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.

Forward:

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
ones.

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
treatment.

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
life.

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
treated.

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.

2.
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
treatments.

4.

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
selected?

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
treatments.


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
disease.

2.
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.

4.
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
trauma.

6.

7.
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
drug.

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
together.

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
parts.

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
exploration.

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
necessary."

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.

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