It's Not "All in Your Head"

By Anastasia Toufexis

As many as 10 million American men suffer from chronic impotence, but not many of them are willing to talk about it, much less seek help. Besides being embarrassed, most sufferers figure that the problem must be "all in your head" and therefore difficult to treat. But they could hardly be more wrong. Medical researchers have determined that up to 75% of all cases of impotence stem from physical problems, most of which can be treated. As new types of remedies, ranging from drug therapy to surgery, come into increasingly widespread use, impotence is no longer a hopeless condition.

Healthy nervous and circulatory systems are vital to achieving and maintaining an erection, researchers explain. When a man is sexually aroused, stimulated nerves trigger a chemical reaction that causes the corpora cavernosa, two rod-shaped bundles of spongy muscle that run along each side of the penis, to relax and draw in extra blood. As the chambers fill, they expand, pressing shut veins that normally drain blood from the organ. With blood coming in and none going out, the penis becomes rigid and erect.

While emotional concerns can upset this process, most trouble results from physical problems. In young men, injury is the main cause of loss of potency. "Coming down hard on the narrow seat of a ten-speed bicycle can damage the arteries or the nerves," says urologist Irwin Goldstein of Boston University School of Medicine, who recently chaired an international conference on impotence research. But the vast majority of impotent men -- most are above age 55 -- are victims of poor habits or illness. Alcoholism, for example, can deaden nerves. Cigarette smoking can reduce blood flow to the penis by constricting vessels and causing the corpora cavernosa to lose elasticity. Diabetes, atherosclerosis and high blood pressure (and the medications used to treat it) can all have damaging effects.

Until the 1980s, the only therapy doctors had to offer was penile implants -- prosthetic devices that are surgically inserted into the penis to mimic an erection. Now, declares urologist Drogo Montague of the Cleveland Clinic, "the implant is the end of the treatment line." Before resorting to implants, doctors are able to draw upon less drastic remedies:

-- Injections of the drugs papaverine and phentolamine into the penis can counteract stiffening of the corpora cavernosa and thus permit engorgement with blood. Dosage is carefully balanced to produce an erection that lasts about two hours, and patients learn how to inject themselves. Urologists recommend that drug use be limited to ten times a month to avoid scarring. Occasionally a patient will suffer a prolonged erection; impotence clinics provide 24-hour emergency service to administer an antidote. Cost of the therapy: $1,200 to $2,400 a year. Robert Batts, 40, a former policeman in Hull, Mass., who became impotent nine years ago after fracturing his back while breaking up a fight, is enthusiastic about the injections. So is his wife Donna, who sometimes signals her mood with the question, "Have you had your shot today?"

-- Researchers have developed a vacuum device that produces an erection. The penis is sheathed in an acrylic tube, and a hand pump is used to force out air from around the penis. The resulting vacuum draws blood into the penis until it becomes rigid. Rubber bands are then slipped onto the base of the penis to keep the blood from escaping; the bands can be left in place safely for half an hour. The vacuum machine costs about $450. Urologist Perry Nadig of San Antonio has followed 340 of his patients who have used the device, some for as long as six years; fully 80% of the men are satisfied with the results. Morton Perrin, 76, of Durango, Colo., whose impotence followed surgery for prostate cancer ten years ago, says he and his wife are delighted: "You'd think we were 26 years old again."

-- When arteries to the penis have become constricted, surgery can sometimes restore blood flow. In one operation, called an endarterectomy, the blood vessel is opened and scraped clean. Doctors also bypass blockages by grafting sections of an abdominal artery around narrowed branches of the iliac artery that lead to the penis. This operation is similar to the one done on clogged coronary arteries, but does not have as high a success rate. Vascular surgeon Ralph DePalma of Washington thinks that vessels to the penis are more fragile because they are subjected to sudden surges in blood pressure.

A third technique being used to clear blood vessels is balloon angioplasty, in which a tiny collapsed balloon is threaded into a blocked passage and inflated. Atherosclerotic plaque is crushed against the artery walls, widening the blood pathway. Yet another delicate operation entails tying off penile veins that fail to close during sexual arousal, thus allowing blood to leak away from the penis and inhibiting an erection. Vascular operations carry steep price tags: $6,000 to $15,000.

Many of the therapies still have drawbacks. After all, resorting to injections or using a vacuum machine can take some of the spontaneity out of sex. So researchers are experimenting with more sophisticated techniques: a pacemaker-like device to stimulate the nerves that initiate an erection and new drug-delivery systems that use long-term skin patches to replace frequent injections. Now that doctors have found ways to treat impotence, the goal is to make the remedies seem less intrusive and more natural.

With reporting by Suzanne Wymelenberg/Boston