An Impotence Case Study: How To Fix What’s Broken

physicalfitnessBy the third week of his outpatient rehabilitation program, Manny was both delighted and dismayed to find that Liz was obviously interested in him. Liz’s infectious laugh had captivated him, and he found himself beginning to come out of his self-imposed exile from society. He even had to admit that he was showing off a little bit just to impress her.

“That’s when it occurred to me that my rehabilitation program was missing a few important elements,” says Manny. “I could dress myself and was even able to get back to work on a part-time basis, but I had been too depressed to give my sex life any important consideration, nor had it been been addressed by any therapist. I wasn’t sure that I could even get a strong erection anymore. It might sound corny, but meeting Liz made me want to be able to pursue romance, marriage, and fatherhood. I needed her emotional support, the love of a family, and, to be frank, my hormones started driving me crazy!”

Sexuality is an important health issue. For persons with disabilities, sexuality has even greater health consequences: It strongly influences both mental and physical fitness. A healthy sex life can be one of the most effective weapons in the battle against depression and isolation. Getting good sleep is key, too, which means ensuring you do not snore and are certain you don’t have sleep apnea. The Best Snoring Mouthpieces review site ( does feature a variety of remedies to ensure not only solid sleep (which greatly affects your sex life longer term), but also better daily energy levels.

Regaining the ability to achieve and maintain an erection may do as much to lift a man’s self-esteem as does returning to productive work. In an article that appeared in the Journal of Neuroscience Nursing in February 2013, Mary Margaret Spica, RN, MS, wrote: “Everyone has the right to be sexual. Sexuality is not earned through work, nor lost through injury and illness. Sexual health cannot be separated from total health.” Individuals like Manny are demanding the help they need to function at their highest level in bed, as well as on the job.

Fortunately, many health care providers are addressing sexuality. Certified sex educators are taking their place beside the occupational therapists, speech and language pathologists, and physical therapists in rehabilitation programs. In the community, education and support are provided by groups such as Impotence Anonymous, its affiliate I-Anon, Impotence Institute of America, Impotence Institute International, and Masters & Johnson Institute.

The bad news is that men and women alike are still putting off talking to their doctors and therapists about one of the most common sexual problems—impotence. Unless encouraged, they may never broach the issue themselves because of embarrassment. Among the 10 to 20 million men in the United States who are impotent, about half of them wait a year or more to discuss it with their doctors. As a result, men whose impotence is a warning sign of heart disease or diabetes go undiagnosed and untreated for these life-threatening conditions.

Additionally, their chronic impotence, which most probably has a physical cause, leads to anxiety and stress, placing unnecessary psychological obstacles in the way of treatment. Most sadly, these men and their partners go through unnecessary torment because they didn’t realize that highly effective treatments are available for almost every impotent man.


Impotence may mean one of two things. First, it may indicate that a man is unable to get an erection that is firm and rigid enough to penetrate a vagina during sexual intercourse. Secondly, it may mean that he can get a strong erection, but is unable to maintain it through ejaculation, or orgasm. While almost every man will eventually have a temporary problem with impotence that is best treated with understanding, rest, and relaxation, a consistent problem should prompt a medical evaluation.

By the way, the term “impotence” is a very old one and will be used for a long time to come. However, you should know that the newer term “erectile dysfunction” is becoming popular as a more clinical and less threatening way to describe the problem.

In order to achieve a satisfactory erection, an intricate process must take place–a carefully orchestrated dance between the skin, the nerves, the blood vessels, the brain, and the structures within the penis itself. A man’s ability to become sexually stimulated is controlled by the hypothalamus and the hormone testosterone, which is manufactured in the testes and the adrenal gland. Sexual stimulation is perceived, either through contact with the skin in various erogenous zones, by erotic visual or mental images, or perhaps through smell. Quickly a message is relayed through the nerves in the spinal cord to the penis.

The muscles at the base of the penis contract, restricting the return of blood from the penis. Blood pools in the spongy tissues within the penis, causing them to become engorged. Meanwhile another signal is sent through the nervous system to the brain. The brain receives the information and a decision is made about whether to continue with the process. It becomes more than a reaction to a stimulus; it is now a conscious response based on emotion as well as learned behavior.


For many years it was assumed that most cases of impotence were caused by a problem in the brain, that it was a psychological problem. Today we know that 75% of these cases have a physiological basis. Disease, trauma, and many different prescribed medications can disrupt the messages traveling between the brain and the penis. Vascular problems may inhibit the buildup of blood in the penis. Some hormonal imbalances lead to a lack of sexual desire.

