• What professional education, training, and degrees do you have? Specifically, what training in sex therapy have you completed?

• Do you belong to any professional organizations? Which ones?

• Have you treated many patients with problems like mine? (Some sex therapists have experience with many patients with erection problems; others do not.)

• What kind of a treatment plan or program would you recommend in my case? Why? What are the alternatives?

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Wally was a typical pelvic steal patient. This 73-year-old retired seaman complained of poorly sustained erections. He was able to get good erections, but as soon as he started to thrust, they would disappear. Of course, both Wally and his wife were upset by this turn of events. The problem had come on gradually, and Wally and his wife didn’t understand what was happening.

First, the doctor took Wally’s penile blood pressure. Then he had him exercise vigorously for about five minutes by going up and down a small staircase, without stopping. After this brief exertion, it was time to measure Wally’s penile blood pressure again.

Sure enough, in Wally’s case, his pressure was noticeably lower after the brief exercise. Often the problem may be solved simply by having the woman on top, and Wally and his wife found this suggestion solved their problem satisfactorily. If this change doesn’t work, surgery to remove the obstruction, to bypass the affected area or to dilate the offending pelvic arteries may resolve the difficulty.

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The squeeze technique is similar to the stop-start method, with one important difference: When a man senses he is going to ejaculate, he puts his first and second fingers on the top of the head of the penis and places the thumb just below this area (see illustration). He squeezes for several seconds, until the feeling of imminent ejaculation goes away. (If the man has begun to ejaculate, it’s important to stop squeezing, because to continue to do so can cause the semen to build up too much pressure in the urethra. Not only is this uncomfortable, but it can occasionally cause bleeding.) Obviously, the squeezing can be done by the partner, and some lovers prefer this. The couple can resume making love when the man feels in control again.

Some people don’t like the squeeze technique because if the couple is having intercourse, the man must take his penis out of the vagina in order to squeeze or be squeezed. An alternative is to squeeze the base of the penis for roughly 15 seconds. The advantage of this method is that the penis may remain inside the woman while it is squeezed, if she is on top.

It’s important to realize that ejaculation does not mean you and your partner can’t continue to caress and be close without further intercourse.

Regardless of the method you try, the following suggestions are helpful.

• Use as many squeezes or stops as you need—as you practice, you’ll need fewer and fewer.

• Apply pressure slowly and firmly, but don’t squeeze so hard that it hurts.

• Don’t become concerned about occasionally ejaculating too soon.

• Keep communication open and clear with your partner. If she gets a little frustrated by the exercise, explore ways of satisfying her that don’t include intercourse, like oral sex.

This is a good place to lay to rest the popular belief that the way to last longer is to think of something else when you’re having sex. Some men count backwards from a thousand or think of baseball scores or other unromantic topics. Not only does this method inhibit your enjoyment, it also prevents you from identifying the point of ejaculatory inevitability—a sense you need to have if you’re going to delay ejaculation. If a man wants to gain control over his ejaculations, he needs to concentrate on the sensations he is feeling.

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Prostate Surgery

The prostate is strategically located—it’s surrounded by nerves that control the penis, and arteries necessary for erection are close by. Thafs why surgical removal of the gland can cause potency problems. The prostate is removed for two reasons: a noncancerous (benign) enlargement of the gland that causes unpleasant side effects, or prostate cancer. Each condition requires a different type of surgery, and the resulting effects on potency can be dramatically different.

Surgery for Benign Enlargement of the Prostate A noncancerous enlargement of the prostate can go for years without causing any problems. Sometimes, however, it can cause serious, even life-threatening situations by causing urine backup and kidney damage.

More often, the prostate enlargement results in irritating but minor difficulties: difficult or slow urination, having to go to the bathroom very frequently and feeling the need to go almost all the time, even when there’s not much urine in the bladder.

The solution to these unpleasant symptoms is the partial removal of the inner prostate, an operation called transurethral prostatectomy (TURP for short). This procedure doesn’t require any incision, since the surgeon inserts his instruments through the end of the penis. And the shell (the exterior) of the gland is left intact. About 10 percent of men over the age of 50 have this surgery.

What does the operation do to potency? The short answer is: It doesn’t hurt, but it doesn’t help. If a man has normal erections before surgery, usually he won’t have any problems after the operation. Fortunately, nature placed the nerves crucial to erection along the outside of the prostate, an area left untouched by the surgeon. If a man does have erection problems prior to surgery, however, typically they won’t get better, and may become worse. Why? It may be because the nerves near the outer layer of the prostate are mildly damaged during surgery, or because of scarring that occurs during healing.

