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Health: It's Not Easy Being Hard

On impotence and its remedies: straight talk from a sympathetic urologist.



Elvis called his "Little Elvis." "From a very young age, boys are fascinated with their penis. They know when they touch it, it gets erect. When they get in the bathtub to play with their duckies, they can play with their penis.

"Young boys have multiple erections. . . . They take this for granted, as part of reaching or attaining manhood. Their sexual prowess becomes identified with their personality.

"This strong attachment a man has to his penis--it's almost as if it were ingrained with his id. It is sort of the outward and visible symbol of his id."

Dr. William Moseley threw up his hands, shook his head, spoke wonderingly, disbelief discordant through his singsong Alabama drawl, as if even after 16 years of urological practice he still found this "strong attachment" a sixth or seventh wonder of the world.

The identification of a boy with his penis "carries over into adulthood," said the urologist. "It's a rare exception a man can't tell you how long his penis is. They've all measured. They know down to the millimeter how long it is. I've never heard any man complain that his penis is too large."

In a test for erectile capacity, urologists rate erections on a rigidity scale of one to ten, with "one" indicating no erection at all and "ten" indicating 100 percent rigidity. A rating of four, five, or six on this scale, said Moseley, "shows that you're barely stuffable, you can stuff it in, but that's it. A 'ten' is every man's blue steelie."

Now in his mid-40s, Moseley grew up in Alabama, went to medical school at the University of Alabama, took his residency at Baylor University in Texas, is married, and has one child, a daughter, now a sophomore in college. He says he chose urology because it offered the entire gamut of patients, male and female, infants to elderly.

"Unfortunately, when men are no longer physically able to perform," said Moseley, "they still equate their self-worth with the ability of their penis to become erect. It's devastating. Once the erection is not there, the self-esteem is not there.

"It's difficult for a man to come in and tell you he is impotent. Some will come in to see me about other problems. And right before they leave, in the last two minutes, they say 'Oh, by the way, you didn't ask me the reason why I came to see you.' Now, I've already taken the complete history, I've already asked, 'Is there anything else you want to talk about?' But right before they go, they'll say, 'I'm not able to have relations,' or, 'I'm not able to have an orgasm.'"

Nine out of ten men at one time or another have found themselves impotent. Occasional failure to sustain an erection--due to stress or weariness, environmental distraction (a mosquito, a knock at the door), too much alcohol or recreational drugs or certain prescription drugs, or a partner of whom one is not fond--although not unusual, can trigger in many a man the downward-spiraling terror of self-doubt.

"Do men," I had asked George, a 43-year-old bartender, "ever talk to you about being impotent?" Not even daffy with drink, said George, not even in the most maudlin and lachrymose of Frank Sinatra "gal who got away" moods, not even to the most father-confessorial bartender will a man say, 'I can't get it up.' That hurts a guy too much, and the pain of it," said George, pointing to his balding head, "it's all in here."

To be impotent is, by Masters and Johnson's definition, to be unable to achieve or maintain an erection that is sufficiently rigid and long lasting to permit intercourse unabated to orgasm. Moseley took the definition further. Perhaps the penis does "go up." But, "if it goes up and goes right back down, that's impotence in my book." Moseley suggested a term he finds more apt than impotence: "erectile dysfunction."

You can "tell" one foot to put itself in front of the other foot and walk. You can make yourself pick up the mess of Sunday newspapers strewn across the carpet. A man cannot "say" to his penis, as if this organ were a grunt at boot camp, "Get hard." Erection, like heartbeat or intestinal contractions, is controlled by the autonomic nervous system. The erection itself is a reflex. ("And it's too bad," said Moseley, "that it's not a conditioned reflex!")

The physiology of erection, of becoming erect, staying erect, is astoundingly complicated. Environment, emotion, nervous system, hormones, blood supply, the penis's erectile tissue: all must converge to produce an erection. Given this perfect symphony of events that must occur, it is not so much a surprise that a penis sometimes, or never, becomes erect, but rather surprising that it ever becomes erect at all.

Three separate chambers run longitudinally through the penis: two corpora cavernosa and the corpus spongiosum. The spongiosum houses the urinary channel or urethra (the tube that runs from the bladder through the center of the penis to its end). The cavernosa run the length of the penile shaft, along both sides of and on top of the spongiosum.

