Written By: Katie Rose

John leans back against the headboard, pillows propped behind his shoulders, staring out the window. Linda lies on her side, facing away from him. She is curled into a ball with the covers pulled up over her shoulder. He knows she is awake, but she won’t talk to him. It’s not her fault -- he knows it’s not her fault. It wasn’t all that long ago they enjoyed a fulfilling sex life. Now whenever they go to bed together, John finds himself nervous and wracked with anxiety, as if he were losing his virginity each time. Or trying to. Why won’t his body do what he wants it to do?

Though hidden behind bedroom doors, John’s anguish is shared by many men. It’s called Erectile Dysfunction, and it’s very serious business. But what exactly is Erectile Dysfunction? Technically speaking, Erectile Dysfunction (or ED) is a condition in which a man cannot get or sustain an erection long enough to reach orgasm or to satisfy the sexual needs of his partner. Most men experience this inability at some point in their lives, usually by age 40, but are not psychologically affected by it. Some men with ED may only be affected by partial or brief erections, on occasion. The most seriously afflicted men suffer the chronic and complete inability to achieve erection (impotence). A severe case of ED can cause emotional and relationship problems, and often leads to diminished self-esteem. ED is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity thanks to improved, successful treatments for ED.

Although ED is not necessarily a consequence of age, it is a condition whose frequency increases with age. Roughly 25% of men 65 and older suffer from ED to some degree or another. Alarming as the statistic may seem at first, it is important to realize ED is considered a medical problem only if it lasts for more than three months. Because the severity of ED spans such a wide range - anything from occasional, brief erections to full-blown impotence - precisely defining it and estimating its incidence is difficult. Estimates range from 15 million to 30 million, depending on the definition used.

According to the National Ambulatory Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7 physician office visits were made for ED in 1985. By 1999, that rate had nearly tripled to 22.3. The increase happened gradually, presumably as treatments such as vacuum devices and injectable drugs became more widely available and discussion of erectile dysfunction became more accepted.

Physiology of Erection
In order to understand ED, you have to study the inner-workings of the penis and what happens to it as it becomes erect. The physiological process of erection begins in the brain and involves the nervous and vascular systems. Neurotransmitters in the brain (e.g., epinephrine, acetylcholine, nitric oxide) are the primary chemicals which get the process going. Physical or psychological stimulation (arousal) increases the production of the key neurotransmitters and triggers the nerves into sending messages throughout the body. Many of these messages are directed to the vascular system, especially in the genital area, and result in a significant increase in blood flow to the penis. Two arteries in the penis supply blood to the corpora cavernosa and to its surrounding erectile tissue. The spongy tissue of the corpora cavernosa engorges with blood and expands due to the increased blood flow and pressure. Erectile tissue enclosed by fibrous elastic sheathes (tunicae) surrounds the corpora cavernosa. Because the blood must stay in the penis to maintain rigidity, neurotransmitters are summoned into action. They stimulate nerves at just the right time to cinch the erectile tissue and prevent blood from leaving the penis during erection. When stimulation ends, or following ejaculation, pressure in the penis decreases, blood is released, and the penis resumes its flaccid state.

Causes: Physical vs. Psychological
Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Diseases--such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease--account for about 70 percent of ED cases. Between 35 and 50 percent of men with diabetes experience ED. Also, surgery (especially radical prostate surgery for cancer) can injure nerves and arteries near the penis, causing ED. In addition, many common medicines--blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug)--can produce ED as a side effect.

“My man is diabetic and has been experiencing some difficulties in this area...not so much getting an erection but maintaining it and having an orgasm. This is a distubing thing only because we both have questioned our abilities and personal worth.” - Clitical Member

Experts believe that psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause 10 to 20 percent of ED cases. Men with a physical cause for ED frequently experience the same sort of psychological reactions (stress, anxiety, guilt, depression).

“I've had problems with acheving erection when I really should have been trying to get some sleep. Stressed out and tired dosn't do much for performance. Really had nothing to do with my partner had more to do with the eight-to-five. Don't assume it's your problem. Encourage him to get some rest. Possibly go fishing or some other "guys time off." - Clitical Member

Other possible causes are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as not enough testosterone.

Yet one more possibility is having a new partner or trying a new activity, such as oral sex or a different position.

“I've only had trouble orgasming when I frist started to receive oral sex. The first few times my girlfriend tried and tried she did it just coudlnt' happen no matter what she or I did.” - Clitical Member

“The only time I've had a problem achieving an erection is when I first started making love. I remember it was when I was trying out the doggy style position for the first time. I couldn't get it (the position - not my penis) to work quite right and I panicked. Well, when I panicked, my penis quickly grew flaccid. It happened every time I would try doggy style intercourse until I finally became confident enough with the missionary position that I felt I could overcome my doggy-style problem, as I knew it was directly related to the stress of not being confident in myself. I haven't had the problem since then.” - Clitical Member

AGE-RELATED PHYSICAL HEALTH ISSUES
Women from different generations have contrasting attitudes and values regarding sexuality. These attitudes and values have health care implications. In general terms, younger women may view the sudden loss of a sexual partner due to illness or traumatic injury as catastrophic. For an older woman, the gradual decline in sexual interest and activity may be considered a normal part of the aging process.

It is important to be aware of the many sexual changes associated with aging for both men and women. They include Testosterone decrease, decrease in the production of sperm, change in the size of testes and viscosity and volume of ejaculate.
Additional changes include slowed response/excitement, more stimulation is required, erection becomes less firm, orgasms are of shorter duration, and multi-orgasmic capacity is impaired.

