(Which the medical community calls "Impotence")

---

Q: How can you tell when an erection problem is systemic or psychogenic?

A: The DIFFERENTIAL DIAGNOSIS of erection dysfunction "ED" is sort of like jumping the high hurdles. If you get firm erections during the night (nocturnal erections), or if you wake up with a good "hard on", we infer that the plumbing and the wiring are in good working shape, and that the problem is probably primarily psychogenic. There is a rare complication for which that does not apply but this cannot be an exhaustive treatise.

Another circumstance that confirms that the problem is psychogenic (caused by your psyche, not by your body) is if you are able to engage in sexual behavior of your preference (involving an erect penis) with one sexual partner but not another (or by yourself). THE CONVERSE IS NOT TRUE: If you are not able to attain or maintain an erection with your usual partner, and then experiment (we're suspending ethics for this illustration) with another partner and are still not able to atain or maintain the erection, it does not NECESSARILY mean that the problem is systemic (body-caused) and NOT psychogenic. It may mean simply that you were so eager to please or excited about doing something "naughty" that you couldn't get or keep the erection.

SYSTEMIC (body-caused) reasons for ED include high blood pressure medication (there are some out now that do not have an ED side effect), diabetes, surgical damage to the nerves related to prostate and other surgery, and other medical conditions.

The single greatest cause of psychogenic ED is IGNORANCE. Every man sometimes cannot attain or maintain an erection.. If he shrugs it off, goes to "plan B", and satisfies his partner in a way alternative to using an erect penis, the chance that he'll be OK the next time is very good. But if the PERFORMANCE MONSTER gets in his head and makes him worry whether he'll be able to PERFORM, he anticipates that there MIGHT be a problem, and during sex play starts to worry about how diminished in the eyes of his partner he will be if he does have a problem, that he guarantees that he will have a problem.

Another point about which most men are ignorant: You're SPOILED! Since you were a teen, all you had to do was relax and you got a boner! And certainly during foreplay it got itself up without any fondling. At some point, however, between ages 40 and 55, it changes a little, and now your penis needs some contact comfort along with everything else, and it usually needs constant neurological stimulation to stay erect.

If you have anticipatory performance anxiety, and no medical compromise, and you rehearse that by repeating the event over and over and over (hoping it will go away and expecting great humiliation if you tell a sex therapist what your problem is), you will guarantee that it will become ENTRENCHED. In that case you need therapy with a competent sex therapist. The fastest acting protocols that have the best chance of lasting involve you with your regular sexual partner.

ACTIONS: First determine if you ever get erections (check yourself during the night or first thing in the morning). If you NEVER get erections get a referral to a Urologist who is comfortable with SEX PROBLEMS (some are not).

If you sometimes get good hard erections -- even if it's not every time you want -- stop putting yourself in the position of failing over and over again. If you ain't fixed it yet, you probably can't on your own. Get to a competent sex therapist sooner rather than later (see elsewhere on the homepage) and take the lead from him or her.

---

COMMENTS ON THERAPIES

The behavioral approach for psychogenic erection dysfunction:

9/28/99 Q:  Hi,
    I searched the bank, and didn't see anything matching my question closely enough. The problem is, whenever my boyfriend realizes we're about to have sex, he loses his erection. He has no trouble staying erect any other time, for oral sex etc. Sometimes all I have to do is look at him a certain way and it springs up, no problem. We decided it must be psychological. Its not that it's bending because its not erect enough, it just completely disappears. He is a virgin, and he is very ashamed about this, and confused. He says he's just nervous. I tell him if he thinks it will happen again, it will. Any suggestions? Any advice would be appreciated!  S.

A:  Dear S.  Because it is situational, it is definitely psychological.  Something is making him anxious enough to lose the erection; the question is what.  It could be fear of pregnancy, fear of failing to please you enough or of "performing" satisfactorily.  Some rural boys were told that there were teeth in there, and that a woman could bite it off if they wanted ("vagina dentata").  The solution is to sneak up on it by making many shades of gray, not black and white foreplay then intercourse.

You need to engage in behavior modification therapy with each other, taking baby steps -- oops -- small steps, forget I said "baby."  Bring yourself to orgasm while he watches intently, making mental notes of how you do it.  Have him bring you to orgasm that way next time (so he'll develop confidence that he can bring you at least to orgasm if he loses the erection).  Same for him -- he brings himself to orgasm while you watch (so he disinhibits from orgasm with you), and you bring him to orgasm manually and/or orally.  Then, you stimulate his penis getting it closer and closer to your vagina, with no goal of penetration.  Make sure that NONE of the liquid that comes out of his penis, INCLUDING "pre-cum" (which contains sperm) gets in your vagina!  When you can rub the tip of his CONDOM COVERED penis along your labia and on your clitoris, without his losing the erection,  you are ready for gradual penile insertion.  On one event, while manually stimulating him, you insert only 1/2 inch and for 3 seconds -- two or three times if his penis stays erect.  On the next occasion, try for an inch for 6 seconds.  Gradually increase depth of insertion and time until you are having intercourse.  If (when) he loses the erection, drop back to the previous event's parameters.

