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SECONDARY IMPOTENCE

The majority of sexually dysfunctional men have secondary impotence, which means that they did engage in sexual activity at one time and were able to acquire and sustain an erection satisfactory for masturbation or intercourse. Then something happened to stifle their natural sexual urges, inhibit erectile capabilities, or meddle with the ejaculatory process.

Details of the vascular anatomy, neurologic connections, and patterns of hormone secretion required for normal male sexual function have already been spelled out. With specific testing, we can recognize abnormalities in blood flow to the penis, neurologic impulses, and hormone disorders. The psychologic prerequisites are somewhat more difficult to define. Dr. Steven Levine, a psychiatrist at Case Western Reserve University in Cleveland, has identified the psychologic underpinnings for a satisfactory sexual life as “a willingness to make love, capacity to relax, and the ability to concentrate on sensation.”

Yet how can we determine whether somebody’s “willingness to make love” is impaired? How do we gauge his “capacity to relax,” or a man’s “ability to concentrate on sensation?” These emotional factors cannot be measured with any precision. All we can do is provide some sense of their impact on sexual function by way of illustration, using performance anxiety as one prototype of psychogenic impotence.

PRIMARY IMPOTENCE

Men with primary impotence have never experienced normal psychosexual maturation, nor have they ever successfully masturbated or engaged in a satisfactory sexual relationship. For many years, primary impotence was believed to be a relatively rare problem. In his Sexual Behavior in the Human Male, Dr. Alfred Kinsey reported that less than 0.4 percent of men under the age of twenty-five had primary impotence. It is possible that this figure underestimated the prevalence of this disorder.
A recent reawakening of interest in the subject of male sexual problems and the availability of treatment has unearthed a cache of men with primary impotence. In one recent study of 573 consecutive men seen at an impotence clinic in a German military hospital, 67 (11.7 percent) had primary erectile dysfunction. All 67 men gave a history of a total absence of fully sustained erections since early childhood or puberty. Surprisingly, physical abnormalities were detected in 57 (85 percent) of them. Only 15 percent had pure primary psychogenic impotence. However, even those with organic causes of their impotence also had significant psychologic difficulties, possibly as a secondary reaction to their lifelong inability to function sexually. The results of the German study have not yet been confirmed elsewhere. In most physicians’ experience, psychologic problems dominate in men with primary impotence.

Effective treatment of men with primary impotence is extraordinarily difficult and often fails. Men with primary impotence who have vascular or neurologic problems must first have the physical defect corrected. Vascular surgery is possible in some cases to reestablish blood flow to the genitalia. Disrupted neurologic connections are less amenable to correction. Circuitous methods to bypass the nerve damage either by inserting a penile prosthesis or by using intrapenile injections to stimulate erections can be considered. Either technique allows the man to experience erections.

Treatment of physical problems is a start, but it does not provide a fully satisfactory or comprehensive treatment. Psychotherapy is necessary to help the man arrive at some understanding of the physical and emotional factors that have contributed to his long-term inability to function sexually. With insight gained from therapy, he should be able to enjoy some sexual satisfaction.

Ralph was thirty-seven years old when he was seen in consultation, ostensibly for evaluation of infertility. The reason for the barren marriage surfaced when Ralph indicated that he and his wife had never had sexual intercourse. Further probing revealed an almost unfathomable depth of sexual nayvete.

Ralph had grown up in a strictly religious household and was made to feel ashamed of the erections he had as an adolescent. He did not know what masturbation meant. His teenage years at an all-male military school provided no enlightenment, as he was shy and reclusive. When asked if he knew how men and women had babies, he responded, “I just get on top and then do it.”

Studies indicated that Ralph was able to have erections and had a normal complement of hormones. An enormous chunk of life, critical for normal psychosexual development, was either not developed or repressed. Ralph was referred to a group of psychologists to see if they could resurrect fragments of his lost adolescence, a daunting task even for the most confident therapist.

This condition, primary impotence, though startling and dramatic, is the exception and not the rule.