The two cavernosa are filled with minuscule spongelike compartments that are capable of filling with blood and becoming rigid. When the penis is flaccid, these compartments are collapsed. But with sexual arousal, blood flow increases and these compartments fill with blood. At the same time that the flow increases, the outflow decreases. More blood is pumped in than out. Ergo erection. Simple hydraulics.

The hydraulics of erection, however, depend upon a properly functioning nervous system, on glandular secretions, and on vascular condition itself. If all these systems are not go, then the chain of reactions requisite to erection will not take place.

The most recent surveys in the United States show 2,100 out of every 100,000 men as diagnosably impotent. (That's 10 to 12 million.) Moseley believes psychologically based impotence has become at least slightly more commonplace. "There's more pressure on a man to perform," he said. "The reason is, in my estimation, we now have fewer and fewer families where the male is the totally dominant one in the household. Both people are working, both are wage earners, both contribute. He's expected to contribute sexually as well as otherwise. Hey, the pressure is on him at work, and the pressure is on him at home. And that fear-of-failure thing can really get some people."

Until recently, the medical community assumed that as much as 90 percent of impotence had a psychological basis. But over the last ten years, as more sophisticated testing devices have become available, some 50 percent of impotence is being diagnosed as having physical causes. Among the most common organic causes are circulatory abnormalities. A degree of arteriosclerosis (hardening of the arteries) that may not cause other symptoms may restrict blood flow to the penis sufficiently to inhibit erection. Sickle-cell anemia can be another cause.

"Fifty percent of all diabetics, by the time they're 50," said Moseley, "are experiencing some degree of erectile dysfunction [due to either nerve damage or circulatory problems]. If they have had the diabetes for long enough, or if they're insulin dependent, it's just a matter of time before the erectile problems begin." Interestingly, impotence is sometimes the first outward sign of the onset of diabetes.

Among other causes are prostate surgery, spinal cord injuries, heart disease, ulcers, and medications prescribed for hypertension. Alcoholism is a significant cause--as many as 80 percent of alcoholics experience lessened sexual desire and impotence--and cigarette smoking can cause transient impotence because nicotine constricts blood vessels.

With all organically caused impotence, said Moseley, "there is a 'psychological overlay' brought on by concern over the actual impotence. I've seen men who had nothing but a prostate infection, but they worried so much, they became impotent for a while."

Moseley's urology practice is roughly half female, half male. Among his male patients, 25 to 30 percent have come to him because of impotency. He sees at least one impotent patient every day. "I'm getting up in the age range where patients have problems I can personally identify with," said Moseley. "It's one of the nice things about the aging physician--you have more empathy with your patients. I used to think objectivity was the most important thing you can have. But you've got to have a personal relationship with a patient, when you work with impotency. A cold and impersonal doctor, unless he's just a mechanical implanter, can't work successfully with these patients. I spend more time with impotent patients than with someone who comes in with kidney stones. If I had an all-impotence practice, I wouldn't have time to get through a day."

If there's anything that Moseley preaches, it's that the very first thing a man should do, if impotence is a concern, is to have a thorough physical exam. Too many men, he said, spend years in psychosexual therapy, only to discover their problem is organic. He told of one patient now in his late 50s who, since the age of 19, had been repeatedly diagnosed as being impotent because of psychological reasons. "He had gone from one psychiatrist to the next, been through several marriages. He'd get an erection, and it would go down." The problem was blood supply--hydraulics, not head trips.

One of the first things Moseley hopes to do with an impotent patient is "to get him to throw out equating erections with self-worth. And the last thing I want him to do is to try to perform when he's not ready." Moseley spoke matter-of-factly, motioning toward his bookcase, "I tell an impotent patient, 'Put that [your penis] on the shelf like it's a cast on a broken arm. Put it aside and rest it.'"

Most normally functioning men have two to five erections, each lasting from five minutes to half an hour, during those periods of sleep that are characterized by rapid eye movements. Until the late 70s, one standard means by which physicians discovered if impotency was psychologically or organically based was the "stamp" test. "We didn't really have monitoring devices," explained Moseley. "We had a roll of stamps. To see the look on a patient's face when you give him ten one-cent stamps and tell him, 'Now, I want you to make a bracelet of this roll and put it around your penis before you go to sleep at night, and when you wake up in the morning, let me know if the stamps have torn along one of the perforated borders.' A guy would look at you and say, 'Oh, yeah, right, Doc, I'm paying $24 for this roll of stamps to make a bracelet to put around my penis. C'mon.' But that's what we had."

