Besides physically caused erection difficulties, performance anxiety is a major source of erectile dysfunction. Therefore, most sex therapy concentrates on reducing or

Sexual Difficulties and Solutions

eliminating anxiety. Initially, a couple uses the sensate focus exercises, understanding that at this point the touching is intended not to result in erection, ejaculation, or intercourse, but to focus on and enjoy the touch without a further goal. The following account shows a common reaction to the exercise:

When the therapist told us that intercourse was off limits, at least for the time being, I couldn’t believe how relieved I felt. If I couldn’t get hard, so what? After all, I was told not to use it even if I did. Those first few times touching and get­ting touched by my wife were the first really worry-free pleasurable times I had experienced in years. (authors’ files)

If a couple wants to, they can agree in advance for the partner to have an orgasm at the close of a session by whatever mode of stimulation other than intercourse seems comfort­able to both (self-stimulation, being touched by the partner, oral stimulation, etc.). When the couple has progressed to a point where both partners feel comfortable with sensate focus, the couple explores what kinds of genital stimulation other than intercourse are particularly pleasurable for the man. When the man experiences a full erection, his partner should stop doing what has aroused him. It is crucial that they allow his erection to sub­side at this point to alter the man’s belief that once his erection is lost it will not return. The couple spends this time holding each other close or exchanging nongenital caresses. Once the penis is completely flaccid, the man’s partner resumes genital pleasuring.

The final phase of treatment for heterosexual couples who desire intercourse involves penetration and coitus. With the man on his back and the woman astride, the couple begins with sensate focus and then moves to genital stimulation. When the man has an erection, his partner lowers herself onto his penis, maintaining stimulation with gentle pelvic movements. It is important to allow the man to be “selfish,” concentrat­ing exclusively on his own pleasure (Kaplan, 1974). Occasionally a man loses his erection after penetration. If this happens, his partner returns to the oral or manual stimulation that originally produced his erection. If his response con­tinues to be blocked, it is wise to stop genital contact and return to the original nondemand pleasuring of sensate focus before moving forward again.

Medical Treatments Some men who have impaired erectile functioning as the result of physiological problems make a satisfactory sexual adjustment to the absence of erection by emphasizing and enjoying other ways of sexual sharing. For other men with erection difficulties, several types of medical treatments are available. Viagra, a pill for erectile problems, became available in 1998. Originally developed for cardiovascular disease, it became the fastest-selling prescription drug in history. Almost 40,000 prescriptions were dispensed in the first 2 weeks on the market (Holmes, 2003). In 2003 and 2004 the FDA approved two additional Viagra-like drugs, Levitra and Cialis. These medica­tions work by prolonging the vasodilator effects of nitric oxide in the body. Blood vessels in the penis expand, and erections result from the increase in blood flow (Hoffman, 2009). Research has consistently shown that a combi­nation of ED medication and couple sex therapy is more effective in helping this problem than medication alone (Aubin et al., 2009).

Viagra, Levitra, and Cialis have similar side effects; the most common are flushing, headaches, upset stomach, and nasal congestion (Gotthardt, 2003; Hazell et al., 2009). Erectile dysfunction drugs can also cause priapism, in which an erection does not subside and can result in permanent damage to penile tissue unless medical treatment is obtained (Adams, 2003). Hydrogen

sulfide is a vasodilator found in small amounts in the human body, and researchers are studying it as another potential treatment for ED (Conner, 2009).

For many couples, erection-enhancing drugs can be wonder drugs that restore the intimacy of intercourse (Verheyden et al., 2007). Many studies have shown significant improvement in the partner’s feelings of sexual desirability and satisfaction as well as her own sexual functioning when the man uses erection-enhancing medications (Eard – ley et al., 2006; M. McCabe et al., 2011). However, some men have found that firm erections are secondary to a good relationship (Metz & McCarthy, 2008). In a troubled relationship the use of such a medication can clarify for the couple that they have other relationship problems, which may lead the couple to work toward resolving them (Coo­per, 2006).

Viagra has greatly increased general conversation and awareness about erectile prob­lems. In fact, men who do not have erectile dysfunction are using erection-enhancing drugs for firmer and longer-lasting erections. The appeal to men to be able to extend intercourse beyond one or more ejaculations contributes to the recreational use of such drugs. Reports also indicate that Viagra has emerged among college students and oth­ers as a party drug for recreational and casual sex (Apodaca & Moser, 2011; Harte &

Meston, 2011). Unfortunately, mixing Viagra and recreational drugs combines endur­ing erections with the poor judgment of an altered mental state in which men engage in high-risk sexual behaviors that they otherwise would avoid (Adams, 2003).

Mechanical Devices Devices that suction blood into the penis and hold it there during intercourse have been available since the mid-1980s (Korenman & Viosca, 1992). Exter­nal vacuum constriction devices, which are available by prescription, consist of a vacuum chamber, pump, and penile constriction bands. The vacuum chamber is placed over the flaccid penis. The pump creates a negative pressure inside the chamber and draws blood into the penis. The elastic band is then placed around the base of the penis to trap the blood, and the chamber is removed (Levy et ah, 2000). Another mechanical device recendy approved by the FDA to help men experience erections is the VIBERECT device. It pro­vides vibrations to two surfaces of the penis, stimulating reflexive reactions that initiate blood flow for an erection to occur (Ostrovsky, 2011).

Surgical Treatments A surgically implanted penile prosthesis is an option for men who are not helped by Viagra or other meth­ods. The main reason for implants is radical prostatectomy.

The surgery is expensive and involves risks, including infection, and men should evaluate this option carefully and include their partner in pre – and postsurgical counseling. There are two basic types of penile implants. One type consists of a pair of semi­rigid rods made of metal wires or coils inside a silicone cover­ing; the rods are placed inside the cavernous bodies of the penis.

Although this type is easier to implant than the second type, a potential disadvantage is that the penis is always semierect.

The second type of prosthesis is an inflatable device that enables the penis to change from flaccid to erect (I Figure 14.7). Two inflatable cylinders are implanted into the cavernous bodies of the penile shaft. They are connected to a fluid-filled reservoir located near the bladder and to a pump in the scrotal sac. To become erect, a man squeezes the pump several times, and the fluid fills the collapsed cylinders, producing an erection. When an erection is no longer desired, a release valve causes the fluid to go back into the reservoir (Shaw & Garber, 2011).

Sexual Difficulties and Solutions

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Neither of these devices can restore sensation or the ability to ejaculate if it has been lost as a result of medical problems. Furthermore, the surgery to implant the devices may diminish sensation. They do, however, provide an alternative for men who want to mechan­ically restore their ability to have erections. Most men who have them report improved sexual activity, and about 85% are satisfied with the results of the surgery (Cortez-Gonzales & Glina, 2009; Richter et al., 2006).