PSYCHOLOGICAL HEALTH ISSUES
FLUCTUATIONS IN SEXUAL DESIRE
Sex therapists document that low sexual desire is the number one complaint that brings couples into treatment. Many professionals believe that if you do not have sexual thoughts, fantasies or urges more than two times a month, there may be a problem. This yardstick is certainly arbitrary, but when either or both partners avoid sexual activity on a regular basis, something is amiss.

Women reach their orgasmic prime in their forties and fifties. It is not unusual for a mid-to-post menopausal woman to experience an increase in sexual interest as she ages. Simultaneously, men begin to experience cardiac and prostate disease, which can cause impotence. At a life period when many women are most interested in making love, their partners begin to lose their ability to perform.

DEPRESSION
Depression frequently accompanies sexual dysfunction in both women and men. In the general population, depression appears to more commonly affect females and older adults. It is important to have this problem evaluated if it is severe. If any individual experiences more than two of the following symptoms, he/she should consult a physician: suicidal feelings, impaired concentration, low energy, lack of interest in usual pleasurable activities(that includes sex), sleep disturbance, and significant weight loss or gain.

DIAGNOSIS
Medical and sexual histories help define the degree and nature of ED. A medical history can disclose diseases that lead to ED, while a simple recounting of sexual activity might distinguish between problems with sexual desire, erection, ejaculation, or orgasm.

A physical examination can give clues to systemic problems. For example, if the penis is not sensitive to touching, a problem in the nervous system may be the cause. Abnormal secondary sex characteristics, such as hair pattern, can point to hormonal problems, which would mean that the endocrine system is involved. The examiner might discover a circulatory problem by observing decreased pulses in the wrist or ankles. And unusual characteristics of the penis itself could suggest the source of the problem--for example, a penis that bends or curves when erect could be the result of Peyronie's disease.

Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Measuring the amount of testosterone in the blood can yield information about problems with the endocrine system and is indicated especially in patients with decreased sexual desire.

Monitoring erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of ED. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then ED is likely to have a physical rather than psychological cause. Tests of nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be applied for best results. Another test, called color phase ultrasonography, also may be done. This evaluates blood flow to the penis.

A psychosocial examination, using an interview and a questionnaire, reveals psychological factors. A man's sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

SEEKING MEDICAL HELP
If you are experiencing erectile dysfunction, medical care is essential. Many primary care physicians are assuming a more active role in the diagnosis and treatment of impotence. This involvement by the non-surgeon is increasing because of the development, in recent years, of non-surgical treatment alternatives, and because most impotence is experienced by patients who are already under the care of a family physician for other disorders.
Prepare in advance for your first visit with the physician. Write down your questions and concerns ahead of time. Some of the information conveyed by the doctor may be technical and difficult to remember. This is no time to be shy. You need to fully understand all of your options. In order to make a sound, mutual decision about the appropriate medical approach to this problem, you need to have all of your question answered. Bring a notebook along if you would like to take notes as you are talking.

TREATMENT
Most physicians suggest that treatments proceed from least to most invasive. Cutting back on any drugs with harmful side effects is considered first. For example, drugs for high blood pressure work in different ways. If you think a particular drug is causing problems with erection, tell your doctor and ask whether you can try a different class of blood pressure medicine.

Psychotherapy and behavior modifications in selected patients are considered next if indicated. A significant number of men develop impotence from psychological causes that can be overcome. When a physiological cause is treated, subsequent self-esteem problems may continue to impair normal function and performance. Qualified therapists (e.g., sex counselors, psychotherapists) work with couples to reduce tension, improve sexual communication, and create realistic expectations for sex, all of which can improve erectile function.

Treatment may also include using a vacuum pump device to draw blood into the penis, using oral prescription medications and herbal products, such as sildenafil, also known as Viagra, or Yohimbine, injecting the medication prostacyclin E into the penis, surgery to improve blood flow to the penis, or implanting an inflatable prostheses into the penis

Sometimes all that is necessary is some honest communication between partners.

“We had a time where it was such a stressful thing that both of us just didn't enjoy it. Now we are more into the let's do what feels right for us. If we feel like it we will and if we don't feel like it we won't try to force the issue.” - Clitical Member

What are the side effects of the treatments?
Each treatment has its own set of advantages and side effects. The vacuum pump is very safe. But one drawback is that the constriction band, which keeps the erection, cannot be left on for more than 30 minutes. Sildenafil or Viagra cannot be used in people who take nitroglycerine because the combination may cause severe low blood pressure and heart attack. Injections are relatively painless, but require careful dose adjustments by a healthcare provider. Surgery is an option that should be discussed with a healthcare provider. There are possible side effects with any surgery. These include bleeding, infection, and reactions to the medications used to control pain.

All of this sounds pretty serious, and it is for those people who have to deal with it. The point is that it doesn’t have to mean the end of a relationship. Education and understanding can go a long way.

If you’d like additional information, check out these places.

Sexual Function Health Council
American Foundation for Urologic Disease
1128 North Charles Street
Baltimore, MD 21201
Phone: 1-800-433-4215 or (410) 468-1800
Email: impotence@afud.org
Internet: www.impotence.org

Finding a Health Care Provider or Counselor
American Urological Association
1120 North Charles Street
Baltimore, MD 21201
Phone: (410) 727-1100
Email: aua@auanet.org
Internet: www.auanet.org
AUA can refer you to a urologist in your area.

American Diabetes Association (ADA)
National Office
1701 North Beauregard Street
Alexandria, VA 22311
Phone: 1-800-DIABETES
Internet: www.diabetes.org ADA can help you find a doctor who specializes in diabetes care in your area.

American Association of Sex Educators, Counselors, and Therapists (AASECT)
P.O. Box 238
Mount Vernon, IA 52314
Internet: www.aasect.org
Check the AASECT website to find a certified sexuality educator, counselor, or therapist in your area.

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