By Tom Cannata
Dysfunction. The new “politically correct” terminology for the age-old problem
of impotency. The very thought of it is enough to send shivers down the spine
of any red-blooded male. Impotency or “E-D,” as it is now called, used to be
one of the least understood medical conditions affecting men. The reasons were
thought to be primarily psychological, a case of “It’s all in your head.” Bear
in mind, we’re not talking about the occasional inability to perform that every
man sooner or later will experience, caused perhaps by first-date nervousness
or maybe one too many martinis. True E-D is defined as the inability to achieve
or maintain an erection long enough for sexual intercourse and/or orgasm, lasting
several months or years. It’s estimated that between
15 and 30 million men suffer from E-D; it’s difficult to zero in on more
exact figures since so many cases go unreported.
The primary cause for E-D has to do with hydraulics. For an erection
to occur, certain muscles in the penis must relax in order for
blood to flow into the two chambers on either side of the penis
called the corpora cavernosa. At the same time, other muscles expand
to help trap the blood inside, making the penis expand. While this
all sounds very simple, a complex series of events must take place.
They include nerve impulses in the brain, spinal cord, and around
the penile area, and responses in the various muscles, fibrous tissues,
veins, and arteries. A problem with any one of the factors can cause
insufficient blood flow, and hence, a weak or absent erection.
Several reasons for insufficient blood flow include injury to the
penile area, chemical imbalances, drugs (especially blood pressure
medications), diseases such as diabetes, arteriosclerosis, and chronic
alcoholism surgery (especially prostate related), and sometimes
simply an aging erectile system.
With the introduction of oral drugs like Viagra the problems associated
with E-D have come to light, and increasing numbers of men have
been seeking treatment for this condition. Various therapies are
available and most men need not suffer with E-D any more. Treatments
include vacuum devices, oral medications, injectable drug therapy,
implant surgery, vascular reconstruction surgery, and psychotherapy.
devices use a plastic cylinder that fits over the penis, to
which is attached a kind of manual vacuum pump. As the air is pumped
from the cylinder, a vacuum is created and blood flows into the
penis, causing an erection. Of course, when the device is removed,
the erection subsides, so an elastic ring or “cock ring”
is slipped over the base of the penis to keep the blood flow in.
The benefits are that it is inexpensive, and relatively easy-to-use
devices can be purchased at virtually any adult toy store or on
the internet. The disadvantages are a lower success rate, an unnatural
feeling, and damage to the penis if the ring is left on too long.
Oral medications, such as
Viagra, by Pfizer, and Levitra,
by Bayer, work by enhancing the effects of nitric oxide, which relaxes
the muscles that allow blood to flow into the penis. The Viagra
explosion in 1998 brought the problem of E-D into the forefront
of public awareness, even hitting the cover of Time magazine on
May third. All jokes aside, oral medications do not cause erections
by themselves. The pros of oral medications include ease of use
(although a certain amount of planning is involved), and it’s
relatively inexpensive (about ten dollars a pop). The cons include
several side effects such as headaches, nasal congestion, and facial
flushing. Patients taking nitrate-based drugs cannot use these pills
because the combination can cause seriously low blood pressure problems.
Although they are prescription drugs, they are widely available
on the Internet, as anyone who has an email address can attest to
the constant bombardment of advertisements. Bad news: Men, if you
don’t have an E-D problem, oral drugs generally will not improve
drug therapy consists of injecting a drug or combination of
drugs directly into the penis to cause an erection. Before you go
running away screaming, know that the injection itself is virtually
painless. The syringes are the tiny 31-gauge size, the same as diabetics
use. The dosage injected varies from 1/20th to 1 milliliter and
is carefully prescribed for each individual. Within ten to fifteen
minutes an erection is produced that lasts between one and two hours.
