sexual problems

The Truth About Impotence

cont. from part 1

Additional Q & As

Additional questions and replies from Dr. Goldstein:

Question (from a 38-year-old Oregon woman):
My fiance, who is 37 years old, has trouble maintaining an erection for more than a minute or two. Commonly, he ejaculates after his erection has faded. When we do succeed in having intercourse, he ejaculates (and loses his erection) with very little stimulation. In any case, ejaculation for him rarely FEELS like an orgasm. He is not sure when this trouble started, because before meeting me last year, he had not had a sexual partner for 10 years. When my fiance sought medical treatment, the urologist took urine and blood samples and later told him that he was physically "OK." He prescribed an anti-depressant (Paxil), which only made my fiance giddy. What do you recommend? How can we find a doctor in our geographic area who is knowledgable and up-to-date in this field? Also, is there any research into what can cause or prevent male orgasm? It seems that erection, orgasm, and ejaculation are three separate, though related, functions. In our case, none of them seem to be working properly. Thank you for any help you can give us!

DR. GOLDSTEIN:
Your fiance has a common erectile quality problem - inability to maintain the erectile rigidity. Because the problem is consistent and affects his satisfaction with sexual intercourse he has met the criteria for having "erectile dysfunction." The usual evaluation would consist of a history, physical examination, and laboratory tests, followed by education, modification of lifestyle etc, and initiation of first line therapy such as sildenafil citrate (Viagra). However, if your fiance wishes, because he is young, he would be considered a candidate for more sophisticated erectile function testing to gain a better understanding of the nature of the dysfunction and to see if he can be cured of his impairment. He should consider seeing a urologist who specializes in this field for more detailed advice. Perhaps calling the American Foundation for Urologic Diseases in Baltimore can help you locate this physician. You fiance could then be assessed for all the sexual dysfunction issues such as erection, orgasm and ejaculation.

Question(from a 53-year-old Texas man):
I am on blood pressure and diabetes pills and cannot get an erection. My doctor said Viagra would not work for me. Why not?

DR. GOLDSTEIN:
Actually sildenafil may work quite well for you. It is indicated for men with erectile dysfunction who have a physical basis for the impairment - a likely scenario in your case. The only contraindication for use of sildenafil is concomitant use of nitrates - pill for treatment of chest pain (angina). If sildenafil does not work, you could try a vacuum device or try intraurethral pellets, self-injections or a penile implant.

Question (from a 59-year-old California man):
My dysfunction started with diabetes and is now further complicated by Peyronie's (bent penis). It has been several years since I have been able to have a normal erection. I have tried the injection in the Drs. office...it proved quite painful due to the bend in the penis. I have been given Viagra to try. If the pill helps with the erection there will still be a severe 90-degree turn in the shaft of the penis, caused by scar tissue (Peyronie's) Is there a surgery available to remove the scar tissue, allowing the shaft to remain straight - and still responsive to the Viagra? I have been told that there is damage to the one side and I will need a graft to fill in space once scar tissue is removed. (At this time, my diabetes is controlled with pills and diet. ) I do have fears of undergoing surgery with a potential for infection due to diabetes.

DR. GOLDSTEIN:
Your problem is unfortunately common and consists of two problems - 1) erectile dysfunction and 2) penile curvature from Peyronie's disease. Management should be linked to close communication with your urologist.

Specifically to manage the impotence, treatment may be initiated with simple things first. New first-line therapies include sildenafil or vacuum constrictive devices. If these fail, second line therapies include self-injection or intra-urethral pellets. Such treatment focus on erection quality is designed to identify if the enhanced erectile function and improved rigidity would allow for functional sexual intercourse despite the penile curvature. If so - then no attention need be given to the penile curvature - which would be simpler.

If attention is needed to correct the penile curvature, based on the above observation, there are traditional simpler medical therapies including vitamin E. Surgical procedures to achieve penile straightening include: 1) excision of the scar tissue and replacement by graft, 2) "a tuck" procedure or 3) insertion of a penile implant can achieve two purposes - penile rigidity and penile straightening. It is important to discuss all these issues with a urologist. There are important risks ad benefits with each treatment. Perhaps calling the American Foundation for Urologic Diseases in Baltimore can help you locate this physician.

