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Chapter One

INTRODUCTION

Man can endure earthquake, epidemic, dreadful disease, every form of spiritual torment; But the most dreadful tragedy that can befall him is, and will remain, the tragedy of the bedroom.

—Tolstoy

Key Points:

· Impotence affects twenty to thirty million men in the United States.

· An equal number of partners may be affected.

· Only a small percentage of males receive treatment.

· Impotence is not caused by aging alone.

· Impotence is treatable in virtually all cases and preventable in most.

· Impotence is no longer a taboo subject.

· As men live longer and boys experience sex at an earliers age, the problem assumes more and more importance.

· It is better to prevent impotence than to have to treat it—even with pills.

    Most normal males, at sometime in their lives, will find themselves unable to have an erection. This problem is not confined to the middle-aged and the elderly but also happens to teenagers and males in their twenties and thirties. For some men this condition develops suddenly and is transient, but for others it may come on gradually and persist as a chronic problem.

    Men whose sexual performance hasbeen successful for years may one day find themselves unable to achieve an erection. This has been experienced even by males who have regarded themselves as marathon bedroom performers. Impotence, the consistent inability to attain and maintain an erection for satisfactory sexual performance, is one of the most common maladies in the United States for which treatment is available but not received. It is estimated that 20 to 30 million men in the United States suffer from erectile problems, yet only 5 to 10 percent seek treatment.

    While the problem is, as one would expect, most common in middle-aged and older males, young men also have cause for concern. Even teenagers may suffer from impotence. (A recent study revealed that by age fifteen, approximately 27 percent of boys have already had sexual intercourse, and by age eighteen, the figure reaches almost 70 percent.)

    In this country, where the standards of living and education are among the highest in the world, we are grossly ignorant about many areas of sexual functioning. Despite recent advances in understanding the physiology of the human sexual response, the average male and female know very little about the cause and effect of a male's inadequate sexual performance. We pride ourselves on caring for our newborn and on educating our children both at school and at home. We instruct them on what to eat and what clothes to wear, and we assist them in getting along with their peers. As children become teenagers, we assign them more and more responsibility in order to ensure their smooth transition into adulthood. We provide them with instruction on how to drive a car and how to become competent in various sports. Sex education classes are now fairly common at the high school and college level. Students are taught human anatomy and the mechanics of sexual functioning. But with rare exceptions, nowhere are they instructed on aspects of sexual failure. Many are not aware that it can occur, and even those who are aware are likely to assume that it is something that will happen to someone else.

    Impotence is an equal opportunity disease not limited to any particular race, socioeconomic level, occupation, marital status, or religious belief. Democrat or Republican, any man is vulnerable! And when one considers that an impotent male's partner may be negatively affected, the magnitude of the problem doubles.

    The good news for men who have the problem: it is treatable. The good news for men who have not yet experienced impotence: it is largely preventable.

    Fortunately the topic of sexual dysfunction is no longer a taboo subject. Impotence is "out of the closet" and the subject continues to surface in books, lectures, and television talk shows.

    The medical profession, recognizing that impotence affects between twenty and thirty million men in the United States, anticipated the importance of this topic. In December 1992, the National Institutes of Health issued a "Consensus Statement" dealing with this topic. Here are several of the panel's conclusions:

1. The likelihood of impotence increases with age but is not an inevitable consequence of aging.

2. Patients' embarrassment and the reluctance of both patients and health care providers to discuss sexual matters candidly contributes to underdiagnosis of impotence.

3. Impotence can be successfully managed with properly selected therapy.

4. Education of health care providers and the public on aspects of human sexuality is essential.

5. Impotence is an important public health problem that deserves increased support for basic investigation and applied research.

    For patients considering treatment for impotence, there are four facts that should encourage them to seek help. First, there has been a vast amount of progress made in understanding the physiology and biochemistry of erections. Second, physicians, psychologists, and sex therapists are now better trained than ever before. Third, new treatments are now available, some of which are minimally invasive. Fourth, virtually every male suffering from impotence can resume a sexual relationship!

