Erectile dysfunction (ED), also called impotence, is the term used when a man is unable to have an erection, and is the second most common male sexual problem. The causes of ED can be either psychological or physical, while the degree of ED can vary from a simple loss of rigidity to a total inability to have an erection. Although ED can strike at any age, it becomes much more common as men grow older. Among men in their late 70s and beyond, some symptoms of ED are almost universal.Because I know how much importance you men put into your erections, let me say right away that ED doesn’t necessarily mean the end of a man’s sex life. Depending on the cause of the problem, several possible solutions are usually available, so take heart.
The precursor: Loss of instant erection
I can say a lot on the subject of impotence, but the most important point has to do not with actual impotence, but with its precursor. The reason its precursor is so important is that it affects every man, at least every man who reaches a certain age in life, so pay careful attention to this section.
It sneaks up on you
Young men get erections all the time, often when they least expect to and at embarrassing times. A variety of stimuli can cause these erections — something visual, such as the sight of a pretty girl in a short skirt; a fantasy about that girl in the short skirt; or even just a whiff of perfume that reminds the young man of that girl in the short skirt. This type of erection is called a psychogenic erection, meaning it is stimulated by something that triggersthe brain to release hormones that cause an erection.
At a certain age — and that age differs with every man, but ranges from his late 40s to early 60s — a man loses his ability to have a psychogenic erection. That ability usually doesn’t disappear all at once; he begins to get fewer psychogenic erections and may not even notice at first. But eventually the decrease becomes apparent to him, and at some point, his psychogenic erections cease altogether.
This change can be a precursor to ED, but it’s not ED because the men experiencing this change can still have erections. The only difference to a man’s sexual functioning at this stage in life is that he needs direct physical stimulation to his penis to get an erection. He has to either use his hands or have his partner use her hands or mouth to make his penis erect.
Spreading the word
The loss of psychogenic erections wouldn’t prove much of a problem if men expected the change, the way that women expect the hot flashes that accompany the start of menopause. Surprising, at least to me, is that so many people still have no idea that this change is part of the natural progression of growing older. This lack of knowledge causes the real problem.
Many men think that they must be impotent when they can no longer get erections the way they used to. Rather than seeking help, they begin avoiding sex. When this happens, wives think that their husbands either are no longer attracted to them or that they are having an affair. Some couples fight over this problem; others withdraw from each other.
This breakdown of a relationship is so sad to me because it’s not necessary. All that these couples have to do is include foreplay for the man exactly the way they have used foreplay for the woman’s benefit all along. If they do this, then they have no problem.
I think that one of the reasons the loss of psychogenic erections isn’t so widely known is that the condition doesn’t really have a name. People may call it a symptom of so-called male menopause, but men don’t like that phrase (and I really don’t blame them) because it’s really not appropriate. We need to coin a catchy phrase for this syndrome; then the media will pick up on it, and a lot of unhappiness can be prevented. I think a good name would be The Male Cooling Off Period. (Why don’t you send your suggestions to me by going to www.drruth.com and clicking on “Ask Dr. Ruth.” Maybe together we can make some real progress toward helping men and women understand this change that causes so much unhappiness.)
Dealing with ED in older men
As a man gets older, his erections begin to get weaker and weaker, and he may need more and more stimulation to get an erection. Some older men can get an erection but can’t keep it long enough to have intercourse. Sometimes they can get an erection, but the erection isn’t stiff enough to allow for penetration.
These are all real, physical problems, but they don’t necessarily spell the end of a man’s sex life. If men understand that age causes these problems, and if they’re willing to take appropriate action, like Mike was in the following example, many men can continue to have sexual relations through their 90s.
“Mike”
I was holding regular clinics in the department of geriatrics at New York University Hospital in New York, and many of the men who came to see me had problems with impotence. I remember one man in particular, I’ll call him “Mike.” He was well into his 80s, and he hadn’t had sex in about a dozen years. When Mike’s erections began to peter out on him, he just gave up.
The only reason this man came to the clinic to see me was that he had started seeing a woman, and she wanted to have sex. When he told her that he couldn’t, she told him that he had to at least try, and so, to please her, Mike sought help from me.
I had him checked out by a urologist and, physically, Mike was fine. I worked with him for about a month, and one day he came to see me in the clinic, beaming. Mike and his lady friend had had intercourse the night before, and he couldn’t have been happier. I’ve helped a lot of people over the years, but I have to say that the morning that man reported to me his newfound success made me the happiest of any.