EVALUATION AND TREATMENT

A detailed medical history is the first step in understanding the nature of the psychologic conflict responsible for the current sexual problem.Batteries of pencil-and-paper tests, in the form of self- or therapist-administered questionnaires, are also available to help establish a psychologic profile of men with sexual problems. The Multiaxial Descriptive System for Sexual Dysfunction Manual (MADSSDM) provides a format for the precise classification of sexual problems. Questions are designed to illuminate specific details of a man’s current and prior sexual activity, desires, fetishes, and concerns. More elaborate probes have been devised to assess his level of sexual knowledge and misconceptions. Still others explore the nature of the man’s sexual fantasies and experiences and ask him to describe his level of satisfaction with his current and prior sexual partners.Like many similar probes, the Florida Sexual Health Questionnaire (FSHQ) developed by Dr. Michael Geisser consists of a series of questions designed to assess a man’s current and past sexual function. This panel consists of twenty questions, some more important than others, and has been useful in segregating men who have psychologic from those whose impotence is caused by physical problems. The very first question is: How often do you think about sexual intercourse? The possible answers are:

Men who check off “1″ are either depressed or suffering from a significant decline in testosterone production, for only depression or a major disruption in testosterone output marginalizes a man’s sexual interest so severely.Other questions are similar in format and are arranged so that the man has the opportunity to check off the frequency of his spontaneous nighttime or morning erections, whether or not he has problems with premature ejaculation, and how often he has problems in acquiring or maintaining an erection, with a slightly different range of possible responses:
1.Always
2.Usually (75 percent of the time)
3.Fairly often (50 percent of the time)
4. Occasionally (25 percent of the time)
5. Rarely (10 percent of the time)
6. Never

Healthy men tend to rack up high scores, whereas men with physical problems cannot bring their scores above 70. Men with psychogenic impotence also score high on the FSHQ.

When an impotent man’s FSHQ score exceeds 72, psychogenic impotence is likely. This is a particularly useful cutoff score, because sometimes it is not possible to determine whether psychologic or physical problems have the upper hand. For example, the sexual dysfunction of diabetic men is often, but not invariably, caused by physical problems. Diabetics are not immune to psychologic pressure, and when their FSHQ scores are greater than 72, it is likely that the negative influence of underlying emotional issues requires attention. In that case, counseling or psychotherapy may be the best way to help that diabetic man retrieve his lost sexual function.

These questionnaires are valuable research tools but do not by themselves confirm a diagnosis of psychogenic impotence. Information provided by these questionnaires can only establish the baseline level of sexual dysfunction. During and after therapy, the questionnaires can be readministered to determine whether medication, psychotherapy, or sex therapy was effective.

A wide variety of services is now offered impotent men with psychologic problems. Psychiatrists, psychologists, sex therapists, and specially trained counselors can all provide help; discussion between therapist and patient (or “talk therapy”) is the primary form of treatment for psychologic problems. Sex therapists can furnish the patient with additional sexual information and education. The patient may need medications, either mild tranquilizers or more powerful antidepressants. In such cases, the services of a psychiatrist are necessary.

At the outset, it must be determined whether the sexual problem is primary or secondary.

IMPOTENCE SYMPTOMS AND DIAGNOSIS

Psychologic factors must be considered instrumental in a man’s impotence if he:

It is not always obvious when emotional problems are causing sexual difficulties. Being impotent is in itself a depressing and anxiety-provoking experience. All impotent men, when first evaluated, appear anxious and, if not overtly depressed, despondent about their loss of sexual function. This is true even for those men whose impotence is caused by neurologic, vascular, or hormonal abnormalities. In their case, any psychologic problems are a reaction to and not a cause of their impotence.

Sometimes psychogenic impotence is the diagnosis by default. After normal nocturnal penile tumescence, penile blood flow, and hormone tests have exonerated neurologic, vascular, or hormonal systems, psychogenic impotence emerges as the only remaining fallback diagnosis. On other occasions, the recognition of organic or psychologic causes of impotence may be solely a reflection of the type of doctor who evaluates the man; the mindset of the examining physician exerts a powerful influence on the ultimate diagnosis. Urologists, internists, and endocrinologists are more likely to look for and find organic rather than psychologic causes of impotence. Psychiatrists are more attuned to recognition of subtle psychologic problems.