It's slow, tedious, and frustrating, but that's how it's done.  Think of learning to swim or ride a bicycle.  Bit by bit, building on the previous behavior.

---

Remember: I am a sex therapist, not a Urologist (a medical doctor who specializes in Urology), so my comments on the various therapies are based on observations of patients in psychotherapy and discussions with those patients' Urologists. A Urologist is prescribing the medical interventions.

A) Yohimbine From the bark of an African tree. Available over the counter in some health food stores BUT:  some of the OTC versions have variable strengths (read on for negative side effects). It is available in dosage-controlled form by prescription as Yocon (R). Negative side effects include headaches and other distracting things. Can you imagine yourself saying: "Not tonight dear. I took the yohimbine, and I have an erection, but I have a headache."? For guys who want the least expensive "just pop a pill" quick fix you can try it, but I wouldn't waste my time.

B) Vacuum Pump These are available from $19.95 to $700+ and all work the same way: to create a vacuum around the penis so that blood fills the Corpora Cavernosa (the cigar-shaped tubes that create an erection by filling with blood). The problem, then, is how to keep the blood from returning to the body. That is accomplished with some sort of cock ring -- a constricting device positioned at the base of the penis. NEVER EVER USE A METAL RING! If your penis gets really full, the engorgement can cut off blood return and you'll have to go to the emergency room. And don't waste time trying all your home remedies. No circulation means no oxygen, which means that after a while tissue will die. After 30 minutes, start worrying. Other cock rings are leather with velcro (infinitely adjustable) or some variation on a rubber band. Without blood flow there is no replenishment of heat, and the penis cools off. One woman at a presentation I made said it powerfully: "I hate it when my husband uses the vacuum pump. In the first place he over-inflates because he's afraid it'll leak and go down, and in the second place, his cock cools off. It's like being fucked by a big cadaver! (Need I say more).

C)  Pellet in the Urethra I have not yet had a patient who had this therapy but numerous men have had a Q-tip stuck inside their urethra for a STD (sexually-transmitted disease) culture, and lots have been catheterized. All report significant discomfort from urethral intervention. Sort of interferes with romance, doesn't it?

D)  Penile Injections For years the drug of choice was Papavarin, but autopsies revealed significant intra-cavernosal scarring. It seems that the drug was pretty caustic. Currently Prostaglandin E1 (letter "E", number "one") is the drug of choice. The bottom line: 100% of my ED patients were "upset" at the thought of sticking a needle into their penis, and 100% eagerly asked the doctor to show them how to do it to themselves after the first time. It's a threshold phenomenon. In hypothetical numbers, 1 cc, 2 cc's, and 3 cc's might have no effect. 4 cc's might yield a 35 minute erection, 5 cc's an hour, 6 cc's 90 minutes, and 7 cc's three hours. It varies dramatically from man to man and is not based solely on weight, metabolism, etc. The needle is very thin -- same gauge as for diabetic insulin. One varies the injection site (e.g. left side, right side, one inch from the base of the penis, two inches from the base of the penis). The liquid is internal to the penis, so to answer the question about whether the injected medication would affect someone giving oral sex, the answer is "no". A nuisance: the med must be kept refrigerated or it loses all of its effect. So, you go to the fridge, inject your penis, and 5-10 minutes later with some stimulation, VIOLA!  like magic it comes up and stays up. A problem: Over-use of the penis to the point of tissue irritation, bleeding, and scabbing, IF the "regained" erect penis is given no rest. Seriously, folks, this can be a problem. I have had more than one man beg me to speak from authority to tell his lover to BACK OFF. Many lovers of the man with ED (Erection Dysfunction, remember?) are so frustrated by months and/or years of abstinance that they want to "make up for lost time." Another problem: After an orgasm the penis might stay erect or deflate some then all by itself return to erection. Some men and some of their lovers find that disconcerting and a sign of insufficient satisfaction (it isn't).

Where do you get Prostaglandin E1?  It must be prescribed by a medical doctor (usually a urologist).

How long/big is the needle?  Short and tiny.  It needs to go only into the corpora cavernosa (find that in an anatomy book or on the internet) AND IT IS VERY SMALL IN DIAMETER.  I am told it is the same guage used for insulin (for diabetics).

