The Ins and Outs of Gay Sex (27 page)

Measuring blood flow to your penis is another critical aspect of any impotence evaluation.
A painless Doppler ultrasound
machine bounces sound waves off blood coursing through your penis, providing an accurate view of blocked arteries or leaky veins.
An angiogram (X ray of arteries taken after dye is injected) is rarely necessary.
Nerve conduction studies provide information about nerve function but also are rarely necessary.

Although I have spent much time discussing physiological causes of impotence, I don’t mean to underestimate the significance of psychological causes—particularly in younger, HIV-negative men.
Don’t forget that about 20 percent of all impotence results from emotional problems—and 20 percent is by no means insignificant.
Any impotence evaluation must also search for psychological causes.
For some gay men, issues relating to their sexuality can certainly affect sexual performance.
If an HIV-positive gay man complains of impotence, most often it results from either a low testosterone level or psychological problems stemming from his illness.
Young men living with HIV rarely have vascular problems.
Instead, heavy-duty head trips prevent them from getting hard.

Even if the doctor corrects a physiological cause for your impotence, you may still have problems.
For many men, both physiological and psychological forces working together increase sexual dysfunction.
By fixing a physiological cause, your doctor can unmask a hidden psychological problem.
A typical example of this situation occurs in older men in long-standing relationships.
Over the years one partner may lose desire for the other and their sex life dwindles.
At first he masturbates, but soon he develops difficulty with even that.
Out of frustration he sees a urologist, who identifies a vascular problem and prescribes Viagra.
The medication brings back the man’s erections but not his desire.
A similar situation occurs in HIV-positive men, who are impotent even with testosterone replacement.
If you remain impotent even with proper medical treatment, see
a therapist.
You may need to sort through psychological problems that are evident only now.

Therapy for impotence falls under two main headings:
pharmacological (drugs) or mechanical.
Many medications treat impotence by increasing penile blood flow, and until recently they were administered by injection directly into your penis (don’t worry, it’s just a small prick) or via a suppository pushed into your urethra.
Now, fortunately, the FDA has approved a pill to combat impotence.
The following is a brief overview of each type of medication.

INJECTION THERAPY
   Exactly what it says.
You inject medication directly into your penile shaft.
The medication produces an erection in about ten minutes, which lasts anywhere from fifteen minutes to one hour.
Three types of drugs administered in varying doses, individually or in combination, are used:
prostaglandin E
₁
, phentolamine, and papaverine.
Expect your physician to try several combinations until finding what works best for you.
Most men find prostaglandin E
₁
gives the best results.
Besides the needle, the main drawback of injection therapy is a slight burning sensation or scarring at the site and possible priapism.
Injection therapy is about 70 percent effective and may work for men with more severe problems when other medications (Viagra) fail.
Once men get over their apprehension of sticking a tiny needle into their penis, they find that the treatment works well with few side effects.
Some even prefer it to Viagra.

I once shared an office with a urologist and watched as men who hadn’t gotten it up for years dashed home with smiles on their faces and bulging pants after their first successful injection.
They couldn’t wait to use what the doctor had given them!

PENILE SUPPOSITORY
   Alprostadil (Muse), a synthetic prostaglandin E
₁
, is a small pellet sold with an applicator that
you pass into your urethra.
Discomfort is minimal, but you must massage your urethra for approximately five to ten minutes while the medication is absorbed and your erection rises.
Erections produced are weaker than those after injection therapy and may dissipate when you lie down—so stay on top.
Urethral burning is the major side effect.

SILDENAFIL (VIAGRA)
   You’ve heard the jokes, now hear the truth.
Viagra became the first pill approved specifically for treating impotence in April 1998.
Viagra works by dilating your blood vessels and was originally tested as a heart medication.
Researchers had hoped it would open blocked coronary arteries, but it failed.
Don’t cry for Pfizer:
While Viagra did little to help men’s hearts, it did plenty for their erections.
The drug dilates penile arteries and increases filling of erectile tissue.

You take Viagra one to two hours before sex, but unlike injection therapy or suppositories, it usually does not produce an erection
without
sexual stimulation.
In that respect, Viagra approaches a natural, physiological erection that subsides after ejaculation.
Seventy to 80 percent of impotent men respond, but headache, palpitations, facial flushing, and visual disturbances (things look blue) are common side effects.

While a tremendous breakthrough in impotence treatment, Viagra is not a panacea.
It can be dangerous and should be taken only if your impotence is real and under doctor’s supervision.
Physicians have documented dangerous interactions and even death when Viagra was taken with other medications (particularly a class of cardiac drugs called nitrates that also dilate blood vessels).
(See
Chapter 12
.
)

Viagra does not increase your sex drive, only the quality of your erections.
It may help remove some psychological
barriers to sex by improving your erections and lessening performance anxiety.
Many men taking Viagra report a generally improved outlook and feelings of self-worth.

Yohimbine, ginseng, and gingko are all natural products available in health food stores purported to improve potency, but their effectiveness has never been proven scientifically.

