Sunday, November 18, 2007

What is impotence? How is it diagnosed? How is it treated?

What is impotence?

Impotence is the inability to achieve and keep enough stiffness of the penis to enter the vagina and have intercourse.

It is normal for most men to have an occasional instance of impotence when tired or nervous. When impotence becomes a pattern or a long-lasting problem, however, it can profoundly affect the emotional lives of men and their sexual partners.

Impotence affects older men more than younger men. Midlife and the later years bring changes in circulation that may affect the sexual organs. Couples need to be more open and understanding with each other about sexual problems such as impotence.

Fortunately, impotence can often be cured.

How does it occur?

An erection is caused when there is increased blood flow into the penis and the penile veins clamp down to make sure the blood is trapped there, causing stiffness. Nerves in the penis provide the sensations of pleasure and help maintain the erection until ejaculation.

There are many possible physical and nonphysical causes of impotence, including:

  • disturbance of blood circulation to the penis
  • overeating and drinking, which diverts blood to the gastrointestinal organs
  • extreme fatigue and jet lag
  • fear of failure at intercourse and loss of interest in sex
  • depression, stress, or anxiety
  • diabetes
  • neurological diseases or injuries, such as paraplegia and multiple sclerosis
  • alcohol and drug abuse
  • low levels of male hormone (testosterone)
  • side effects of medications for heart disease, high blood pressure, and nervous disorders (tranquilizers)
  • complications after radical surgery for cancer of the prostate.

How is it diagnosed?

If impotence lasts longer than 2 months or is a recurring problem, you will want to have a physical exam by your doctor or ask him or her to refer you to a doctor who specializes in erectile problems.

The exam will include urine and blood sugar studies so that the doctor can rule out diabetes. In addition, the doctor may want to measure the male hormone level in your blood.

The doctor may want to test penile blood flow and pressure and may also want to measure the nighttime stiffness of the penis by the stamp test or snap gauge test. In the snap gauge test, a band is placed around the penis before you go to sleep. If there is an erection, the snap gauge will break.

For the stamp test, you take a strip of stamps (such as Easter Seals) and make a ring around the nonerect shaft of the penis, moistening and sealing the stamp overlap before going to sleep. (Do not use postage stamps because the glue is too strong.) If an erection occurs during sleep, the stamp ring will break, waking you, and allowing you to feel the degree of erection. Awakening the next morning with the ring intact means you did not have an erection while you were sleeping. Repeat the test the next two nights. If you have the same negative result three times, you probably have impaired circulation in your penis.

If the doctor has ruled out physical problems as a cause of your impotence, he or she will probably refer you and your partner to a psychotherapist or family counselor.

Psychological problems causing impotence are varied, but most can be helped. Therapy often leads to improved function in other areas of life as well as in sexual function. Psychotherapists often like to work with both partners. Therapy, like other treatments, can be uncomfortable although worthwhile. If you have concerns about your referral, ask to discuss them with your primary doctor.

How is it treated?

If you have low blood pressure to your penis or have a problem with blood flow to it, you may have several options.

Drug Treatment

If a man's level of male hormone (testosterone) is low, he can take monthly injections (in the arm) of testosterone.

Drugs may also be used to get more blood to enter the penis through the arteries, producing or enhancing an erection. Drugs can be injected directly into the penis to produce an erection. The new drug Viagra (sildenafil) can be taken as a pill rather than injected into the penis.

Viagra can help men have and keep an erection. It should be taken about an hour before sexual activity. Viagra should not be used by men who are taking nitrates because the combination could make the blood pressure too low. Erythromycin and some antifungal medicines can interact with Viagra, too, so a lower dose of Viagra is prescribed for men taking these medicines. Viagra can cause some mild side effects, including flushing, headache, and less commonly, indigestion.

Individualized combinations and dosages of other drugs can be self-injected into the penis when an erection is desired.

An occasional problem with injections has been priapism (painful and prolonged erections), requiring emergency treatment. Therefore, the injections must be done only with a doctor's prescription. A man will usually become erect in 3 minutes or less. Men with hormonal or nerve problems will usually respond in 5 minutes. Erections occurring from injections usually last as long as an hour.

External Mechanical Devices

There are mechanical devices that trap blood in the penis to cause an erection. They come with a vacuum chamber, a pump, connecting tubing, and elastic bands. The system requires time and dedication on the part of the couple to become comfortable with it. There are a number of such devices on the market. They may be covered by Medicare when the problem is vascular and the device is prescribed by a physician.

You insert the soft penis into the vacuum chamber tube connected to a pump by a piece of tubing. You then apply suction by using the small hand pump. Negative pressure or suction pulls blood into the penis producing an erection. The blood is held in the penis by placing a tight band, similar to a rubber band, around the base of the erect penis. You should not keep the band in place longer than 30 minutes or fall asleep with it on.

Advantages of these devices include:

  • Initial positive results increase the desire to remain sexually active.
  • They may help to reestablish penile blood flow by creating stiffness.


Men who have defects of penile arteries or veins may choose surgery to correct the defects.

Invasive Mechanical Devices or Implants

These are mechanical devices actually placed inside the body.

Invasive devices are used only when:

  • There is nerve and vascular damage.
  • There has been no improvement with mechanical devices used outside the body, hormonal replacement therapy, or medical treatment of the cause.

Treatment involves inserting a mechanical device or prosthesis into the spaces where the blood normally collects to stiffen the penis.

Although the overall success rate of the penile prosthesis is greater than 95%, many urologists urge couples to consider simpler, less expensive alternatives before surgery.

The urologist or doctor will discuss the advantages and disadvantages of each type of device and help the couple select the appropriate one. The implant has rods or cylinders that can be inflated or deflated at will. Most prostheses can be inserted during a one-day surgery requiring no overnight hospital stay.

Semi-rigid or rigid implants:

Advantages of a semi-rigid or rigid implant are:

  • It is inexpensive.
  • It is simple to insert.
  • It can be inserted under local anesthesia.
  • It is always ready for use once it is in place.
  • It has a 20-year successful history.