Question (from a 50-year-old California man):
At $10 per tablet, Viagra is expensive. What good reasons can you offer for *not* sparing myself the expense of an office visit and simply getting a small supply from Mexico? Are there real dangers to this? I feel capable of reading and understanding the PDR. All drugs have contraindications to beware. What are those of Viagra?

DR. GOLDSTEIN:
Sildenafil citrate (Viagra) has been approved as safe and effective for the treatment of male erectile dysfunction. If you have compaints consistent with erectile dysfunction, you should see a physician. Erectile dysfunction may be caused by prostate cancer, unrecognized diabetes, hypertension, renal failure, hypogonadism, depression, other psychologic conditions, aortic aneurysm, lumbo-sacral disc disease, use of medications, etc. The evaluation consists of a history (medical, sexual, psychosocial), physical examination and laboratory tests. If needed a psychologic assessment may be added. Education and modification of lifestyle issues or changes in medication may be instituted under physician care. If appropriate, Viagra may be initiated. There are few contraindications other than concomitant use of nitrates.

Question (from a 32-year-old California woman):
Dr. Goldstein,
My partner and I have a wonderful sex life, however, we rarely engage in intercourse. When we try to have intercourse either he loses the erection while putting on a condom (I have tried many distractions during the process) or he will lose the erection during penetration. Once in a great while he will lose the erection while I give him oral sex. When he does maintain his erection thru penetration he often orgasms very quickly and says that it was too intense and he couldn't control it. Is this considered sexual dysfunction?? Or impotence?? Most often we engage in great oral sex instead...When I try to discuss it with him (in a non-threatening way, and when we're not having sex) he says "making a big deal about it only makes it worse." Could it be entirely psychological or combination of problems??

DR. GOLDSTEIN:
It is difficult to make diagnoses on patients based on the minimal information contained in the e-mail. Based on the above, it sounds that he has both erectile dysfunction (failure to maintain) and premature ejaculation. They may be independent or related sexual dysfunction phenomena. I would STRONGLY encourgage him to seek medical help - we can usually make such a great difference in these cases. Both conditions can be very easily managed.

Question (from a 60-year-old Florida man):
I was an active alcoholic between the ages of 15 and 51. I have not used any addictive drugs in the last nine years. During the last three years, I have used testosterone cream and 25 MG 2x/day DHEA supplements in an unsuccessful effort to overcome impotence. Furthermore, I am concerned about the possible cancer threat with their continued use. I have three questions:

1. In your opinion, is my concern about cancer valid?

2. Will Viagra be effective in someone who obviously has impaired adrenal function?

3. What are your recommendations for treating impotence due to alcoholism?

DR. GOLDSTEIN:
In your opinion, is my concern about cancer valid? Yes, yes and yes. Prostate cancer is very common - about one in eight men will develop prostate cancer and prostate cancer is a leading cause of death in men your age. Testosterone definitely helps prostate cancer cells grow. One should get a PSA (prostate specific antigen) blood test every three to six months if one is being treated by testosterone.

Will Viagra be effective in someone who obviously has impaired adrenal function? There are several rare disorders of the adrenal gland - but if you have one - this should be managed by an endocrine specialist. If impotence persists despite appropriate treatment of the adrenal condition, then Viagra may be added.

What are your recommendations for treating impotence due to alcoholism? Alcoholism may cause impotence by a number of mechanisms especially from psychologic and nerve-related damages to the penile erection process. Assuming appropriate counseling has been tried, medical treatment may involve the use of Viagra.

Question (from a 47-year-old Florida man):
I have read books which provide instruction on how to exercise the PC muscle in order to better ejaculation control, and in fact, achieve orgasm without ejaculation. The benefits touted are the ability to maintain an erection after orgasm, more frequent orgasms, better erections, etc.

