Below is the text of the May 12 live event RealAudio question and answer session with Dr. Irwin Goldstein, additional questions and answers sent in following the live event, and the entire set of questions and answers in list form.
Live Event Q & As | Additional Q & As | List of Questions
KEN BADER: Hello, I'm Ken Bader, coming to you live from NOVA at WGBH in Boston. In the studio with us tonight is Urologist, Dr. Irwin Goldstein, a leading expert on one of the most talked about subjects in America today, impotence. Ever since the Food and Drug Administration approved the oral medication Viagra, the spotlight has been turned on a condition that is estimated to affect up to 30 million American men. But Viagra is not the only treatment for impotence. What other options are available? For the next hour, Dr. Goldstein of the Boston University Medical Center will respond to questions sent in by our Web listeners. Please be aware that this event will consist of general advice and is not intended to be a substitute for visiting your own physician should you require medical assistance. Dr. Goldstein, thank you for joining us.
DR. GOLDSTEIN: Ken, thank you. Glad to be here.
KEN BADER: And here's our first question. It comes from a 29-year-old woman from right here in Massachusetts and she asks, "Do women suffer from impotence and if so, how would you diagnose it?"
DR. GOLDSTEIN: Women do suffer from sexual health issues. Women probably have a very similar physical problem related to blood flow, and they diminish vaginal lubrication and increased time to vaginal arousal and diminished sensation and diminished orgasm. We're primarily treating women who are post-menopausal with a history of cigarette smoking and diabetes and high cholesterol, just like the men who suffer from circulation problems with their sexual dysfunctions. We intend to one day have ultrasound studies to record blood flow to the clitoris and vagina, which we are in development now. We will record things like pH of the vagina and other aspects of the physiology of the vagina. And right now, unless and until other drugs become available, our primary method of increasing the blood flow in these women who have dysfunction because of decreased blood flow will be the Viagra. And we've anecdotally utilized this in a series of women and actually have seen remarkable results. Pfizer has an on-going study in Europe at four cities in which women are given either placebo or different doses of Viagra. And these studies will be considered to be done in the United States starting the end of this year.
KEN BADER: OK, another question from another woman listener. She's 53 years old and she's from Washington, D.C. She writes: "I've heard a lot of men talking about getting Viagra so they can have better sex. If they don't already suffer from impotence will it really allow them to have better sex?"
DR. GOLDSTEIN: That's a very commonly asked question. Is Viagra useful in men with normal erectile function? And the answer is it probably is not useful. You can't really get a better erection than a normal erection. However, there's a caveat here. Some people claim to have normal sexual activity and are having sexual activity, but with say a 50 percent erection, which really only allows two or three minutes. So whereas they're having sexual activity they may not be having normal erections during the sexual activity. And it gets a little confusing to listeners. So you may go to a party, and John may say, hey, I'm having intercourse three times a week, but you'll speak to the wife who will say, well, the intercourse is really not that great compared to what it once was. In that population who's sexually active with less than perfect erections, Viagra is very successful.
KEN BADER: So the bottom line is, yes?
DR. GOLDSTEIN: Well, it's yes, but it depends what you define as normal. A man who is able to have an erection, rigid, sustained in the basement, goes to the second floor of the house, and then the attic of the house, and Viagra won't help him.
KEN BADER: We have a question from a 69-year-old gentleman in Florida. He says, "Can the sexual function be reinstated following a radical prostectomy. If so, how?" And he says, "Incontinence has placed a severe damper on foreplay and arousal."
DR. GOLDSTEIN: Prostate cancer is a very common problem in men, unfortunately. And like women with breast cancer, radical... or prostate cancer occurs in one in eight men. And one of the common treatment options for men with prostate cancer for a long term cure is a radical prostate. And unfortunately, the nerves and arteries that bring blood to the penis are often next to the prostate. And in removing the prostate during surgery, sometimes the plumbing and the nerves to the penis can be injured. We have had good success with Viagra, in radical prostate patients. But if the Viagra isn't successful, we've had very, very nice success with the pellet therapy, and the injection therapy, and we've even had wonderful success with implants. So if you have prostate cancer, get the treatment. If you're concerned that impotence is a consequence there are great therapies to reestablish sexual function after the prostate therapy.
KEN BADER: Here's a question from a 62-year-old gentleman from Florida. He writes, "Even with treatment to correct impotence, it can still be difficult to ejaculate or reach orgasm. Why is that? What would inhibit ejaculation and/or orgasm?" He says, "They are still possible but not frequent. It's kind of a hit or miss thing." He adds, "I never know when I'm going to be able to function normally, either with a vacuum pump or Viagra."
DR. GOLDSTEIN: Those are, those are wonderful thoughts that we commonly hear about. People think that erection and ejaculation and orgasm are sort of all the same, and in fact, physiologically they're extremely different. Impotence is the inability to get an erection. Orgasm is a sensory phenomenon that occurs with stimulation to the skin of the penis, which passes to a portion of the brain. And ejaculation is the reflex from that sensory activity, which then results in fluid release from the end of the penis. In many reasons that you don't have orgasm, it can be from drugs. It can be from aging, sensation changes in the penis. You need to see a doctor for that one to find out which is the reason. In many cases, use of a vibrator will add so much increased sensation to the brain that it will result in ejaculation and orgasm. Sometimes the vagina simply doesn't provide the standard sensation for orgasm.
KEN BADER: So Viagra has no effect on --
DR. GOLDSTEIN: Well, you know, that's an interesting question. You know, Viagra, statistically, in the New England Journal paper, when it's released will show that orgasm was enhanced by Viagra as well as intercourse satisfaction, and overall satisfaction, independent of erection. The only thing Viagra didn't work on was libido, successfully. Which is good, because you don't want things to increase your desire. You should intrinsically have your own desire. So Viagra may yet be another therapy for a sexual disorder in the male.
KEN BADER: A 70 year old gentleman from New Jersey asks, "What about drug interactions with Viagra. For instance, is it compatible with Prozac?"
DR. GOLDSTEIN: There are very few reasons to not take Viagra that we presently know of. There's an eye problem called retinitis pigmentosa that means you should not be on Viagra. And it's a rare vision issue. And there's a pill that is called nitro-glycerin, or versions like nitro-glycerin. Nitro-glycerin would be a fast acting nitrate. There are medium acting and long acting nitrates. Short of those two conditions, it's reasonable to use Viagra. Now, should you use Viagra to overcome medication problems, Prozac being one of them, but actually the most common medication problem is cardiac medication or hypertension medication. But let's just say Prozac is the issue. Absolutely, use Viagra to overcome the adverse effects of other pills. If you have to be on any medication stay on that medication. If it has the side-effect of diminished erectile function use the Viagra or other therapies to restore that erectile function.
