Impotence affects about one out of every ten American men, yet many of them don't seek help because they're embarrassed, they think there's no solution or they believe the problem is "all in their minds." Unfortunately, these men are missing out on a wide variety of treatment options.

Impotence, the persistent inability to achieve and maintain an erection for intercourse, affects as many as 18 million men in the United States between the ages of 40 and 70. Until recently, doctors thought impotence was mainly rooted in psychological causes. Now it is believed that 50 to 70 percent of all cases are caused by physical problems. Erection difficulties tend to increase with age, but that is not the only or even the most important factor. Your general physical and psychological health, as well as lifestyle habits and certain medications, can all cause impotence, but you don't have to live with this problem. In most cases, impotence can be successfully treated.

How Does an Erection Occur?

In order to get an erection, several parts of the body must work together. The brain sends a message of sexual arousal through the nervous system to the penis. This message causes the muscles along the penis to relax. At the same time, the artery to the penis dilates to twice its diameter, increasing the blood flow sixteen-fold, and the veins which carry blood away from the penis are blocked. As a result, the two spongy-tissue chambers in the shaft of the penis fill with blood and the penis becomes firm. A breakdown in any of these systems makes getting or keeping an erection difficult.

How is Impotence Diagnosed?

Virtually all men occasionally fail to get an erection. That's normal. But if a man has trouble getting or maintaining an erection about 25 percent of the time, he should see an urologist. These physicians specialize in disorders of the kidneys, bladder, prostate, penis and urethra.

Usually, after asking questions about when and how the impotence developed, the urologist will give the patient a complete physical exam to determine if his hormone levels are normal and if the blood vessels, nerves and tissues of his penis are working properly. If this initial work-up doesn't pinpoint the cause of the problem, a nocturnal penile tumescence test can be done.

Men with no physical abnormalities almost invariably have nightly erections during sleep. The patient may spend a few nights in a sleep laboratory where a gauge that measures the frequency and duration of nocturnal erections is attached to the base of the penis. A home version of this, the snap-gauge test, can also be used. Before going to sleep, the patient attaches the gauge to the base of his penis. During the night, the gauge will break at different degrees of penile rigidity and show whether a partial or full erection has taken place during sleep. If nocturnal erections do not occur, the impotence is most likely physical. Additional testing is then required to identify the precise cause of the problem.

What Are the Physical Causes of Impotence?

Physical impotence occurs when there is a problem with any of the systems needed to get or maintain an erection. The good news is that potency can usually be restored when a man is treated for underlying medical conditions, when medications are adjusted or when lifestyle habits are changed.



Here are some of the top causes of impotence:

• Vascular Disease. Hardening of the arteries can affect the artery leading to the penis so that it cannot dilate enough to deliver all the blood necessary for an erection. Impotence can also occur if the nerves that control blood flow to the penis are damaged.
• Diabetes. One out of every four impotent men has diabetes, which can cause nerve deterioration (diabetic neuropathy). Impotence may result if nerves or blood vessels that control the flow of blood to the penis are affected. In some cases, keeping the diet and blood sugar under control can decrease impotence. But permanent nerve damage can result in a chronic problem.
• Disease of the Nervous System. Some conditions, such as multiple sclerosis, Parkinson's disease and spinal cord injuries, can affect or cause impotence.
• Cancer Surgery. Surgery to remove cancer from the prostate, bladder, colon or rectal area can cause impotence if the nerves and blood vessels that control erections are damaged in the process of removing cancerous tissue.
• Medications. Some prescription medications for high blood pressure, depression, spinal cord injury, diabetes and other conditions can cause temporary impotence by interfering with the nerve impulses or blood flow to the penis. Doctors may be able to adjust the dosage of a drug or change the medication to reverse or minimize the problem.
• Smoking. A recent study at the New England Research Institute in Watertown, Massachusetts, found that impotence was equally common among smokers and non-smokers in general. However, among men with certain health problems, those who smoked were much more likely to have potency problems. For example, 56 percent of smokers with heart disease were completely impotent compared with only 21 percent of non-smokers with the disease.
• Alcoholism. Excessive alcohol consumption disrupts hormone levels and can lead to nerve damage. This type of impotence may be reversible or permanent depending on the severity of the nerve damage. Some clinical studies suggest about 25 percent of all alcoholics become impotent--even after they stop drinking.
• Hormone Imbalance. Abnormal testosterone levels are rare, but they can cause impotence. In addition, other illnesses, such as kidney failure and liver disease, can disrupt the balance of hormones.

What Are the Psychological Causes of Impotence?

A man who is depressed, under stress, or worried about his "performance" during sex may not be able to have an erection. Qualified therapists or counselors who specialize in the treatment of sexual problems can often help diagnose and sort through these problems. Some impotence problems can be solved when a man understands the normal changes of aging and how to adapt to them. For example, as men get older they generally need more direct stimulation to achieve an erection. They may also have less firm erections, take longer to ejaculate and need more time between erections.

Relationship woes can interfere with potency and so can job stress, depression or financial worries. Impotence may also be the result of deep-seated emotional trauma, such as having been sexually abused as a child. Qualified psychotherapists can diagnose such problems and help men understand and overcome them.