Psychologic Factors Affecting Potency and Ejaculation

The recognition of the physical — vascular, neurologic, and hormonal -determinants of normal male sexual function has for the moment taken center stage and relegated to the background the important role of psychologic or emotional factors that can conspire to disrupt a man’s sex life. It wasn’t always this way. Subtle variations in a man’s psychology, his emotional life, or the way he related to his sexual partner were once considered to be the only explanations for impotence. Today, with a broader understanding of both the physical and emotional underpinnings of a healthy sex life, we can now build on the pioneering work of the psychologists, psychiatrists, and sex therapists who were the first to venture into the area of the sexuality of men and women. In this chapter, you will learn how a man’s psyche can interfere with his sex life, be able to recognize the signs of an emotional conflict, and read about ways to cope with or find help for the depression, anxiety, or panic that still so commonly interfere with sex.

Our current understanding of the male sexual response cycle is based in large part on the contributions of psychiatrists, psychologists, and behavioral scientists. Until recently, only they had the opportunity to delve into issues relevant to male sexual function. Others did not challenge the mental-health profession’s exclusive dominion over sexual matters. Sex was discussed in psychiatry and psychology textbooks only.

As a result, medical textbooks published before 1980 were not inclined to devote much attention to the subject of impotence because at that time it was commonly believed that 90 percent or more of impotence was psychologic in origin. This limited perspective has been reconsidered. Current medical textbooks discuss impotence extensively and thoroughly. Today, physicians recognize that in addition to psychologic problems, physical or organic (vascular, neurologic, or hormonal) abnormalities can disrupt the male sexual response cycle.

Whereas men with organic types of impotence have physical conditions that require correction, men with so-called psychogenic impotence are physically capable of sex but are blocked by some emotional discord. Psychogenic impotence is a generic diagnosis encompassing a constellation of problems, including performance anxiety, lack of sensate focus, recent or deeply rooted emotional conflicts, and depression. Anxiety and other emotional factors may impede sexual satisfaction by causing premature or delayed ejaculation. Effective treatment is available once a correct diagnosis is made.

Cocaine and impotence

Cocaine enjoys a reputation as an aphrodisiac. However, substantial evidence is accumulating to indicate that chronic cocaine use, alone or in combination with alcohol, ultimately causes sexual dysfunction. Cocaine alone stimulates secretion of the sexually inhibiting hormone prolactin. Cocaine also causes spasms in arteries; blood flow to the penis cannot be sustained if arterial spasms persist. Studies in detoxification centers have demonstrated that partner sex, masturbation, and orgasm frequency decline with chronic cocaine use. Sexual function can return to normal after cocaine detoxification and abstinence. A drug-free interval of nine months to one year is required for restoration of libido and potency.

Opiate Drugs and Impotence

Morphine, heroin, and methadone fall into a class of drugs known as opiates. They have a profound negative effect on the hormonal regulation of male sexual function. All serve to depress the normal pattern of secretion of the hypothalamic hormones that trigger the release of LH and ultimately testosterone. Low testosterone production, decreased libido, and impotence are all common among chronic heroin, morphine, and methadone addicts.

Marijuana and impotence

Tetrahydrocannabinol (THC), the active ingredient in marijuana, is thought to have a positive effect on male sexual function by increasing sensate focus. However, substantial evidence has now accumulated to indicate that chronic THC use has an adverse effect on both male sexual function and fertility. An enlargement of the male breast (gynecomastia) and a progressive decrease in serum testosterone levels have been noted in chronic marijuana users. In animals, THC use has a negative effect on sexual interest and performance and has a curiously devastating impact on the fertility of male offspring.

Mice exposed to THC in doses equivalent to three marijuana cigarettes daily have high miscarriage rates, and their offspring have a fourfold increase in chromosomal abnormalities. A trend of progressive decrease in fertility extends through the first and second generation of male mice whose parents have been exposed to marijuana. Translation of this mouse research into human terms should be available shortly as the first and second generations of male children born to parents of the Woodstock generation reach reproductive age.