KEN BADER: Dr. Goldstein, here's a question from a gentleman, 64 years old from New York. He says, "For all my adult life my erection has curved downward rather than upward to my embarrassment." He says, "I once told a urologist about this, but he simply said I didn't have a full erection. Since it was firm, I didn't believe him, but couldn't convince him he was wrong. Is this a common condition. Have you ever heard of it?"
DR. GOLDSTEIN: Yes, it's a fairly common condition. It's actually called congenital penile curvature. There are two ways to have penile curvature. One where you acquire it, and that's usually from an intercourse injury. And most commonly you get that with a partner in the superior position. You can also be born with curvature and that is essentially what this gentleman has. It makes intercourse difficult in certain positions, especially if it's significantly bending downward, and we've seen patients where the degree of bending is more than 90 degrees. And it's a congenital problem where the urinary system, the urethra, which is a part of the penis, is shorter than the erection chamber. So as the whole penis erects, of course you don't see that in the flaccid state, only when it erects, but it's like a tethering, as the erection generates, the urethra doesn't stretch like the erection chambers and the system is bent down. Surgical correction is actually not complicated, usually as an outpatient, and that would be the solution for many men.
KEN BADER: We have another question here, "Dr. Goldstein, I have heard of a topical cream being introduced. What do you know of this product?"
DR. GOLDSTEIN: Actually, Viagra being the example of a first line therapy for erections, which is a little more user friendly than say, pellets, or vacuum devices or injections or implants, there are a host of other things being developed. There are other pills being developed, and now we're in the era of topical creams. There are a series of companies generating topical cream data. Here at Boston University we're working on one. We actually have a little more than 100 people on the topical cream. And it looks like a very exciting alternative to oral pills. Not everybody is happy with an oral pill, and topical creams will fill their needs. Just a little caveat, topical creams will be widely used for treatment of the very first question we had, which was on female sexual dysfunction. I think women are a little more at ease using a topical substance to enhance blood flow delivery to the vagina and/or clitoris than perhaps an oral pill. So it's for the future. It will be, I don't know, the early 2000's when it's released, and it will be very widely effective.
DR. GOLDSTEIN: Anything to enhance this sort of one hour to one and a half hour delay that you get with this drug at the present time. When we look back, many years from today, let's say the year 2005, there will be probably three or four, maybe five or six drug companies with similar drugs like Sildenafil, which is a phosphodiesterase type 5 inhibitor, that have probably better onset of action, better deliveries than Viagra. But we will always remember Viagra for its ability to stimulate the entire country. You opened your talk by saying this is the most talked about subject in America, impotence. And I have to share with you, having been in this field for almost 20 years, it was the least talked about subject in America until this drug. So we will remember Viagra for allowing us to discuss this and as time goes on we will have just better ways to manage it.
KEN BADER: A 50-year-old fellow from Ohio writes to ask, "What treatments are effective for erectile dysfunction for diabetic men with circulatory problems and/or neuropathy?"
DR. GOLDSTEIN: Yeah, unfortunately, diabetes is not a great disease to have in terms of the ability to get penile erections. It's extremely common to have erection problems with diabetes. And we advise you to have visits to a doctor and be managed in a way very similar to non-diabetics. You would undergo a history, physical examination, laboratory tests and probably managed by first-line therapies such as Viagra. Should these fail, then second line therapies, which would involve the pellet or the injection, or if those fail, third line therapies such as implant would be advised. We have had success with diabetics, with circulation problems, and nerve damage with Viagra.
KEN BADER: A 39-year-old male listener writes from Virginia, "Would consumption of alcohol cause a decrease in erection firmness?"
DR. GOLDSTEIN: That's an excellent question. It depends on the degree to which the alcohol is consumed. In the Massachusetts Male Aging Study, which was a large-scale, randomized, community-based sample of men who were assessed for what predicted erectile function, in addition to how often erectile function existed, which would be prevalence, ethanol use or alcohol use was actually not a statistical indicator of erectile dysfunction unless and until the alcohol consumption was fairly excessive. There are lots of reports that minor use of ethanol actually prevents vascular disease, which turns out to be probably the basic underlying dysfunction in the majority of men with erectile problems. So I guess the message is, you can drink minimally, but not excessively, and still maintain erectile function.
KEN BADER: This is an interesting question from a 45-year-old man from New Hampshire. He writes, "I have no problems achieving an erection, nor do I have problems sustaining it, but I do have trouble reaching an orgasm. Is this a sign of impotence?"
DR. GOLDSTEIN: It's a similar question to one we've just answered. Orgasm, ejaculation and erection are real separate sexual functions in men. Of course, another sexual function is drive, what we call libido. There are several reasons for men to have delayed orgasm, or diminished orgasm. And the most common, I would think, is just simply aging, changes in sensation. Since orgasm ultimately is a sensory event, sensation must reach a certain part of the brain in sufficient quantity as to then release what we call a propagating wave, which spreads in a portion of the brain resulting in the pleasure of orgasm. If you don't reach this ultimate sensation event in the brain, orgasm won't happen. Also medications prevent orgasm. Medications for example, such as things like Prozac, drugs that are for depression, we actually use for men who have premature ejaculation to slow down their orgasm ejaculation reflex. I would strongly encourage you to see a doctor. One of the best therapies we now have is vibration therapy, to enhance the amount of stimulation to the important part of the brain that orgasm is happening.
KEN BADER: Here's a question from a 31-year-old woman in Ohio. She writes, "My husband is 31 and has suffered from impotence for about six months. We are at a loss for a reason why this has occurred. He is not able to achieve and maintain an erection. However, he is able to achieve orgasm and ejaculate through masturbation, during which he still does not achieve an erection." Her question is, "Do you have any explanation for why this may be occurring?"