    Impotence is best regarded as a "couples problem." While impotence may be catastrophic to the male, the difficulties that the female partner encounters should not be underestimated. A very solid relationship may be threatened or destroyed. The woman who does not understand her partner's "ups and downs" may become confused and uncertain, and may experience frustration, guilt, or anger. For younger women, the problem may be a "relationship breaker."

    The introduction of Viagra provides hope to nearly all impotent males and treatment for a great many. (Other oral medications such as phentolamine and apomorphine await FDA approval.) However, major issues still need to be addressed. What is the underlying cause of the impotence—is it perhaps undiagnosed diabetes, narrowing of arteries, or another serious problem? What about interaction with one's partner? Is impotence really a reflection of a poor or deteriorating relationship?

    In addition, not every impotent male can take "the pill." It cannot be used by anyone taking medications containing nitrates. And while it will help the majority of patients, millions of men will need to seek another avenue of treatment.

    Most important, PREVENTION is preferable to any form of treatment.

    Three critical facts about impotence underlie this book. The first is that many cases of impotence can be prevented through lifestyle changes, good medical care, better understanding, and psychological adjustments. The second is that impotence is not the inevitable consequence of aging. The third is that when problems with erections do occur, solutions, either medical or psychological, can be found for nearly every case. Very few have to resign themselves and conclude, "Well, I'll just have to live with it." The path to sexual health lies ahead.

    It is our belief that:

· Wellness is better than illness!

· Prevention is better than treatment!

· Treatment is better than suffering!

Chapter Two

A LOOK AT THE PAST

Not to know what has been transacted in former times is to continue always as a child.

—Cicero

Key Points:

· Impotence is not a new problem. It has always been a topic of concern.

· Over the centuries, many forms of treatment have been recommended—few of which are accepted methods today.

· Studies of the mechanism of erection have accelerated dramatically over the past twenty years.

· A better understanding of how erections occur has opened the door to new, minimally invasive treatment options.

    The problem of impotence is age-old. It is well documented in history. Sexual anxiety in childhood as a cause of impotence in adult life was recorded in Greek mythology. King Phylacus asked his physician, Melampus, to cure his son, Iphiculs, who was suffering from impotence. Melampus discovered that in childhood Iphiculs had seen his father brandishing a bloodstained gelding knife. He became terrified that he was going to be castrated, and it was this fright that allegedly accounted for his impotence in later years. By carefully pointing out how his fear had developed, Melampus was able to cure Iphiculs of his impotence.

    A passage from Genesis (20: 1) has been interpreted by some as a description of how Abimelech became impotent as divine punishment for taking Abraham's wife: "But God came to Abimelech in a dream by night and said to him, behold, thou art a dead man, for the woman which thou has taken; for she is a man's wife."

    The preoccupation of man with sexual potency and his fear of impotence is evident in literature and mythology throughout the centuries. For the ancients the potency of the king was believed to affect the success of the harvest and well-being of the people. Impotence was often seen as resulting from a divine curse or the result of bewitchment called down by a vengeful enemy.

    Beginning in the Middle Ages and for many years thereafter, impotence was believed to result from a curse inflicted by witches. A dramatic example of this concerns Don Carlos (1661-1700), who was the last of the Spanish Hapsburgs. He failed to give Spain an heir; this later led to the War of the Spanish Succession. Don Carlos was described as physically weak and of limited mental ability as a result of many generations of inbreeding. Despite two marriages, he was unable to produce the vitally needed heir to assure continuation of his family line. It was believed that he was impotent. Exorcisms were performed, but his impotence persisted to the end of his life. When he died, so did the Spanish Hapsburgs.

    In the Middle Ages, those practicing witchcraft believed that impotence could be produced by tying knots in a cord or strip of leather and then hiding the knotted piece. This practice was known as ligature, and the affected party supposedly remained impotent until the cord was found and untied.

