|
������������������������ MALE
SEXUAL DYSFUNCTION ���������������������� by Ed Bryant � ���� One of the most feared complications of
diabetes, "erectile
dysfunction", commonly known as "impotence", is also one of the
most treatable.� More than 50%
of diabetic men may experience
this complication, but over 95% of cases can be successfully
treated.� With proven treatment available, and
new treatments appearing, a diabetic experiencing this
problem does have options.� It
isn't something he or
any other man or his partner should have to live with. ���� Many men do not feel their difficulties,
especially with their sexual
performance, are a fit subject to discuss with their partners.�
They couldn't be more wrong.�
To avoid making things worse,
a man needs to move beyond the old idea that the sex act
is something he does.� He is
part of a relationship, and
what interferes with one affects both.�
A man's partner is
equally involved. ���� Achieving and sustaining an erection requires interaction between
the neurological, arterial, hormonal, and psychological
functions of the body.� Simply,
a lot of different parts
have to work right.� Proper hormonal balance, normal
sex drive and emotional make up, functioning nerves and blood
vessels, and healthy penile tissue are all required.� Libido, the interest in sexual activity, and potency, the ability
to perform, must both be present. Several different
sets of nerves are involved.� Erection
is a function of the
parasympathetic nervous system, but orgasm and ejaculation
are controlled by a different set of nerves: the sympathetic
system.� Both orgasm and ejaculation
can occur without erection. ���� "Erection is a hydraulic phenomenon,
that occurs involuntarily,"
says Arturo Rolla, MD, of Harvard University School of Medicine.�
"Nobody can will an erection!" Anything that limits
or impairs blood flow can interfere with the ability
to achieve an erection, no matter how hard a man tries, or
how much he wants to achieve one. ���� Although sexual vigor declines with age,
a man who is healthy, physically
and emotionally, is able to produce erections, and
enjoy sexual relations, regardless of his age.� Impotence is not an inevitable part of the
aging process. ���� On occasion any man may experience the inability
to achieve or sustain
an erection.� Such transient
episodes are common and may
be attributed to illness, fatigue, stress, etc.� The occasional inability to perform, however
traumatic to both partners,
is normal. ���� Repeated inability to achieve and sustain
an adequate erection can be
caused by anything that affects a man, psychologically
or physically.� Psychological,
or "psychogenic,"
impotence can follow major life changes, stressful events,
or even the fear of becoming impotent. The physiological
changes associated with fear can themselves cause
erectile dysfunction!� When a
diabetic discovers the source
of his difficulties is not physical that it
is due simply to a fear of the ramifications sexual
function is usually restored.� But
to tell the difference
between physical and psychogenic impotence, and
to make any progress against it, requires that you TALK about
this sensitive issue with your partner, your physician,
and, ideally, with a urologist specializing in male impotence. ���� Sexual dysfunction can contribute to psychological problems such as
feelings of inadequacy, frustration, loss of self esteem,
and despair.� Strained relationships
with partners may well
result.� It is important for
men to discuss the problem
with their partners and to promptly seek medical attention.�
Many may find counseling helpful. ���� Diabetic impotence is generally a result
of the blockage of blood
vessels responsible for erection, damage to the nerves that
dilate those blood vessels, or a mixture of the two.� In some cases, re establishing good glycemic control may decrease
the impotence, though permanent damage to nerves and vessels
may not be reversible. ���� A diabetic man can decrease his risk of
impotence by carefully controlling
his diabetes.� Poorly controlled diabetes and high
cholesterol increase the chances of vascular complications,
especially vessel blockage, which may lead to erectile
dysfunction, or to other circulatory problems. ���� Exercise regularly, and avoid nicotine and
alcohol. Smoking causes
constriction of the blood vessels and contributes to
arterial blockage.� Good health
practices help men prevent
impotence. ���� Impotence, the chronic inability to have
and sustain an erection adequate
for sexual intercourse, may be a symptom of a more serious
disorder.� Seeking prompt medical
help for sexual dysfunction
can lead to early diagnosis of other problems.� Identification of the source of impotence can point the way to