DR. GOLDSTEIN: This is a great question and one that speaks of many different topics. So let's do the best we can in a short period. The fact that he has an erection problem that is consistent for six months meets the actual definition of impotence. We don't include men who have impotence with one night of activity. The second issue that this question addresses is the orgasm. Ejaculation clearly can happen normally in men without erections. You can actually have wonderful quality, well maybe not wonderful quality, but less forceful orgasm and ejaculation without good quality erections, but at least you can have them and get the sexual release. So they're not related. The young person aspect, that he's only 31, is a fascinating discussion in erectile activity, because by and large this is a disease of aging, and of aging blood vessels secondary to cigarette smoking and diabetes and high cholesterol. What we're finding more and more is that the young impotence is due to the same vascular damage, but that vascular damage is due to trauma. And I just wonder if we can ever speak to the other side of this. That this man is not a bicyclist or is a karate person, has been kicked in his crotch or has fallen on a fence post or fallen on a piece of concrete in his crotch, because that is likely the explanation if you think about it. I would strongly encourage this individual to see, in particular, a urologist, where specialized testing can be taken.
KEN BADER: Here's an interesting situation described by a 43-year-old male listener from Florida. He says, "Recently, I have experienced difficulty in sexual arousal. What effect does a geographical relocation, such as moving from 3,800 feet elevation to sea level, that's number one. Number two, gaining approximately 20 pounds, and number three, having an increase in stress related to job change, have to do with this?" Three interesting situations.
DR. GOLDSTEIN: Well, gaining weight, having stress, and geographic location, are great reasons for having arousal problems. Arousal is very much related to how one feels, how one is comfortable, how one -- it's as much psychologically as an indicator of psychological health as anything is. So simply waiting this one out or actually seeing a psychologist to gain more control over your situation, your psychologic stress, would be useful. There are other reasons for poor arousal and that of course is related to hormones. And that is another possibility for this individual, to get tested for hormones. The most common reason for arousal when you have an erection problem is the erection problem. Because if you're, you know, if you can't perform, your arousal situation diminishes greatly.
KEN BADER: A question from a 34-year-old resident of Indiana. He's a male. And he asks, "What role does frequent (once a day) masturbation play in a man's inability to achieve erection later on in life? He says, I masturbate frequently, and have begun noticing less rigid erections."
DR. GOLDSTEIN: That's a great question, but to the best of my knowledge there is no relationship between the frequency of masturbation and the onset of an erection problem. You could almost argue that frequent erections are good for erections. The sort of the opposite of "if you don't use it, you'll lose it" sort of syndrome. If you are experiencing erection problems and they're consistent and they're lasting six months, it is a reason to see a physician. There may be some other issue such as we just discussed earlier. Some trauma to the crotch region. Another obvious possibility is just simply slow down on the masturbation frequency and see if your erections restore themselves. But in a young man, having an erection problem is worth seeing a physician about, because it's not a good time to have an erection problem, when you're young.
KEN BADER: Dr. Goldstein, here's another question from the Midwest. A 64-year-old man writes, "I had an implant 2 1/2 years ago. I find that when really stimulated, erectile tissue goes beyond the erection established by the implant. This has been a total surprise. Is it possible that Viagra would additionally enhance the erection? I'm certain that you know that the implant erection leaves the head of the penis somewhat flaccid. Might Viagra help that also?"
DR. GOLDSTEIN: This is an absolutely great question and it just speaks to the valuable role Viagra is having in the treatment of all types of sexual conditions. I had the exact same patient walk in my office yesterday and I put him on Viagra, and today he called, and he's had far better erections with his implant on Viagra than without the Viagra and his implant alone. So it looks like Viagra can stimulate residual tissue that still exists within the penis of a man with an implant. Just to sort of expand the answer, we are now using Viagra in conjunction with men who inject themselves, and we're using Viagra in conjunction with men who use the pellets. And we're using Viagra in men who are undergoing psychologic therapy. And in fact, I do a procedure called a bypass operation for younger men who have blocked arteries and I'm starting to use Viagra as a sleeping pill in these patients. Why would I use it as a sleeping pill? Because it actually enhances the erections when you sleep. And we're finding that men enjoy that. And we find that in by-pass patients, giving Viagra in that way as a sleeping pill enhances their night erections, gives them better ego, better satisfaction and have a better result with the implant, with the by-pass operation.
KEN BADER: A 60-year-old man here in Massachusetts writes, if a 50 milligram Viagra pill has no effect, is it safe to try two pills, that would be 100 milligrams, without first checking with my doctor or urologist?
DR. GOLDSTEIN: Well, in general when you change the dosage of medications, you should consult your physician. If you're taking a 50 milligram tablet and not experiencing any of the side effects and also not getting the erection, it's not unreasonable to increase the dose because that would be what the doctor would tell you to do. But of course, again, with all medications it is wise to check with your physician.
KEN BADER: A 28-year-old male listener from New Jersey writes, "Dr. Goldstein, what is the length in time of a normal erection? Also what is the length of a normal erect penis?"
DR. GOLDSTEIN: Those are two good questions. Well, the duration of a normal erection should be related to the stimulation. If you have a partner that you find stimulating and you wish to have intercourse with that partner, and you wish to have intercourse for 30 minutes or 45 minutes, or an hour, and both are engaging in this relationship, you should be able to maintain the erection for that long. The average penile erect length is about 5 1/2 inches long in the United States of America. Now there are some fascinating things relating to penile length, and that's called penile anthropometry, which is the study of body part length. What's interesting about erect penile length is there are racial differences, there are differences in that you can predict erect penile length. The body part that predicts erect penile length is arm length, interestingly enough. And that if one smokes or has hypertension or cigarette smoking or diabetes or high cholesterol, you actually, compared to people who don't, you actually have a shorter penis. So those are some of the interesting observations, about erect penile length that we're now understanding.
KEN BADER: A 49-year-old male from South Carolina writes, "One question I have not seen answered about Viagra, does an individual maintain an erection after orgasm?"
DR. GOLDSTEIN: OK, the answer to this question is really based on, do you have sexual stimulation after orgasm. Many men, of course, go right to sleep after orgasm, so they're not going to have sexual stimulation, so they will lose their erection. If one is in a situation where sexual stimulation is maintained after orgasm and ejaculation, then it is quite possible to either reerect or to maintain the erection. Remember, the role of Viagra is to prevent the breakdown of a second chemical inside the penis that persists the muscle relaxation and increases the blood flow. So all of that works as long as there is on-going sexual stimulation.
KEN BADER: An interesting question from a 49-year-old woman in Massachusetts. She says, "My husband is 62, and he has a problem with his heart's electrical signals causing him to skip a beat, usually when he gets more active. At some point his cardiologist says he will need a pacemaker. Currently, he has impotence in terms of being able to sustain an erection for more than a few minutes. What effect or risks would a pacemaker have on the various treatment for impotence?"