The morning cure
For many men, the best solution to their problem with impotence is just to change their sex habits to suit their age. The easiest suggestion I can offer older men is to have sex in the morning instead of at night. Because you’re probably retired and have no children at home, you have no reason to always try to have sex at night, except the force of habit. However, here are good reasons that illustrate how changing your routine can help you to become better lovers:
Older gentlemen are often tired after a long day. Getting the blood to flow into the penis is what an erection really is, so the more tired you are, the more difficult it is for this process to work correctly. In the morning, you have more energy, and so you can get erections more easily.
The male sex hormone, testosterone, is at its peak level in the morning and at its weakest at night. Because this hormone is instrumental in effecting erections, trying to get an erection in the morning makes a lot of sense.
Now, I don’t recommend trying to have sex first thing in the morning because the older you are the longer it takes you to get your body warmed up for “action” such as sex. Because you probably don’t have to be on a rigid schedule, I suggest waking up, having a light breakfast, getting your blood flowing, and then taking your partner back to bed for a sexual interlude.
Some older men resist this suggestion at first. For some reason, doing all that planning doesn’t suit them. But if they listen to me, many men find that the fires that had died down start burning once again.
The stuff technique
Now, if some men think having sex after breakfast is strange, imagine how hard-headed some men are when it comes to getting them to try to have sex without first having an erection. But sometimes this technique works the best.
The stuff technique is just what it sounds like. The man, with the help of his partner, stuffs his nonerect penis into her vagina. Sometimes, after a man begins to thrust, the blood flows into his penis and that elusive erection finally rises to the occasion. The best position for doing this will depend on the physical condition of both partners. If the man has any difficulties holding himself up in the missionary position, it may be better to use the side-by- side position. And because this technique doesn’t always work — or may never work for some men — try it for a few minutes, and if it doesn’t seem like an erection will occur, then drop it.
Managing short-term impotence
Unlike ED, short-term impotence is almost always psychological in nature. Many, many men, at one time or another, suffer from impotence — meaning that they can’t have an erection when they want one. In fact, sometimes because they want an erection so badly these men fail, as Jimmy discovers in the following example.
Susan and Jimmy
Susan was a transfer student, and Jimmy spotted her the very first day he returned to college in his senior year. She had the type of looks he’d always dreamed of, and, to his amazement, when he struck up a conversation with her, she responded.
Jimmy had slept with a few other girls during his college years, but the thought of actually going to bed with Susan drove him wild. He managed to play it casual for a while, and, after a week went by, he asked her out on a date. She accepted, and they had a great time. They had a few more dates, each one advancing further than the last, so that, on his fifth date with her, Jimmy was pretty sure that they were going to have sex.
The anticipation was almost torture to Jimmy, and he had an erection for much of the day. They went to a dance and, with their bodies clinging to each other during all the slow dances, Jimmy felt that he was as ready for sex as he ever had been.
Jimmy had never had problems getting an erection, but as they were walking back toward his dorm, he started having doubts about his ability to please Susan. He was sure that someone as good-looking as Susan had had sex with all kinds of guys, and he began to question whether or not he could stand up to the test. By the time they got back to his room and took off their clothes, Jimmy was in a state of pure panic, and his penis reacted accordingly by staying limp. Jimmy was more embarrassed than he ever thought possible.
Anticipatory anxiety has caused many a Jimmy to experience similar problems. Anticipator y anxiety means the fear or expectation of a possible failure causes an actual failure. If a man starts worrying about his erection, usually doing so is enough to prevent him from having one. And the more he worries, the more likely that he will fail the next time he tries. Many men, because of one failed erection, have suffered through years of misery.
Visit a urologist
In younger men, having erectile difficulties is more often than not psychological rather than physiological, so curing the problem is usually easy with the help of a sex therapist.
If a young man comes to my office with a problem such as this, the first thing I do is send him to visit a urologist, which is a medical doctor who specializes in the care of the genitourinar y tract, the urinary tract in men and women and the male genital tract.
One reason I send men who experience impotency to a urologist is to make sure that their problem isn’t physical, which I can’t handle because I’m not a medical doctor.
The other reason I send them off to have their physical plants checked out is that just getting that clean bill of health is often enough to clear up the problem.
You see, many of these men worry so much about something being wrong with them that just hearing from a doctor that they’re A-OK is enough to give their penises the psychological lift they need. Even if the doctor’s visit itself isn’t sufficient, it’s a very good first step.
Build confidence
After sending an impotent client to a urologist, my next job is to build the man’s confidence in his penis back up to what it was before he ran into trouble. Sometimes just getting him to masturbate does the trick. Sometimes I have to get him to do certain confidence-building exercises with his partner.