Disadvantages of a semi-rigid or rigid implant are:

  • It is always at its full size.
  • It may be hard to conceal. A malleable semi-rigid implant can be bent to hide it and brought into position when desired.

Inflatable Implants:

Advantages of an inflatable implant are:

  • It can be easily hidden. It uses a pump tucked in the scrotum above the left testicle and a fluid reservoir behind the pubic bone. The hollow cylinders that replace the erectile tissues are connected to the reservoir and can be inflated or deflated at will. The penis returns to a resting state when the fluid is returned to the reservoir from the cylinders by reversing the flow with the pump.

Disadvantages of an inflatable implant are:

  • It is more expensive.
  • Its insertion requires a hospital stay of 24 to 48 hours.
  • Since it is more complex, there are more ways in which the device could stop working.

For More Information

Information and support are available through Impotence Anonymous (IA) and Impotence Institute of America (IIA). The hotline for both is: 1-800-669-1603.

You may want to write the IIA at:

The Impotence Institute of America
119 South Ruth
St. Maryville, TN 37801-5746

Monday, October 29, 2007

Impotence treatments: Implants, Vascular Re-constructive Surgery, External Vacuum Therapy

The purpose of this site is to provide comprehensive information on
impotence, and objective information on all currently acceptable medical
treatments. However, readers should understand that like most publications
distributed by a medical supplier, this one has a bias for the treatment
therapy and products it is most familiar with, in this case external vacuum
devices and Osbon ErecAid® System.

For more information on external vacuum devices, a list of the published
clinical studies on ErecAid® System, or referral to a physician in your
area who is familiar with vacuum therapy, please call Medic Drug's Impotence Information Center at 1-800-686-8886, ask for Bill at Ext. 118.


Until a few years ago, men had few choices for erectile dysfunction. This
is not the case today. Thanks to a large amount of creative work
accomplished recently, virtually every impotent man can now be treated
successfully. The choices range from oral medications to injections, from
psychological therapy to surgery, and from external devices to internal

Most of these treatments are found in the urology area, where they have
been for 15 years. But this is starting to change. General practitioners
have discovered that they can safely prescribe many of the treatments
available. This is important because erectile dysfunction is often the
first overt symptom of serious conditions like diabetes, high blood
pressure and vascular disease.

Ten to fifteen percent of all men have some degree of impotence; this
statistic includes one out of every three men over age 60. Most of these
men visit a family doctor on occasion which means that if the physician is
alert and inquisitive about sexual function a golden opportunity exists to
discover the impotence, determine its underlying cause and offer successful

Because of the availability of many good treatments, no man has to live
with impotence any longer. By investing one hour of your time to read this
guide, you will learn about treatments that could dramatically change your

The choice is up to you. The information contained in this booklet is
presented in layman's language for easy understanding. Good luck with
whatever treatment you select.

Table of Contents:

1. Admitting Impotence to Yourself
2. Three Tough Questions
3. Understanding the Erectile Process
4. What Causes Impotence?
5. Choosing Your Doctor
6. What Happens at the Doctor's Office?
7. Current Treatments for Impotence

o Yohimbine Tablets
o Hormone Medication
o External Vacuum Therapy
o Injection Therapy
o Types of Implants
+ Rods
+ Multi-Component
+ Self-Contained
o Vascular Surgery
o Sex Counseling and Therapy

8. Choosing Your Treatment
9. Health Insurance and HMO's
10. Medicare Coverage

Admitting Impotence to Yourself
A lot of men become sexually impotent, but never admit it to themselves.
Sadly, this denial prevents them from enjoying sexual activity on a regular
basis again. A man who behaves this way has a lot of company. Up to 30
million American men are impotent, but fewer than 5 percent have ever been

Ignoring the problem was normal behavior years ago, but today sexual
wellness is often viewed as an indicator of total health. As more men are
living longer, they have an interest in treating impotence. The pride
factor does not inhibit treatment as it once did. Today, there are many
effective treatments to choose from, both surgical and non-surgical. But
the first step is admitting the problem.

We begin by defining what impotence is:
Impotence is the inability to have an erection that is rigid enough and to
maintain it long enough to complete sexual intercourse.

If your erections do not become firm enough to allow vaginal penetration,
you are impotent. If your erections have the necessary rigidity, but are
only firm briefly, you may have an impotence problem. If your erection
loses its strength upon penetration, you probably have the problem. If any
of these scenarios fit you, it may be time to admit it and take the first
step toward a treatment that can change your life.

Ask Yourself Three Tough Questions

The answers to these three questions may determine whether you should
seriously seek impotence treatment.

1. What is your degree of motivation? After long periods without sexual
activity, men and women fall out of the habit of having sex. Mere
curiosity about a particular treatment is not enough. To stand a
better chance for success, you should define yourself as eager or
extremely eager to resume sexual activity on a regular basis.

3. What is your willingness to learn new techniques? In order to
successfully use any of the treatments discussed here, a man must take
some physical action to make the erections happen. If you learn how to
perform this action, you should get a consistent erection every time.
Your willingness to perform this action and to work your way through
the learning curve is vital. If you resist using new methods to
achieve an erection, you will probably not be successful with these


5. What is the degree of your partner's support? Asked more directly, the
question is, "Does your partner also want to become sexually active
again?" Is she willing to help you decide which treatment to use? Is
she willing to have sex with you using the treatment you both

Conviction, strong emotion and basic masculine motivation are needed to
resolve sexual dysfunction problems. If your three answers are negative,
you should lower your expectations of success with any of the impotence

How Do Erections Occur in a Potent Man?
[Image]Successful erections require the coordinated actions of a healthy
brain, pliable blood vessels, fully functional nerves, and certain
hormones. Erotic stimulation, triggered by the five senses or by memory,
begins the erectile process. The nervous system responds by sending
chemical messages to and from the pelvic area.

These messages cause the smooth muscle tissue inside the penis to relax.
The blood vessels dilate, allowing more blood to flow into the corpora
cavernosa, the two erectile bodies within the penis. Like sponges, they
capture more blood, swelling and lengthening the penis. When all of the
spaces are occupied with blood, the organ becomes rigid. The enlarged
corpora cavernosa take up so much space inside the penis that strong
pressure is exerted against the penile veins, greatly reducing their
outflow of blood.

