Although many sexual topics are now "out of the closet," impotence is still a subject that arouses fear and anxiety in many men and women. Impotence is also known as "Erectile Dysfunction." We will use these terms interchangeably in this discussion.

This emotional reaction is further strengthened by the lack of knowledge on the part of patients, their partners, and health care professionals. Most people were never taught about the erection process in school, let alone given accurate information from other sources. Much of the knowledge about penile anatomy and physiology has only become available in the last five years.

Sometimes impotence is all in the head.

Ignorance, fear, a lack of information, embarrassment, and anxiety provide a fertile breeding ground for sexual problems. While some problems related to the ability of the penis to become hard and ready for sex are tied to physical problems, some cases of impotence are linked to psychological issues.

Even when impotence is tied to physical problems, there can be psychological underpinnings that must be addressed with successful treatment of the physical causes. For example, many couples have serious emotional reactions to the loss of erectile ability and to what they believe it represents, and have adjusted their relationships to explain and compensate for their emotional problems. When treatment of the impotence is successful, there still are the underlying relationship problems that need attention.

Our goal is to restore a healthy physical and emotional outlook to the patient and his partner and therefore improve their ultimate satisfaction with successful treatment of impotence.

In order to achieve this goal, it is important to:

• Educate: explain in detail the mechanism of erections and the many causes of problems; dispel any myths that may exist concerning erections.
• Try to get the partner involved in the process. Such participation enhances communication and can identify sources of stress and anxiety for everyone.
• Perform accurate diagnosis of the physical and emotional aspects of the erection problem.
• Educate partners on alternatives for treatment and the expected outcome and risks of each treatment.
• Help the couple define a plan for rebuilding their sexual and emotional relationship based on their own particular physical and emotional circumstances.
• Continue to support couples with counseling in adjusting to their new situations and reevaluate them in case of future difficulties.
• Prevention: address factors that can either now or in the future complicate or cause erectile problems such as smoking or high cholesterol.

What causes an erection?

During an erection blood fills two chambers in the penis and is trapped there. The erection begins when the arteries open up as the smooth muscles of the vessel walls relax.

The veins which drain the blood then close down and prevent blood from leaking out. A man must have an adequate blood pressure to carry blood into the penis, and can have no leaks in the veins of his penis that will allow the blood to escape.

The nerves are the control mechanism which coordinate the increase in pressure in the penis as well as the closing down of the veins. A man needs sufficient levels of testosterone in order to have the desire, feel aroused, and to get an erection.

Any physical or emotional factor that affects a man's arteries, veins, nerves, or hormones can impact his erections. A man must allow himself to relax in order for the blood vessels of the penis to also relax so that he can get and maintain an erection.

A discussion of the problem followed by a physical examination is the first step toward diagnosing the cause of the problem. How does a physician detect what might be going wrong? The starting points of a workup include the following steps:

• Assessing nerve function is done by pinprick
• Assessing reflexes and toe position.
• Blood flow is measured by assessing pulse and penile blood pressure.
• Hormone status is assessed by evaluating testicle size and inspection of the prostate through a prostate exam
• Preliminary screening includes blood tests to audit male hormone level, thyroid function, presence of diabetes and a man's cholesterol level.
• A stress audit involves a questionnaire to be completed at home.

Is impotence just a symptom of old age?

According to Masters and Johnson, at least 25 to 30 percent of people in their 60's have intercourse at least weekly...and that's not weakly.
There are normal changes in a man's sexual function as he gets older, but these are not impotence and do not mean he is going to lose his erectile ability (in other words, you don't wear out your penis.) These changes come on slowly and include:

• Taking a longer time to reach an erection.
• The erection being slightly less firm than when he was younger.
• An increased ease in delaying orgasm and ejaculation (a positive change for many couples).
• A loss of force in ejaculation.
• A decrease in volume of the fluid ejaculated.
• The erection being lost more readily after orgasm.
• An increase in the amount of time it takes from orgasm to the time that a man is able to get another erection.

Most men and women are able to adjust to these changes and still have a perfectly satisfactory sexual relationships. Although a man of 60 may not be able to run a mile as fast as when he was 18, he should be able to cover the distance and may even enjoy the scenery more. The same goes for his wife, especially since she may appreciate the increased ease with which he can delay ejaculation.

A few additional important facts are:

• Most men experience erection problems at some point in their lives due to job, alcohol, stress or mental problems.
• Past sexual practices, including masturbation, do NOT cause impotence.
• An occasional problem does not mean a man will develop a chronic condition.
• Physical factors can directly affect a man's ability to get and maintain an erection.
• The mind is very powerful and a man with or without any physical problem can sabotage his erections just by worrying about his ability to perform.

The important point to remember is that sexual intimacy need not end when you become a senior citizen. And, finally, if you or your partner have an intimacy problem in this day and time, you need not suffer any longer as successful treatment is readily available.

What a man thinks when he is unable to "get hard?"

Many men view impotence as a real challenge to their self-esteem. Furthermore, many men believe a number of myths surrounding potency problems. Some men may fear they themselves have caused their erection problem by past actions such as infidelity or masturbation.

A man may have feelings of guilt because he no longer fulfills what he views as his role as a man. It is also common for a man to fear that impotence is the first sign of his physical decline toward old age and death. Most men, even when they admit there is a problem, are reluctant to ask for help.

