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Overview
According
to Masters and Johnson, at least 25 to 30 percent of people in their
60s have intercourse at least weekly...and that's not weakly.
There are normal changes in a man's sexual function as he gets older,
but this does not always include impotence and does not mean he is
going to lose his erectile ability (in other words, you don't wear
out your penis.) These changes come on slowly.
Most
men and women are able to adjust to these changes and still have
a perfectly satisfactory sexual relationships. Although a man of
60 may not be able to run a mile as fast as when he was 18, he
should be able to cover the distance and may even enjoy the scenery
more. The same goes for his wife, especially since she may appreciate
the increased ease with which he can delay ejaculation.
The
inability to "get hard"
Worry
is the first time you can't do it a second time; panic is the second
time you can't do it the first time.
Although
many sexual topics are now "out of the closet," impotence
is still a subject that arouses fear and anxiety in many men and
women.
This
emotional reaction is further strengthened by the lack of knowledge
on the part of patients, their partners, and health care professionals.
Most people were never taught about the erection process in school,
let alone given accurate information from other sources. Much of
the knowledge about penile anatomy and physiology has only become
available in the last five years.
Sometimes
impotence is all in your head
Ignorance,
fear, a lack of information, embarrassment, and anxiety provide a fertile
breeding ground for sexual problems. While some problems related to
the ability of the penis to become hard and ready for sex are tied
to physical problems, some cases of impotence are linked to psychological
issues.
Even when impotence is tied to physical problems, there can be psychological
underpinnings that must be addressed with successful treatment of the
physical causes. For example, many couples have serious emotional reactions
to the loss of erectile ability and to what they believe it represents,
and have adjusted their relationships to explain and compensate for
their emotional problems. When treatment of the impotence is successful,
there still are the underlying relationship problems that need attention.
Our
goal at the Male Health Center is to restore a healthy physical and
emotional outlook to the patient and his partner and therefore improve
their ultimate satisfaction with successful treatment of impotence.
In
order to achieve this goal, it is important to:
-
Educate:
explain in detail the mechanism of erections and the many causes
of problems; dispel any myths that may exist concerning erections.
-
Try
to get the partner involved in the process. Such participation
enhances communication and can identify sources of stress and
anxiety for everyone.
-
Perform
accurate diagnosis of the physical and emotional aspects of
the erection problem.
-
Educate
partners on alternatives for treatment and the expected outcome
and risks of each treatment.
-
Help
the couple define a plan for rebuilding their sexual and emotional
relationship based on their own particular physical and emotional
circumstances.
-
Continue
to support couples with counseling in adjusting to their new
situations and reevaluate them in case of future difficulties.
-
Prevention:
address factors that can either now or in the future complicate
or cause erectile problems such as smoking or high cholesterol.
More
important facts
- Most
men experience erection problems at some point in their lives
due to job, alcohol, stress or mental problems.
- Past
sexual practices, including masturbation, do NOT cause impotence.
- An
occasional problem does not mean a man will develop a chronic
condition.
- Physical
factors can directly affect a man's ability to get and maintain
an erection.
- The
mind is very powerful and a man with or without any physical
problem can sabotage his erections just by worrying about his
ability to perform.
The
important point to remember is that sexual intimacy need not end
when you become a senior citizen. And, finally, if you or your partner
have an intimacy problem in this day and time, you need not suffer
any longer as successful treatment is readily available.
The
emotions involved in impotence
Many
men view impotence as a real challenge to their self-esteem. Furthermore,
many men believe a number of myths surrounding potency problems. Some
men may fear they themselves have caused their erection problem by
past actions such as infidelity or masturbation.
A man may have feelings of guilt because he no longer fulfills what
he views as his role as a man. It is also common for a man to fear
that impotence is the first sign of his physical decline toward old
age and death. Most men, even when they admit there is a problem, are
reluctant to ask for help.
What some men think about sex:
- Men
shouldn't express certain feelings.
- Sex
is a performance.
- A
man must orchestrate sex.