Impotence and Alcohol

The negative effect of alcohol consumption on sexual function has been known for many years. Shakespeare was well aware of the initially disinhibiting but ultimately intrusive role of alcohol. In Macbeth, the porter says, “It [drink] provokes the desire, but it takes away the performance.”

It is possible that moderate alcohol consumption provides some tranquilizing benefit to alleviate sexual anxieties. However, the adverse effects of excessive alcohol consumption on sexual performance have been well documented and commonly experienced. Many currently fully potent men can recall an isolated episode of alcohol-induced impotence. This is primarily due to the soporific effect of alcohol. Inebriated or only slightly tipsy men planning to have sex find that there is a point when the sedative effects of alcohol overcome its disinhibiting effects. In such cases, libido is squelched in favor of a good night’s sleep.

Several critical functions necessary for normal male sexual activity are temporarily or irreparably impaired by excessive alcohol consumption. Alcohol inhibits the ability of the testicle to produce testosterone, the major hormone responsible for sex drive or libido. Alcoholic men with low serum testosterone levels have little or no interest in sex.

Alcohol-induced liver damage causes a shift in testosterone metabolism so that this vital male hormone is shunted away from the path that leads to the creation of the even more potent male hormone dihydrotestosterone and into a direction that favors the increased production of a female hormone, the estrogen estradiol.

Inappropriate high serum estrogen levels cause alcoholic men to have enlarged breasts (gynecomastia) and a characteristic flushing of the face and palms.

The reproductive function of the testicle is also impaired by heavy drinking. Infertility is a common result.

Alcohol damages the nerves that allow erection and ejaculation to occur. Many alcoholics are unable to produce semen by masturbation because they can no longer ejaculate forward. The nerve damage caused by alcohol results in retrograde ejaculation.

Many of these changes are reversible with abstinence. Recovery of potency and fertility is most likely in those men whose drinking has not damaged the liver or the nerves that allow erections or ejaculation to take place.

A precise itemization of the total amount of alcohol a man must consume to qualify as a heavy drinker or an alcoholic is not readily available. Most men would like to believe that an alcoholic is someone who drinks more than they do. This is an unfortunate delusion. However, it is still not known exactly how much a man can drink with impunity or at what point his cumulative alcohol consumption is sufficient to usher him across his own sexual and reproductive Rubicon.

Cigarettes and impotence

Heavy cigarette smoking damages the large arteries supplying blood to all areas of the pelvis and limits the amount of blood available for erections. In addition, and perhaps more important, cigarette smoking damages the tiny blood vessels in the penis that must enlarge to accept the substantial onrush of blood expected during the course of normal erection.

Autopsy studies of heavy smokers show that the small arterioles in the penis are universally narrowed and scarred, no longer retaining the elasticity needed to expand. In contrast, the small penile blood vessels of nonsmokers are normal. This is true for both young and old men alike.

It is no longer necessary to rely solely on anatomic specimens to demonstrate the negative impact of cigarettes on male sexual function. The same information can be obtained by examining the smoking habits of men enrolled in impotence clinics. In two separate surveys, cigarette smoking among impotent men was two times higher than in the potent men. Over 58 percent of impotent men turn out to be active smokers, and 81 percent will admit to heavy cigarette use in the past.

The rate of blood flow into the penis can be measured and calculated as a penile brachial index (PBI) (see Chapter 10). Impotent men who are heavy smokers have a clearly subnormal PBI, indicating that blood flow is inadequate for normal erections.

It is believed that when men stop smoking, penile blood vessels can reconstitute themselves to allow for normal blood flow and restoration of erectile capability. As with any other type of cigarette-induced vascular disease, the critical factor allowing recovery seems to be the number of cigarettes smoked and the duration of the smoking habit.

It is not yet clear how much cigarette smoking a man can tolerate without compromising his sexual function. In dogs, the inhaled smoke from only two cigarettes impairs canine erectile function. In the human, casual smoking may not have a deleterious effect. However, irreparable damage to the penile blood vessels and impaired erectile capability appear to be inevitable for men who smoke packs or fractions of packs a day for several decades.