    Witchcraft and impotence played a significant role in the history of several western nations. King James I of England wrote the treatise Daemonologie on the subject. James intervened in the trial in which the Countess of Essex attempted to divorce her husband on the grounds of impotence.

    Some important literary figures were afflicted with sexual difficulties. For instance, George Bernard Shaw's sexual life is controversial. While some believe he was promiscuous, others believe he was impotent. Some have attributed the conjectured impotence to homosexual tendencies that caused Shaw sexual anxiety. His own marriage was described as one of "contractual sexlessness."

    Rousseau related an episode of impotence that occurred when he was with an attractive prostitute. "Suddenly, instead of the fire that devoured me, I felt a deathly cold flow through my veins; my legs trembled; I sat down on the point of fainting and wept like a child."

    Twenty-three hundred years ago, Hippocrates noted that a preoccupation with business as well as a lack of female attractiveness could cause impotence. And the Hindus warned that impotence could follow an encounter with a female a man found distasteful.

    The Malleus Maleficarum, a manual dealing with witchcraft published in 1488, discussed the causes and treatment of impotence. Remedies included the use of splints and special herbs.

    The reticence about discussing sexual topics in Victorian times rendered impotence an unlikely topic in literature, and the condition was only hinted at obliquely. For example, George Elliot's Middlemarch recalls the impending marriage between the elderly former clergyman Edward Casubon and the young and attractive Dorthea Brooke with the comment: "Good God! It is horrible. He is no better than a mummy. For this marriage to Casubon is as good as going into a nunnery."

    While the fear of impotence plagues the ordinary man, biographers point out that notable figures such as D. H. Lawrence, King Richard I, Louis XVI, Napoleon, and Edgar Allan Poe were troubled with impotence at some time in their lives for various reasons. One theory held is that sexual continence is directly related to artistic creativity and dedication to one's profession. Names such as Chekhov, Flaubert, Beethoven, Lamb, and Ruskin, as well as celibate clergymen, bear witness to this opinion.

    The concern and preoccupation with male potency has been a subject for the arts and a private worry of the common man. The frequency of impotence as a theme has reached to the point where one review of Edward Albee's Who's Afraid of Virginia Woolf stated: "It also dwells on impotence, a long established Broadway theme that has lately hardened into an obsession. No serious play is complete without it."

    As for worries of the "man in the street," Lawrence Durrell reminds us of this common concern in his novel Balthazar with the words of the Frenchman Pombal: "His only preoccupation is with losing his job or being impotent: the national worry of every Frenchman since Jean-Jacques."

    Even today an unconsummated marriage due to impotence can be the cause for annulment of a marriage in the Roman Catholic Church. Impotence that is known to preexist marriage is an impediment to the reception of the sacrament of marriage in the Catholic Church.

    Many societies devised their own unique methods of treating impotence. In Europe, "phallic foods" were once popular; these included fresh eggs, lobsters, leguminous plants, French beans, and oysters. Years ago, Egyptians regarded the crocodile's penis as a symbol of virility. Some actually ate the crocodile's penis in order to increase their potency.

    Treatments that were in vogue only forty years ago now seem rather curious. Metal rods were either heated or cooled and then passed into the penis in order to alleviate any inflammation therein. Another form of therapy consisted of electrical shocks to the testicles. Some doctors advocated an operation to tighten the muscles beneath the scrotum, which were considered to be weak. A most interesting apparatus was the penile splint. This peculiar-looking device allowed the male to penetrate the female even when his penis was soft.

    From a historical viewpoint, enormous strides have been made in the treatment of erectile insufficiency, and these will be covered later. It is of interest, however, to look to the researchers of the past. The work of Ancel and Bouin in France in the early 1900s and that of Steinach in the 1920s suggested that vasectomy promoted sexual rejuvenation. In 1936, Niehans noted the positive effects of this procedure in correcting impotence. In 1918, Voronoff, a Parisian, declared that youth could be restored by transplanting a portion of monkey testicles into man. That same year, Lespianasse, a professor of genitourinary surgery at Northwestern University, treated male impotence by implanting slices of human testicles taken from fresh cadavers into a small incision made in the abdomen of the sexually inadequate male.