- A
man always wants and is always ready to have sex.
- All
physical contact must lead to sex.
- Sex
equals intercourse.
- Sex
requires an erection.
- Good
sex is increasing excitement terminated only by orgasm.
- Sex
should be natural and spontaneous.
In
this enlightened age, the preceding myths no longer have any influence
us.
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Symptoms
- Taking
a longer time to reach an erection
- The
erection being slightly less firm than when he was younger
- An
increased ease in delaying orgasm and ejaculation (a positive
change for many couples)
- A
loss of force in ejaculation
- A
decrease in volume of the fluid ejaculated
- The
erection being lost more readily after orgasm
- An
increase in the amount of time it takes from orgasm to the time
that a man is able to get another erection
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Diagnosis
How
does a physician detect what might be going wrong?
The
starting points of a work-up include the following steps:
- Assessing
nerve function is done by pinprick
- Assessing
reflexes and toe position
- Blood
flow is measured by assessing pulse and penile blood pressure
- Hormone
status is assessed by evaluating testicle size and inspection
of the prostate through a prostate exam.
- Preliminary
screening includes blood tests to audit male hormone level, thyroid
function, presence of diabetes and a man's cholesterol level.
- A
stress audit involves a questionnaire to be completed at home.
A
man may also apply a simple snap gauge that can reveal if the penis
is becoming erect during the night. The normal male has about two
or three erections a night. The snap gauge is a painless tool that
unsnaps when the penis becomes erect, revealing that an erection
occurred when the man was asleep. This can tell the physician that
the man's equipment is working, and that there may be another cause
that is interrupting the natural erection process.
There may be more specific testing required based on the results of
the physical exam and screening tests.
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Treatment
Oral Medications
Yohimbine
is a useful first-line treatment for erection problems. It appears
to help about a quarter of the men who try it, and side effects are
usually minimal. Currently, medications are being tried in clinical
studies, including a medicine called Sidenafil, which in Europe has
shown excellent preliminary results, especially in men who have primarily
a psychological cause.
Topical
Medications
On
the horizon are new methods of applying medicine to produce erections.
Creams rubbed on the skin of the penis and pellets inserted in the
tip of the urethra are under trial and some show promise.
Injection
Therapy
This
is a very effective treatment for many men, and improvement in the
drugs have reduced side effects. Look for prostaglandin E-1 or a combination
of several medications based on prostaglandin.
Vacuum
Devices
Devices
that produce erection by suction continue to be safe, effective, and
economical.
Penile
implants
Penile
implants have been successfully used since 1960 to treat over 100,000
impotent men. Surgery, however, to insert a penile implant should only
be performed in rare situations. When a man can't or won't succeed
with other treatments, an implant is the last resort. Of all the approaches,
this one caries the most irrevocable consequences. Once you've had
an implant, that's it — the normal spongy tissue has been damaged
and destroyed, and your chances of ever functioning normally again
are gone.
Just because an implant is the last resort
doesn't mean it's not a good one. A modern implant, when properly installed
in the right
patient,
can work wonders. It restores a man's ability to enjoy a full relationship
with his partner, making his life whole again.
Just as there are different
types of makes and models of cars, there are also various styles
of implants available. But the three-piece
(two cylinders, reservoir and pump) models tend to produce the happiest
patients. Besides an expensive surgical procedure, significant side
effects are possible. These include mechanical failure (reportedly
five percent), infection (devastating, but only two percent), erosion,
migration, intractable pain, and auto inflation. While some question
the possibility of reactions similar to breast implants, since the
fluid is saline, there is no adverse reaction with the leakage. Furthermore,
the body appears to form a capsule around the components, almost
in a self-protective manner.
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FAQ
How
can a man relax and let things happen naturally?
It
is a widely accepted fact that for a man to have sexual desire, to
be able to be aroused to erection and orgasm, he must feel relaxed.
Our emotions about a given situation are determined by what we think
about that situation. This is called the ABC's of thinking and feeling:
A.
The situation.