At this point, the erect penis contains eight times more blood than the
same flaccid or non-erect penis. As long as the sexual stimulation is
continued, an erect stage can be maintained until orgasm and ejaculation.

What Causes Impotence?
Impotence is not a disease, but a secondary condition brought on by other,
primary causes. It is a side effect, a symptom of something else. Thirty
years ago, when men went to their doctors asking for help for erectile
problems, they were told that there was no treatment because it was caused
by aging, or it was all in their heads (psychological). A generation of
research has been conducted in the intervening years. With more knowledge
now, doctors divide this very common disorder into four general causes:

1. Psychological
2. Physical (Organic impotence)
3. Mixed origin-both psychological and physical
4. Unknown origin

About 85% of this problem is due to a physical (organic) cause. Slightly
more than 10% is totally psychological, or "all in your head." The other 5%
is unknown. The 85% figure includes a mixture of physical impotence with
psychological involvement. Once a man fails to become erect a few times, he
places more stress on himself to have an erection by sheer will power. When
this too fails, he often begins to have a psychological problem.

The main point here is this: 85% of all impotent men are that way because
something within the body, other than the penis, is malfunctioning.
Psychological Impotence describes the problem when physical causes cannot
be found. Pure psychological impotence usually comes on suddenly. It can be
caused by job stress, a troubled marriage, or financial worries. Any
nagging everyday situation which occupies conscious and subconscious
thoughts can cause impotence. Depression or concern over poor sexual
performance can cause it.

It should be noted that every man experiences temporary periods of
impotence at one time or another during his life. That's entirely normal,
and you don't need treatment unless the problem is persistent.

Physical Impotence develops gradually and is characterized by any of these
three basic functional problems:

1. Failure to initiate results from impaired release of the chemical
messages sent by the nervous system. The inability to develop an
erection is common in cases of hormonal insufficiency, spinal cord
injury, radical pelvic surgery, multiple sclerosis and Parkinson's

3. Failure to fill results from poor blood flow into the penis. The
inability to develop an erection rigid enough for intercourse is
caused by blockage in the arteries, common in cases of pelvic trauma,
hypertension, smoking, diabetes and high cholesterol.

5. Failure to store results from venous leakage when blood escapes too
quickly from the penis, leaking back into the body. This inability to
maintain an erection rigid enough for intercourse is common in cases
of hypertension, smoking, diabetes, high cholesterol and pelvic


The consensus of most authorities is that the table below represents an
accurate distribution of the various causes of physical impotence.

* The important thing to remember is that most causes of impotence are
physical and often beyond your control. While it is not good to have these
physical problems (diabetes, high blood pressure, stroke or prostate
disease, etc.), they are conditions you can probably accept and feel
comfortable about trying to correct.

* Diseases of the blood vessels (vascular disease) is the leading cause of
impotence. Vascular disorders include arteriosclerosis (hardening of the
arteries), hypertension, high cholesterol and other conditions which
interfere with blood flow. If poor blood flow occurs in the heart, or
coronary vessels, it causes heart attacks; when it occurs in the brain it
causes strokes; and when it occurs in the penis, it causes impotence.

* Another problem, "venous leakage," occurs when the penile veins are
unable to close off (constrict) properly during an erection. Constriction
of the veins holds the blood in the penis to maintain the erection. When
the veins "leak," blood escapes too quickly back into the body, and the
erection fails.

* Diabetes is a very common cause of impotence. This disease can damage
both blood vessels and nerves. When nerves are affected, the brain cannot
properly transmit the sexual stimulus that creates an erection. About 50%
of all diabetic men experience impotence after the age of 55.

* Radical pelvic surgery may also result in impotence. Surgical procedures
involving the prostate gland the bladder or colon may sever the nerves
involved in erectile response. Radiation treatment in this area can also
affect the erectile process.

* Neurologic (nerve) disease is another cause of impotence. Neurologic
disorders affect the nervous system and include multiple sclerosis,
Parkinson's disease and spinal cord injury with paralysis.

* Deficiencies of the endocrine system are another source of erectile
dysfunction. For example, low levels of testosterone or thyroid hormone
often cause poor quality erections. Excessive production of prolactin by
the pituitary gland may contribute to a low testosterone level and lack of
desire. Diabetes is also considered an endocrine disease.

* Prescription drugs often cause Impotence as a side effect, and over 200
medications fall in to this category. Never change a dosage or stop taking
a prescribed drug without the advice of your doctor.

* Substance abuse affects erectile function as well. Illegal drugs and the
excessive use of alcohol or cigarettes can seriously damage the blood
vessels and nerves involved in a normal erection.

* The Logic to Use in Choosing A Doctor
Where do you go? What type of doctor diagnoses and treats impotence? How do
you get the best answer? Almost all erectile dysfunction in the USA is
treated by the six types of professionals listed below:

1. Family Practitioners
2. Urologists
3. Internists
4. Endocrinologists
5. Psychiatrists
6. Psychologists

Family practitioners, internists, and endocrinologists are primary care
physicians most likely to be your family doctor or principal physician.
This is the doctor you consult first about impotence. He or she knows the
most about your medical history and current condition. If he chooses not to
treat you, he may refer you to another physician who treats impotence
regularly. Many family doctors, however, are now treating this problem
using non-surgical treatments.

As surgical specialists of the genito-urinary system, urologists are
closely identified with impotence. Of about 10,000 urologists in the USA,
some 3,500 of them actively treat impotence.

Psychiatrists and psychologists may be consulted if your doctor cannot find
a physical cause for your problem. In many cases, a psychological aspect
develops after impotence has been present for a while.

Your doctor's job is to help determine, through simple tests, the cause of
your impotence, and to help you choose the simplest, safest and most
effective treatment.

What Happens at the Doctor's Office?
The purpose of your visit to the doctor is to answer two questions:

1. Why am I impotent?
2. What can I do about it?

The second question assumes that you will be able to select from a number
of treatments. You could also choose abstinence. Though each doctor may
approach diagnosis and treatment differently, your physician will help you
understand the cause of your impotence and your options for dealing with
it. Remember it is your doctor's job to help you determine which treatment
option is best for you.