A number of diseases lead to impotence. Diabetes is the most common of all physical causes of impotence, affecting as many as 69% of all diabetic men over 50 years old. It affects both the small blood vessels and the nerves of the penis. Cardiovascular disease, including hardening of the arteries, is the second leading physical cause, responsible for 30% of the cases. Hardening of the arteries can keep sufficient amounts of blood from flowing into the penis during sexual arousal. In addition, many hypertensive drugs can have impotence as a side effect. Neurological disease such as multiple sclerosis (MS) and the sexually transmitted disease syphilis disrupts transmission of messages through the nervous system. Cancer or cancer treatment can physically affect the nerves and blood vessels that control erections.

Twenty-one percent of impotence cases are caused by trauma, whether accidental or surgical. Spinal cord injury and surgery to remove tumors of the prostate gland, the spinal cord, the penis, or bladder may damage the nerves and blood vessels that control erections.

Of course, psychological problems do contribute to impotence. Even those with organicor neurological-based impotence will often develop a psychological barrier to a return to normalcy and will require counseling as part of their therapy. A strictly psychologically induced case of impotence is usually characterized by its sudden development and the patient’s ability to have normal erections during his sleep.

Two conditions, inadequate hormone levels and age, are overrated as causes of erectile dysfunction. Less than 10% of impotent men over 40 years of age are producing low levels of testosterone. In general, if a man grows a normal beard, he has adequate testosterone. Age is one of the most commonly blamed causes of erectile dysfunction. Though erections change with age, impotence should never be considered an inevitable part of aging.


Before World War II, no treatments for impotence were available. Today almost every man can be successfully treated. Some therapy is as simple as changing medications, controlling diabetes before damage to the blood vessels and nerves is done, receiving counseling, getting exercise and rest, and avoiding alcohol and other drugs. Other therapies are more complicated, may seem “unmanly,” and can be somewhat expensive. Several procedures involve surgery. The choice of which, if any, of these procedures should be made based on a doctor’s advice.

Treatment options depend on the underlying cause(s) of impotence. If the problem is neurological, a method that bypasses the usual sensory pathways is required. Of course, totally insensate men will not be able to enjoy the tactile experience of the resulting erection, but the erection can still be achieved.

If the man had experienced erections before becoming impotent, he is more apt to be able to achieve an erection from psychological stimulation alone. If a vascular problem, such as leakage or obstruction, is the culprit, vascular surgery may help or an impotence therapy must be chosen that allows blood to flow into and become trapped within the penis.

The most commonly used treatments include mechanical vacuum devices, micro self-injections, and surgically implanted prostheses. Hormone medications and oral prescriptions of Yohimbine are much less commonly used. Occasionally vascular reconstruction surgery is recommended for selected patients. All of these common therapies can be extremely effective, may be used in combination with one or more other therapies, and are often covered by insurance policies and Medicare Part A or B, if they are medically necessary. Each therapy poses certain risks that users should discuss with their doctors. These procedures address the erectile dysfunction only, not the underlying cause. None of them should be considered unless a thorough medical evaluation has been completed and the source of the impotence has been identified. Impotence is, after all, a symptom of another condition, not a primary disease itself.


Vacuum devices, also referred to as blood entrapment devices, are the least invasive and are often recommended by urologists as a first step in therapy. Osbon Medical Systems introduced the ErecAid System vacuum device on the market in 1974. ErecAid works by placing a container over the penis and vacuuming the air out of the container. As the air is pulled out, blood fills the spongy tissues of the penis. In order to keep the blood from immediately flowing out again, a band is placed around the base of the penis before the container is removed. The resulting erection is sufficiently firm for penetration, even though it has a “hinge-effect” because the tissues behind the band, at the abdominal wail are no longer engorged with blood. Joanne Hoffman, one of the 24-hour support staff available to users, reports that Osbon has never had a report of any safety or health problems as a result of using the ErecAid System other than bruising due to over pumping. Practice usually eliminates this problem. The newer, battery-controlled model, ErecAid Plus, provides more control over the vacuum and requires less manual dexterity. The ErecAid System has been used successfully for all types of impotence and has an overall satisfaction rate of over 90%, according to the company. Both Osbon products are available by prescription only. ErecAid Classic sells for $395 and ErecAid Plus for $455.

Synergist Limited has another, technologically simple approach to vacuum-induced erections. The Synergist Erection System uses a soft, reusable condom-like silicon sheath rather than a container. After the sheath is placed on the flaccid (nonerect) penis, the user forms the vacuum by gently sucking on a tube connected to the sheath. The sheath remains on the penis during intercourse, with the tubing wrapped loosely around the base of the Synergist Erection System. Rather than constrict blood flow, the erection is preserved because the vacuum is sustained until the Vacu-1oc valve is opened.