The advantages to injection therapy are a high success rate, very
few side effects, and an erection that does not subside immediately
after orgasm. Disadvantages include possible buildup of scar tissue,
and a dangerous condition known as “priapism,” or an
erection that will not subside, if the dosage is not strictly followed.
surgery may be the answer for those with severe E-D or where
no other treatment is effective. A stiff plastic or silicone implant
is inserted into the penis to give it the rigidity needed to perform
intercourse. More elaborate implants include internal hydraulic
systems where fluid is pumped from an implanted reservoir into inflatable
plastic chambers inserted into either side of the penis. The pros
of implant surgery include an “erection on demand,”
since the erection is controlled by the patient. The cons of implant
surgery are its irreversibility, chance of infection, and the risks
associated with any surgery.
In many cases E-D is the result of reduced blood flow to the penis,
and can be helped by
vascular reconstruction surgery. The blood vessels that carry
blood to and from the penis are small, smaller than the lead in
a lead pencil. These fragile arteries can be damaged by accidents,
injured during sports, or blocked from plaque buildup. The surgical
procedure consists of replacing the damaged or blocked blood vessels
with healthy blood vessels from other parts of the body, similar
to a heart bypass but on a much smaller scale. The advantage of
vascular reconstructive surgery is the possibility of restoring
full erectile capability with no ongoing need for medications or
treatments. The disadvantages are a somewhat lower success rate
than other therapies, and again, the risks associated with all surgeries.
While it has been determined that most
cases of E-D are physical in nature, it should be noted that
there exist some cases of psychological reasons for E-D, which may
be helped by psychotherapy. Additionally, psychotherapy may be used
in conjunction with other therapies to help reduce the overall stress
and anxiety associated with E-D.
Dealing With Erectile Dysfunction - My Story:
I consider myself a very sexual person - that is, sex is and has
always been an important part of my life. Since my mid thirties,
I had been noticing a reduction in the rigidity and staying power
in my erections. I’m also somewhat of a nervous, anxious person,
so I was rarely able to get an erection with a new partner until
after a few attempts. After those attempts I could achieve an erection,
but it didn’t seem to last as long as I wanted and sometimes
not long enough to complete intercourse. One night I was in a hot
tub with my wife and some close friends, and I couldn’t help
noticing that the other guy was sporting a raging hard-on. I was
sitting there, flaccid as could be, trying to figure why my equipment
wasn’t “up to the task.” This set my mind to wondering
if I didn’t have a problem. When I mentioned it to my family
doctor, he said, “Well, you’re not eighteen anymore,
don’t worry about it.”
Not being satisfied with that as an answer, I consulted a local
urologist. He gave me an initial exam and scheduled me for a test
to determine blood flow capabilities. During this test, they injected
me with a drug that made my penis become startlingly erect. “Wow,”
I thought, “It hasn’t felt like this in years!”
They proceeded to check the blood flows by using an ultrasound machine,
the same kind used in pregnancies and to examine organs like kidneys
and the heart. After about an hour they gave me another shot to
bring down the erection, and then I waited for the doctor to discuss
The urologist said that the tests confirmed that the blood flow
on one side was reduced about by about forty percent, and on the
other side, about sixty percent. I was operating at “half-mast”
as they say. Although I kind of felt relieved that it wasn’t
“all in my head,” I expected that he would now give
me the answer to my problems.
“I can give you an implant,” he said resignedly, “But beyond that there’s not
much I can do for you. However, I can give you a referral to a physician in
Boston who’s one of the top doctors in this field.” I left his office with the
name and phone number of Dr. Irwin Goldstein, Professor of Urology & Gynecology
at the Boston University Medical Center.
I called that day and scheduled an appointment for the next week.
At BUMC they gave me a similar procedure to the one I had locally,
but this one was greatly enhanced. There were about a dozen people
present, doctors, nurses and technicians, in a room full of high-tech
computerized equipment. They gave me the shot to produce the erection,
along with some Novocain. Needles were inserted into my penis (that’s
why the Novocain!) and saline fluid was pumped in and out of me
as they checked for arterial flows and venous leakage. The tests
confirmed the earlier reports, except that they were much more accurate
(“The left side is 42.7% reduced and the right side is 61.4%”).