the prevention of strokes, heart attacks, and other life
threatening illnesses.� Learning
is the first step to recovery,
especially when fear is the culprit. ���� Regardless of the cause, if a man does not
have or cannot sustain
erections adequate for vaginal penetration, and the problem
continues over a period of four to five weeks, he should
recognize a problem exists, and seek medical help.�
Don't delay erectile dysfunction doesn't just go away! ���� In treatment of impotence, the choice of
doctors is most important.�
Among the best choices are those practicing at centers specializing
in erectile dysfunction, urologists who subspecialize
in the treatment of impotence, and other physicians specifically
trained in this field.� Most people's first
contact is with their family doctor.�
Ask that first physician
for a referral to a medical professional who
is particularly familiar with this disorder.� Local hospital referral services may keep lists of such experts
who practice nearby. ���� After the interview and physical exam, the
doctor will determine whether
the erectile dysfunction is psychological or physical in
nature.� Where diabetes is present,
a vast majority of instances
of erectile dysfunction have a partly or completely physical
cause.� But based on examination
and interview, the
doctor may determine the cause to be psychological,
and if so, refer the man to a qualified health professional
specializing in psychologically‑induced erectile dysfunction.�
This may be a psychiatrist, psychologist, sex
therapist, or marital counselor. ���� Troy A. Burns, MD, formerly Medical Director
of the Diagnostic Center
for Men, in his GETTING HELP:� A
Patient's Guide for Men With
Impotence (1994, now out of print) reported that an
old at home test for erectile activity during sleep (the
lack of which would suggest physically caused
impotence) was the postage stamp test. The patient was
instructed to wrap several stamps snugly around his penis
at bedtime.� If the stamps had
perforated by the time he
awakened, some penile tumescence probably occurred!� Of course more sophisticated tests are used today. ���� Impotence is sometimes a side effect of
medications prescribed for
other disorders.� Such medications
include: some antihypertensives
(diuretics and beta blockers), ulcer medications, the
heart medication Digoxin, antihistamines used for allergy
control, antipsychotics, commonly used tranquilizers such
as Diazepam, certain antianxiety drugs, certain narcotics,
anticholinergics, tricyclic antidepressants,
and many illegal drugs.� Elavil
and other tricyclic antidepressants,
sometimes used to treat the pain of neuropathy,
can cause, trigger, or aggravate impotence. Be careful of interactions
between your medications and any "alternative"
herbal supplements too�� tell
your doctor what you're taking.�
A person's unrelated disorders may also contribute to the
problem, as over the counter medications, including certain
eye drops and nose drops, have been associated with
erectile dysfunction. ���� If you experience erectile dysfunction,
and you are using other medication(s),
discuss it with your doctor.� By adjusting the dosage
of current medication(s) or by switching to alternates,
erectile dysfunction may be alleviated.� Ask your doctor or pharmacist for information about side effects,
and be sure to read the package insert in the container.�
Consult a physician before discontinuing any medications.
���� Much is now known about the causes and treatments
of erectile dysfunction,
and impotent men should be aware of their various treatment
options.� Although surgery is
one choice, 95% of
cases are resolved by nonsurgical means, and the National Institutes
of Health recommends trying nonsurgical treatments
before more invasive methods.� All options should
be considered, but the man's personal preferences and
those of his partner are vital in the choice of treatment.�
For purpose of discussion I've divided treatments into
three categories:� medications,
external mechanical devices,
and surgery. Medications ���� Topical "Vasodilators" May Improve
Blood Flow: �When diagnosis indicates
a problem in the vascular system, particularly arterial
insufficiency, externally‑applied vasodilators (example:�
nitroglycerine ointment) can be used to dilate arteries,
improving blood flow into the penis. Commonly used in
treatment of high blood pressure and associated heart
disease, such ointment is applied to the penis to increase
penile arterial flow and improve erections.� The most notable side effect of nitroglycerine ointment is that
it may give the female partner headaches, as it is absorbed
into her bloodstream through the vagina. To prevent this,
the man should use a condom. Another topically applied