If a testosterone deficiency caused your impotence, as commonly occurs in HIV-positive men, replacement therapy is available in transdermal patches (Testoderm, Androderm), which administer testosterone gradually through the skin, or via injection.
The two most common injectable testosterone preparations are testosterone enanthate (Delatestryl) and testosterone cypionate (Depo-Testosterone or Virilon).
Prepare for a 200 mg injection on an every-other-week basis.

There are advantages and disadvantages to each type of testosterone preparation.
Gradual hormone administration provided by a patch may be more natural, but many men find its daily application too bothersome.
The patch can irritate your skin and prompt stares and unwanted questions in locker rooms and bedrooms.
Although injections are given with a small needle, they frighten away some men.
Testosterone levels tend to be high immediately following injection and low just before the next dose.

MECHANICAL TREATMENT
   Except for vacuum pumps and cock rings, which draw and keep blood in the penis, the mechanical treatment of impotence is generally surgical.
If leaky veins are your problem, a cock ring may work; if not, some surgical procedures occlude these veins and help keep blood in your erectile tissue.
Penile prostheses are the mainstay of mechanical treatment of impotence, but they have major downsides.
Your erection won’t look or feel natural (or even as good as the one you get from medication).
The surgical insertion of any prosthesis permanently destroys erectile tissue, making medication therapy impossible.

There are basically two types of prosthetic devices:
a semirigid rod or an inflatable chamber.
If you choose a rod prosthesis, the doctor places one in the upper spongy erectile chambers on each side of your shaft.
Your penis is stretched over the rods, which provide enough rigidity for penetration.
I know what you’re thinking; just forget about it.
Rods do not affect sensation, orgasm, or ejaculation and won’t lengthen your penis:
They are measured to fit exactly what you already have.
Rods come with varying degrees of flexibility or hinges so they can bend down along your leg when not in use.
Your erection is not natural looking and most closely resembles a penis on a stretching rod.

An inflatable prosthesis works with a hydraulic pump that, when squeezed, sends water from a prefilled holding chamber into reservoirs implanted on either side of your penile shaft.
Your penis goes from flaccid to hard as the need arises.
Again, your erectile tissue must be hollowed out for the reservoirs, so if the prosthesis is removed, medications are not an alternative.

Which is better, flexi-rod or inflatable prosthesis?
Most doctors I know say that the inflatable prosthesis is better because it can be inflated whenever you need it.
One doctor told me that comparing these prosthetic devices one to the other is like comparing a Mercedes to a Yugo.
“When you have an inflatable prosthesis it’s like you’re driving a Mercedes.
There just is no comparison.”
Although pumps have many more mechanical parts than rods, they are surprisingly reliable.
Either prosthetic must be removed if infection develops.

With the advent of excellent medications to treat impotence, a mechanical prosthesis should be reserved for patients
who can’t tolerate the drugs because of side effects or fear of needles, or for those few patients who don’t respond.
(Remember, if the pills don’t work, the injections might.
) Medications produce a normal-looking erection, and you can always fall back on a prosthesis as a last resort.

With any prescription drug there is always the potential for abuse, and impotence medications are no exception.
These drugs—whether in pill or injectable form—are intended for men who can’t get it up, not for men who just want to keep it up for hours at a time.
There are many reported cases of normal guys who gave themselves injections in search of the ultimate performance, but what they got instead was priapism!
One patient I warned not to try it didn’t care and said he was getting a friend to give him a shot for the White Party.
“There’ll be no stopping me” were his parting words as he left my office.
He was right.
Now he’s permanently impotent.

Viagra doesn’t require an injection, and abuse within the gay community has skyrocketed.
So far no reported cases of priapism from Viagra have been reported, but that doesn’t mean it won’t happen.
I’ve already overheard men saying “I did a Viagra,” the way they talk about a hit of Ecstacy or some other designer drug.
What most men don’t realize before they swallow the pill is how bad the side effects can be.
If Viagra is the only way you can get an erection, you’re more willing to put up with the pounding headache, dizziness, blue vision, and palpitations.
If you can get hard anyway, these side effects don’t exactly enhance your sex drive.
Viagra and poppers can also be a deadly combination.
(See
Chapter 11
.
) My advice:
Don’t even think about it.

I stepped into the exam room and a patient I hadn’t seen for a couple of years leaned against the counter.
His jeans were tight and his leather jacket draped over the back of my chair.
He looked every bit as gorgeous as I remembered.
“What brings you back?”
I asked.

“My hernia’s fine.
It healed up great.
Now I’ve got a different problem down there.”
He hesitated and I waved him on.
His cheeks turned a light shade of pink.
“I’ve got premature ejaculation.”

My eyebrows arched.
“How long has that been going on?”

“About three months.”

“Only during sex or even with masturbation, too?”

He shrugged.
“Never thought about it.”

Before going any further I decided to ask the crucial question.
“How long can you go before you ejaculate?”