B. The thought or label about the situation.
C. The emotional outcome that results from how one labels the situation.
For
example, if the situation
A.
is that a man is going to have sex, the thought
B. is that he is worried about being able to function, then the resulting
feeling
C.
is that he is anxious.
As
a man moves from pleasure and relaxation to performance and anxiety,
the chances of problems increase. In other words, the concerns or
fears of being able to perform are sufficient to produce anxiety
and result in a lack of ability to attain or maintain an erection.
All men have a psychological reaction to an erection problem even if
its cause is primarily physical.
What
do women think when a man can't get hard?
When
a man has an erectile problem, the couple has a sexual problem.
The women in the relationships frequently have questions, doubts, resentments,
insecurities, and a need for information, understanding, and reassurance.
Too often the man alone is seen as the patient and his partner is -
at best - barely acknowledged, and - at worst- merely tolerated or
even discouraged.
It is not enough if the partner's participation is limited only to
hearing the patient's interpretations of the doctor's replies. Filtering
information and questions through the patient to the woman can lead
to misunderstanding and unhappiness. The woman's own concerns and questions
must be addressed. Unlike many areas of medicine where only the patient
is treated, with erection problems both members of the couple need
to be considered.
Sometimes a woman, raised on the myths of men as highly sexual and
always ready, sees her partner's erection as an emotional lie detector.
A woman may view an erection as proof that a man loves or desires her.
Therefore, she believes the absence of an erection means he doesn't
care, or doesn't find her attractive.
A potency problem can spiral into a major communication breakdown in
a short period of time. A typical scenario goes like this: a man experiences
erection difficulties, feeling ashamed, embarrassed, and "less
of a man," he withdraws from his partner. With the lack of ability
to perform, it's not uncommon for men to have a marked drop in their
desire or libido. After all, why put yourself in a position where you
may not be able to perform? Over time, he may go so far as to refuse
to kiss her, hug her, even to hold hands with her, saying, as did one
man, " I didn't want to start anything I couldn't finish." He
may start arguments to avoid sexual encounters. Because he doesn't
understand that he has a health problem, not a character defect, he
may refuse to discuss the issue with anyone including his partner,
his doctor, a friend. Meanwhile, the partner is feeling rejected, neglected
, and full of self-doubt. She may question her own attractiveness.
She may wonder if her husband still cares for her. She may even think
he is having an affair. She may withdraw. She is often afraid to bring
up the subject that is so obviously painful for her husband. The result:
each partner is isolated and miserable. Unfortunately, the Male Health
Center has seen relationships end over this situation.
A number of women whose partners have potency difficulties feel inadequate.
It's not uncommon for a woman to blame herself. A woman may be fairly
open about her self-blame or she may keep her feelings quite hidden.
A woman may also feel hurt and angry because her partner has withdrawn
from her physically and emotionally. The relief felt by an insecure
partner who understands she is not to blame can be enormous and can
enable her to more fully participate and support her partner's diagnosis
and treatment.
What
causes an erection?
During
an erection blood fills two chambers in the penis and is trapped there.
The erection begins when the arteries open up as the smooth muscles
of the vessel walls relax.
The veins which drain the blood then close down and prevent blood from
leaking out. A man must have an adequate blood pressure to carry blood
into the penis, and can have no leaks in the veins of his penis that
will allow the blood to escape.
The nerves are the control mechanism which coordinate the increase
in pressure in the penis as well as the closing down of the veins.
A man needs sufficient levels of testosterone in order to have the
desire, feel aroused, and to get an erection.
Any physical or emotional factor that affects a man's arteries, veins,
nerves, or hormones can impact his erections. A man must allow himself
to relax in order for the blood vessels of the penis to also relax
so that he can get and maintain an erection.
A discussion of the problem followed by a physical examination is the
first step toward diagnosing the cause of the problem.
How
does stress relate to impotence?
Stress
is defined as any mental or physical demand that is placed on a person.