DR. GOLDSTEIN: That is a wonderful question and the answer is that unless a patient has angina, which means chest pain and relates that chest pain to blocked arteries and is treated by nitrates, and the most common example is nitroglycerin, there is no contraindication. So having a pacemaker would not be a contraindication if it was not associated with angina and treatment by nitrates or the example being nitroglycerine. If nitrates are used it is contraindicated. It should not be that you are taking Viagra.
KEN BADER: Here's a question I suspect is on a lot of listener's minds. It comes from a 52-year-old woman in Michigan. She asks, "What are the side effects to the new pill?"
DR. GOLDSTEIN: Well, those, thank the Lord, the side effects of Viagra are quite minimal. And I'll just introduce an interesting point. It's been out only a month. Hundreds of thousands of people have used it, and to the best of my knowledge there really haven't been reports of serious adverse events. There are side effects like in any medication, but the beauty of this medication is it's quite safe. So, the side effects are headache, facial flushing, nasal congestion, a blue green color discrimination problem, stomach upsetness, leg cramping, skin rashes, urinary tract infections, shortness of breath. All of these are very, very minimal and rarely encountered side effects. It in general is quite a safe medication.
KEN BADER: A 29-year-old male listener from Ohio writes, I am currently taking 200 milligrams of Zoloft per day. Could Viagra help with the erectile dysfunction side effect?
DR. GOLDSTEIN: Oh absolutely. We had a question earlier about Prozac and Zoloft is basically a different form of what we call serotonin reuptake inhibitors, and Zoloft and Prozac are examples of that. Yes, these drugs not only inhibit erection, they also prevent orgasm and ejaculation and for the purposes of erection I would certainly encourage the use of Viagra to countereffect the anti-erection effect of Zoloft.
KEN BADER: A gentleman from New York, 42 years old, writes, "My wife and I have relations every so often, about once or twice a month. On occasion," he says, "I will experience a total misfire. That is to say I will ejaculate without having an orgasm." He says, "My gonads sometimes get ready without me. What is this? Should I be concerned?"
DR. GOLDSTEIN: He shouldn't be concerned. It's unusual in males to ejaculate without orgasm, but it obviously can happen again. Orgasm, ejaculation and erection are separate physical phenomenon. If this 42 year old male has certain medication that he's on, that may affect orgasm. If there's issues of sensation, a loss from multiple sclerosis or spinal cord injury or things like that, or have had surgery, these things need to be discussed obviously at the level of a physician. But I certainly would not worry if there's a rare misfire.
KEN BADER: Dr. Goldstein, we have a question from a 70-year-old gentlemen in Florida. He says, "I was told that impotence in my case was caused by the inability to retain blood in the penis because of a leaky valve. Is this a common occurrence? If so, which treatment is most likely to succeed?" He says, "Currently, I use a pump, but I have difficulty in applying the constriction band quickly enough to prevent some loss of rigidity."
DR. GOLDSTEIN: That's an excellent question and thank you for asking it. Leaky valves are one of the most common physical reasons for men having erection problems. Just to explain quickly, like any hydraulic system and the penis, and a rigid erection is the equivalent of a hydraulic system, the physical requirements are that a pressurized source of fluid be delivered to the hydraulic structure, and in the case of a tire it's pressurized air, in the case of a penis, it's pressurized blood. And the pressurized fluid need to be contained within the hydraulic system. So in the tire it has a valve. In the penis there are in fact valves that keep the blood in the penis. The reasons for leaky valves are the same as atherosclerosis, hardening of the arteries, cigarette smoking, diabetes, hypertension. With men who have impotence, whether it's due to a leaky valve or not, they should start with first line therapies. And the first line therapy in this case would of course be Viagra. Second line therapies would be injections or pellets, and third line therapies would be implants. I would encourage you to use the Viagra and maybe join the Viagra with the vacuum device, even though you're having a few problems with it.
KEN BADER: Here's a question from a male listener in New York. He's 46 years old and he asks, "Does a childhood operation for undescended testicles put one at higher risk for impotence?"
DR. GOLDSTEIN: The surgical treatment for undescended testicles would not necessarily place you at risk for the development of impotence. If the problem is specifically erection problems there really should not be a relationship. If the problem is lack of interest, where the testicle may have been injured, and the hormone, the male hormone released may be diminished, that would be the relationship. A 46-year-old man who has specific erection problems is probably not related to the undescended testicle and may be due to some early vascular disease, such as cigarette smoking, diabetes, high cholesterol, or may be related to some bicycling type accident or injury or fall to the perineum.
KEN BADER: From Indiana comes this question from a 28-year-old male listener. He says, "I have multiple sclerosis. I have a hard time maintaining an erection. And if I am nervous I cannot get an erection. Is this a form of impotence or something that can be associated with my multiple sclerosis and would it be worthwhile to investigate to using this new oral medication to help me stop feeling inadequate?"
DR. GOLDSTEIN: OK, an excellent question. And this is very likely what we call neurologic impotence. Multiple sclerosis is plaque formation within the central nervous system. One of the locations that the plaque can occur is in the nerves to the penis. We call them sacral roots 2, 3 and 4, S 2, 3 and 4. And multiple sclerosis pathology can occur there. We have had nice success with Viagra in multiple sclerosis patients and I would strongly encourage you to seek a physician to prescribe this for you.
KEN BADER: From Georgia, a 23-year-old male listener writes, "I am a 23-year-old man and have ever since the age of 18, suddenly my ejaculatory fluid amount went drastically down, and my erectile ability decreased quite a bit. I've been to a physician and he has tested my testosterone, my adrenal glands and he says those are normal. Can you please give advice on what hormones to test for impotence in someone as young as me? Also, does a high prolactine level cause impotence and decreased semen?"
DR. GOLDSTEIN: That's an excellent question. Since age 18, a man who is now 23, has noted not only problems with ejaculation but problems with erection. His evaluation has focused pretty much exclusively on hormonal status. What I would encourage this individual to do is to either return to this doctor or see another doctor and have the focus shifted from the primarily hormonal based evaluation to an evaluation that's based on blood flow delivery to the penis. The strongest reasons for 23-year-old people having diminished quality erections are due to blood flow changes, again probably from some accident or injury than they are related to hormonal changes.