    Stanley, a physician working with a captive population at San Quentin Prison in California, published a paper in 1922 citing a thousand testicular implant surgical procedures that had been performed on 656 patients. Unlike Lespianasse, who used human testicular tissue, Stanley chose the testicles of goats, rams, boars, and deer. The testicles from these animals were cut into strips with a knife in sizes suitable for the filling of a pressure syringe. The testicular substance was then injected by force underneath the skin of the abdomen. Stanley noted no significant difference in the effects produced by the testicular material taken from the various animals. Today, testicular implantation, using either human material or material obtained from animals, is not considered a valid procedure.

    Evidence of the increasing interest in the scientific study of impotence and other sexual problems is seen in medical textbooks. Campbell's textbook of urology has been a bible for the urologist for many years. In the third edition, published in 1970, approximately one page is devoted to impotence and four pages to masturbation. Premature ejaculation is not even discussed. In the fifth edition of this text, published in 1986, the topic of premature ejaculation is given only four sentences. In the sixth edition of Campbell's Urology, published in 1992, more than fifty pages are devoted to the problems of impotence. The problem of premature ejaculation is given a single page.

    An important period is unfolding in the history of impotence. Our knowledge of the causes of and the appropriate treatment for erectile insufficiency is increasing exponentially. As knowledge continues to accelerate, a new understanding of how an erection occurs has led to a variety of simpler and more acceptable treatments.

Chapter Three

WHAT IS IMPOTENCE?

Definitions might be good things if only we did not employ words in making them.

—Rousseau

Key Points:

· Impotence is the consistent inability to attain or sustain an
erection sufficient for satisfactory sexual performance.

· Impotence is not the same problem as sterility, loss of libido (sex drive), or premature ejaculation.

· In this text, the terms, "erectile insufficiency", "erectile dysfunction," and "impotence" will be used interchangeably.

    Impotence is the inability to attain or sustain an erection sufficient for satisfactory sexual performance. Impotence may take many forms. For example, a male may be able to achieve an erection and begin intercourse, but the penis may become soft before completion of the act.

    There is a movement in medical circles to rename impotence "erectile insufficiency." This is consistent with medical terminology used to designate problems in other organs, such as liver failure (hepatic insufficiency), heart failure (cardiac insufficiency), kidney failure (renal insufficiency), and failure of the lungs (pulmonary insufficiency). Another term sometimes used to describe impotence is "erectile dysfunction." In this book, all three terms will be used and are considered synonymous. This is in conformity with other written information on the subject as well as terminology used in the media.

F.D., a fifty-year-old attorney, noticed a change in his sexual ability approximately three months before seeking medical attention. His past history was not unusual, and he had not experienced prior difficulties with intercourse. However, recently he had noticed that while his erections started out in a normal fashion, the penis seemed to soften upon attempted insertion into the vagina. Initially, he attributed this to a state of physical fatigue, but when it occurred persistently, he sought advice. His female partner was very aware of the difficulty because the sexual act did not last long enough for her to have an orgasm.

    Certain males may be able to achieve an erection only when gazing at pornographic material or in complete privacy. However, these individuals cannot perform with a female partner.

A. G., a thirty-one-year-old male, had been raised in a strict religious setting in which sexual activities were frowned upon. Masturbation was not acceptable in his society. He related to his physician that he had no trouble achieving an erection when he saw pornographic material either in a magazine or a movie, but that he had not been able to consummate his recent marriage because of failure to get a sufficient erection.

    Some men can function sexually with a prostitute or other women for whom they have no emotional feelings but find themselves impotent with a woman for whom they truly care.