These exercises usually involve prohibiting intercourse for a while, but allowing the couple to engage in other sexual activity. The man can usually get an erection when he doesn’t have the pressure of needing an erection to penetrate the woman. After he gets his erection back, transferring that confidence to having erections when he plans to have intercourse is usually easy. In the majority of cases, if he’s willing to work at it, I can get him back to his old self.
Study sleep habits
If the man is physically sound but doesn’t respond to treatment, the next step is to find out whether he has erections while he’s asleep.
During the course of the night, a healthy man gets several erections during REM or “dream” sleep. He’s not necessarily having an erotic dream or any dream at all, but having erections is definitely part of the male sleep pattern. This phenomenon even has its own name, nocturnal penile tumescence, and initials, NPT. Having initials means it’s really official.
Because a man usually doesn’t have performance anxiety while he’s asleep, a man who suffers from impotence while he’s awake but doesn’t have a physical problem usually has erections while he sleeps.
The simple, at-home test to find out whether you’re having erections during your sleep is to wrap a coil of stamps around the base of your flaccid penis. (A few turns around the penis should be enough to keep it in place.) If you find the circle of stamps broken when you wake up, you probably had an erection. (Once in a while the tooth fairy goes astray, but usually she’s too busy putting coins under children’s pillows.)
If the coil of stamps doesn’t work, and I still suspect nighttime erections, a sleep lab is the next step. At a sleep lab, physicians substitute the stamps with plastic strips and Velcro connectors, which are more reliable indicators than postage stamps. And doctors have even more precise devices, if needed.
If all this testing doesn’t turn up any sign of erections, then I have to send the client back to the medical community because I can’t do anything for him.
But for many men, these tests do uncover some erectile functioning, which probably indicates that the problem is psychological in nature. This is not true 100 percent of the time, but it certainly deserves following up. The basic aim is to build back the man’s confidence to the point where he can have erections while he is awake — and even with a woman around.
Monitoring your erections as a clue to your health
As most people know, smoking and obesity increase the risk for heart disease. But studies have proved that long before troublesome symptoms present themselves, a man is likely to notice differences in his ability to have an erection, which can be caused either by being out of shape or from smoking. So this leads to a few conclusions:
- If a man notices any changes to his erections, he should immediately consult with his physician to be checked for any signs of heart or circulatory disease.
And while exercise is good for many reasons, a man who strengthens his heart through cardio workouts also maintains his ability to have erections. A recent study showed that men who expended energy equivalent to running 1.5 hours a week reduced the chances of encountering problems with ED by 30 percent as compared to men who didn’t exercise.
That same study found that men who didn’t exercise and were also overweight were 21⁄2 times likelier to develop ED than men who led active lifestyles and were of normal weight. So by keeping your weight down,you can help to keep you know who up.
Giving Mother Nature a boost
If none of the techniques discussed in the previous sections helps you to deal with your impotence, then you may have to help Mother Nature with medical or mechanical assistance. In fact, 80 percent of erectile dysfunction (ED) problems occur as a result of serious medical conditions including diabetes, hypertension, or prostate cancer surgery. These conditions are much more common in older men, though they can happen in men of any age.
Oral medications
The FDA’s approval of the drug Viagra in 1998 significantly enhanced the med- ical world’s arsenal of weapons for treating ED. Developed by the drug company Pfizer, this little blue pill is effective in 75 to 80 percent of men who suffer from ED. The biggest exception is men with heart conditions who take nitrates such as nitroglycerin because the combination of the two drugs can be deadly.
Viagra, the brand name given by Pfizer to the drug sildenafil, must be taken one to four hours before sexual activity and requires sexual stimulation to take effect. Patients who take Viagra may have some mild side effects, such as headaches or seeing halos around objects, but they don’t seem to bother most men who take the drug. Viagra has become very popular, and, disturbingly, not only with men who suffer from ED, but also with men who believe it will increase their sexual pleasure even if they can have erections without the drug. The following are some of the reasons taking Viagra may be dangerous for men who can have erections:
Viagra is a prescription medicine. Men who don’t have ED and take it do so without a prescription.
Viagra has side effects. Men with ED may be willing to endure those side effects as a trade-off for having erections. But because the FDA hasn’t given Pfizer approval to use Viagra on men without ED, it’s not yet known what those side effects can do to them over the long term.
Some men get priapism, a permanent erection, from taking Viagra. Although no concrete studies have been done, men who can normally get erections and still take Viagra may be more prone to this condition than men who can’t have erections naturally.