Since it does not interfere with blood flow, the Synergist Erection System can be used as long as desired. The sheath decreases sensitivity, occasionally leads to vaginal dryness, and interferes with conception. But for some users, these problems are not significant or are easily compensated for. The Synergist Erection System sells for $400 and is available only from the company at 800/422-9005.


One of the most recent developments has been the introduction of micro self-injections. Doctors can prescribe dosages of vasoactive drugs that cause the blood vessels in the penis to enlarge. Three medications are used: papaverine, which has not been approved by the FDA for impotence therapy; phentolamine, which is used in combination with other drugs; and prostaglandin E-1. The drugs are injected into the base of the penis, near its juncture with the body and must be administered accurately.

Despite how it sounds, the extremely fine gauge needle causes little pain. The resulting erection takes about 20 minutes to develop and can last from about 30 minutes to much longer, depending on the strength of the dosage. Unlike natural erections, the drug induced erection does not immediately subside after ejaculation. (This demands a little extra planning if you’re interested in having sex before leaving for work in the morning!) The injections are generally safe, but possible side effects include bruising, priapism (prolonged erections), and delayed scarring with penile curvature. Doctors caution that causing an erection that lasts for more than four hours or more than eight to ten times a month could increase the incidences of side effects. Injections cost between $5 and $15 per dose.


Surgical implants, called penile prostheses, are the most invasive and possibly the most expensive measure. The procedure involves the placement of rods or inflatable chambers into the penis where the spongy chambers are located (the end of the penis, or glans, is not implanted). Since this procedure causes permanent damage to the interior of the penis, it is usually considered a last, but usually satisfactory, resort.

Implants fall into three categories: semi-rigid implants, inflatable implants, and self-contained implants that may be either inflatable or mechanical. The semi-rigid implants are made of two flexible rods that cause a permanently enlarged penis. The penis can be bent close to the body when not involved in sexual intercourse. Mentor Corporation’s Malleable Penile Prosthesis is made of silicone. Surgery to place the Malleable Penile Prosthesis is usually considered minor surgery with small, unnoticeable skin incisions.

Inflatable implants are composed of two inflatable chambers that fill with fluid for erections and empty after intercourse, mimicking a natural erection. The chambers are surgically placed in the penis. The fluid reservoirs, the pump that causes the chambers to fill, and the tubes that connect them are placed behind the muscles in the lower abdomen and in the scrotum. Mentor’s Alpha I Inflatable Penile Prosthesis is a self-contained hydraulic system that allows penile firmness to be controlled. Mentor’s Mark II Inflatable Penile Prosthesis is a simplified modification of Alpha 1. The reservoir, pump, and release cap is a single unit called a Resipump. Surgery for both is usually through a single small incision either in the lower abdomen slightly above the base of the penis or on the undersurface of the penis where the penis and scrotum join.


The technology is available to overcome erectile dysfunction, but erections alone cannot satisfy any man or his partner. Both partners should carefully consider the alternatives before undergoing any therapy. Many impotent couples have maintained happy, loving marriages by simply finding creative alternatives to vaginal sex.

The human body has more than one erogenous zone. Stimulating the mouth, nipples, cheeks, ears, neck, shoulders, insides of the arms, hands, waist, navel, insides of the thighs, base of the spine, buttocks, back of the knees, and soles of the feet can produce surprising reactions! In another article by Spica, “Educating the Client on the Effects of COPD on Sexuality: The Role of the Nurse,” she suggests that couples get their focus away from orgasm; cuddling, embracing, sensual body massage, establishing good emotional rapport, sharing of intimate moments, anal eroticism, and mechanical devices may be very satisfying. After all,

“A stiff penis does not make a solid relationship, nor does a wet vagina. Absence of sensation does not mean absence of feelings. Urinary incontinence does not mean genital incompetence. Inability to move does not mean inability to please. The presence of deformity does not mean the absence of desire. Inability to perform does not mean inability to enjoy.”

Dr. Ted Cole University of Michigan “Sexuality and the Spinal Cord Injured.” Human Sexuality: A Health Practitioner’s Text.

Emily Shelton specializes in articles centering on medical terminology, technical procedures, and medical/legal issues.


Research noted in an editorial in the November 3, 1990 British Medical Journal indicates a high degree of sexual recovery for men with spinal cord injuries, especially among those with injuries higher up the spinal cord. The research was conducted on 38 men who used wheelchairs. Thirty-six of the men were capable of erections with 25 of those sufficient for intercourse. In 12 cases the erections were psychologically induced with no other stimulation. Seventeen men could expel semen. The article reported that paraplegics should not be discouraged because half of the patients who regained .potence were impotent during the first three months after injury. Some who improved did not do so until up to two years later.

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