Does it hurt, burn, or sting?  I have never personally tried it, but almost all of my patients who use it say that it is literally a shallow pin prick.  Brief slight twinge.  IF YOU INJECT OUTSIDE the corpora cavernosa, it burns inside your penis for awhile (tolerable, disappointing, and uncomfortable).  But hey!  ALL the patients have said that the benefit (erections) is worth the cost (slight brief discomfort).

E) Penile Implants This is the therapy of last resort because it is irreversible. Something is inserted surgically into the penis to achieve rigidity. The least expensive is a bendable bar. The penis is grasped along the shaft at the base and near the tip and pressure is exerted to straighten the penis. After sexual activity the process is reversed and the penis bent to the desired shape. At the other end of the complexity and cost spectrum is a hydraulic implant. A reservoir of liquid is inserted into the abdomen with tubes to the penis and scrotum. Inside the scrotum a control device is implanted to transfer the liquid from the reservoir to balloon-like tubes inside the penis. One squeezes a part of the scrotum repeatedly to pump up the penis, and one presses a different location to open the valve and allow the fluid to flow from the penis back into the reservoir. This is the most invasive, there is always a risk associated with surgery, and these devices on rare occasion have ruptured internally.

VIAGRA ... Need I say more ?????

---

Dear Reader: What question about erection dysfunction remains unanswered in your mind? Please let me know.

sexdoc

---


6/23/99 Q:  Dr Fitz,
  Finally someone on the net that I can discuss impotence with.  My story is
this:  I'm 56yo, overweight, with a past history (quit 10 years ago) of
heavy (3pks+/day) smoking. Had quintuple bypass surgery last year.  Heart
supposedly ok.  Just recently found out about the link between smoking and
ED.
  I have suffered from ED since about 1969.  Prior to that, occasionally had
erection difficulties, but during the first year and one-half of my 2.5yr
marriage, I was like a stallion.  I was able to go 2-3 times a night (not
every night!), the sex was great.  Unfortunately, I married someone who had
been seriously emotionally and physically abused.  I had suffered some
emotional abuse also and suffered from occasional depression (I was unaware
of what it was at the time).  We both had lousy self-concepts and were young
and naive.  Over the course of our marriage, my wife became increasingly
unhappy, had difficulty holding a job, and became more and more critical
until it seemed like nothing I did was right.
  I came in due course to accept her (de)valuation of me and (I think in
self-defense) began to withdraw sexually from her.  We divorced after 2.5
years.  No kids.  My sexual withdrawal included masturbating before she came
home from work so I wouldn't be interested in sex.  It got to the point that
I couldn't get it up even when I wanted to.  By the time we divorced, I was
almost completely impotent.  We never came to blows, but I have always felt
that i was a battered husband, at least emotionally.
  Anyway, I dated over the next 2 or 3 years, with one steady relationship
for a couple of those years.  My sex drive returned in full force, but my
ability to maintain an erection dwindled to nothing.  I am now and have been
for three decades unable to get hard.  Sometimes if I'm very aroused, and
near orgasm, it seems to swell up, but not become rigid.
  I tried injection therapy and had one semigood erection but the next time
I somehow injected myself in the wrong place.  It was so painful I threw the
needle across the room and have been unable to try that mode again.  My
psychiatrist gave me a prescription for viagra but it seems to have little
effect, although I only tried a couple of times and without a partner.
   I have met someone over the internet whom I am very interested in and she
is aware of my ED.  But I really would like to be able to fuck her normally.
I love oral sex and am quite good at it, but I would really like to solve my
ED problem if it is solvable.
   Are you aware of any medications coming down the pike which might work?
My urologist (several years ago-I don't have one now) said my problem seems
to be complicated by poor blood circulation. My experience with the
cardiovascular problem seem to bear that out.  I wonder if there are bypass
operations for the penis?  Are there any other options?  I feel stupid
trying to fix the problem at this late date, but it's taken me this long to
find someone who I really want to have in my life (and also this long to get
my self-concept on a high enough level as well).
   Any guidance you can give will be greatly appreciated.
Sincerely,  J.
 

A:  Dear J.,

If I had ED my first therapy of choice would be injections of Prostaglandin E1 (letter E number one).  But that, and MUSE, the urethral pellet, are dependent upon enough plumbing to get the blood in, and trap it there.  If you are so compromised, no chemical can help.

I suggest trying the Viagra on an empty stomach (has affected some men), and trying the Prostaglandin.  If what you injected was Papavarin, it does burn like hell if in the wrong site.

Medical experimentation along with supportive sex psychotherapy are your best shots.

If you are systemically incapable of supporting a biological erection, an implant is your best bet.  Because of the possible problems with the hydraulic implants, if I were to have an implant I'd opt for the bendable bar.

I hope this helps.

sexdoc

---

Return to the Sexdoc's Homepage