All physicians will first record your medical history, including
psychological and sexual aspects. They may ask about stress and fatigue and
about the relationship between you and your partner. Some questions may be
very person al, but your doctor needs to know about your present sexual
functioning in order to treat your impotence.

One sure question is, "Do you wake up in the morning with an erection?" If
you always wake up with an erection, your physical system works, and the
impotence may be psycho-logical. If you never wake up with an erection, it
suggests a physical problem with blood vessels or nerves.

Whether you start treatment with your family doctor or a urologist, the
initial approach will probably be conservative. Conservative, non-surgical
treatments for impotence have proven very successful, and most patients
find surgical treatment unnecessary.

In diagnosing your impotence, your doctor will first look for obvious
contributing factors. For instance, diabetes, alcohol abuse or prostate
surgery can cause impotence. "Short cut" diagnosing may be appropriate when
your medical history strongly points the way.

The Family Doctor
After recording your medical history, a family doctor may do a complete
physical exam, including a rectal exam to check your prostate. He will also
check your genitals for abnormalities that could interfere with effective
treatment. For example, some men have Peyronie's disease, a curvature of
the penis caused by plaque formation. Certain treatments cannot be used if
the curvature is severe.

Of particular interest when diagnosing the cause of impotence are various
blood pressure readings, the results of blood tests, and an update on the
medicines you take.

The Urologist
If your family doctor is not comfortable with treating impotence, he or she
may refer you to a urologist, who may prescribe any of the known treatments
for impotence. He or she may also do all the examining and testing already
mentioned, if not done by your family doctor. The urologist will conduct
additional, more sophisticated tests if you are thinking about a surgical
correction for your impotence.

The Current Treatments for Impotence
A panel of experts met in Washington, D.C. in December 1992 to define the
state of the art in the diagnosis and treatment of impotence. In treatment,
they recommended that "as a general rule, the least invasive procedures
should be tried first." Their statement then listed current treatments in
this order:

1. Psychotherapy or counseling, if appropriate
2. External vacuum devices (such as ErecAid® System)
3. Penile injection therapy
4. Penile implant surgery
5. Vascular surgery

A few men may be helped by taking an oral drug like yohimbine, but
undesirable side effects may occur, and results are usually weeks away. A
few may also benefit from taking hormone medications, but unless the
hormone deficiency is severe, this treatment may not help.

Vacuum therapy with ErecAid® System, the original external vacuum device,
is probably the most widely recognized first-step treatment since it works
for all types of impotence and has minimal side effects. Even if other
non-invasive treatments, like yohimbine or counseling, are tried first,
vacuum treatment can be applied concurrently to get immediate results.

Penile injections have been used for over a decade with about a 70% success
rate, but many men express disdain for this treatment when they learn that
it involves a needle stuck into the penis. However, there are many
impotence clinics which specialize in this therapy.

Implanted devices, of course, involve surgery. Experts now believe that
this treatment, once considered as the "gold standard" therapy, should only
be done as a last resort, when the lesser invasive treatments have failed.
The placement of an implant permanently alters the interior of the penis.
If a pill is finally invented which cures impotence, it will surely require
healthy corpora cavernosa in order to work. An implant prevents this part
of the penis from being useful again.

The bar graph below shows the estimated percentages of men on various
impotence treatments at this time.

Yohimbine Tablets
This natural aphrodisiac from the bark of the yohimbehe tree is sometimes
prescribed by doctors for men with intermittent erectile dysfunction. In
most of these cases, the physician suspects a psychological problem, but
cannot prove it. The drug is used to stimulate desire and improve the
quality of the erection. Dispensed in tablet form, yohimbine is taken three
times a day for 4-6 weeks to test its effect. Costs are about $40 a month.
Even if the tablets work, which they do in 15-20% of patients, stopping the
tablets may return the patient to his former state of impotence. Side
effects may include headaches, sweaty palms, dizziness, and nausea. Men
with ulcers or hypertension probably should not take this drug.

Hormone Medication
A severe deficiency of the male hormone, testosterone, can cause impotence.
The nature of the treatment is to give the man either oral testosterone or
an injection in the arm or buttocks to raise the hormone to acceptable
levels. In these cases, the treatment can be an effective one. Only about
4% of the male population, however, have the problem and can benefit from
the treatment. Side effects of testosterone replacement therapy can be
serious, and patients with a medical history that includes liver disease,
heart disease, kidney problems, or prostate cancer should probably avoid
supplemental testosterone. This chemical can lead to the retention of
fluids, enlargement of the prostate, and damage to the liver.

External Vacuum Therapy
This treatment is a simple, non-surgical method of producing a quality
erection. The external vacuum device was created by Geddings Osbon, in the
early 1960s, to solve his own impotence problem. He created the ErecAid®
System, based on negative pressure and tension rings, to produce and
maintain a naturally engorged erection every time one was needed.

The vacuum System (two versions are depicted) consists of a clear plastic
cylinder, a hand pump or battery pump, and a special tension ring. The user
stretches the tension ring around the open end of the cylinder, then
inserts his penis into that end. Holding the device firmly against his body
to form an air seal, he uses the pump to remove air from inside the
cylinder. This creates a partial vacuum around the penis, causing the
body's blood to enter the corpora cavernosa. This engorges the penis in a
way similar to a natural erection.

To maintain the erection, it is necessary to reduce the outflow of blood
from the penis. Therefore, while the penis is still under vacuum pressure,
the tension ring is pushed from the cylinder on to the base of the penis.
This breaks the seal of the vacuum, allowing the cylinder and pump to be
removed and laid aside. The user can maintain an erection for up to 30
minutes, wearing only the tension ring. This procedure, which takes about
two minutes, is used whenever an erection is needed.

The ErecAid® System has been effective for over 90% of men who have used
it. Men who have had their prostates removed are successful with it. Men
who have had penile implants installed and later removed can often use this
system successfully, as can men with blood vessel blockages. Psychological
patients are successful with it, as well as diabetics.