KEN BADER: Here's an excellent practical question from a 66-year-old gentleman in North Carolina. He asks, "What all is involved for a man to do in order to receive a prescription for Viagra? Can I just go to the doctor and ask for it, and he'll give me a prescription? I'm a 66-year-old male with no medical problems."
DR. GOLDSTEIN: An individual who believes he meets the definition of impotence or in the medical world, we use erectile dysfunction, here is what you would have to have to meet the definition. A consistent, for a period of usually around six months, problem with erection quality, usually obtaining and maintaining the erection that effects satisfactory sexual intercourse, or satisfactory sexual activity. So if you meet that definition of a consistent problem with the quality of erection that affects satisfaction during sexual activity, please see a local doctor. You need to see an internist or a primary care doctor. If you'd like you could see a urologist. You would undergo a history, a physical examination and some laboratory tests and most likely after education and attempts to modify your lifestyle, end up with a prescription for Viagra.
KEN BADER: This question follows right out of that answer. It's from a 58-year-old male listener in Florida. He says, "How do you find a competent urologist?" Listen to this. "In the last three years I have gone to two, both asked questions and neither gave me any physical exam. The first was part of an impotence clinic. He suggested I masturbate. The second gave me a pill made of some African tree bark. I've since read it doesn't work. And then suggested having his nurse show me how to inject myself. Right or wrong I didn't go back to learn how to do this. The doctors on the show all seemed to look at a possible physical cause before prescribing any treatment. Thank you."
DR. GOLDSTEIN: Well, I appreciate your call, and I apologize for your unfortunate experience with my colleagues. The only thing I can say to you, I guess, is that your evaluation happened prior to the Viagra era. Now were you to go to either a competent urologist or internist or primary care doctors you would be managed, not with the oral pill from tree bark, which again, has never been shown to work, but now with a drug, which has been shown to be safe and effective for the treatment of impotence, and that is, of course, Viagra. Should Viagra fail you would then be considered for second line therapies, which would be injections or vacuum devices or pellets, and third line therapies would be penile implant devices. First line therapies now are the oral pill, Viagra, potentially psychologic therapy, and you should be able to find many physicians to help you with this management.
KEN BADER: Here's an interesting situation from a female listener. She's 67 years old and she lives in Georgia. She writes, "My husband had a penile prosthesis inserted a few months ago, and has experienced some disappointment. He had been experiencing gradually increasing impotence for several years and was more than anxious to have this done. Is it possible that because of his dysfunction we both sort of put sex out of our minds, or does it just take a long time to adjust to this method? He has coronary heart disease and takes a great deal of medication. He is 65 and although he has problems, is very active."
DR. GOLDSTEIN: I need to know much more information. Penile implants have a excellent success rate, about 80 percent in men who have impotence. We've been using penile implants since the early 1970s and considering it's now the late 1990s, it's almost 25 years of experience. The design of the devices have improved greatly and there is usually in four to five people great satisfaction, as was seen on the show. I need to know a little bit more of why your partner has this disappointment. Maybe there's something that could be done that's simple that can enhance that disappointment so that there's satisfaction. We're now even using Viagra in men with penile implants to enhance their satisfaction. So we need more information.
KEN BADER: A 47-year-old gentleman from North Carolina writes, "When I have an erection only the left half of the penis seems to inflate. I am able to achieve orgasm, but there is discomfort in the penis on the side that is inflated, similar to too much pressure. Is there a reason and a solution?"
DR. GOLDSTEIN: Without seeing you, the left half inflates and the right side doesn't. The one thing that comes to my mind is a condition called Peyronie's Disease, and I'm surprised despite all these questions we've had today, I haven't heard from one patient who has had Peyronie's Disease. This condition involves thickening of the wall of the erection chamber. And of course, things that inflate and increase in volume require elastic or elastic properties of the wall. So if the wall is scarred and can't inflate then that would be a condition called Peyronie's Disease. Peyronie's Disease is also associated with pain and you described this pain. Peyronie's Disease is a condition which occurs generally from trauma during intercourse, primarily from partner superior intercourse. And one would need to see a doctor and discuss this with him for appropriate management.
KEN BADER: From North Carolina comes this gentleman's question. He says, "I'm a 35-year-old man who has visited a vascular specialist to determine if I had any vascular reason I have problems obtaining an erection. The specialist determined I had no vascular problem. He did not suggest anything to help me have an erection." He asks, "How normal is this, and do you think Viagra would help since I suspect my problem is more mental?" He adds, "My wife wants me to see another doctor."
DR. GOLDSTEIN: Well, this is a tough question because it's a little more specialized. I don't know what tests your vascular specialist did to rule out or rule in that you had a vascular problem. A man who is 35 years old who has erection problems statistically is more likely to have a blood vessel vascular problem, if he's going to have a physical problem. Of course there could be psychologic problems. Viagra would be an excellent treatment for any man, whether young or old, who meets the definition of impotence, which is a consistent problem obtaining and maintaining an erection for satisfactory sexual activity. It sounds like you would meet that definition and Viagra may be useful for you. Should you wish to be considered for potential curative surgery, if the problem is physical and related to blood vessel blockage, I guess another consulting doctor would be indicated here.
KEN BADER: Here's an interesting question from a gentleman 47 years old in Michigan. He writes, "What is the relationship to sexual dysfunction, if any, to protracted sexual inactivity or abstinence?"
DR. GOLDSTEIN: We answered this question in a roundabout way earlier. Protracted sexual activity, actually has a name, and we call it Widower's Syndrome...
KEN BADER: Inactivity.
DR. GOLDSTEIN: Yeah, inactivity, protracted inactivity. We use the word, Widower's Syndrome. And that is someone, for example, who is happily married and unfortunately, the partner passes on. And this man takes many years until he has enough energy to find a new partner and is essentially inactive for a protracted period of time. And we go back to the concept of, if you don't use it you will lose it. We have strong scientific beliefs in this statement that having an erection is good for an erection. For men who have impotence and believe that it's related to protracted inactivity, having Viagra would be a useful tool. But perhaps taking Viagra as a sleeping pill. We're going to look into it that way in the future. Taking it as a sleeping pill would enhance the nighttime erections, so these wouldn't be sexual erections. So the protracted inactivity could actually be generated or reversed, if you like, by taking the pill at night, and enhancing the duration of the natural erections that you get when you sleep. You get about three hours of erection if you sleep eight hours. It's about four or five or six episodes, each lasting about 30 minutes to 45 minutes. And Viagra has the capability of enhancing that. When you speak to men who take Viagra, one of the universal findings and statements by them is that they wake up with erections like they were 18 years of age again. And that's because it enhances the nighttime erections.
