Impotents' Anonymous Support Group

Patients feel better after attending an IA (Impotents' Anonymous) meeting. One patient stated, "Just, that I had done something made me feel better. The fact that other people had worked through and were experiencing the same type of problems that I was going through made me feel better. I was not a freak. I was not alone."

The advantage for a patient attending an impotence support group is that both the man and his partner have the opportunity to learn about impotence. They not only learn factual information regarding impotence, but more importantly see and feel the effects of impotence on their lives. The despair, sadness, pain and most importantly the hope that there is life after an erectile problem has been solved. Only when a man really hears and feels the effect that impotence has had on his life, will he be motivated to look for a solution.

The experiences of others can be a facilitative tool to helping him seek help. Women, on the other hand are more interested in the whole relationship and hearing about how other couples have solved their problems. Most women are concerned about the change in their partner's confidence and loss of closeness in their relationship. Some IA groups have IA-ANON groups where the women can meet to discuss their issues. There is a lot of support from patients who have already undergone treatment and this can be extremely helpful for the couple seeking an answer to their problem. You can call Impotence Institute of America & Impotence Anonymous at (800)-669-1603 and ask if there are any support groups in your area.

Diagnosis of Impotence

History

The patient's history of his erectile problem is very significant and can help the physician make a proper diagnosis. First the doctor will want to know if the man is able to get any kind of erection with foreplay, masturbation, or upon awakening in the middle of the night or in the morning. Frequently, these night erections are noticed when the man has to get up to urinate in the middle of the night. These erections are associated with the dream phase of a man's sleep. This dream phase is called REM sleep. REM stands for "rapid eye movement". It is a positive sign if the man is capable of achieving any kind of erection at all.

If the man's impotence is secondary to the treatment of prostate cancer, he may give a history of having good erections prior to either surgery or radiation, and then noticed the onset of ED immediately after the treatment phase. Sometimes, he may slowly regain some or all of his function as time passes. Some men will see improvement up to 1 year following surgery.

Medications

Many medications can affect a man's erectile function. Most medications used for the treatment of hypertension and depression may inhibit the normal erectile response. Most of these medications inhibit normal erectile function by either decreasing the amount of blood reaching the penile chambers or working centrally in the brain by inhibiting the initiation of the erectile process. At times, the offending medication can be changed with an alternative medication, that may result in a return to normal sexual function.

Hormone Therapy

Prostate cancer thrives on the male hormone, testosterone. Often the patient will be treated by combined hormonal blockade or an orchiectomy (surgical removal of the testicles. Without testosterone, there is loss of sexual libido. However, men may still be sexually active, using Viagra, MUSE, penile injections, the vacuum device or other treatments. Some men have had the penile implant.

Medical Research Offers Hope

Viagra

For many years men have dreamed of a magic pill that would solve their impotence problems. With the release of Viagra, we have experienced valuable hope and help to the millions of men suffering from ED. Viagra is a medication which was originally designed to increase bloodflow to the heart for men with angina or chest pain. During initial clinical trials, many f men experienced unexpected erections. Viagra has been investigated in numerous clinical trials, has been prescribed to over 8 million men , and over 20 million prescriptions have been written worldwide. Viagra has been shown to be efficacious and safe in the treatment of ED. The clinical results have been successful in most men. Viagra has been shown to be effective in about 70 percent of men with organic impotence and up to 92 percent of men with psychogenic impotence. Ask your health care provider about the use of Viagra and its contraindications and side satisfactory.

Uprima (Apomorphine)

This is a medication manufactured by TAP Pharmaceuticals and is awaiting final approval by the FDA this year. Apomorphine is being evaluated for the treatment of psychogenic and also organic impotence. It appears to work by blocking the adrenaline response initiated by the brain and helps initiate the erectile response. Men with psychogenic impotence have the ability to achieve an erection but tend to lose it soon after starting intercourse because they are afraid of possibly failing. When a man has failed previously with sexual relations, his body will emit small doses of adrenaline and negative messages from his brain. From an emotional event, a physical response occurs. The adrenaline causes constriction of the penile arteries and subsequently there is loss of the erection.

Uprima helps to initiate the erectile response by sending positive messages from the brain through the spinal cord to the penis. The adrenaline response is blocked. A recent in home study showed effectiveness of Uprima for men with all types of ED. The medication is taken sublingually (under the tongue) just prior to sexual relations. Uprima works within 10-20 minutes for the vast majority of patients.

It is necessary to proceed with foreplay and then start the desired sexual activity. Uprima has been effective in certain groups of patients. The benefit of this medication is that it works quickly. The primary side effect, nausea, was seen in a small percentage of men. It was more common with higher doses, but further research shows that by cutting back on the dose has worked well with much fewer side effects.

