HOW DO YOU DIFFERENTIATE BETWEEN PHYSICAL AND PSYCHOLOGICAL CAUSES?
Our goal as doctors is to either find or exclude a physical cause. This will impact on the treatment of our patient. On consulting with a new patient, we start by taking a focused history of his condition. In my experience, the issues that are important at the onset of this complaint are:
• the age of the patient
• the onset and duration of the problem
• the severity of the problem
• his social situation
• other risk factors.
Age
As you would imagine, the older the patient, the more likely 11 is that his condition is due to a physical cause. Similarly, the younger the patient, the more likely it is that his condition is psychological in origin. This is by no means a strict rule as several other physical factors may contribute to a decrease in the level of blood flow into the penis.
Onset and duration of the condition
II the erectile dysfunction came on quite suddenly, without an obvious physical cause; it is more than likely that this condition is psychological in origin. If the onset is slower and over a long period of time, then the cause is most likely physical.
Severity of the condition
II you are able to achieve a strong sustainable erection during the night or first thing in the morning, and then your problem is more likely psychological in origin. You can easily test this yourself by sticking two stamps that are still attached to each other to the shaft of your penis. If you wake up and the two stamps have separated, you most likely had an erection during the night.
If you are able to produce a strong sustainable erection while masturbating, then your problem is probably psychological. If, however, the maximum erectile strength that you achieve while masturbating is consistently less than adequate for penetration, or less than it used to be, then the cause will most likely be physiological.
If you can consistently get an erection strong enough for penetration, but are typically unable to maintain the strength of your erection in the vagina, then again, the cause is probably physiological.
Social situation
Men who are most likely to develop psychological impotence are those who are going through particularly stressful situations. This includes stress at work and financial stress, but it is more commonly related to the type of stress resulting from difficulties with marriages or relationships. A man who has gone through a divorce, separation, or who has become a widower, often finds it very difficult to regain his confidence in the bedroom.
Peter, 32 years old, labourer
Peter had been married to Louise for three years. Louise had been married once before, but this was the first time for Peter Throughout their turbulent marriage, Peter had been tormented by his feelings of inadequacy in the bedroom. In the early stages of their relationship, Louise had made comparisons between Peter and her previous husband, Steve.
'Steve might have been a bastard/ she said, 'but in the bedroom he was fantastic/
On another occasion, Louise had commented on how much bigger Steve's penis was than Peter's.
During their arguments, which became more and more frequent, Louise often made reference to how inferior Peter was sexually in the bedroom compared to other partners that she had had in her past.
Peter began to experience problems having sex with Louise from the time of her very first comments about his inadequacies. On occasion his erection would not even be strong enough for penetration. Sometimes he would ejaculate too quickly, and other times not at all. Louise, not being very sympathetic by nature, felt that she did not sufficiently arouse Peter. This, in turn, made her feel inadequate.
Over the ensuing months, Peter started to avoid situations that would lead to intercourse with Louise. He would fall asleep on the couch or stay at work late. He would complain of being tired or not feeling well if she wanted to have sex. This situation led to Louise thinking that he was having an affair.
The relationship deteriorated and they eventually started divorce proceedings. Very soon after they separated, Louise started a new relationship. Peter had contact with her only during the divorce proceedings. It seemed to him as if she was much happier in this new relationship which pushed him further into a state of depression.
Twelve months after they had separated, and after taking antidepressants for nine of those months, Peter decided to explore the possibility of sex again. He went to a brothel and tried having sex with a prostitute. This was a disaster. No matter how much stimulation this skilled professional provided, Peter could just not get hard enough to penetrate her vagina. Eventually, the lady brought him to orgasm through masturbation and fellatio with his semi-rigid erection.
By the time I consulted with Peter, he was avoiding all physical contact with women. If he met a girl and the situation was heading for the bedroom, Peter would terminate the relationship. At times, he couldn't even look at himself in the mirror because of how humiliated he felt about his condition. He didn't even feel worthy enough to masturbate.
The physical examination of Peter indicated that there was nothing wrong with his genitalia or the rest of his body. There was nothing in his medical history either which indicated a physical cause. I started him on injection therapy that provided him with a sustained, strong erection for one hour. His erection would stay up even after he ejaculated.
Peter's response was miraculous. Two days later, he went to see another prostitute, this time after he had injected himself with an intrapenile injection (a combination of papavarine, phentolamine, octropine and prostoglandin E1). Peter experienced the best sex he had ever had. That night, he was woken as a result of a throbbing erection, which he masturbated to bring down. The same happened the following morning. The whole of that day, sex occupied his mind. The following day, he went back to the same prostitute he had seen the first time. Even prior to injecting himself, he had developed a nearfull erection. He went ahead and used the injection, but that was the last time that he has ever had to use the treatment again.
When I saw Peter a week after our first meeting, he was a different man. He was brimming with enthusiasm and was far more confident. He had joined a dating agency on the advice of a friend and was waiting for word of his first date in twelve months. I never saw Peter again, but I'm sure it was because his problem was cured and he no longer required treatment.
*18\4*
