organic impotence and about a 90% success rate for psychogenic impotence. Side effects occurring in less than 10% of patients, are: headache, flushing, stomach discomfort, nasal congestion; and at high doses, vision changes. It must be taken 1-2 hours before sex and arousal must occur before it will be effective.

YOHIMBINE - is an extract from the bark of the yohimbe tree and is available in health food stores or by prescription from a doctor.

There is some benefit for patients with psychological problems, but it does not help with impotence that stems from physical causes. It has few side effects, though it occasionally causes anxiety and an increase in blood pressure. Doctors who do not specialize in the treatment of impotency will often prescribe this medication before help is sought from a specialist. The success rate with YOHIMBINE is about 40%.This success rate is very close to what may be expected from a "sugar pill" and is not recommended as an effective treatment for impotence.

VASODILAN - also known as ISOXSUPRINE - is prescribed as a vasodilator to dilate the blood vessels. This is useful in patients that smoke since it overcomes the restriction of blood flow that is caused by smoking. This has a very low rate of success.

TRAZODONE - also known as DESYREL - is an antidepressant that can sometimes be used by very careful and intelligent patients. The success rate is about 60%, but may cause an erection that lasts too long which can cause damage to the inner penile chambers. This is sometimes prescribed with YOHIMBINE , but cannot be used without the patient being made aware of the effects of an erection that lasts more than 4 to 6 hours. TESTOSTERONE - as an oral medication (METHYL TESTOSTERONE and TESTOSTERONE UNDECANOATE ) may be used for patients with impotence and low testosterone levels in the blood.

BROMOCRIPTINE - also known as PARLODEL - is used when impotence is due to too much prolactin in the blood, such as from a pituitary adenoma. It is highly effective in select patients.

PATCHES AND INJECTIONS

TRANSDERMAL PATCHES - also known as ANDRODERM and TESTODERM. Patches are available for patients with low testosterone levels in their blood. The success rate is about 50%, and the patch is placed on the upper back, arms, thighs, abdomen, or scrotum.

TESTOSTERONE INJECTIONS - know as TESTOSTERONE CYPIONATE, TESTOSTERONE ENANTHATE and TESTOSTERONE PROPIONATE can be injected into the buttocks. Testosterone patches or injections frequently will improve libido and sometimes erections when the impotence is due to low testosterone.

Men using patches or getting testosterone injections or pills need frequent medical testing to monitor the levels of PSA (prostate specific antigen) in blood and the prostate to detect prostate cancer.

URETHRAL INSERTS

The Muse is a tiny insert that fits into the urethral opening of the penis. The Muse contains the drug Prostaglandin E-1. The success rate is about 60-70%.

PENILE INJECTIONS

These have a success rate of 50 to 85% and are a very useful treatment for impotence. Because the man injects himself, 5 to 10 minutes before he wants an erection, it requires some skill and training. The results are dependable and the drugs are safe.

PROSTAGLANDIN E-1 (Caverject, Edex) is the most popular medication for self-injection. Papaverine and Phentolamine are sometimes used in combination with Prostaglandin E-1 to minimize possible side-effects of Papaverine alone or Papaverine and Phentolamine combined, because in combination a lower amount of each medication can be used. Prostaglandin E-1 is frequently used alone and is by far the safest of the three medicines.

PENILE PUMP

A penile pump is a vacuum erection device that is manually operated by the patient. A pump creates a vacuum which in turn makes the penis hard. A special constricting ring is then placed at the base of the penis and this keeps it hard. These devices may be useful in men with impotence of almost any cause. This device has a success rate of 40 - 65%.

PENILE IMPLANT SURGERY

This requires the placement of two implants in the penis; one in the left erectile chamber and one in the right. The implants and the pump which fills the implants are totally concealed inside the body and give excellent cosmetic and functional results in most patients.

The success rate is from 80 to 90% in terms of patient and partner acceptance, and almost 95% in terms of patient satisfaction. The implants are FDA approved.

There are two categories of implants: - the non-inflatable rods which are bendable and can be manipulated to give an erection, and inflatable implants which contain fluid to give a more natural erection. This fluid is transferred within or to cylinders in the penis to give hardness.

While less than 5% of patients choose this form of treatment initially, the final choice of treatment is a penile implant in 10% of patients. In the U.S.A., approximately 20,000 implants are performed each year.

VENOUS LIGATION SURGERY

This type of surgery can help when impotency is caused by the penile chambers filling but not retaining the blood. Its success rate is only about 15%. Most of these patients could successfully be treated with the penile pump alone instead of surgery.

PENILE ARTERY BYPASS GRAFT SURGERY

For problems with arterial flow to the penis, arterial bypass graft surgery is very similar to the surgical procedure used for coronary artery disease.

Using an artery from the lower belly, this bypass surgery creates new blood flow to the penile arteries. This has a success rate of 60 - 80%. However, it should be used in very selected patients with impotency.

NEW TREATMENTS THAT WILL BE AVAILABLE
WITHIN THE NEXT TWO YEARS

There are some very effective oral medications that will change the treatment of impotency in a very dramatic way.

ORAL PHENTOLAMINE - also known as VASOMAX is a pill that has a success rate of 50%.

TOPICAL PROSTAGLANDIN E-1 with an enhancer for absorption through the skin. The success rate is about 60 - 70%.

L-ARGININE is a pill with a success rate of approximately 30%.

APOMORPHINE is a pill with a success rate of about 70%.

For more information on AMSD contact:
E. Douglas Whitehead, M.D., F.A.C.S., Medical Director
Association for Male Sexual Dysfunction
24 East 12th Street, Suite 2 - 1
New York, NY 10003
Toll-Free Telephone: 1-800-575-1112
International Telephone: +212-620-5308
Phone: 212-794-1616
Fax: 212-983-2476