VASOMAX

Vasomax (Regitine or phentolamine) is another medication that works to increase penile blood flow. It is currently undergoing investigational clinical trials in the United States and world wide. The medication has previously been used for years to help with erections as an injectable medication. Recently, the manufacturer, Zonagen, Inc., in Texas, has developed an oral delivery system for this medication which is designed to work within about 10 minutes. It will be most useful in those men with mild vascular problems causing their erectile failure. It will probably not be effective in those men with severe erectile failure. Vasomax is being developed by Schering Plough and studies are waiting to resume.

Other New Medications

ICOS -ICOS has developed a longer-acting medication similar to Viagra. The ICOS drug is also a Phosphodiesterase V (PDE-V) inhibitor. ICOS is developing this medication with Eli Lilly. The ICOS medication has a longer half-life and will work up to 24 hours after administration. This medication will probably achieve FDA approval by the year 2001-2002. Here I quote from an ICOS press release:

"The first patients have entered a Phase 3 clinical trial with IC351, Lilly ICOS LLC's inhibitor of PDE5, for the treatment of erectile dysfunction. IC351 is an inhibitor of an enzyme, phosphodiesterase type 5, found in vascular smooth muscle cells. Following the initiation of the global Phase 3 clinical program ICOS received a $15 million milestone payment from its joint venture partner, Eli Lilly and Company. Over twenty Phase 1 and Phase 2 clinical trials have been initiated with IC351 including four Phase 2 efficacy studies. Data from the efficacy studies have shown that IC351 was well tolerated and significantly improved erectile function. IC351 has been administered in a wide dose range in both on-demand and daily therapies and in a broad range of erectile dysfunction patients. It is estimated that approximately 70 million patients worldwide are affected with erectile dysfunction."

Many females also have sexual dysfunction issues. Women have been added to the ICOS clinical trials. Trials using Viagra on women are also ongoing.

Bayer - Bayer is also working on a Viagra-type medication that looks promising. They have just completed their Phase II. Bayer, which aims to start large trials in the spring, hopes to have a drug in this category that is effective for up to 18 hours, compared with four hours for Viagra. Pfizer itself is looking for newer, better PDE inhibitors.

Nexmed - Nexmed has a prostaglandin E cream that is placed in the urethral opening. This medication is in Phase II trials in the United States. Initial studies overseas have shown an excellent response. We are performing trials as of May 2000 and will await results on the effectiveness and safety of this product.

MUSE (Medical Urethral System for Erection)

This is a product developed by Vivus Corporation in California. It is a small cream pellet with the active component being Prostaglandin E1. The pellet dissolves and is absorbed through the urethra into the cavernosal bodies. This results in dilation of the cavernosal erectile tissue of the erectile chambers.

It has about a 66 percent success rate in the clinical studies. The man is instructed to void prior to using the medication. He then inserts the applicator into his penis and releases the medication. The penis is massaged and usually within 10-20 minutes, the man will achieve an erection. It has been well tolerated by most men and there have been no side effects from women with possible transfer of seminal fluid. MUSE has been effective in a certain group of patients who have been very happy with their results.

The VIVUS Company has recently re-formulated MUSE by adding a drug they call ALIBRA to make it easier to be absorbed and more efficacious.

Vacuum Erection Devices

These are devices that work to create an erection mechanically. They consist of a hollow, cylindrical tube that is placed over the penis. There is a pumping device which creates a vacuum, thus drawing blood into the penis. Once the penis is enlarged and firm, an elastic ring device is released from the cylinder and is slipped onto the penis. The blood is then trapped in the penis, giving it rigidity. Many men have found these devices to be successful. The advantage is that there are no medications or invasive procedures. The disadvantage is that there is some preparation time and less spontaneity of the sexual act. These devices are covered by Medicare and many insurance companies.

Injection Therapy

Injection therapy was first introduced at the American Urology Association meeting in Las Vegas in 1984. Dr. Brindley was presenting a paper on how the medication, Papaverine, could be used to dilate the blood vessels in the penis and create an erection. Papaverine had been used in open heart surgery to dilate blood vessels which were in spasm following the bypass procedure. When Papaverine was squirted on the coronary vessels, they would dilate and allow them to function properly. The thought of a foreign object in the penis is just too much for most men to ever consider.

Today there are two injection medications which have been approved by the FDA. They are Caverject, manufactured by Pharmacia-Upjohn and the medication, Edex, manufactured by Schwarz Pharma. These medications are effective in about 85 percent of patients. The active erectile medication in both of these drugs is Prostaglandin E. Occasionally, Papaverine by itself or with Regitine and Prostaglandin E will be used. This tri-mix combination is much better than any one of them used alone.

Injection therapy has been a very successful mode of treatment. Between 85 percent-90 percent of men respond with good results. It has offered many men and their partners a very effective way of regaining their sexual relationship. Frequently, men will even regain their own natural erections.