But during the past few years, injections of papaverine have been used as a quick in-office screening test for determining if impotence has a physiological or psychological basis. Normally prescribed as an antispasmodic, papaverine has also been used to increase blood flow throughout the body. Fifteen milligrams of papaverine injected directly into the side and base of the penis with a needle of very small gauge causes a pronounced and sustained increase in blood flow into the penis, turning most men who have no organic cause for impotence into a "ten"--fully erect and rigid. Such an injection will allow a man to remain erect for up to two hours. The erection will often, but not always, disappear after orgasm. With papaverine, said Moseley, "if the penis becomes erect, you know everything is working--the neurological, the blood supply. So you can assume, then, that the problem is psychological."

Some sex therapists recommend patients to Moseley specifically for papaverine treatment. "If they're refractory to the psychological treatment, if that hasn't worked out--and hey, if for whatever reason, the penis does not get erect, psychological or organic, the end result is simply that it's not standing up! That kind of patient, if he's fairly stable, I can give papaverine injections."

At first, Moseley gives the papaverine injections in the office. Then, once the proper dose is established, the man is taught to give himself the injections at home. The papaverine, said Moseley, gives confidence to a man to go ahead and try intercourse without the drug, "because he knows he has his backup." Ideally, the man whose impotence is psychologically based with eventually go off the papaverine.

Until the advent of papaverine injections and the development of sophisticated testing for venous leaks, a urologist could suggest psychological counseling and the penile prosthesis or implant. There wasn't that much in between. "Most patients, they'd just as soon you operated on their heart than their penis," said Moseley. "The man's soul is definitely below the belt." But impotency, as he likes to point out, "is not life threatening." One option for treatment of impotency is no treatment. "You need to make clear this is an option, that it's OK to choose it, that there are other ways to sexual gratification that you and your wife or partner can practice," he noted. "They have to know it's OK not to do anything. A lot of patients really don't want to have anything done. You can see the relief on their face when you tell them, 'You don't have to do anything.'"

Moseley sees two types of patients who complain of being impotent: "ones who've never seen anyone before, and ones in flight from other physicians." Among the latter, some have been to what Moseley calls "implant factories." In these "factories," he said, "the only thing that has been stressed to the patient is that "There's an operation to fit your problem."' There has been, Moseley noted sternly, "very little emphasis on what the nature of the man's impotency problem may be or what the alternative treatments are, or what the patient himself wants. It [an implant] is more or less what the physician has to offer." But very recently, in response to patient demand for alternatives to implant surgery, Moseley believes there has been a decrease in the stridency of implant advertising and an increase in numbers and types of options this advertising mentions.

The first penile prosthesis was made, in 1936, from cartilage taken from a man's rib and implanted in the penis. It was not successful, said Moseley. Next there was an external splint, surgically placed beneath the skin of the penis. That, too, was not successful. In 1965, two physicians constructed an implant that consisted of a pair of semirigid rods to be placed in the cavernosa. In 1973, at Baylor, Dr. Brantley Scott developed the inflatable penile prosthesis, which mimics the natural erectile process.

There are now three basic types of penile implant: the semirigid, hinged silicone rod; the semirigid or malleable rod with a stainless steel or silver core wire that allows it to be bent up and down; and the inflatable penile prosthesis. Cost of these prosthetic units--not counting surgical or hospital fees--will range from $1,200 to $2,800. In the U.S. there are four major manufacturers of penile prostheses. Worldwide, some 300,000 men have had surgical penile implantations, the majority of them in the last decade.

On the chair next to me, Moseley sat down and opened a battered suitcase. "My little bag of tricks," he said, and drew out from a clutter of sample penile implants a "semimalleable," with its two silicone rods, each with a core of stainless steel. He bent the rods, explained that with this prosthesis, a man can "bend it, tuck it down under, do everything with it but tie it in a pretzel."

He showed the OmniPhase, "essentially," he said, "like a bicycle chain. When you put tension on it, the internal cables tense up." This also used the two rods, which as in all the implants are inserted into the cavernosa. "Here it is like this," said Moseley. "It's flaccid." The two rods hung. "To make it erect, you just push down on it," Moseley pushed, "and it cocks it, so to speak." He pushed down, and indeed, the rod became erect.

An implant, explained Moseley, doesn't affect neurological status. After an implant, a man will have the same sensations he had prior to surgery. If a man has been able to ejaculate before he had the implant, there is no reason he shouldn't ejaculate after his implant is in place. If he was anorgasmic before his surgery--if he does not ejaculate--then he won't ejaculate once the prosthesis is in place.