vasodilator, Minoxidil, was found to have fewer side effects
and be more effective than nitroglycerine cream.� Although some cases of erectile dysfunction
respond well to this kind
of therapy, the effectiveness of vasodilator products
has not yet been determined by the scientific community. ���� Yohimbine Therapy Shows Promise:� Yohimbine medication comes from the
bark of a tree that grows in Africa and India. The extract,
long used as an aphrodisiac and folk remedy for impotence,
has proved effective in some impotence cases.� It is not known exactly how the medication
works, but it seems to
affect the central nervous system by suppressing nerves
that normally restrict erection.� It's thought that yohimbine
may also increase libido desire in some men.� The few side effects of yohimbine tablets can
be easily alleviated.�
Many doctors prescribe this therapy for cases of very mild,
physically caused dysfunction or for psychological impotence.�
This therapy does have merit and should be considered. ���� Viagra, Pfizer, Inc.'s oral medication for
the treatment of male
erectile dysfunction (impotence) was approved by the
U.S. Food and Drug administration on March 27, 1998.� Viagra is a simple pill, priced about $7 per dose, and appears
to successfully treat a wide percentages of cases.� Although sometimes contraindicated where circulatory disease
is present (talk to your doctor first!), for some, it may
be the most convenient treatment of all. � ���� Uprima, manufactured by TAP Pharmaceuticals,
works in a similar manner,�
but where Viagra acts directly on the circulatory system,
Uprima stimulates the appropriate neurotransmitters
in the human brain.� It appears
to work more quickly than
Viagra.� An FDA advisory committee, meeting in April
2000, has recommended that FDA approval be given for this
medication.� It should be available
shortly. � ���� Vasomax, by Zonagen Pharmaceuticals, is
still another anti‑impotence
oral medication.� An oral form
of the proven anti‑impotence
injectable medication phentolamine, it is already approved
in Mexico, it is in final clinical tests in the U.S.� If all goes well, it should be available late
in 2000. ���� Penile Injection Therapy:� Many sources report that penile injection
therapy has an estimated 80% rate of success.� Injected directly into the penis, the medication produces erection
by relaxing certain muscles, increasing blood flow into
the penis and restricting outflow.�
The therapy has disadvantages,
such as risks of infection, pain, and scarring fibrosis
in the penis, and it may create "priapism,"
a prolonged, painful erection lasting six hours or more (although
reversible with prompt medical attention). The most popular
medication is Upjohn Corporation's Caverject, the
first to be approved for such use by the FDA. Note: The MUSE
system, described below, administers the same medication, without
needles. ���� Drug Combination Injection Therapy:� Therapies using combinations of
drugs have been developed and are proving to be a good "fallback"
for individuals who experience difficulties with
Caverject alone.� "About
15% of all individuals who
try therapy with� Caverject experience significant pain
at the injection site,"� says
Troy A. Burns, MD.� "For these 15%, a combination of Caverject,
Papaverine, and
Phentolamine produces less or no pain." Alternatives ���� The MUSE System, by VIVUS, is a noninvasive
alternative to penile injection.�
The user dispenses his medication (a pellet of alprostadil/Caverject)
with an eye dropper like applicator, directly
in the urethra.� No needles are required.� Both the drug and the delivery system have
been approved by the
Food and Drug Administration for this use. For many impotent
men, the MUSE may be the therapy of choice. ��� ���� "Rejoyn" is an inexpensive, nonprescription
alternative to the many vacuum
actuated devices described below. Described by its
manufacturer as a "support sleeve," it does not "cause"
an erection, but rather supports the flaccid penis as if it
were erect. External Mechanical
Devices ���� This category of treatments for erectile
dysfunction includes external
vacuum therapies; noninvasive external mechanical devices
that produce painless erections by causing blood to
flow into the penis while constricting outflow of blood.�
Such devices imitate a natural erection, and do not interfere
with orgasmic experience.� External vacuum therapy
mechanisms are approximately 90% successful in causing and
sustaining an adequate erection.� All
are portable, and costs
range between $200 $500, covered under most insurance
plans, and Medicare Part B. ���� The vacuum constriction device consists
of a vacuum cylinder, various
sizes of tension rings, and a vacuum pump, either hand operated