KEN BADER: From Connecticut comes this question from a 45-year-old male listener. "Does hernia scar tissue from an operation cause any type of blood flow dysfunction?"
DR. GOLDSTEIN: No. From Connecticut, I can say to you emphatically, hernia scar tissue does not impair blood flow function. There are cases where people say having had a hernia leads to erection problems. There's very little reason for hernia to impact on erectile function in a negative way, but I would strongly encourage you to get tests, since you are young, and find out what the basis for the erection problem is. Again, if you have impotence and wish to get managed by Viagra that would be a good choice for you.
KEN BADER: A 47-year-old listener from Michigan writes, "My wife has almost no sexual desire. She has had diabetes for 28 years and is on Prozac and Valium. What is the more likely cause of the sexual problem, the diabetes or the medications and what would be the best treatment?"
DR. GOLDSTEIN: Boy, that's a great question and one day we will have all of the research on what causes female sexual dysfunction. At the present time where the research is a little scarce what my opinion would be in this case is that the diabetes is doing what it does in men. It's blocking blood vessels, injuring nerves and affecting tissues of the female genitals. Prozac, as it does in men, inhibits erectile function, would inhibit vaginal and clitoral function. In her, low desire may be reflective, possibly of diminished circulation to the vagina and/or clitoris during sexual activity. And we are now finding that Viagra can help in these cases. Now there's a caveat here. Viagra is not FDA-approved for the treatment of female sexual dysfunction at the present time. We are prescribing Viagra at Boston University for such women under controlled environment and controlled circumstances to assess the effect. Hopefully, in a short period of time, Viagra will be assessed by a large drug company, like Pfizer for the safe and effective treatment of female sexual disorders such as your wife.
KEN BADER: No shortage of questions tonight, Dr. Goldstein. This one comes from right here in Massachusetts, a 41-year-old male. He writes, "The day after I take Viagra I feel hung over. I have a headache and feel slightly sick." He asks, "Do the other drugs that are coming onto the market have similar side effects? How do these other drugs cause an erection?" He adds, "I was left impotent as a result of surgery to remove a tumor from my rectum one year ago. I tried the injection therapy and that worked fine. But," he adds, "It is not very appealing. Not my idea of foreplay."
DR. GOLDSTEIN: Well, lots of information in this question but let's do the best we can. If you're having side effects from Viagra, my suggestion is, if you're using the 100 milligram tablet, cut back to the 50 milligram tablet, and you may not have your headache and feel sick. And you would still have the advantage of using an oral pill and not having the need to inject. The new drugs coming on the market are drugs that will be shown by the FDA one day, hopefully, to be safe and effective for the treatment of impotence. The next drug, which appears likely to be submitted to the FDA is a drug that blocks how stress affects the penis. Stress acts on the penis through specific receptors called alpha receptors, and these drugs are alpha blockers. There's also another drug which stimulates the erection center in the brain and you take that as a tablet underneath your tongue, what we call sublingual. They're not going to be available for at least a year, so we have to get something active in you right now. The first advice is to cut back on the dose of Viagra, and the second advice may be to go back to the injections. While it may not be appealing, it obviously did work in you and you may have to do that.
KEN BADER: Dr. Goldstein, here's another question that I suspect is on a lot of people's minds. It comes from a 58-year-old male listener in Virginia. He says, "Does a vasectomy cause any of the symptoms of male impotence as one grows older?" He says his sex life and functions were fine before 50 but have gradually diminished. Again, he's 58 years old now. And then he asks, "Would a reversal be possible and would it help me function?"
DR. GOLDSTEIN: For some reason we get people who always think that a vasectomy is related to impotence. There is no relationship that I can report from multiple studies studying thousands of men who under control situations didn't have a vasectomy, or under situations had a vasectomy and looking at things like erectile problems. People are also concerned of vasectomy in prostate cancer, and there's absolutely no relationship between vasectomy and prostate cancer. Having a reversal could happen, but if you are hoping it reverses your impotence, it won't. A 58-year-old male would most likely have erection problems from vascular disease, such as cigarette smoking or diabetes or high cholesterol. I would suggest you seek your doctor. And if you like, undergo testing. But specifically, you could simply try Viagra and see if it restores your potency, even though you have had a vasectomy.
KEN BADER: A 49-year-old woman listener in Massachusetts writes, "My husband has had a problem with not being able to get as hard as he used to. He gets an erection but it is easily bendable and reduces my pleasure drastically. He also takes much longer to have an orgasm. He is 46 years old and this has been going on for a few years." She asks, "Would Viagra be a good option for him?"
DR. GOLDSTEIN: Wow, this is a great question because someone asked earlier, do normal people, would benefit from Viagra. Now since you are sexually active and really he is at least hard enough to penetrate in you, some people may think that "he's normal." When obviously, as you state, he's not as hard. He has longer to achieve orgasm. There are sexual dysfunctions going on here. Yes, by all means, he would be an excellent candidate for Viagra. He is actually the ideal, in fact, candidate for Viagra. Since he's in his 40s and has erection problems, you might want to have him undergo testing to see if there are early vascular conditions. Because if there are, perhaps maybe he could get a cardiac stress test and see if other vascular conditions are abnormal such as the blood circulation to his heart, which would be very important to know.
KEN BADER: Here's a listener from North Carolina. He's a gentleman and he asks this question. "Can I use the vacuum therapy and Viagra at the same time?" Here's a bit of background he provides. "I am 58 years old with a radical prostate removal because of cancer. The cancer was contained in the prostate. I have not had good success with the injection. I could not get it stiff enough for penetration. I was using 1.0 strength with the injection." He says, "The vacuum method does not get it stiff enough for good penetration."
DR. GOLDSTEIN: Your question is can vacuum constriction devices be made better by taking Viagra? Well, the data is not in since Viagra is so new. But we are presently using Viagra alone, we're using Viagra with pellet therapy, using Viagra with shot therapy, using Viagra with implant therapy, and Viagra with vacuum constriction device therapy. And we're now even using Viagra to enhance erections at night. So we are just discovering the magical ways Viagra can help men and their sexual dysfunctions. And of course, we're now using Viagra in women. So we're now seeing how Viagra works in all of this. I would encourage you to try all therapies to help your situation. Injections are not functioning and the vacuum device is not perfect. So maybe Viagra will turn the corner. Of course, the other option is you can undergo a penile implant, should you desire to enhance your sexual function.
