November 20, 2000

By Zachary Levin

Michael Alto

y neighbor Victor is a plump man in his 50s who is exceptionally devoted to his wife of 35 years, Rosa. When we talk, it's usually about her. His eyes gleam when he recalls how in her youth Rosa was the most beautiful salsa dancer in Spanish Harlem. Victor tells me how in the spring they walk hand in hand in Central Park, and he picks fresh flowers to place in Rosa's hair. It's clear that their passion for each other is alive and well -- so it came as a shock to me a while back when Victor said sadly, "I can't make mami happy no more." When his comment didn't fully register with me, Victor looked down to the area below his belt. "Es muerto," he said: It's dead.

A good urologist or psychotherapist might begin by telling Victor he should refrain from thinking of his penis as being "dead." Even the term impotence, which comes from the Latin word meaning loss of power, is no longer in fashion. Now it's politically correct to refer to Victor's condition as erectile dysfunction (E.D.). The National Kidney and Urologic Diseases Information Clearinghouse defines E.D. as a "consistent inability to sustain an erection sufficient for sexual intercourse." The term is commonly misused; it's applied to problems with ejaculation, orgasm, or a lack of sexual desire. Nevertheless, the more delicate term erectile dysfunction -- spun by pharmaceutical companies like Pfizer -- has taken some of the sting out of the condition. The new terminology has made the problem easier to accept, so that some 30 million American men who are affected by this disorder can feel comfortable coming forward to seek treatment.

As E.D. as you wanna be

"E.D. is whatever you want it to be," says Jed Kaminetsky, M.D., clinical assistant professor of urology at New York University School of Medicine. "You may not be able to get it up twice a night anymore, or you may no longer get hard as steel -- you're not impotent, you've got E.D. I think the term E.D. leaves it up to the patient's discretion."

To hear Dr. Kaminetsky explain it, patients would sooner have their teeth pulled than admit that their penis has the consistency of overcooked spaghetti.

Still, most men would not disclose their E.D. as frankly as Victor did to me, even to a doctor. To hear Dr. Kaminetsky explain it, patients would sooner have their teeth pulled than admit that their "unit" has the consistency of overcooked spaghetti. Men come into his office and complain about urinary problems, a pain in the testicle; they'll say anything but "Doc, my erections aren't what they used to be." Dr. Kaminetsky handles this by asking all of his male patients how their erections are. "They'll say, 'Well ... they're fine,' " explains Dr. Kaminetsky. "And then before they leave, they'll say, 'You know, I was thinking about what you asked me before. What about this Viagra?'"

The majority of E.D. cases have a physical cause. Conditions such as kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, and vascular disease can cause E.D., as can diabetes -- over 50 percent of diabetics experience severe E.D. Injuries to the penis, pelvis, spinal cord, prostate, and bladder can also have a negative effect. Side effects from high blood pressure drugs, antihistamines, and antidepressants can also be a downer for the penis. Any of these may disrupt blood flow in the genitals, which has the potential to cause E.D.

Erectile dysfunction is significantly more common in older men. A study published in 1999 in the Journal of the American Medical Association showed that men aged 50-59 are three times more likely to experience E.D. than men aged 18-29. In men under 40, E.D. is more commonly attributed to psychogenic causes. Stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure can all be obstacles to a normal erection.

It's not always apparent whether a patient's E.D. is the result of a problem of the mind or one of the body. Dr. Kaminetsky goes over a patient's medical and sexual history and considers other factors as well -- a 70-year-old who can't get it up is not suffering from a rookie's precoital jitters, for example. In the ambiguous cases -- or when a young man refuses to believe his E.D. is psychologically based -- Dr. Kaminetsky administers a nocturnal penile tumescence test. It measures the rate of the erections a man has in his sleep; healthy men have involuntary erections while slumbering. "If they're getting perfectly normal erections while they're sleeping," says Dr. Kaminetsky, "well that tells us that the physical mechanism works. I'll show them the graph; the erections they're having are lasting 45 minutes at a time. That'll convince them. I think it's important that patients believe it." If, in fact, a patient's E.D. is a result of emotional turmoil, that's generally where the urologist leaves off and the psychologist comes in.

A man's toolbox is his castle

Those experiencing E.D. should have faith: This disorder is common and treatable. But what's actually going on when the old tool isn't working as it's meant to? Within the penis are two spongy cylinders, called the corpora cavernosa, which run the length of the organ. They contain smooth muscles, stringy tissues, veins, and arteries. When a man becomes sexually aroused, his nervous system communicates the arousal to his penis, causing the muscles of the corpora cavernosa to relax. Blood flows in and creates pressure, which makes the penis expand. A membrane surrounding the cylinders helps to trap the blood, thus keeping the organ engorged. The penis becomes flaccid when its muscles contract, halting the inflow of blood and opening outflow channels.

One might say these are historic times for the penis. In March 1998, the Food and Drug Administration approved sildenafil citrate (Viagra), the first pill developed to treat E.D. Pfizer developed sildenafil citrate first as a heart medication. The company then discovered during tests that patients on the medication were experiencing better erections. The drug works by sending more blood to the genital region, which helps facilitate arousal and an erection -- and this works for men of all ages. "The best way to describe what Viagra does to your sexual function is [to say that] it turns back the clock 15 years," says Dr. Kaminetsky. He estimates the drug to have worked for 80 percent of his patients.

In the past, men desperate to achieve erections were limited to penile-injection drugs, vacuums, and in extreme cases, penile implants. Now men can pop 50-milligram tablets of sildenafil citrate, and in an hour star in a video that would put Tommy Lee and Pamela Anderson to shame. Look at Bob Dole: The 70-something politician may have been slack at the polls in 1996, but as a spokesperson for Pfizer's wonder drug, he knows how to be at full-mast where it counts.

• Outside Link: Impotence World Association/Impotence Institute of America
• Outside Link: Information on erectile dysfunction from the American Foundation for Urologic Disease