Some men will have erections lasting just a few minutes and others can have the dose titrated up to allow a 30-45 minute erection. The length of time is directly related to the dose of the medication used. An infrequent problem can be an erection that lasts between 2-4 hours or more. Injection therapy can be very useful in men recovering from radical prostatectomy where the nerves may have been bruised or in shock, yet not completely damaged. The use of the injection may help kick start the engine and also keep the smooth muscle necessary for achieving an erection. Injection therapy immediately following radical prostatectomy or radiation therapy may prevent atrophy of the smooth muscle necessary for erection which is associated with non-use of the penis.

The fear of the penile injection is what scares every man to the core when he is first informed of this form of treatment. The thought of a penile injection is totally foreign to every man. The thought of a needle to such a sensitive area is difficult for any man to comprehend. I have found that the man's fearful expectations are much worse than the actual injection process. Most men visualize the injection going into the glans penis. In actuality, it goes into the base of the penis and feels like a tiny pinch. When examining a patient, I will pinch him at the base of the penis and ask him would he be willing to trade that pinch for a 45 minute erection. Most men are willing to try an injection for diagnostic or therapeutic evaluation, but fear of the injection is a high hurdle which every man must jump.

We have been able to overcome the fear by using an automatic injection device which hides the needle and automatically advances it while injecting the medication with minimal discomfort. The whole process is more of a mental issue than the actual discomfort of the injection. The automatic injector is spring loaded and the man doesn't even see the needle. The patient is shown how to align the injector. Most men usually go to the bathroom and can quickly complete the process. The erection is usually complete within 5 to 10 minutes. The most common side effects of injection therapy include minor bruising and discomfort. There can be possible scarring to the penile chambers.

Treatment With a Penile Prosthesis

Proceeding with a penile prosthesis can be one of the most difficult steps for a patient to take. Most patients are extremely nervous, anxious and fearful about a penile implant. Many patients will not even consider an implant as a viable option in the treatment plan. Common questions are, "How can all that equipment fit into me? Will sex feel natural? Will I be able to ejaculate? Will other people know that I have an implant? Will I look natural?" These questions and many more need to be asked and answered.

Getting a penile implant is a very serious decision. The patient and his partner should never be forced into any specific type of treatment. I like patients to consider proceeding with an implant only after they have been fully educated on all of the treatment options and are completely ready emotionally and intellectually.

How Does a Penile Implant Work?

A penile implant gives rigidity to the penis. There are two erectile chambers which normally fill with blood. An implant is a cylindrical device which fills the erectile chambers and gives rigidity during the sexual act, allowing a man to once again enjoy normal sexual relations. More than 250,000 implants have been placed. Men can usually still achieve orgasm and ejaculation with an implant if they were able to do so before.

Men who become impotent following radical surgery, radiation, or cryosurgery, may find the emission of seminal fluid decreased or completely absent. However, they will still experience the sensation of orgasm. The implant works by giving penile rigidity and consists of several basic types:

Semi-Rigid Implants

These were the first implants developed. They are made of silicone and may have an internal core of a braided silver wire which helps them to be pushed downward when the prosthesis is not in use and to be placed upward when a man wants to be sexually active. These types of implants are usually placed in the man who has arthritis and has decreased manual dexterity. They are simpler and have fewer things that can go wrong. There are fewer malfunctions of the device requiring revision work. More physicians know how to put in these types of implant

Inflatable Penile Prosthesis

This implant was developed by Dr. Brantley Scott in 1973. Today this offers the most effective way of fixing the impotency problem. We are looking at very good success rates with the new products. Initially the inflatable penile prosthesis had many problems, but they have been re-

engineered. Today, we are looking at about a 90-95 percent success rate at 5 years after implantation. This means that if 100 implants were placed, at least 90 of them would still be functioning in 5 years. There are stronger, better materials available today. The problem areas or weak links in the implant have been re-designed to allow a much more natural product which has seen very good patient and partner acceptance. In fact, both manufacturers of the inflatable penile prosthesis give the patient a life-time guarantee on their products with free re-placement of the implant if there should ever be a mechanical malfunction.

The inflatable penile prosthesis consists of two cylinders which are implanted into the penis. A pump which is placed in the scrotum, and a reservoir is placed either behind the abdominal muscles or in the scrotum. The complete device is under the skin and is not visible to the naked eye. A man can shower at their golf, tennis, or health club without anyone being aware of his implant. These prostheses can be inserted at an outpatient surgery center or as an inpatient in the hospital. The procedure lasts about 1 hour or less in an experienced surgeon's hands. Most men tolerate the surgery very well. I tell my patients that this procedure causes about as much discomfort as a glorified hernia procedure. The scrotal area is usually the most tender and there is a heavy feeling in that part of the body for 2-4 weeks. Most men can return to their work within 1 to 4 weeks depending on the physical demands of their job. Men performing very physical jobs may require more time off work.

Buy this Book Now!The prosthesis is activated when the man pushes on the pump through the scrotal skin. The pumping action transfers fluid from the reservoir into the penile implants in the erectile bodies. These types of devices have been very successful and seem natural for both the man and woman. Implants are usually only necessary in about 10 percent of patients. The rest of patients can be treated medically or with an vacuum device.