The manufacturer of the System polls new owners to determine the
effectiveness of the product. Over 200,000 men have been surveyed. When
questioned about the 6-month period just prior to acquiring the vacuum
System, 76% of the men reported that they had had no sexual intercourse or
very irregular sexual activity. After using the System for 90 days, 80%
said they were having sexual intercourse at least twice a month. Initially,
it takes practice to use the System. 42% of patients learn to use it in one
day, and 90% master it in two weeks. 69% can create a usable erection
within two minutes.

An unexpected statistic which emerged from the survey pertained to the
occasional restoration of natural erections. About one in four (26%)
reported that after using the System for a number of months, they were
sometimes able to have intercourse without using the device. This means
that the use of a vacuum device to force blood into the penis may have the
effect of bringing back some sexual power, some of the time. This was also
noted in a Case Western Reserve University Medical School study (Cleveland,
Ohio) in 1989-1990.

The most significant advantage of the ErecAid® System is that it works
without requiring surgery or a healing period. As such, it is non-invasive.
It is used on the body (not in the body), and can stay in a dresser drawer
or on a shelf when not in use.

Another advantage is cost. The hand-pump ErecAid® costs the patient $395,
and the battery model, $455. Most other impotence treatments are far more
expensive. The major components of both Systems have lifetime guarantees,
and medical insurance coverage is available in many cases.

A significant advantage is that the erections are of high quality, lasting
longer than natural ones, and they do not usually disappear after an
orgasm. Also, once the erection technique has been learned, the patient can
achieve reliable, consistent erections each time. The erection stops when
the tension ring is removed, recommended to be no longer than 30 minutes.

With some men, minor side effects can occur, such as petechiae and
ecchymosis. Petechiae are caused by placing the penis under negative
pressure too rapidly. Reddish pinpoint-size dots appear on the surface of
the penis. The penis may need to be reconditioned slowly after a prolonged
period of inactivity.

Ecchymosis is a bruise caused by the penis being held under vacuum pressure
too long. Neither condition is painful nor serious and does not need
treatment. They stop happening after a few uses. A final side effect is a
temperature drop of 1-2(deg)in the penis, caused by the tension ring. No
major injuries have ever been reported concerning the ErecAid® System.

This device may not be an appropriate treatment for men who have sickle
cell anemia, leukemia, or blood clotting problems. Proper use of it
requires some manual dexterity and average hand strength. All criticism of
these devices centers around the use of tension rings, and the loss of
spontaneity in lovemaking. Many men believe, however, that they are far
better sexual partners with the device.

Penile Injection Therapy
[Image]Physicians learned in the early 1980s that some medications injected
directly into the corpora cavernosa would produce an erection within a few
minutes. Urologists now routinely use this method to treat men by teaching
them self-injection techniques to use at home.

Currently, three medications are used for this purpose. Papaverine was the
first one used. Phentolamine, an alpha blocker, was used second, initially
as an additive to papaverine, and later to prostaglandin El, the third

Papaverine and prostaglandin both act on smooth muscle tissue in the
corpora cavernosa, while phentolamine is more effective in the tiny penile
arteries to prolong the erection. Most doctors mix all three drugs

Diabetic needles (27 or 28 gauge, a half-inch long) are used for these
injections. The patient must learn to inject the base of the penis using
less than 1 cc. Either corpus cavernosum may be injected but not the
urethra. Hand pressure is applied afterward for 2-3 minutes to prevent
bleeding. Ideally, erections will last 30-60 minutes and will become more
rigid if stimulation occurs.

With injection treatment, high quality erections are available on demand,
and they last longer than natural ones. The erection does not always
disappear at orgasm or ejaculation. Injections work in about 70% of all
cases. The 30% failure is often due to poor blood flow or venous leakage.

There are concerns with injections. The key ones are priapism, pain,
dropout rate, and cost. Priapism is the word to describe an unwanted,
prolonged erection. Injecting too much of the drug may cause an erection
which lasts much longer than intended. After four hours, men should seek
medical help for reversal of the erection. This is done by injecting an
adrenaline-like drug into the penis.

The pain from injecting is primarily from the needle puncture. Many men are
frightened to think of injecting the penis with a needle. This apprehension
may account for the high dropout rate for men on injections. A 1990 study
(University of Chicago) showed that 51% of the group dropped out after
receiving only a test injection. The average patient stayed in the study
group for seven months before leaving it. Other men, however, inject
successfully for years.

Depending on the exact mix of the drugs, an injection costs $5 to $15. If a
man is sexually active twice a week, the annual cost will range from $520
to $1560. Third-party insurers, especially Medicare, do not usually pay for
these treatments because the FDA has not approved the drugs for impotence
treatment, and is still considering using them for impotence treatment to
be experimental.

Introduction to Implants
In 1972-73, physicians began doing penile implants to help with lost
potency. Over the years since then, three distinct types of implants have
been used. Today, surgeons implant about 20,000 of these devices per year
into American men who choose this treatment. Semi-rigid rods account for
about 35%; multi-component inflatable implants are thought to be 45% of the
total; and self-contained devices make up the last 20%. In all cases, two
synthetic cylinders are surgically placed inside the corpora cavernosa of
the penis. After 4-6 weeks, a man is ready to engage in sexual intercourse.

These devices are either mechanical, inflatable, or hydraulic. Their
implementation permanently alters the corpora cavernosa, ending all hope of
the return of natural erections, so this treatment should be considered a
final step, not an early one. There is also the usual risk of infection
with surgical procedures, and eventual malfunction or deterioration of the
device may require other surgeries.

Semi-Rigid Rods
[Image]Two bendable rods have an outer coating of silicone and inner,
parallel, silver or stainless steel wires or interlocking plastic joints
held together by a cable. With this rod, the penis is always erect, but can
be bent down. To prepare for intercourse, the man simply bends the penis to
a "ready" angle.

The rate of complication is low and many of these rods are inserted as an
outpatient procedure with a local anesthetic. The surgeon's skill is
important since he has to properly "size" the implant to your penis. Cost
is approximately $6,000-$10,000, including the surgery.

