Erectile 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.

Vacuum 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 your performance.

Injectable 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.

Implant 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 results.

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 upstairs!”

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 easily?
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 and 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.