Other pharmaceutical companies have developed drugs that have the same function, including Levitra (vardenafil) from Bayer & GlaxoSmithKline and Cialis (tadalafil) from Lilly ICOS. Cialis can be effective for up to 36 hours, which is why some call it the “weekend drug.” Because I’m not a medical doctor, I’m not going to say which of these pills may be right for you. Please don’t try to order any of these online without first checking with your doctor.
They all have side effects and you don’t want to do any serious harm to yourself.
But because these pills aren’t right for up to 30 percent of all men who suffer from ED, let me give you some information on other options.
Penile implants
Penile implants are either hydraulic or non-hydraulic. The non-hydraulic prostheses are basically semi-rigid rods that doctors surgically implant within the erectile chambers. Although they are reliable, they have one major drawback — after the surgery, the penis is always in a rigid state. You can push your penis down when you’re not having sex, but the erection may still be visible, which can be embarrassing.
The surgery required for the penile implant does leave soreness in the area, and you can’t have sex for several weeks. But most men report very good results and are quite happy. The only men who seem to complain are those whose hopes were too high, and who expected to have erections as strong as the ones they had in their youth. This won’t — and can’t — happen because the erection is permanent, and it needs to be at least somewhat concealable.
The hydraulic prosthesis has a fluid reservoir and a mechanical pump that a man uses to fill the prosthesis and create an erection when he wants one. Men report liking the system, and recent improvements have made the devices very reliable. Like the non-hydraulic implant, it requires a surgical procedure. Unlike the non-hydraulic implant, you only have an erection when you want one, which is more like the natural erection.
Injection therapy
Another method that was developed in the 1980s is self-injection therapy. The latest product is Caverject (alprostadil), which is similar to the oral medication used to treat ED. A man injects his penis with a medication that relaxes the muscles, thus allowing blood to flow into the penis and cause an erection. Although the thought of injecting yourself in that particular spot may not sound appealing, the penis is relatively insensitive to pain, so you can barely feel the injections. Most men who use this system have reported good results. Possible side effects include scarring and, rarely, priapistic erections — sustained erections that won’t go away without medical treatment. Because Caverject is injected right into the penis and doesn’t affect other organs as much as oral medications do, this method may be appropriate for men who can’t take a pill. Check with your doctor.
Caverject takes between five and twenty minutes to become effective and lasts for about an hour. Men should not use it more than three times a week, and always wait 24 hours before using it again.
Vacuum constriction
Another method of relief for impotence is the use of vacuum-constriction devices. Basically, a man places a vacuum pump over the penis, and as the airis pumped out, blood flows in, creating an erection. He then places a ring at the base of his penis to hold the blood in place.
I do receive letters from men and their wives saying that vacuum pumps work wonders (and at least these devices don’t require surgery). But certain side effects have kept vacuum-constriction devices from becoming popular:
- The erections these devices produce aren’t as rigid as those produced with a prosthesis.
- Sometimes mild bruising occurs as a result of using these devices.- Some men have difficulty ejaculating after using these devices.
But vacuum-constriction devices are a possible alternative for someone who doesn’t want to, or can’t, undergo surgery or use a drug, and who doesn’t care to stick a needle into his penis every time he wants to have sex. Also, giving your penis an erection is actually good for it because an erection brings fresh blood into the arteries of the penis. So for men who no longer have nighttime erections, the use of a vacuum device can be looked at as a means of exercising their penis.
The down side of these “up” therapies
Whether a man takes a pill, injects himself, or uses a vacuum pump to get his erection, the fact that he can have an erection doesn’t necessarily mean his partner will be ready to have sex. If a man without ED approaches his wife for sex and she turns him down, he may be frustrated but he also knows that he’ll have plenty of additional erections, perhaps even during the course of that same day. But a man who pops a pill or injects himself may be a lot more demanding because he has gone to some “lengths” to obtain his erection. If he doesn’t consult with his better half, then she may not enjoy any resulting sexual interplay. So, a couple should decide together which method will work best for them and when to use one of these ED therapies, instead of the man making the decision on his own.
Some couples, the ones who have always had a good sex life and look at ED as a major problem, don’t mind using one of the oral medications. But some women, who have either never enjoyed sex very much or have lost interest in their later years, consider their husband’s inability to have sex a godsend.
Their attitude may seem wrong, but no one can know what their married life has been like, so one can’t jump to conclusions.
For these reasons, I believe that no man should use one of the methods for overcoming ED without first having a long talk with his spouse. Men should decide ahead of time how to deal with the physical and psychological changes that such therapies will bring into their lives. In some cases, men may need to undergo some sort of psychotherapy — sexual or marital — to successfully make this transition. So, although society should praise the development of Viagra, people must exercise some caution as well.