Dr. Goldstein was upbeat in our follow-up discussion. He gave me
several alternatives, among them surgery and injections, both of
which I immediately dismissed as too drastic. Then he said, “There’s
a drug company who’s working on a pill to help impotence,
and they’re looking for volunteers to take part in a study.
Would you be interested?” What? There’s a pill to help
this? (Remember, this was 1996, three years before Viagra was approved
and hit the market). I figured, what did I have to lose? “Sign
me up!” I exclaimed. Although my wife was a bit uncertain
about me taking some unapproved medication like a guinea pig, I
had no compunctions about trying this out.
And so I became a part of the Pfizer Sildenafil Citrate (soon to
be Viagra) double-blind drug study. The term double-blind means
that you get coded medication that neither I, nor the doctors would
know if I was receiving a full, three-quarter, one-half, one quarter,
or no dose at all (also known as a “placebo.”)
For the first month I received no pills at all, but had to record
my sexual activity and answer questions like, “How strong
would you rate your erection?” and “Were you able to
penetrate?” and “Were you able to complete intercourse?”
Talk about feeling like you’re under a microscope, sometimes
my wife and I would be laughing our asses off so much that there
was no way we were going to finish what we started anyway.
Finally after four weeks I got my pack of pills. I sure was anxious
to try these out, yet I had no idea what to expect. I was hoping
they wouldn’t be the placebos since this phase was to last
six months. Anyway I raced home, had dinner, popped my first pill
and waited. They said it would take about thirty minutes to kick
in if it did at all, and I’ll tell you they were some of the
longest minutes of my life. After about twenty five minutes or so
I started feeling a bit of facial flushing, like I might have been
standing in sunlight. Also I was beginning to get a little stuffy
and the lights in the room seemed a bit bright. These were some
of the side effects the doctors had mentioned, so I knew I had received
at least some level of medication. I didn’t get an erection,
but they had cautioned me that it sexual stimulation was still needed
in addition to the pill in order for the erection to occur. I said
to my wife, “I think it’s starting to work,” and
she replied, half amused and half amazed, “You better get
I did get a good erection and it did seem to last longer, but I
think I was still way too anxious about the whole situation to “complete
the act” as they so clinically state in the reporting forms.
It wasn’t until the third or fourth try that we finally got
in the groove and figured out the timing of the medication. For
me, it seemed to work best on an empty stomach and peaked about
forty five minutes after taking it. So there was always a bit of
planning involved in that I wanted to be at or near the orgasm stage
within that time frame. Also, the effects were diminished after
eating a big meal, so the idea of going out to dinner and then home
for a night of hot sex seemed out of the question.
By the end of the six-month trial we had our routine established.
Mornings were best, mostly because of the empty stomach and probably
also because we were more rested then. I had also heard that men’s
testosterone levels were higher in the morning. But although it
was working for me, it left a few things to be desired. Mornings
meant weekends, and that left far too many days in between. Also,
I was concerned as to what would happen after the six months until
the drug was hopefully approved.
The good news was that Pfizer decided to extend the study. I was
given another six-month period and another supply of medication
(I had to meticulously account for each pill, much to the chagrin
of many of my friends who virtually begged me to let them “try
one”). Later, after the second six-month period Pfizer graciously
allowed the men in the study to continue by supplying us with all
the medication we wanted. Then, in 1998, the FDA gave its approval
to Viagra and the rest became history.
I continued to use Viagra over the next few years, with mixed results.
At times, it seemed to work like a charm, returning all of the vigor
and potency of my younger days to me. At other times, it seemed
to not work at all. I really had to fine-tune the timeliness of
my lovemaking to the time of day and the peak effectiveness of the
drug. The stuffiness and nasal congestion were still a problem,
especially since what more do you need during hot sex but to breathe
I began to look for an alternative.
At my next follow-up meeting with Dr. Goldstein at BUMC, I inquired
about the possibility of the penile arterial revascularization.
I reasoned that since I had been diagnosed as having a blood-filling
problem with those low flow arteries, that this operation might
do the trick. Usually, in order for me to go anywhere near a hospital,
the situation better be damn near critical, but since finding an
alternative was so important to me, I decided to take the plunge.