1. Is there any benefit for a man to engage on a regular program of PC muscle training of 100 contractions a day?

2. Does the prevention of ejaculation during orgasm increase the ability to maintain an erection, and allow for more frequent orgasms?

3. I've noticed that by practicing extended contraction of the PC muscle, it will sometimes automatically go into spasm. Is there any benefit to this? Any negative effect on a man's anatomy?

DR. GOLDSTEIN:

1. Is there any benefit for a man to engage on a regular program of PC muscle training of 100 contractions a day? There is much anecdotal information on this topic, but not good scientific knowledge. In my opinion, there is only a minimal effect on ejaculation in an otherwise normal male.
2. Does the prevention of ejaculation during orgasm increase the ability to a maintain an erection, and allow for more frequent orgasms? The prevention of ejaculation during orgasm is extremely difficult to perform during normal intercourse. If one could prevent ejaculation, this would definitely enhance the intensity of a subsequent orgasm.
3. I've noticed that by practicing extended contraction of the PC muscle, it will sometimes automatically go into spasm. Is there any benefit to this? Any negative effect on a man's anatomy? There is probably no harm to inducing a spasm in this or any muscle.

Question (from a 50-year-old California man):
Dear Dr. Goldstein, My experience suggests that a male can experience the physical phenomenon of ejaculation without always experiencing the mental/physical phenomenon of orgasm. Thus, my question concerns the relationship of these, both neurologically and psychologically. I'd also be curious to know if non-human i.e. animals, experience orgasm, or if their brain structures somehow don't allow this.

DR. GOLDSTEIN:
Orgasm is a sensory phenomenon which occurs in the septum of the thalamus. After receiving appropriate sensory information from the penis and genitals, a disproportionate amount of neurotransmitter is released into surrounding thalamic tissue. This causes a depolarizing wave to affect a wider area in the thalamus. Pleasurable sensation is passed to appropriate cortical sensory areas of the brain (orgasm) - while the spreading wave causes activation of ejaculation pathways. It is possible to ejaculate with only a minimal orgasm.

It is unclear if orgasm occurs in lower animals.

Question (from a 46-year-old Pennsylvania male):
With all the publicity associated with Viagra, several friends and I have discussed the product and our relative sexual function. We are all in our mid to late 40's, none of us suffer from hypertension or diabetes, we are not on medications. We are all married with children. We are perfectly functional, by that I mean we get erections and would never think of ourselves as impotent. But we have all aged. Our sex drive-libido is not as high. We all realize it comes with aging. What is much more of a disappointment is the diminished firmness of our erections. We all feel it is very noticeable and it is NOT in our heads. It doesn't get as hard as it used to. We can't help but wonder if Viagra enhances blood flow to the penis for someone who doesn't get any erection, would Viagra have the potential to improve blood flow for someone whose blood flow has decreased with aging but is not impotent per se.

DR. GOLDSTEIN:
If you (or any of your friends) meet the definition of erectile dysfunction, that is, you have a consistent (for at least six months) inability to obtain or maintain and erection of sufficient quality for satisfactory sexual intercourse, then you may wish to undergo evaluation and treatment by a local MD.

There is such a condition as mild erectile dysfunction - you don't need to wait until the dysfunction is severe.

Question (from a 26-year-old man in France):
I'm 26 and I have not had many sexual experiments. Unfortunately it seems that every time I try with a new girl, I fail to obtain a real erection, though I have no problem obtaining a hard and stable erection via masturbation.

So I wonder if the overwhelming experiment of having pre-sex pleasures with a girl could handicap my capacity of having a real erection afterwards. Is it possible that too much excitation causes temporary impotence because of some organic reason?

And finally, of course, would Viagra help?

DR. GOLDSTEIN:
Is it possible that too much excitation causes temporary impotence because of some organic reason? Too much excitement may lead to release of adrenaline and early loss of your erections. Try and relax under circumstances with a new girlfriend or seek professional counseling from a sex therapist.

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