Just a couple of generations ago, men had to accept impotence as a likely consequence of aging, like graying hair and a thickening waist. Younger men sometimes suffered, too, but most of the causes of impotence -- heart disease, diabetes and major surgery -- are more common to the older set.
But now that people are living longer, couples who want to maintain a robust romantic life are finding help from an array of solutions. These range from drug therapy to vascular surgery to increasingly sophisticated penile implants.
Older men are "charging after life just like we are and they consider being able to function sexually just as important as we do," said Dr. Mel Duckett, a urologist.
To handle this increased demand, Dr. Duckett opened the Maryland Regional Impotence Center just over a month ago. The Lutherville center is the first in the Baltimore area devoted exclusively to impotence, offering diagnostic procedures, the services of an internist and a psychologist, and a wider array of facilities and treatment options than most urologists in private practice can provide.
One out of every eight to 10 men suffers from impotence -- that's about 10 to 12 million men nationally, and an estimated 100,000 inthe greater Baltimore area, Dr. Duckett says. Most of his patients are between 50 and 70 years old.
Achieving erection is a complex process involving the brain, nerves, and many valves, veins and other mechanisms in and around the penis.
Any component can fail, which is why there are so many different causes of impotence. But since swelling the penis to erection requires a six-fold increase in blood supply, the most common medical reason for impotence is an impeded blood flow.
Eric, a 68-year-old diabetic, had not achieved erection for a year before he visited Dr. Duckett. Many men wait as long as five or 10 years before consulting with a physician.
"When you can't perform, it starts acting on your mind," Eric said, recalling the sexual problems he and his wife of 40 years experienced.
He chose a semi-rigid penile prothesis as the best treatment. This implant is permanently erect, but it is relatively simple and unlikely to fail. When not in use, he just tucks it out of the way.
"Nothing is as good as what God gave you," conceded Eric, and he did warn of some pain with surgery.
But for him, the bottom line is clear: "When you want to have intercourse, it's there. A year ago it wasn't."
During the first office visit, Dr. Duckett reviews the patient's medical, sexual and psychological history to help pinpoint the source of the problem.
A staff psychologist counsels patients if the problem is not primarily medical. Doctors estimate that anywhere from 10 to 50 percent of all impotence cases have psychological causes, such as stress, marital trouble or performance anxiety.
Even impotence with a medical source usually has an accompanying psychological component to fuel the problem as men come to feel inadequate and their partners feel guilty.
If diagnostic techniques show the problem is physical, the first treatment is usually a form of drug therapy. Some types of medication are taken orally while others are injected directly into the penis.
Another non-surgical procedure uses a chamber and a pump to create a vacuum, making an erection easier to attain. An elastic band is then placed around the base of the penis to maintain the stiffness.
For more serious cases, there are two common types of surgery.
One involves reconstruction of tiny veins leading into the penis or the removal of veins which are draining it too quickly.
The other surgical remedy, which is much more common, is some type of penile implant. Besides the semi-erect type, there is a variety of inflatable implants, which can be as erect or flaccid as a regular penis.
Some have small pumps in the scrotum with the testicles. Others have a chamber in the penis tip to store the fluid -- usually saline solution -- which fills the implant. Deflation requires bending the penis or some other simple method for releasing the pump.
Dr. Duckett says he does most of his surgeries on an outpatient basis so outsiders -- such as nosey co-workers or grandchildren -- never need to know.
Most medical insurance plans cover all procedures and even surgery, which costs an average of $6,000, he said.
Causes of impotence
Major physical causes of impotence in the United States.
Diabetes mellitus: 40 percent
Vascular disease: 30 percent
Post-radical surgery: 13 percent
Spinal cord injury and other traumas: 8 percent
Other endocrine problems: 6 percent
Multiple sclerosis: 3 percent
Source: "Impotence: Current Diagnosis and Treatment" by Stephen W. Leslie, M.D.