Dr. Goldstein warned me that although the success rate was high,
it wasn't guaranteed, but that I would be no worse off than I was
now. At the very least I could continue taking Viagra and at least
have partial success. We scheduled the operation for May of 2000,
after my busy work season but before the summer, which I love. The
worst part would be the six-week waiting period after the operation,
during which no sex, not any kind, in the least bit, would be permitted
to allow for complete healing.
The operation went smoothly and was deemed a success by Dr. Goldstein.
He pulled a portable ultrasound machine into my room that evening
and turned up the volume so I could hear the pounding of the blood
pouring through the transplanted artery. I was released the following
day with the repeated cautionary remarks about abstaining from sex
for the required six weeks. I figured I could do it, even though
the last time I went six weeks without sex of any kind was when
I was about twelve years old.
Over the next few weeks I experienced very strong “nocturnal”
and “early morning erections,” as Dr. Goldstein termed
them. I couldn’t wait for the six-week period to pass. Finally,
I had my final checkup and was given the green light! We had planned
a nice dinner and evening (no longer would I have to wait to have
sex on an empty stomach!) and basically jumped into bed. Again,
my anxiety got the best of me and although I achieved a good erection,
I was unable to reach orgasm. Well, I had waited six weeks; I could
wait another day. The next few tries yielded the same results: a
good erection, but no orgasm. I went back on the Viagra and got
some varying results, but was feeling a bit depressed; maybe I was
expecting too much too soon.
The next couple of years were similar to before the operation.
I began experimenting more by taking a pill and a half, or even
two pills at once (a strict no-no from the doctors!) I even figured
out how to take the pill before dinner, eat a quick meal, and then
hop in the sack before the peak effectiveness wore out. By the summer
of 2003 I began wondering if I was building up a tolerance to Viagra.
After all, I had been one of the original users of the drug and
been taking it for about seven years by then. Doctors insisted that
it wasn’t possible for the drug to lose its effectiveness,
but how did they know? I was fairly unique in that I had such a
long history with the drug.
Right around that time, the new drug Levitra, by Bayer, received
FDA approval. Levitra was supposed to work in a similar fashion
to Viagra, but without the side effects like stuffiness and facial
flushing. Also, you were supposed to be able to take it after a
meal with no loss of effectiveness. I leapt at the chance to try
it! Succumbing to buying it over the internet, I typed in my symptoms
and then a virtual physician wrote me a prescription. I handed over
my credit card numbers for two hundred dollars plus thirty nine
for next day delivery. The following morning the FedEx man carried
my salvation into my office in the form of a Letterpak; inside I
could hear the ten Levitra pills I ordered shaking around.
They worked, but no better than the Viagra. I still got stuffy and
when I tried it after a meal it was about fifty percent effective
for me. It was time for another appointment with Dr. Goldstein.
I met with Dr. Ricardo Munarriz, Assistant Professor of Urology
& Gynecology, who works closely with Dr. Goldstein at BUMC.
He reviewed my case with me and point blank suggested, “Why
don’t you try the injections?” I had dismissed this
option very early on, as the thought of sticking a needle into my
penis wasn’t my idea of fun. I had no idea what it was like,
and all I could conjure up in my head was the image of trying to
stick a red, swollen, painful, bleeding penis into a vagina –
not very appealing! However, by then I was ready to try anything.
Dr. Munarriz indicated that he thought I’d be very happy with
the results and essentially alleviated my fears. So I took a deep
breath and said, “OK, where do we begin?”
We began five minutes later with an injection of 1/10th of a milliliter
of a custom combination of drugs called Trimix. The doctors at BUMC
through their own research have concocted a mixture of papavarine,
phentolamine, and prostoglandin E1. These three drugs work together
to relax the smooth-muscle tissue of the penis, relax the walls
of the penile arteries and block the constricting action of the
sympathetic nervous system on the erectile tissue.