What are the Treatment Options?

When treatment of underlying physical or psychological problems fails to restore potency, a man and his sexual partner can consider one of the following solutions:

1. Viagra. The most recent treatment for impotence approved by the FDA, this prescription drug is expected to benefit 70% of men with erectile dysfunction and has revolutionized the way impotence is treated. All a man needs to do is pop a Viagra pill an hour before sexual activity and the medication works on normal body chemistry to allow blood to rush into the penis when a man is sexually stimulated (men should take no more than one pill a day). Despite all the hype about Viagra, men should exercise caution in deciding whether this drug is right for them (see sidebar).
2. Vacuum Device. With this treatment, a man slips a hollow, plastic cylinder over his flaccid penis. He then attaches a hand pump to draw air out of the cylinder, creating a vacuum that draws blood into the penis. Once the penis is erect, the man slips an elastic ring over the cylinder onto the base of his penis and removes the cylinder. The ring will keep blood from flowing out, allowing intercourse. Note: This device should only be used when seeing a doctor regularly since mishandling can damage the penis.
3. Self-Injection. One or more drugs (papaverine, phentolamine and prostaglandin-E1) can be injected into the penis to increase blood flow. The injection is nearly painless and produces a more natural erection than a vacuum device or implant. However, until the proper dose is worked out, a man might have a prolonged and painful erection. In rare instances, an erection that does not go down after ejaculation may require surgery.
4. Penile Implants. Surgical implants can be used as alternatives if the above treatments are unsatisfactory. Experts at the Mayo Clinic say there is a 10 to 15 percent chance that an implant will malfunction within five years, but the problem almost always can be corrected. Over 90 percent of patients are satisfied with these devices. The two major types are:

• Malleable Rods. Two long rods (also referred to as semi-rigid prostheses) are inserted into the outer channels of the penis through a small incision in the lower abdomen or scrotum. Each rod is one solid piece and so remains erect at all times. However, they can be bent close to the body for concealment. Because there are no moveable or inflatable parts, malfunctions are rare.
• Inflatable Cylinders. These devices consist of one or two inflatable cylinders, a finger-activated pump and an internal reservoir that stores liquid used to inflate the tubes. All components--the cylinders, pump and reservoir--are implanted within the penis, scrotum and lower abdomen respectively. When the pump in the scrotum is manually squeezed several times, the fluid from the reservoir is released into the cylinders. They expand and create an erection, which is maintained until the release valve on the pump is squeezed to return the fluid to the reservoir.

Viagra: Time to Separate Reality from Hype

When Viagra-the first pill to conquer male impotence-was approved earlier this year, doctors couldn't keep up with their patients' demands for prescriptions. All the brou-ha-ha is easy to understand. If normal sexual function can be restored by simply swallowing a little pill, why bother with devices, injections or implants? Still, the wonder drug that can has its limits. And reports of deaths among men taking the sex pill is causing some alarm.

Viagra seemed to burst on the scene out of the blue, but it does have a track record. Sildenafil citrate, the active ingredient in Viagra, was originally developed to treat high blood pressure. It didn't work for that disorder, but in 1993, Pfizer Pharmaceuticals, the drug's manufacturer, started clinical trails of Viagra involving more than 3,000 men with varying degrees of impotence associated with diabetes, spinal cord injury, history of prostate surgery, and other illnesses. The results: 48 percent of men with severe impotence were almost always able to get aroused when using Viagra, and 70 percent of men with milder problems had success using the pill. Men with diabetes or radical prostate surgery had somewhat less improvement than did other groups.

One of the little love pill's major assets is that men who take it get turned on "naturally." That is, Viagra does not directly cause erections as do other impotence treatments. Rather it affects a man's response to sexual stimulation. Taken one hour before sexual activity, the drug acts by enhancing the effects of a chemical the body normally releases into the penis when sexually aroused. This increases blood flow into the penis, which results in an erection. (Viagra should not be taken more than once a day.)

On the down side, there have been reports of deaths and severe side-effects in some men taking Viagra. Men with a history of heart trouble, heart attacks, and low blood pressure should be examined carefully before getting a prescription for the drug, and heart patients taking nitroglycerin or other nitrate-based drugs must not take Viagra because the mix may cause a deadly dip in blood pressure. Other adverse effects of Viagra may include headache, flushing, indigestion, and temporary changes in vision--including seeing a 'blue haze.' Opthalmologists are concerned that the long-term effects of Viagra on vision are not yet known. Men with sickle cell anemia, leukemia, or multiple myeloma should also avoid Viagra because it is feared that they may develop priapism--a persistent, painful erection that can permanently damage the penis. Additionally, men are cautioned against using other treatments for impotence while taking Viagra as such combinations have not been tested yet.

Despite problems linked to the sex pill, enthusiasm for it among patients and doctors is still riding high. But men are cautioned to use common sense. They should not take it before having a thorough medical history, including a review of medications, and a physical examination. Viagra is a drug with potentially serious heatlh consequences and is meant only for men diagnosed with impotence. It is not a novelty item for men who achieve normal erections and simply want to heighten their sexual prowess.