Dr. M.J. Bazos, MD Patient Handout

ERECTILE DYSFUNCTION

About Your Diagnosis
Erectile dysfunction, commonly referred to as male impotence, can have both physiologic and psychological causes; however, much more attention has been devoted to the physiologic causes of this disorder. Erectile dysfunction increases dramatically in later life, from about 10% of men in their 60s to 30% by their 70s. It increases even further in men between 70 and 80 years of age. Most of the patients with erectile dysfunction in this age group have heart and blood vessel disease; however, many cases are medication induced. It can also be caused by a neurologic disturbance, radiation, diabetes, hypertension, smoking, being overweight, and being sedentary (not exercising). By definition, erectile dysfunction is persistent or recurrent inability to get or to keep an adequate erection until completion of sexual activity. As do most sexual disorders, male erectile dysfunction causes marked distress and difficulties with interpersonal relationships. Psychogenic erectile dysfunction, which is caused by emotional and not physical reasons, is more difficult to diagnose. An important finding in making the diagnosis of emotional or psychosocial impotence would be that the individual may have reliable, firm erections under some circumstances and be impotent in other situations. In evaluating the individual with erectile dysfunction, the doctor will inquire about the relative firmness and length of time of erections under the following circumstances: masturbation, sex other than intercourse, sex with female or other male partners, stimulation with explicit materials such as sexually arousing movies or pornography, erections in the middle of the night, or in particular, erections upon arising from a night’s sleep. Most males, particularly those who are younger, awaken with an erection. Obviously, in the absence of diseases that are known to cause impotence, and if an individual can have an erection with masturbation or early morning awakening, then the likelihood of psychogenic impotence is very high.
Living With Your Diagnosis
Erectile dysfunction can be lifelong or acquired later in life. It can be generalized or associated with specific situations, and it can be caused by psychological factors or a combination of psychological and physical factors. In psychiatric terms, lifelong male impotence typically involves some kind of anxiety or confusion about sexual identity, including such issues as transvestism, homosexuality, or a psychiatric diagnosis that increases the patient’s fear of being sexually close to a partner (e.g., schizophrenia or schizoid and avoidant personality disorders). Occasionally, a physician may not ask you about your sexual functioning. Although you may be hesitant or somewhat embarrassed to discuss it, it is very important that you mention sexual dysfunction to your psychiatrist or family doctor because many of these conditions can be successfully treated. Obviously, for the man with lifelong impotence, the earlier he is into treatment the better. Individuals who are anxious about their first sexual encounter and have impotence secondary to that have particularly good outcome with treatment. The outlook for success among older men who have had lifelong erectile dysfunction is poor. In contrast, men who have had long-established good potency, who have recently lost their erectile abilities, so-called acquired psychogenic impotence, have a much better prognosis than those with a lifelong pattern. These men can be treated individually or in couples therapy, and the psychiatrist will try to identify the cause of the impotence and suggest treatment for it. Often, an affair outside of marriage, or some discord in the relationship is responsible for secondary or acquired impotence. Potency is frequently lost after a separation or divorce, as well as after the death of a spouse (widower’s impotence). Other risk factors for impotence include the crumbling of a man’s financial or occupational life, the occurrence of a serious new physical illness, such as a heart attack or stroke, or when the man’s wife becomes seriously ill. Regardless of what stressor may have caused secondary impotence, the basic problem is still one of performance anxiety. The anxiety that a man who is impotent feels involves initially a fear that he will not be able to obtain an erection, and if he does, worrying whether it will be maintained long enough or is hard enough for the completion of sexual activity. Needless to say, such preoccupation diminishes the satisfaction of any sexual intercourse.
Treatment
The most basic treatment for this form of anxiety is to ask the man to make love with his partner without trying intercourse on several occasions, just to show him how different lovemaking can feel when he is not overly concerned with failure of potency. Often this enables the man to relax and concentrate
on lovemaking, and refocuses attention on pleasing his partner and obtaining pleasure for himself. This technique is known as sensate focus. One of the major problems in our culture that leads to impotence has to do with the belief that men should be able to perform intercourse with anyone, anywhere, and in any circumstance. It is impossible for most men to live up to this expectation. Physicians who are not psychiatrists have three basic treatments to offer men with impotence. They often prescribe (1) the use of a vacuum pump; (2) the injection of a substance into the penis that causes blood vessels to open up, thereby increasing blood flow to the penis; or (3) surgical implantation of a penile prosthesis. This last procedure is often done
in patients who have sexual dysfunction from diabetes. Although some may be hesitant to admit it, most men at some point during their sexual lives are unable to get and/or keep an erection. It is only when this function is persistent and causes significant distress that presents to the doctor.
The DOs
It is important to discuss this condition with your physician. As mentioned previously, the physician may not ask about your sexual functioning; however, you should not be too embarrassed to discuss any problems you are having. Secondly, make sure you tell your physician all the medications you are taking because many medications, including many of the antidepressants, can cause sexual dysfunction. Thirdly, talk to your partner. It is very easy for some partners to assume that a male’s difficulty with erection is somehow related to the fact that they are less pleasing and less desirable, and so some feelings of guilt may arise. Keep the lines of communication open. Common-sense measures including regular exercise and a healthy diet are very helpful in normal sexual functioning. However, the most important thing to remember in acquired impotence is to relax. Like many conditions in the field of psychiatry, worrying about it only makes it worse. There are many activities that can be engaged in that are part of making love that do not have as high a degree of performance anxiety.

The DON’Ts
You should be realistic about your sexual ability. Do not expect to have completely normal sexual functioning during periods of high stress or during periods of grieving or significant depression. Impotence during these times is temporary, and becoming anxious about it only makes it worse. Do not engage in drastic actions like having an affair or getting a divorce.

When to Call Your Doctor
Contact your doctor if you notice blood or discharge from your penis, if sexual intercourse becomes painful, if you have a long-lasting erection that persists after intercourse, or if your concern about this condition leads to severe depression or suicidal thoughts.

Websites:
Impotence Information Page: http://www.demon.co.uk/hernia/nfo/mcd.html
Impotence: Its Reversible: http://www.cei.net/~impotenc
Successfully Treating Impotence: http://www.impotent.com