or electric.� The penis is placed
in a cylinder to which
a tension ring is attached.� Air
is evacuated from
the cylinder by means of the pump, creating a vacuum, which produces
the erection. The cylinder is removed, leaving
the tension ring at the base of the penis to maintain the
erection. ���� Vacuum therapy devices have a few minor
disadvantages. One must interrupt
foreplay to use them.� THE TENSION
RING MUST BE REMOVED
AFTER SUSTAINING THE ERECTION FOR 30 MINUTES, TO PREVENT
PENILE BRUISING.� You must use
the correct size tension
ring.� Although considered to
be basically pain
free, initial use may produce some soreness. Such devices may
be unsuitable for men with certain disorders related
to blood clotting.� In general,
vacuum constriction devices
are successful in management of long term impotence,
and they enjoy wide physician acceptance.� They are relatively inexpensive, and they work on simple principles,
so they are easy for patients to understand.� ���� "At our institute," says Troy
A. Burns, MD, founder and former medical
director of the Diagnostic Centers For Men, "each doctor
regularly prescribes such devices 20 to 30 times a month.�
Complaints are rare; and very rarely do we have anyone bring
them back.� They usually work
really well." Surgical Treatments ���� There are many other less invasive and less
expensive options, and surgery
should be considered only after all others have proved
unsatisfactory.� Of the two kinds
of surgery performed,
one involves implantation of a penile prosthesis; the
other attempts vascular reconstruction. Less than 5% of
impotent men may benefit from vascular surgery.� Expert opinion about surgical implants has
changed during recent years;
today, surgery is no longer so widely recommended.� Even though it is 90% effective, surgery is expensive in both
monetary and human terms, but it is one available option
for impotent men.� The decision
to have or not have surgery
is one that should be made by the man and his sexual partner. ���� Companies that market surgically implanted
prosthetic devices sell only
to hospitals and physicians and will not provide the selling
price to consumers.� Some years
ago, I checked prices,
and found that the malleable prostheses cost about $1400, and
inflatable devices cost about $4000 ‑‑ just for parts.��� If the man elected to undergo the surgery,
and fees were totaled
(surgical, operating room, and the markup on the prosthesis),
the cost would be thousands more. ���� The main risk associated with penile surgery
is infection.�� Although every attempt is made during the procedure itself
to prevent infection, it can develop, and may force removal
of the prosthesis.� As with all
invasive procedures, there
may be some pain, bleeding, and scarring. I also note that
the device itself might fail to work properly and may
have to be removed.� If for some
reason the prosthesis or parts
become dislocated, surgical removal may also be necessary.�
With a general success rate of about 90%, any of the
devices will restore erections, but they will not affect
sexual desire, ejaculation, or orgasm. ���� Prostheses:� Many different types of penile prostheses are available,
in three categories:� rods, inflatable prostheses, and
self contained prostheses.� Semi
rigid or malleable rods
are the simplest and least expensive of all. Their main disadvantage
is that the penis remains constantly erect, which may
cause problems with concealment. ���� Inflatable prostheses are complex mechanical
devices that imitate the
natural process of erection.� Parts
are inserted surgically
into the penis and scrotum, and activated by squeezing.�
When erection is no longer desired, a valve on the
pump is pressed, and the penis becomes flaccid. Disadvantages
include risk of mechanical breakdown or leakage.� Fully inflatable devices are the most expensive of the three categories,
because of the complicated surgery necessary to implant
the parts. ���� Self contained single unit prostheses are
similar to the inflatable
types, but more compact.� The
entire device is implanted into
the penis.� When erection is
desired, the unit is activated
by either squeezing or bending, depending on which of the
two types of self contained prostheses is used.� Some of the mechanical types have been known
to fail during intercourse;
the inflatable device can sometimes be difficult to operate. ���� All penile implants will produce erections
suitable for intercourse.� When decisions are being made regarding the kind of surgery,
other factors should be considered. According to Bruce
A. MacKenzie in IMPOTENCE WORLDWIDE (Volume 7, No.2),
purpose is only one of several elements considered when
selecting an implant.� MacKenzie