But enough of the science, within fifteen minutes I had that elusive
raging hard-on so reminiscent of my youth! I could actually feel
a power and fullness in my penis that I hadn’t felt in a long,
long time. They let it stay for about half an hour and then had
to give me a different injection to “bring me down.”
The next time they had to cut the dosage way down. Three days later
I was given an injection of half the amount of Trimix. I got what
I felt was about a three-quarters erection which the doctors was
about right. In the clinical environment of the hospital they aimed
for about a sixty percent erection, so with some sexual stimulation
and foreplay under normal conditions, I’d have all of the
erection I’d ever want. It sounded great to me!
This only left one remaining factor – I had to be taught
how to self-inject. The nurse pulled out this huge soft-rubber penis
– made extra large for teaching purposes, he assured me –
and showed me exactly how to do it. He let me give it a couple of
tries, drawing saline from a drug vial and injecting it into this
monstrous dick at just the right angle. Then he wrote up the prescription
and sent through the order that would be delivered to my door in
one or two days. He also gave me a prescription for the micro-needles
that I could fill locally. Costco, he told me, would probably give
me the best deal. I shook my head in amazement.
I don’t have to tell you that I filled the hypo script that
night, in preparation for a test flight the following day. Sure
enough, FedEx came through again; this time it was in a small Styrofoam
cooler with ice packs inside. The drug needs to be kept refrigerated
to maintain its effectiveness and quickly breaks down with heat.
That evening, it was time – time for me to make my first injection
– and into my own penis, no less! Very carefully, I used alcohol
swabs to wipe the top of the vial, inserted a micro-needle, and
drew out the magic potion. (My wife and I jokingly refer to this
as “Love Potion No. 9”). Returning the vial in its container
to the refrigerator, I brought the hypo and a second alcohol swab
into the bedroom. After wiping down the side of my penis, I held
my breath and slowly inserted the needle into my manhood. Surprisingly,
it was totally painless, even less than at the clinic! I squeezed
the plunger like I had been taught, and 1/20th of a milliliter of
Trimix surged into my corpora cavernosa. That much volume is about
the size of a small drop, so I didn’t feel anything going
in either. I removed the needle and held the swab against myself
with a slight pressure for about 3 minutes. There was no pain or
soreness at all, even at the site of the injection.
Now I started watching the clock – I knew it took about fifteen
minutes to kick in. After about eight minutes I was starting to
feel its effects, and by twelve minutes had a full erection ready
for action! Of course the psychological factors were working; I
knew this was effective, and this wasn’t the clinic, it was
my bedroom with my wife lying naked in front of me. The effects
were tremendous! I felt like I hadn’t felt in twenty years.
We went at it and soon I exploded with a deep and satisfying orgasm.
My wife commented that she, too, could feel the difference in size
and virility. One of the benefits of these injections is that the
erection is maintained long after you come, so premature ejaculation
is never a problem. Like the Energizer Bunny, you can keep going
I have finally found my Golden Fleece, my Holy Grail of E-D therapy.
I haven’t touched a Viagra in four months, and I am enjoying
a near 100% success rate with these injections. I have occasionally
“missed” with the micro-needle, probably hitting a vein
that carried the magic potion away from my penis into some nether
region of my body. If I’m sure this has happened, (twenty
minutes or so and no reaction), a second shot is all that’s
needed to get me “up and running” again. I can have
a huge dinner, have sex morning, noon and/or night, and not have
to worry about timing issues since I have about a two-hour window
in which to perform. I have had no side effects.
My only regret is not having explored this possibility sooner.
Sure, the very idea of penis injections is totally abhorrent to
most men – it was to me seven years ago. Had I tried this
first, I probably would never have taken Viagra and certainly wouldn’t
have had the surgery, although I’ll never really know if the
surgical procedure is a factor in my success with the injections.
Although the injections worked best for me, each man needs to be
evaluated and make his own choice when searching for treatments
for Erectile Dysfunction. I think the hardest step is the first
one, to contact your physician or urologist for evaluation. With
this condition now being openly and frankly discussed, and with
so many options available,
men need not suffer silently with E-D.