It takes two: Coping with erectile dysfunction

Even though erectile dysfunction is something that happens to a man, that man is usually someone's sexual partner. For this reason erectile dysfunction is a condition a man and his partner should cope with together. Women can play an important role with helping their husbands or partners seek treatment and in turning this often difficult experience into an opportunity to learn new ways to enjoy each other sexually. Interestingly, many women are going through their own difficulties with sexuality at the same time their partners are experiencing erectile dysfunction. It's important to keep in mind there are many pleasurable things you both can do that do not always require your mate to have a full erection.

WHAT IS ERECTILE DYSFUNCTION?
Nearly every man has trouble getting an erection from time to time. Erectile dysfunction is not the occasional failure to have an erection one night after several drinks, or even for several nights in a row during a stressful time. True erectile dysfunction in when the penis doesn't get hard enough or softens too soon after erection -- is the inability to attain and maintain an erection sufficient for sexual intercourse at least 25% of the time.

Erectile dysfunction can strike any man old enough to have an erection but is more common in later life. More than one-third of 40-year-old men have some degree of erectile dysfunction, and by age 65, almost two-thirds do. But erectile dysfunction is not an inevitable part of aging. Even though testosterone levels decline, nerves lose their edge, and tissues become less elastic with age, these factors do not explain many cases of erectile dysfunction.

WHAT CAUSES IT?
An erection requires an extraordinary orchestration of physical systems. Sexual arousal may start in the brain -- with a sight, smell, or memory -- or through direct stimulation of the penis. In either case, nerves along the spine must signal the release of several chemical messengers that dilate the penile blood vessels, which causes roughly six times the usual amount of blood to flow into the penis. Blood becomes trapped in the penis, allowing the erection to be maintained. At some point the chemical messengers subside, the blood vessels return to their usual size, and the penis becomes limp.

Several conditions can interfere with this process. In the past, most cases of erectile dysfunction were considered psychological. Doctors now think that 80% of erectile dysfunction is the result of a physical condition interfering with the normal functioning of the nerves and blood vessels. But it's more useful to think of erectile dysfunction as having multiple causes -- psychological and physical -- that often work in concert.

Any condition that impairs blood flow or nerve cell communication to the pelvic area and penis can cause erectile dysfunction. This includes vascular disease, especially atherosclerosis, or hardening of the arteries; diabetes, which leads to both nerve and blood vessel damage; degenerative diseases of the nervous system such as multiple sclerosis and Parkinson's disease; spinal cord injury; and nerve damage that results from various surgeries of the bladder, back, prostate, and rectum. Certain medications used to treat high blood pressure, depression, and anxiety are thought to cause 25% of all erectile dysfunction.

Sometimes a physical condition that causes erectile dysfunction can lead to psychological distress and performance anxiety that makes getting an erection even more difficult. When this happens, a man may begin to avoid his partner or make excuses for not having sex.

WHAT HAPPENS TO COUPLES
A common pattern among couples dealing with erectile dysfunction begins with a series of unsuccessful tries at sexual intercourse; the man withdraws emotionally from his partner; the woman loses some of her self-esteem because she thinks he's lost interest in her; the man stops initiating sex for fear of another failure; and the couple draws apart emotionally and physically. There are additional scenarios. A menopausal woman may be having hot flashes, getting less sleep, and feeling less sexual. She may experience vaginal dryness and find intercourse painful. Her partner might interpret these occurrences as lack of sexual interest in him, which compounds his problem with erectile dysfunction.

Communication is the best way to combat these isolating behaviors. But what's the best way to bring up the subject of sexual dysfunction? If a woman is willing to break the ice, she can start by acknowledging how difficult it is for her and her partner to talk about it but urge that it's important they do. If her partner resists, she might suggest getting help with the talking part from a psychologist, psychiatrist, sex therapist, or specially trained social worker. Sex therapists say it's critical a woman realize how devastating it is to her partner not to be able to get an erection. At some point, the partner of a man with erectile dysfunction should reassure him that his erection is not the most important part of lovemaking and be willing to let him know what does give her pleasure. Many couples who begin to explore other ways to give each other pleasure find their sex lives become more fulfilling.

In addition to counseling, there are many treatment options a couple can explore when the man is experiencing erectile dysfunction. Most of them require an appointment with a urologist, who will take an extensive history and do several tests to discover the existence of any physical reasons for the erectile dysfunction. Depending on the result, the doctor may recommend sildenafil citrate (Viagra), injections of alprostadil (Caverject and Edex), alprostadil pellets that can be inserted in the penis before intercourse, yohimbine pills (Yocon), or any of a number of devices and implants. Several medications are currently awaiting further development or FDA approval. It's unlikely, however, that any one treatment is the answer. It's more likely that coping successfully with erectile dysfunction will involve some combination of medical treatment and counseling, as well as a strong desire on the couple's part to keep communication between them alive. Most treatments also require a positive attitude and patience on a woman's part when she is helping her partner cope with erectile dysfunction.

SOME THINGS TO KEEP IN MIND
Sex therapists and counselors say it's important for couples not to view intercourse as the ultimate goal of sexual activity. Instead of concentrating on the man achieving an erection, couples should engage in other pleasurable activities involving manual and oral stimulation that may not result in intercourse. Women also should realize that a man does not need an erection for him to reach orgasm.
If a couple has not had sex for a long time, the old adage "use it or lose it" may have come into play for both partners. If the woman is postmenopausal, her vagina may have lost some of its elasticity, making intercourse painful. Likewise, research suggests that when a penis has been flaccid for long periods of time, lack of oxygen-rich blood (which floods the penis during erections) leads to changes in muscle cells that resemble scar tissue. In both cases, it's important to continue to stimulate the genital area to help keep tissue loss at bay. Women also can do Kegel exercises (see HWHW, March 1998, p. 2).
If a couple is engaged in sex and the man loses his erection, it's important the couple continue their sexual activity. Erections come and go, and unless one partner is upset, it's better simply to continue to give each other sexual pleasure in ways that do not require an erect penis. Keep in mind that with age, both men and women take longer to become sexually stimulated.
Viagra may cause an erection, but it also can cause problems for a couple. On Viagra, a man can be erect without being excited. His partner may not have had the chance to get in the mood. She also may be troubled thinking her partner's sexual interest in her comes from a pill, not from sexual attraction.
Couples should make sex a priority, not just something that may or may not happen when they go to bed at the end of the day. In fact, testosterone levels in men are lower in the evening and both partners may be tired. Sex on a weekend morning may be more satisfying, perhaps even become a regular "date." Partners also should try to incorporate sensuality and sexuality into their day, not so much as a sexual act but as loving touches and physical play.
RESOURCES
Passionate Marriage: Keeping Love & Intimacy Alive in Emotionally Committed Relationships, David Schnarch, PhD (Henry Holt, reprint edition, 1998)
The New Male Sexuality, Bernie Zilbergeld, PhD (Bantam Doubleday Dell, revised edition, 1999)
American Association of Sex Educators, Counselors and Therapists P.O. Box 238 Mount Vernon, IA 52314-0238 www.aasect.org
Send a self-addressed stamped envelope for a list of certified sex therapists in your area.

• A special report, "What to Do About Erectile Dysfunction," is available for $16 from:

Harvard Health Publications
P.O. Box 421073
Palm Coast, FL 32142-1073
E-mail: harvardpro@palmcoastd.com

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