KEN BADER: A quick question from a 47-year-old fellow in Massachusetts. He asks, "Is there any connection between circumcision and impotence?"
DR. GOLDSTEIN: We often get that question as we do with the vasectomy. In this particular situation I unfortunately have seen a case where an odd complication happened during circumcision that actually did cause the erection problems. So this is a little different than vasectomy. Although for the most cases, circumcisions are entirely benign and rarely are the reasons for erection problems. Since you are in your 40s and having an erection problem, I would strongly encourage you to seek a local doctor and get an evaluation.
KEN BADER: Here is the last question we have time for tonight, and it's a very good one. It comes from a 32-year-old gentleman in South Carolina. He asks, "I would like to know, what are the preventive actions to take against impotence?" A very good question.
DR. GOLDSTEIN: Spectacular question. The ones that are obvious are don't ride a bicycle. Don't smash your crotch in karate. Don't fall on fence posts. So preventing trauma and respecting the perineum. That would be my favorite. The most obvious, obviously, is to prevent the ravages of aging by taking control of your blood pressure. Keeping your weight down. Not having diabetes or at least if you have diabetes to get the maximum control you can. To avoid using drugs unless you have an obvious medical problem, because oftentimes drugs influence erectile performance. And the final answer, as it concerns preventative, is the concept of using Viagra to enhance the duration of nighttime erections. We have substantial evidence that would show that men who start becoming impotent start losing their night erections. That's one of the first things they see. We're hoping that if we get men at this early level where they're now starting to see just the beginnings of night erections that they used to get, easily and routinely, that they're now not getting, is to start taking drugs like Viagra or other ones as they become available, to enhance night erections. We hope to actually prevent impotence with all these measures.
KEN BADER: Dr. Goldstein, this has been a most enlightening and fascinating hour. Thank you very much for being here.
DR. GOLDSTEIN: Ken, really, thank you for the opportunity to be here, and I thank all of the people for their great questions. They really were a typical day in the office.
KEN BADER: Well, on behalf of Dr. Irwin Goldstein and the staff of NOVA, I'm Ken Bader in Boston, thanking you for joining us and wishing you a very good night.
Question (from a 38-year-old Oregon woman):My fiance, who is 37 years old, has trouble maintaining an erection for more than a minute or two. Commonly, he ejaculates *after* his erection has faded. When we do succeed in having intercourse, he ejaculates (and loses his erection) with very little stimulation. In any case, ejaculation for him rarely FEELS like an orgasm. He is not sure when this trouble started, because before meeting me last year, he had not had a sexual partner for 10 years. When my fiance sought medical treatment, the urologist took urine and blood samples and later told him that he was physically "OK." He prescribed an anti-depressant (Paxil), which only made my fiance giddy. What do you recommend? How can we find a doctor in our geographic area who is knowledgable and up-to-date in this field? Also, is there any research into what can cause or prevent male orgasm? It seems that erection, orgasm, and ejaculation are three separate, though related, functions. In our case, none of them seem to be working properly. Thank you for any help you can give us!
DR. GOLDSTEIN:
Your fiance has a common erectile quality problem - inability to maintain the erectile rigidity. Because the problem is consistent and affects his satisfaction with sexual intercourse he has met the criteria for having "erectile dysfunction." The usual evaluation would consist of a history, physical examination, and laboratory tests, followed by education, modification of lifestyle etc, and initiation of first line therapy such as sildenafil citrate (Viagra). However, if your fiance wishes, because he is young, he would be considered a candidate for more sophisticated erectile function testing to gain a better understanding of the nature of the dysfunction and to see if he can be cured of his impairment. He should consider seeing a urologist who specializes in this field for more detailed advice. Perhaps calling the American Foundation for Urologic Diseases in Baltimore can help you locate this physician. You fiance could then be assessed for all the sexual dysfunction issues such as erection, orgasm and ejaculation.
Question (from a 53-year-old Texas man):
I am on blood pressure and diabetes pills and cannot get an erection. My doctor said Viagra would not work for me. Why not?
DR. GOLDSTEIN:
Actually sildenafil may work quite well for you. It is indicated for men with erectile dysfunction who have a physical basis for the impairment - a likely scenario in your case. The only contraindication for use of sildenafil is concomitant use of nitrates - pill for treatment of chest pain (angina). If sildenafil does not work, you could try a vacuum device or try intraurethral pellets, self-injections or a penile implant.
Question (from a 59-year-old California man):
My dysfunction started with diabetes and is now further complicated by Peyronie's. It has been several years since I have been able to have a normal erection. I have tried the injection in the Drs. office...it proved quite painful due to the bend in the penis. I have been given Viagra to try. If the pill helps with the erection there will still be a severe 90-degree turn in the shaft of the penis, caused by scar tissue (Peyronie's) Is there a surgery available to remove the scar tissue, allowing the shaft to remain straight - and still responsive to the Viagra? I have been told that there is damage to the one side and I will need a graft to fill in space once scar tissue is removed. (At this time my diabetes is controlled with pills and diet. ) I do have fears of undergoing surgery with a potential for infection due to diabetes.
DR. GOLDSTEIN:
Your problem is unfortunately common and consists of two problems - 1) erectile dysfunction and 2) penile curvature from Peyronie's disease. Management should be linked to close communication with your urologist.
Specifically to manage the impotence, treatment may be initiated with simple things first. New first-line therapies include sildenafil or vacuum constrictive devices. If these fail, second line therapies include self-injection or intra-urethral pellets. Such treatment focus on erection quality is designed to identify if the enhanced erectile function and improved rigidity wouold allow for functional sexual intercourse despite the penile curvature. If so - then no attnetion need be given to the penile curvature - which woudl be simpler.
If attention is needed to correct the penile curvature, basded on the above observation, there are traditional simpler medical therapies including vitamin E. Surgical procedures to achieve penile straightening include: 1) excision of the scar tissue and replacement by graft, 2) "a tuck" procedure or 3) insertion of a penile implant can achieve two purposes - penile rigidity and penile straightening. It is important to discuss all these issues with a urologist. There are important risks ad benefits with each treatment. Perhaps calling the American Foundation for Urologic Diseases in Baltimore can help you locate this physician.