All implants are tailored to fit each man. For the surgery, a general anesthetic is used. With the most complicated of implants, surgery takes 45 minutes to an hour. There is a hospital stay of two to four days. Chances are that a man will have a great deal of discomfort at first. Moseley advises that there be no intercourse for four to six weeks after surgery. The principal complication is infection, of which there is about a 2 percent chance. With that chance, of course, comes the possibility of having to remove the prosthesis. Since Moseley went into practice, he has had one patient, a diabetic, whose penis would not heal after surgery. The implant had to be removed.

With normal erection, the glans penis becomes distended and rigid. With rod-type implants, there is rigidity but not the distension or lengthening. "You have to be sure to let a patient know this," said Moseley. "Because after surgery, he is going to think his erection is a half-inch shorter than it was before. They come in saying, 'You made it shorter!'"

One of Moseley's patients, Jim B., requested the "semimalleable" implant with stainless steel core. At first, said Jim, "it was so sore I couldn't bend it, and it was sticking out of my pants." He lived, he admitted, in sweatpants during that time. "Maybe some guys would walk around the mall and flaunt it, but I was embarrassed."

He still has some difficulty keeping the prosthesis "down." "It always looks like I have an erection. I don't want to look like a walking gigolo. I push it to the side, but then it moves. So I touch it to move it back. I look like I'm playing with myself, fingering myself like a three-year-old boy."

After a while, Jim went to Moseley's office for a checkup and registered his complaint about the "bulge." "Moseley suggested I bend it way down, under the testicles. I had been afraid, I think, to bend it that far. He told me, 'That's stainless steel in there, Jim, it's not going to break.'"

Jim also had another problem with the implant. He travels frequently, and in one airport that he has been to twice, he has had trouble. "I went through security. The buzzer buzzes. I take out keys, coins, go back through, it buzzes again. I take off my watch, my glasses, go through again. Same thing. Buzzer goes off. There are guys behind me, waiting. I'm holding up this line. But there's nothing more to take off. So the guard wants to frisk me, runs me up and down with his metal detector. He finally gives up, says, 'You look OK, go ahead.' I got home and told [his wife] Penny, and she said, 'My God, Jim, it's your implant. It's that metal rod in there!'"

After demonstrating the OmniPhase, Moseley pulled an inflatable prosthesis out of his bag--the "Inflatable 700," made by American Medical Systems. There were two inflatable tubes, again for implantation into the cavernosa. There was a tiny pump the size of a quarter and a small reservoir that holds either sterile saline or a dilute mixture of X-ray dye and the saline. (If the implant should develop a leak, the X-ray dye makes it possible quickly to find where the leak is.) The reservoir is surgically placed behind muscles of the lower abdomen. The pump is implanted in the scrotum. Valves and tubes connect all three parts.

When a man wants to become erect, said Moseley, he reaches down in the scrotum, squeezes, and the pump forces the liquid from the reservoir into the inflatable tubes. The pressure of the liquid stretches the tubes, expanding the penis in girth as well as length. It is this type of implant that gives the most realistic erection. Moseley squeezed the pump and the tubes filled.

Occasionally, a man who simply wants an implant will come to see Moseley. "They feel that the relationship with their partner would be fine if they could just have an erection. I say, 'Hey, that's not the case. Get your relationship together and then come back and see me. I'll be glad to see if you have a physical problem, but the last thing I am going to tell you is that one of these will fix it.'

"This operation doesn't stop with the man. Some wives, initially, feel threatened. They fear that their husband wants to get the implant so he can go out in the neighborhood, make conquests. She fears it's not really for her that he's doing this, but so he can chase young ladies." For this reason--and others, suggested Moseley--sexual counseling may be very important after an implant.

Women generally "find this really erotic," said Moseley. "The best thing about it is that sexual intercourse is no longer time related. The couple can go at their own pace. When they're through with it, they can just reach down, press the release valve, and the water returns to the reservoir and the penis to its flaccid state." He pressed the valve, and the water went back into the reservoir. "When it stays down like that," he said, "it's not obtrusive. Out on a nude beach, it might be a little bit. But men never complain about looking a little bit more endowed than they thought they used to be."

As Moseley packed up the sample implant collection, a big grin spread across his face. It was the pleasure of a person who likes a piece of well-designed equipment. "In 1962, back at the University of Alabama," he said, "stuff like this was not available."

Art accompanying story in printed newspaper (not available in this archive): photo/Craig Carlson.

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