S.R., a forty-seven-year-old male, never married, had recently begun dating an attractive woman who worked in his office. He respected her greatly, and they developed a close emotional relationship. He regarded her as a very special person. His sexual history was normal, and on one occasion, five years earlier, he had gotten a woman pregnant and she had had an abortion. On his first occasion in bed with his new female companion, he could not achieve an erection. Despite her patience and encouragement, intercourse did not occur.

    Certain males can perform only if they fantasize that they are with a different woman.

D.M., a thirty-eight-year-old male, had been married for seven years and was the father of two children. Recently his sexual interest in his wife had seemed to decline, and intercourse usually occurred only if she initiated it. Erections became increasingly difficult to attain and maintain until it reached the point where D.M. would close his eyes during intercourse and imagine that he was in the arms of his secretary.

    Some males cannot understand why sometimes they are able to perform well sexually, yet at other times are unable to perform at all.

M.F., a forty-four-year-old male, directed a highly successful business that he had founded. He had his emotional ups and downs, which seemed to be connected with how well his business was running. He enjoyed sexual activity, and he and his wife had intercourse two or three times a week. After a six-week period in which he was unable to achieve an erection, he sought medical attention. During this same period of time, he was in the midst of a lawsuit that threatened his company's financial position.

    Some individuals who have repeatedly failed to get an erection despite the most opportune circumstances declare that they are not really interested in sex and won't try again.

B.F., a sixty-one-year-old executive, was forced by his female partner to see a physician because of impotence. When they were interviewed, the woman complained that her partner was not interested in sex at all. In private, B.F. disclosed that he had attempted intercourse with a young secretary from his office and with another woman whom he had met at a recent business convention. Both of these women were unusually attractive and most receptive to his advances. Yet he had been unable to achieve an erection with either of them. He had now failed with three different women in a very short period of time. His sexual drive had waned, and he expressed a general disinterest in sexual activity.

    All of the above are examples of impotence. While some men can't get an erection, others complain of not being able to maintain one long enough to complete sexual activity. Certain men can function sexually only with some women, but not with others. Some can achieve an erection and ejaculate through self-stimulation, but not with a female partner. Despite some differences, all of the above problems are variations on a common theme—a lack of satisfactory erections.

    Medical authorities divide impotence into primary and secondary forms. Primary impotence refers to the rare male who has never in his life had an erection sufficient for sexual performance. In secondary impotence, which comprises the vast majority of cases, a male has had erections and engaged in successful intercourse in the past but currently his erectile ability is significantly reduced or absent.

    In order to understand disorders of male sexual function, certain other terms need to be defined. "Ejaculation" refers to the projection of semen. This is caused by contraction of muscular tissue within the penis and pelvis. "Orgasm" occurs at the culmination of the sexual act and is a pleasurable sensation representing both physical and psychological response to ejaculation.

    Disorders of ejaculation, including uncontrollable (premature) ejaculation and failure to ejaculate, are not, strictly speaking, a part of impotence, but either of these conditions represents inadequate sexual performance and may lead to an impotent state.

    "Impotence" and "sterility" are commonly confused terms. Sterility is the inability to have children and is often due to a lack of production of a sufficient number of normal living sperm. A sterile man may be able to have good erections. An impotent man, on the other hand, may produce sperm of normal quality but not be able to impregnate his partner because he cannot achieve an erection sufficiently strong to permit successful intercourse.

    There is another crisis that many impotent men experience—loss of libido. Loss of libido is a decline in sexual interest or urge—a dwindling sex drive. When impotent males are asked to list other sexual problems, this is one of the most often cited. The fact is that a decrease in libido may occur as a consequence of impotence or it may precede the onset of erectile difficulties. On the surface, it is easy to understand how a man who cannot achieve an erection sufficient for intercourse may, after a period of time, lose interest. Whether this is a defense mechanism may be debated.

    It is more common for a loss of libido to follow the onset of impotence than to precede it. In either instance, it may be a cause of great concern to the male. He may wonder if it is another sign of a generalized deterioration.