Disadvantages are these: Because the penis is always erect, it is difficult
to hide under a swimsuit or tight-fitting clothes; the erection is due to
metal and silicone, not the flow of blood into the penis; and, finally, the
surgery is not reversible.

Multi-Component Inflatable Implants
[Image]This implant has two or three components. Inflatable cylinders are
placed in the corpora, a fluid reservoir goes into the abdomen (or scrotum)
and the pump is placed in the scrotum. A squeeze of the pump moves fluid
from the reservoir to the cylinders, causing rigidity. Another pump squeeze
reverses this process.

A skilled urologist, using general anesthesia, implants this device for a
total cost of $12,000-$15,000. After 4-6 weeks of healing, the patient may
begin to use it. Mechanical failure or patient infection are the two most
common complications. Both can cause a need for more surgery. Key factors
are (1) the surgical procedure is not reversible, and (2) the erection
stems from saline solution, not the bloodstream.

Self-Contained (Inflatable) Implants
[Image]Two cylinders are placed inside the penis. Each one contains a pump,
fluid, and release valve. A squeeze of the head of the penis forces a fluid
transfer to the forward chamber, causing rigidity. A certain bend of the
penis causes fluid to flow back into the storage area, ending the erection.

Using general anesthesia, a urologist implants the device for a total cost
of $10,000 - $12,000. After 4-6 weeks, sexual activity starts.
Complications: Device failure and infection. Important factors are (1) this
is not reversible, and (2) the erection is from saline solution and plastic

Vascular Re constructive Surgery
Penile surgery of this type is like heart bypass surgery, which reroutes
the blood supply around blockages. Fewer than 1% of impotent men are
candidates for this procedure, and the failure rate is very high.

Venous ligation is a penile surgical procedure in which the surgeon
attempts to repair the veins causing venous leak. This procedure was
popular until physicians began to realize that it offered only a temporary
solution. Many patients required another operation within a few years.

These procedures cost about $15,000 and should only be done by surgeons
experienced with the procedures, preferably in an investigational setting.
Complications may include: permanent numbness near the incision and scar
tissue which may shorten or "torque" the penis. Also, the surgery may need
to be repeated.

Sex Counseling and Sex Therapy
Sex counseling refers to consultations with a qualified counselor who helps
the couple to identify, understand, and cope with their sexual concerns.
Sex therapy is more structured in that it uses counseling, but also
includes a time element and specific exercises for the couple. Exercises
are meant to remove stress from areas of the relationship that influence
sexual function. They may include sexual touching and other sexual

When the cause of impotence has a strong psychological involvement, sex
counseling or therapy can be very effective. Couples should seek this
therapy only from a trained professional with a good reputation.

Which Treatment Should I Choose?
Several factors must be considered in selecting a treatment. A few of them
have been outlined below.

Partner's opinion. Ask her to go through this booklet with you. Ask her to
visit the doctor with you. Does she lean toward one treatment more than the
others? If you are young with no partner, you may be happier with implants
and injections.

Frequency of sexual activity. Will sex be performed twice a week, twice a
month, or twice a year? Select a therapy which is consistent with the
estimated amount of use.

Must you change the way you live? A permanently erect penis (semi-rigid
rods) may keep you out of a swimming pool forever. Ask your doctor about
any compromises you may have to make.

Treatment sequence. The best way to look at impotence therapy is that the
simple, inexpensive, reversible treatments should be tried first, while the
more complex, expensive, non-reversible treatments should be attempted
later. The ErecAid® System, yohimbine tablets, and sex therapy might be
tried earliest since all are relatively inexpensive and reversible. Last on
the list are injections, vascular surgery, and implants. All of these are
invasive therapies which cause internal changes in the penis. If some new
treatment appears in the future which requires the corpora cavernosa to be
healthy, you probably will miss out on it if you have permanently altered
the erectile bodies.

What are the odds of re-operation? Ask your physician about the odds of
having repeat surgeries. Ask about the failure rate of the implant he is
recommending. Ask about the failure rate of the various vascular surgeries.
Injections may only be temporary. The majority of men choosing injections
have switched to another treatment within one year. Ask your doctor why.
Ask about "fibrosis" caused by the frequent needle punctures. Make sure you
know about "priapism" and how it is reversed. Learn about how the body can
develop a tolerance to the drugs, making you use larger and larger doses.

ErecAid® System in a backup role? A large number of patients select the
ErecAid® System as their primary treatment. But it should be noted that
some men use the System along with injections. Why? By using a tension
ring, it is possible to inject less drug to get a good result; also, the
two treatments can be alternated so that the weekly limit of two sexual
encounters can be exceeded. An ErecAid® System is also sometimes used to
enhance the rigidity of an implant. This is a safe practice for rod
implants, but becomes riskier with the inflatable models.

Financial considerations. What is the out-of-pocket cost of the treatment
selected? How much will health insurance pay for? What are the guarantees
or warranties of the treatment chosen?

Maintenance costs. Ongoing costs for treatment must be identified. For
example, yohimbine tablets have an ongoing cost, as do penile injections.

Safe and effective treatment? Has the chosen therapy received FDA marketing
approval? Have clinical studies been performed for this treatment? Is the
treatment backed up by a reputable provider, with liability insurance?

Physician, heal thyself? A medical publication asked urologists, in 1990,
how they would treat themselves if they became impotent. The question was:

If you or a close family member suffered from erectile dysfunction, which
treatment would you choose/recommend as the first step?

The answers came back as follows:

Health Insurance and Impotence
Insurance companies will generally pay for impotence treatment when the
cause is physical. Your physician must specify on the claim form the
physical cause of your impotence and that your treatment is "medically

If your physician diagnoses a psychological cause, many insurance companies
will deny the claim, unless state law mandates limited coverage. Some group
policies exclude coverage for impotence of any type.

Health Maintenance Organizations (HMOs)

Most HMOs consider sexual health to be an integral part of an individual's
total health, so they will generally provide treatment unless there is an
exclusionary clause in the patient's contract.

HMO physicians generally try to guide patients to the most effective
treatment at the lowest cost. For this reason, external vacuum devices are
usually favored because of the high success and relatively low cost.