Stress comes from "good" things as well as events labeled
as "bad." Adrenaline is an erection buster. Adrenaline is
fine when we're cheering for our favorite team or in the middle of
a heated argument... certainly not when we'd want to get an erection.
A person's reaction to stressful events is physiological. Stress can
cause a man's heart rate to increase, and it can elevate blood pressure,
increase muscle tension, and speed breathing. This phenomenon is called
the "fight or flight" response.
What some people don't know is that stress can pile on and cause a
cumulative effect. Constant arousal due to stress, can affect sleep,
energy level, and concentration, as well as sexual desire and functioning.
Most patients and their partners are not surprised that stress can
cause an ulcer or a rise in blood pressure. They are often surprised,
however, that these factors can have an effect on erections. A man's
normal response to stress, such as being afraid or angry, is for the
nervous system to move blood away from "nonessential" activities
and into muscles so that he can either fight or get away from the situation.
Ironically, fear of not being able to achieve an erection can actually
cause an impotence problem. That's because if a man thinks that he
is not going to get a erection, his body may respond to this belief
by shunting blood away from his penis, thus making his erection go
away.
Are
there any medical conditions that may affect sexual intimacy?
There
are a number of medical conditions that are associated with impotence.
Probably the most common is the use of certain medications that have
side effects that can affect a man's potency. Examples are drugs used
to treat high blood pressure, sedatives, tranquilizers, and pain pills.
Fortunately, the side effect of impotence is reversible when the dosage
is altered, or a different medication is prescribed by the physician.
Medical illnesses that are often associated with impotence are diabetes,
heart conditions and kidney and liver diseases. There are various surgical
procedures that are often associated with impotence. The most common
are cancer surgery of the colon, rectum, bladder, and prostate gland.
Most problems of intimacy in the elderly can successfully be treated.
If a woman is suffering from the problem of estrogen deficiency, then
she should consult with her gynecologist who might prescribe some form
of estrogen replacement therapy. If a man suffers from impotence, he
should contact a urologist who has sophisticated diagnostic techniques
to identify the cause of the problem and recommend appropriate treatment.
I
know there's an injectable medication that produces erections,
but I can't face the needle. Is there an alternative?
Although
many men are quite pleased with injections, you're not alone in your
dislike of needles. In the long run, self-injection is well accepted
by only about half of my patients. A number of devices have been developed
to hide the needle—including a pen-like apparatus about the size
of a cucumber that extends the needle with a push of a button—but
the needle-prick sensation is still there. Fortunately, a couple of
new approaches to inducing erections have arrived recently or soon
will.
Some of my patients participated in a clinical trial of urethral inserts
of prostaglandin E1, the same medication used for injections. With
this approach, the dose is slipped into the urethra using a small,
plunger-like device. There it is absorbed through the urethra and into
the penis.
At first, I was surprised that men didn't object to inserting the medication
into their urethra, but it hasn't turned out to be a problem. As is
the case with injections, the erection lasts up to an hour, and side
effects are really minimal, generally at most only a mild burning sensation
for 10 or 15 minutes after the insert is placed. Early results suggest
that inserts are as successful as injections (85 to 90 percent get
erections), which is very successful indeed. Approval by the FDA is
pending and should arrive shortly.
Sildenafil is an oral medication that was developed in England to treat
angina (chest pain from heart problems). Sadly, it proved ineffective
against angina, but it turned out to have a pleasant side effect. Men
involved in trials of sildenafil reported having more and firmer erections
and more frequent sex. It seems to be most helpful for men with erection
problems that aren't physically based. Trials are underway but approval
isn't expected for another two years.
A little farther out on the horizon, an oral medication absorbed under
the tongue is now undergoing early trials to determine an effective
dose with minimal side effects. It may be a number of years before
it becomes widely available, but you should ask your doctor to keep
you up to date on progress.
You might also consider trying a vacuum device, which produces an erection
through suction developed by a pump. Most men can achieve an erection
using one, although many also tire of bothering with the apparatus
every time they want to have sex. It works, but it's not for the singles
set.
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