said, "To those who wish
to simulate nature to the furthest extent then a fully
inflatable would be their choice; for those who wanted
something relatively simple, ready to use, lower cost, one
day less in the hospital their choice would be the hinged or
malleable; to those who wanted a compromise between the two
a hybrid they would choose a self contained; and for those who
wanted the least expensive (low end of the line) the semi
rigid would fit the bill." ���� Vascular Reconstructive Surgery for Impotence
uses highly sophisticated
techniques and equipment to physically correct the underlying
causes of impotence in the penis. The surgeon may
attempt reconstruction of the arterial blood supply, or remove
veins when the cause is due to leakage. Less than 5% of
men with erectile dysfunction have such surgically treatable
impotence! ���� When quality of life is affected by erectile dysfunction, a
man should seek a physician's help preferably that of a carefully
chosen specialist.� Don't wait
for your doctor to ask you
about sexual functioning talk about it! Nothing is cured
by silence.� Talk about it with
your partner/spouse
too, as she is equally affected by this condition.� Remember you're both involved, so she is integral to the
relationship, and deserves complete honesty. �Relationships are solid only when couples consider
each other's feelings,
so COMMUNICATE WITH YOUR PARTNER. ����� COMPANIES THAT MARKET IMPOTENCE THERAPY
SYSTEMS ���� American Medical Systems, 10700 Bren Road
West, Minnetonka, MN
55343; telephone: 1‑800‑328‑3881; website: (www.visitams.com).� They offer prosthetic devices. ���� American MedTech Corporation, 5217 Wayzata
Blvd., Suite 140, Minneapolis,
MN 5541627; telephone:� 1 800
524 8014; website: (www.rejoyn.com).�
They offer the "Rejoyn Support Sleeve" and
other external/vacuum devices and impotence treatments. ���� Coast to Coast Home Medical, Inc., 12773
Forest Hill Blvd., Suite�
102B, Wellington, FL 33414; telephone: 1‑800‑ 330‑6316.� They distribute� vacuum constriction devices. � ���� Encore, Inc., 2300 Plantside Drive, Louisville,
KY 40299 1928; telephone:�
1 800 221 6603.� They offer vacuum constriction devices. ���� Mentor Corp., 501 Mentor Drive, Santa Barbara,
CA 93111; telephone: 1‑800‑235‑5731;
website: (www.mentorcorp.com). They offer prosthetic
devices. ���� Mission Pharmacal Co., 10999 IH‑10
West Suite 1000, San Antonio, TX 78230;
telephone: 1‑800‑531‑3333; website: (www.missionpharmacal.com).� They offer the VED line of vacuum constriction devices. �� ���� Soma Blue Corp., PO Box 10026, Augusta,
GA 30903; telephone: 1‑800‑827‑8382;
website: (www.somablue.com).�� They offer vacuum constriction
devices. ���� Pfizer, Inc., 235 East 42nd Street, New
York, NY 10017; website: (www.viagra.com).� They offer the oral impotence medication Viagra. ���� Pos‑T‑Vac, 1701 N. 14th Street,
P.O. Box 1436, Dodge City, KS 67801; telephone:�
1 800 627 7434; website: (www.postvac.com).� They offer vacuum constriction devices. ���� TIMM Medical, Po Box 5679, Hopkins, MN 55343;
telephone: 1‑800‑438‑8592;
website: (www.erectionsolution.com).��
Successor to Osbon
Medical Systems, they offer both vacuum constriction and
prosthetic devices. ���� VIVUS, Inc., 605 E, Fairchild Drive, Mountain
View, CA 94043; telephone:
(650) 934 5200; website: (www.vivus.com). They offer their
noninvasive MUSE delivery system for the drug alprostadil (Caverject). �������� RESOURCE LIST OF INFORMATION AND SERVICES ���� Diabetes Action Network of the National
Federation of the Blind, 811 Cherry
Street, Suite 309, Columbia, MO 65201; telephone:� (573) 875 8911; website:� (www.nfb.org/voice.htm). �They offer other information pertinent to diabetes
and its ramifications. ���� Impotence World Association/ The Impotence
Institute of America, P.O. Box
410, Bowie, MD 20718‑0410; telephone: 1 800 669‑1603
or (301) 262‑2400; website: (www.impotenceworld.org).� An educational/charitable foundation, they
disseminate information about male impotence and treatment options,
and publish a periodical titled IMPOTENCE WORLDWIDE. ���� National Federation of the Blind, Materials
Center, 1800 Johnson Street,
Baltimore, MD 21230; telephone: (410) 659‑ 9314; website:
(www.nfb.org).� Hours: 8:am to
5. pm.� They offer advice about
blindness, and copies of this and other articles about
ramifications of diabetes, singly in large print, or together
on an audiocassette titled:� "Diabetes Action Network
Articles." � ���� National Kidney and Urological Diseases
Information Clearinghouse,
#3 Information Way, Bethesda, MD 20892‑3580; telephone: (301)
654‑4415; website: (www.niddk.nih.gov/nkudic.htm).� Part of the National Institutes of Health,
they publish an "Impotence Fact Sheet," free upon request. |
||
�����