Penile injections and implants are used less often. The initial costs for
penile injections are relatively low, but costs accumulate as long as the
patient is sexually active. Penile implants, with higher initial cost and
higher risk of complications may be considered for payment by the HMO only
after the patient has tried more conservative treatments.

Medicare and Impotence
Medicare coverage is divided into Medicare "A," which covers surgeries,
hospital stays and the more costly medical services; and Medicare "B,"
which covers doctors' office visits, medical devices and the less costly
items and services.

If you have FICA taxes deducted from your paycheck, you will be covered by
Medicare A at no charge when you reach 65. Medicare B costs about $30 a
month and may be deducted from your Social Security check.

Surgical treatments for impotence are usually covered by Medicare A in most
states, as long as your doctor verifies a physical cause of the impotence
and states that the treatment is "medically necessary." Vacuum devices are
covered under Medicare B. Penile injection therapy is not covered since the
drugs used for injection have not yet been approved by the FDA as a
treatment for erectile dysfunction.

As of late 1993/early 1994, Medicare is reimbursing for external vacuum
devices under Medicare B. With a valid prescription, you may obtain a
vacuum device from Medic Drug, a medical

Knowing your interest in the latest medical advances, we wanted to
share with you information about The Upjohn Company's new product,
CAVERJECT Sterile Powder (alprostadil for injection), which is now
available. As the first pharmacological agent indicated for the
treatment of impotence, CAVERJECT provides an effective option for men
suffering from impotence.

Impotence is the inability to achieve or to sustain an erection
adequate for sexual intercourse. It's a common, treatable condition,
yet over 90% of affected men never receive treatment. This is because
often they're reluctant to discuss the subject with their doctor.

Until recently, many health care professionals believed impotence was
psychological. Patients were often told, "It's all in your head."
Today, experts have learned that up to 75% of impotence cases aren't
psychological in nature. Impotence is often a symptom of an underlying
physical condition and can be medically treated.

Most men experience occasional impotence at some time, usually as a
result of fatigue, temporary stress, or excessive alcohol consumption.
Temporary impotence is not something to worry about. However, if the
condition persists or interferes with your normal sexual activity, you
should consider seeing a doctor who specializes in treating impotence,
typically a urologist.

Impotence can now be managed effectively with CAVERJECT which is
indicated both for the treatment of impotence due to neurogenic,
vasculogenic, psychogenic, or mixed origin and as an adjunct in the
diagnosis of impotence. CAVERJECT contains alprostadil, the naturally
occurring form of prostaglandin E (PGE), and normally induces an
erection within 5 to 20 minutes, once the optimum dose has been
established. The dose must be individualized for each patient by
careful titration under physician supervision. (See DOSAGE AND
ADMINISTRATION section of the prescribing information.)

The activity of CAVERJECT is localized to the penis. Mild to moderate
penile pain, generally well tolerated, is the most frequently reported
side effect of injection, occurring in approximately one third of
patients. *CAVERJECT is contraindicated in men with a known
hypersensitivity to the drug or conditions that might predispose them
to priapism, and in men with penile implants or anatomical deformities
of the penis.

I hope this information has been helpful to you. Please feel free to
contact us with any questions.

*Among patients reporting pain, not every injection was associated
with it. Of 21,490 injections studied, 11% were pain related.

Tuesday, October 23, 2007

Complications of penile lengthening and augmentation seen at one referral centre.


Scrotalization: One possible result of a penile lengthening operation, in which the skin that had once been just behind the penis advances down the shaft. This pubic hair-bearing skin is bunched up around the shaft, resembling a scrotum that extends above as well as below the base of the penis. It is useless for intercourse, and comparatively devoid of sensation.

Peyronie's disease: A disease of unknown cause in which the corpus cavernosum is surrounded by dense fibrous tissue, causing deformity and painful erection.

Epispadias: A malformation in which the urethra's opening is located on the dorsal (upper) side of the penis.

Penile lengthening is widely accepted as a necessary treatment for men with very short penises who suffer from Peyronie's disease, epispadias, or penile retraction following spinal injury. Only recently has it been adopted as a cosmetic technique for healthy men. The normal approach is to cut the suspensory ligament, which connects the base of the upper side of the penis to the pubic area. With this released, the penis can theoretically hang lower when flaccid. The operation is known as inverted V-Y plasty, after the shape of the incisions made. All 12 of the patients looked at here had undergone V-Y plasty.

Penile girth augmentation, which involves injecting fat from other parts of the body, is a purely cosmetic treatment. If the experiences of the 10 Californian patients who tried it are any guide, it can only be described as a remarkably unsuccessful procedure. In fact, it is practically guaranteed to fail in the long term, because such fat transplants lose 55% to 90% of their volume after one year. Moreover, such deposits as there are tend to be very unevenly spread, giving the penis a bulbous and misshapen look. Two of these patients had attempted to have this problem rectified with further injections into the narrow areas, but without success. In another patient the fat had migrated immediately after the operation to the underside of the penis, giving it an appearance quite different from that desired. Such fat deposits can be removed by resection, but there is a risk of losing erectile function by cutting the blood flow to the overlying skin.

Scarring, scrotalization and wound infection were common results of V-Y plasty in these patients. Four of the 12 patients required hospitalization for infections. Two suffered skin breakdown which required scar revision -- unfortunately these repair attempts failed. Six of the 12 had already undergone secondary operations in an effort to correct cosmetic deficiencies before they turned to the authors for help. Two patients had raised scarring at the base of the penis bad enough to cause pain during sex, one to such an extent that he no longer had intercourse. Four patients suffered scrotalization, a deformity that was fortunately reparable by reversal of the V-Y plasty. One patient was afflicted with severe ventral penile deflection -- in other words, his penis pointed straight down even when erect -- as a result of the severing of his suspensory ligament. He had to be warned that he would be unlikely to maintain penetration.

Four other patients exhibited sexual dysfunction of one sort or another. One had already been impotent due to diabetes; another had reduced libido, a third had poor erections, and one found penetration difficult because of excess fat deposits on the shaft. Several patients showed signs of neurological injury to the penis. All patients reported feelings of guilt, shame, and intense embarrassment, which could contribute psychosomatically to sexual dysfunction.