Question (from a 50-year-old California man):
At $10 per tablet, Viagra is expensive. What good reasons can you offer for *not* sparing myself the expense of an office visit and simply getting a small supply from Mexico? Are there real dangers to this? I feel capable of reading and understanding the PDR. All drugs have contraindications to beware. What are those of Viagra?
DR. GOLDSTEIN:
Sildenafil citrate (Viagra) has been approved as safe and effective for the treatment of male erectile dysfunction. If you have compaints consistent with erectile dysfunction, you should see a physician. Erectile dysfunction may be caused by prostate cancer, unrecognized diabetes, hypertension, renal failure, hypogonadism, depression, other psychologic conditions, aortic aneurysm, lumbo-sacral disc disease, use of medications, etc. The evaluation consists of a history (medical, sexual, psychosocial), physical examination and laboratory tests. If needed a psychologic assessment may be added. Education and modification of lifestyle issues or changes in medication may be instituted under physician care. If appropriate, Viagra may be initiated. There are few contraindications other than concomitant use of nitrates.
Question (from a 32-year-old California woman):
Dr. Goldstein,
My partner and I have a wonderful sex life, however, we rarely engage in intercourse. When we try to have intercourse either he loses the erection while putting on a condom (I have tried many distractions during the process) or he will lose the erection during penetration. Once in a great while he will lose the erection while I give him oral sex. When he does maintain his erection thru penetration he often orgasms very quickly and says that it was too intense and he couldn't control it. Is this considered sexual dysfunction?? Or impotence?? Most often we engage in great oral sex instead...When I try to discuss it with him (in a non-threatening way, and when we're not having sex) he says "making a big deal about it only makes it worse." Could it be entirely psychological or combination of problems??
DR. GOLDSTEIN:
It is difficult to make diagnoses on patients based on the minimal information contained in the e-mail. Based on the above, it sounds that he has both erectile dysfunction (failure to maintain) and premature ejaculation. They may be independent or related sexual dysfunction phenomena. I would STRONGLY encourgage him to seek medical help - we can usually make such a great difference in these cases. Both conditions can be very easily managed.
Question (from a 60-year-old Florida man):
I was an active alcoholic between the ages of 15 and 51. I have not used any addictive drugs in the last nine years. During the last three years I have used testosterone cream and 25 MG 2x/day DHEA supplements in an unsuccessful effort to overcome impotence. Furthermore, I am concerned about the possible cancer threat with their continued use. I have three questions:
DR. GOLDSTEIN:
In your opinion, is my concern about cancer valid? Yes, yes and yes. Prostate cancer is very common - about one in eight men will develop prostate cancer and prostate cancer is a leading cause of death in men your age. Testosterone definitely helps prostate cancer cells grow. One should get a PSA (prostate specific antigen) blood test every three to six months if one is being treated by testosterone.
Will Viagra be effective in someone who obviously has impaired adrenal function? There are several rare disorders of the adrenal gland - but if you have one - this should be managed by an endocrine specialist. If impotence persists despite appropriate treatment of the adrenal condition, then Viagra may be added.
What are your recommendations for treating impotence due to alcoholism? Alcoholism may cause impotence by a number of mechanisms especially from psychologic and nerve-related damages to the penile erection process. Assuming appropriate counseling has been tried, medical treatment may involve the use of Viagra.
Question (from a 47-year-old Florida man):
I have read books which provide instruction on how to exercise the PC muscle in order to better ejaculation control, and in fact, achieve orgasm without ejaculation. The benefits touted are the ability to maintain an erection after orgasm, more frequent orgasms, better erections, etc.
DR. GOLDSTEIN:
Question (from a 50-year-old California man):
Dear Dr. Goldstein, My experience suggests that a male can experience the physical phenomenon of ejaculation without always experiencing the mental/physical phenomenon of orgasm. Thus, my question concerns the relationship of these, both neurologically and psychologically. I'd also be curious to know if non-human i.e. animals, experience orgasm, or if their brain structures somehow don't allow this.
DR. GOLDSTEIN:
Orgasm is a sensory phenomenon which occurs in the septum of the thalamus. After receiving appropriate sensory information from the penis and genitals, a disproportionate amount of neurotransmitter is released into surrounding thalamic tissue. This causes a depolarizing wave to affect a wider area in the thalamus. Pleasurable sensation is passed to appropriate cortical sensory areas of the brain (orgasm) - while the spreading wave causes activation of ejaculation pathways. It is possible to ejaculate with only a minimal orgasm.
It is unclear if orgasm occurs in lower animals.
Question (from a 46-year-old Pennsylvania male):
With all the publicity associated with Viagra, several friends and I have discussed the product and our relative sexual function. We are all in our mid to late 40's, none of us suffer from hypertension or diabetes, we are not on medications. We are all married with children. We are perfectly functional, by that I mean we get erections and would never think of ourselves as impotent. But we have all aged. Our sex drive-libido is not as high. We all realize it comes with aging. What is much more of a disappointment is the diminished firmness of our erections. We all feel it is very noticeable and it is NOT in our heads. It doesn't get as hard as it used to. We can't help but wonder if Viagra enhances blood flow to the penis for someone who doesn't get any erection, would Viagra have the potential to improve blood flow for someone whose blood flow has decreased with aging but is not impotent per se.
DR. GOLDSTEIN:
If you (or any of your friends) meet the definition of erectile dysfunction, that is, you have a consistent (for at least six months) inability to obtain or maintain and erection of sufficient quality for satisfactory sexual intercourse, then you may wish to undergo evaluation and treatment by a local MD.
There is such a condition as mild erectile dysfunction - you don't need to wait until the dysfunction is severe.
Question (from a 26-year-old man in France):
I'm 26 and I have not had many sexual experiments. Unfortunately it seems that every time I try with a new girl, I fail to obtain a real erection, though I have no problem obtaining a hard and stable erection via masturbation.
So I wonder if the overwhelming experiment of having pre-sex pleasures with a girl could handicap my capacity of having a real erection afterwards. Is it possible that too much excitation causes temporary impotence because of some organic reason?
And finally, of course, would Viagra help?
DR. GOLDSTEIN:
Is it possible that too much excitation causes temporary impotence because of some organic reason? Too much excitement may lead to release of adrenaline and early loss of your erections. Try and relax under circumstances with a new girlfriend or seek professional counseling from a sex therapist.
Q&A with Dr. Irwin Goldstein | Impotence: Causes and Treatments | Resources | Broadcast Transcript
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