How some men think about sex:

• Men shouldn't express certain feelings.
• Sex is a performance.
• A man must orchestrate sex.
• A man always wants and is always ready to have sex.
• All physical contact must lead to sex.
• Sex equals intercourse.
• Sex requires an erection.
• Good sex is increasing excitement terminated only by orgasm.
• Sex should be natural and spontaneous.

Stress is defined as any mental or physical demand that is placed on a person. Stress comes from "good" things as well as events labeled as "bad." Adrenaline is an erection buster. Adrenaline is fine when we're cheering for our favorite team or in the middle of a heated argument...certainly not when we'd want to get an erection.

A person's reaction to stressful events is physiological. Stress can cause a man's heart rate to increase, and it can elevate blood pressure, increase muscle tension, and speed breathing. This phenomenon is called the "fight or flight" response.

What some people don't know is that stress can pile on and cause a cumulative effect. Constant arousal due to stress, can affect sleep, energy level, and concentration, as well as sexual desire and functioning.

Most patients and their partners are not surprised that stress can cause an ulcer or a rise in blood pressure. They are often surprised, however, that these factors can have an effect on erections. A man's normal response to stress, such as being afraid or angry, is for the nervous system to move blood away from "nonessential" activities and into muscles so that he can either fight or get away from the situation.

Ironically, fear of not being able to achieve an erection can actually cause an impotence problem. That's because if a man thinks that he is not going to get a erection, his body may respond to this belief by shunting blood away from his penis, thus making his erection go away.

How can a man relax and let things happen naturally?

It is a widely accepted fact that for a man to have sexual desire, to be able to be aroused to erection and orgasm, he must feel relaxed.

Our emotions about a given situation are determined by what we think about that situation. This is called the ABC's of thinking and feeling:

• A The situation.
• B. The thought or label about the situation.
• C. The emotional outcome that results from how one labels the situation.

For example, if the situation (A) is that a man is going to have sex, the thought (B) is that he is worried about being able to function, then the resulting feeling (C) is that he is anxious.

As a man moves from pleasure and relaxation to performance and anxiety, the chances of problems increase. In other words, the concerns or fears of being able to perform are sufficient to produce anxiety and result in a lack of ability to attain or maintain an erection.

All men have a psychological reaction to an erection problem even if its cause is primarily physical.

What do women think when a man can't get hard?

When a man has an erectile problem, the couple has a sexual problem.

The women in the relationships frequently have questions, doubts, resentments, insecurities, and a need for information, understanding, and reassurance. Too often the man alone is seen as the patient and his partner is - at best - barely acknowledged, and - at worst- merely tolerated or even discouraged.

It is not enough if the partner's participation is limited only to hearing the patient's interpretations of the doctor's replies. Filtering information and questions through the patient to the woman can lead to misunderstanding and unhappiness. The woman's own concerns and questions must be addressed. Unlike many areas of medicine where only the patient is treated, with erection problems both members of the couple need to be considered.

Sometimes a woman, raised on the myths of men as highly sexual and always ready, sees her partner's erection as an emotional lie detector. A woman may view an erection as proof that a man loves or desires her. Therefore, she believes the absence of an erection means he doesn't care, or doesn't find her attractive.

A potency problem can spiral into a major communication breakdown in a short period of time. A typical scenario goes like this: a man experiences erection difficulties, feeling ashamed, embarrassed, and "less of a man," he withdraws from his partner. With the lack of ability to perform, it's not uncommon for men to have a marked drop in their desire or libido. Afterall, why put yourself in a position where you may not be able to perform? Over time, he may go so far as to refuse to kiss her, hug her, even to hold hands with her, saying, as did one man, " I didn't want to start anything I couldn't finish." He may start arguments to avoid sexual encounters. Because he doesn't understand that he has a health problem, not a character defect, he may refuse to discuss the issue with anyone including his partner, his doctor, a friend. Meanwhile, the partner is feeling rejected, neglected, and full of self-doubt. She may question her own attractiveness. She may wonder if her husband still cares for her. She may even think he is having an affair. She may withdraw. She is often afraid to bring up the subject that is so obviously painful for her husband. The result: each partner is isolated and miserable. Unfortunately, the Male Health Center has seen relationships end over this situation.

A number of women whose partners have potency difficulties feel inadequate. It's not uncommon for a woman to blame herself. A woman may be fairly open about her self-blame or she may keep her feelings quite hidden. A woman may also feel hurt and angry because her partner has withdrawn from her physically and emotionally. The relief felt by an insecure partner who understands she is not to blame can be enormous and can enable her to more fully participate and support her partner's diagnosis and treatment.

Medical conditions that may affect sexual intimacy

There are a number of medical conditions that are associated with impotence. Probably the most common is the use of certain medications that have side effects that can affect a man's potency. Examples are drugs used to treat high blood pressure, sedatives, tranquilizers, and pain pills. Fortunately, the side effect of impotence is reversible when the dosage is altered, or a different medication is prescribed by the physician.

Medical illnesses that are often associated with impotence are diabetes, heart conditions and kidney and liver diseases. There are various surgical procedures that are often associated with impotence. The most common are cancer surgery of the colon, rectum, bladder, and prostate gland.

Most problems of intimacy in the elderly can successfully be treated. If a woman is suffering from the problem of estrogen deficiency, then she should consult with her gynecologist who might prescribe some form of estrogen replacement therapy. If a man suffers from impotence, he should contact a urologist who has sophisticated diagnostic techniques to identify the cause of the problem and recommend appropriate treatment.