All of these problems were compounded by the very poor cosmetic results, and the failure of the V-Y plasty operations to achieve their main aim -- lengthening of the penis. Only one of the twelve patients said his penis was longer than before the operation, while nine reported no change and two said their penises were actually shorter.

This was not a planned survey of success rates in penis augmentation. There are no figures telling what proportion of these operations end in failure, either in this paper or anywhere else. Obviously, satisfied customers are unlikely to present themselves at a urological unit, so there were no controls. Two patients were found in the university's sexual dysfunction clinic who had undergone augmentation and declared themselves not dissatisfied with the result. One had been impotent already, while the other had Peyronie's disease. In both cases, the doctors who had performed the augmentation had failed to treat their primary condition.

The Society for the Study of Impotence has decreed that in view of the total lack of reliable evidence for the efficacy of augmentation, it should be regarded as an unproven experimental procedure. The authors of this paper, it seems, are strongly inclined to agree.

Questions for Dr. Wessells:

1. Could V-Y plasty theoretically lengthen the erect penis as well as the flaccid one?

Release of the suspensory ligament of the penis theoretically increases penile length. V-Y plasty changes the configuration of the skin which would otherwise prevent the penis from assuming a lower position in relation to the pubic bone. No published data exists regarding the effectiveness of penile lengthening in normal men. In a study of cadaver dissections, division of the suspensory ligament and V-Y plasty resulted in only a 1.6 cm increase in flaccid length and a 1.6 cm increase in erect length. Honest surgeons performing penile lengthening have suggested that a man can expect to gain one inch in flaccid length from the procedure, with minimal change in erect length.

2. Did you see any cases of urinary incontinence or similar problems?

We didn't see any urinary problems due to penile augmentation. The nerves which supply the bladder are far from the surgical site of penile augmentation. Problems with penetration can occur due to ventral deflection or excessive fat placed around the shaft of the penis.

3. What reasons did your patients give for attempting augmentation, especially those who were already impotent?

The impotent men were led to believe that the penile lengthening would solve all their sexual problems. It is unlikely that any preoperative evaluation of their sexual dysfunction was carried out.

Most of the other men responded to advertisements touting the procedure. Many were told that the procedure could be performed without complications and that their penises would be larger. The logic was: "Who wouldn't want a larger penis if there were no drawbacks?" Several of the men faced mid-life concerns about their masculinity and saw the procedure as a way to rejuvenate their lives. Popular culture is filled with jokes and references to penile size, and penile augmentation plays on fears of having a small penis.

4. What sort of doctor is carrying out this surgery? Is there any redress for disfigured patients?

Urologists and plastic surgeons perform most penile augmentations. No sanctioned training exists in this field in America, and no national organisation or board certification process can monitor the procedure. An article in the Wall Street Journal on June 6th of this year suggested that penile augmentation was a new source of income for doctors feeling the pressures of managed care. A few surgeons performed the majority of operations on the patients we saw, and other more scrupulous doctors continue to carry out penile enlargements.

Disfigured patients can write to their state medical board to obtain the necessary papers to lodge a formal complaint against their surgeon. There are also reports in the lay press regarding patients who have brought suit against their surgeon.

Very few patients actually have penises small enough to warrant augmentation. Since the procedure has not been proven to increase penile size, normal men should be very wary of penile augmentation, and demand objective documentation of their surgeon's previous results with this technique.

Complications of penile lengthening and augmentation seen at one referral centre.

Hunter Wessells, Tom F. Lue and Jack W. McAninch.

Purpose: Complications of the recent cosmetic technique of penile lengthening and girth enhancement are reviewed.

Materials and methods: During a 16-month period 12 men presented with complications of penile augmentation performed elsewhere. All 12 patients had undergone release of the suspensory ligament and 10 had received autologous fat injection.

Results: The chief complaint was poor cosmetic appearance (irregular residual fat nodules in seven men, skin deformity and scarring in four and scrotalization in four). Reoperation was necessary in six patients, wound complications occurred in six and sexual dysfunction was reported by four. Only one patient reported a subjective increase in penile length.

Conclusions: Although a verifiable complication rate may never be available, the morbidity of elective penile lengthening and girth enhancement is noteworthy. These cosmetic techniques should be regarded as experimental.

Most Men Say They're Happy with Their Penile Prostheses

The surgical insertion of a penile prosthesis is usually the last resort for men for whom other impotence treatments haven't worked. In this surgery, a small pump device about the size of a walnut is implanted in one side of the scrotum, and two tubes extend up either side of the penis. In the newer inflatable devices, which are the most popular today, manually pumping the device forces fluid into the tubes and creates an erection. The tubes are easily emptied using hand pressure.

Unfortunately, the devices destroy the tissue inside the penis that allows erection. So once a man has a prosthesis, other treatments for impotence will no longer work. Therefore, effectiveness and customer satisfaction are big issues!

Researchers attending the annual meeting of the American Urological Association reported, however, that most men with penile prostheses are quite satisfied with them.

In a follow-up study, led by researchers at the University of North Carolina Medical School, records of 372 men, who had received one of the most popular devices (AMS 700CX) at one of seven different U.S. medical centers, were evaluated for reliability of the prosthesis. Later, 207 men were interviewed about their experience with the device.

The prostheses were functioning properly in 92 percent of recipients after three years, and in 86 percent after five years. When interviewed, 86 percent of the men expressed satisfaction with the device, and 88 percent said they would recommend it to other patients.

These results agree with a study reported last year by the Health Technology Assessment Agency of the Spanish Ministry of Health. These researchers reviewed more than 40 articles from medical journals to evaluate effectiveness of these devices and patient satisfaction with them.

Looking at a variety of brands and designs, the Spanish team estimated that the devices were, on the average, about 80 percent effective, with the newer inflatable devices up to 100 percent effective. Surgical complications and infections were low. Sexual satisfaction for patients with the devices ranged from 72 to 96 percent; again, with the newer inflatables getting the highest ratings.

In the United States alone, about 20,000 penile prostheses are implanted each year. It's good to know that for most men, they work!