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William, a man under stress, feels he cannot relax. He is preoccupied with the source of his tension. He is not enjoying life one moment at a time. Instead, he worries about what happened before and what is coming next. Consequently, he will find it difficult or impossible to relax and enjoy his senses in a sexual encounter. If, still in this frame of mind, he does succeed in having intercourse, he may not experience real pleasure. Often, such distress may lead to erection problems, which in turn can cause further stress and self-doubt. A vicious cycle can develop. To counteractthis, a man in this situation needs to find time to enjoy himself and feel alive. He needs to say no to outside pressures and yes to his own pleasures.

Clearly, William needs to make some adjustments in his life, to help him handle some of his increased stress. He mightfind a daily swim, regular deep breathing exercises or taking a stress management class would put him in the here and now and help him live more fully.

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If you have used laxatives regularly over many years, your bowels may no longer respond to them, and you may become more and more dependent on increasingly stronger laxatives. Perhaps you find that your bowel movement seems less likely to result in a feeling of relief. Some people spend a great deal of time during visits to the doctor describing their bowel problems, hoping to discover a magic formula for a good daily bowel movement and freedom from constipation. However, a bowel movement does not have to occur every day for you to be healthy. Some normal older people have a bowel movement only every two or three days. What is important is that when you do have a bowel movement, it is not excessively hard or difficult and does not cause discomfort.

It is important to distinguish between constipation as a result of a change in bowel habit and constipation that has existed for many years, or chronic constipation. The former may be an early sign of blockage of the intestine, sometimes from an inflammation or a tumor. If you have a change in bowel habits, you should consult your physician as soon as possible. If you suffer from long-standing and progressive constipation, you should be examined for an underactive thyroid gland (hypothyroidism). Sometimes local causes, such as hemorrhoids or fissures (sores in the anus), exaggerate a tendency toward constipation.

Your physician may find that your constipation is caused by poor bowel habits. He will advise you to try to discontinue the use of laxatives, which excessively stimulate the bowel, and replace them with safer substances, such as psyllium mucilloid or lactulose. You should make sure that your diet contains sufficient fiber in the form of bran, whole-wheat and other whole-grain breads and cereals, raw and cooked vegetables, and fruits, as well as an adequate intake of fluids. This gives the lower intestine enough bulk to stimulate a normal bowel movement. The ultimate goal is to have a bowel movement of sufficient frequency so that it is well formed, not excessively hard, and easy to expel. But it does not have to be a daily occurrence.

A change in behavior may also be helpful. Try to have a bowel movement following meals and try not to hurry. It is advisable to avoid enemas. However, while you wean yourself from laxatives, if a normal pattern does not become quickly established, an occasional enema is preferable to a strong laxative. Increasing your physical activity is also beneficial in breaking the constipation cycle.

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In some older people, however, there is an abnormality in the temperature-regulating mechanism. This may lead to an excessive rise of temperature with an infection, or it can occur if you have spent too much time in the sun or in an extremely warm environment. The opposite also occurs. A severe infection may be present without causing an elevation in your temperature.

Whenever you have a fever from an infection, other symptoms usually point to the source of the illness. Bacterial infections of the urinary tract usually cause burning when you pass urine and an urgency to urinate frequently. A lung infection often leads to coughing and the production of phlegm. We usually recognize the muscle aches and pains of a cold or influenza, and the fever usually subsides by itself within a few days. Fever caused by bacterial infections usually decreases after treatment with antibiotics has begun to be effective.

Some unusual illnesses in older people can cause fever that is not the result of infections. These ailments often lead to the great confusion in diagnosis and treatment. Unlike most infectious causes of temperature elevation, despite treatment with a few days of aspirin or an antibiotic, the elevated temperature does not return to normal. Sometimes the temperature goes up and down, either daily or weekly. At times it may even stay up for a week or two and then fall to normal for a few weeks and then go up again.

Various types of inflammation and certain tumors, especially of the blood or lymph glands, can cause fever. The temperature can also be elevated during unusual infections, such as bacterial endocarditis or tuberculosis. In these circumstances the temperature will not decrease with the usual fever-lowering medications such as aspirin, or if it does, the fever soon returns. Antibiotics may not lower the temperature, or do so only temporarily, and the fever may return after the medication is stopped.

An illness accompanied by fever should be carefully evaluated. Most of us recognize such simple causes of temperature elevation as a cold or influenza. If you have a fever that does not fall within a few days, or it if returns time after time, whether or not you have taken medications such as antibiotics, you should have a full examination and explanation from your physician. It is very dangerous for you to treat yourself with antibiotics repeatedly, especially if after a course of treatment your fever returns.

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Some of these tests may be done by any physician; others are so sophisticated that only a specialist has the skill to do the test properly. These tests pose little danger, although some of them are uncomfortable. Many can be done in a doctor’s office and or on an outpatient basis in a hospital or special clinic, which does not require an overnight stay.

Colonoscopy is possible because of the development of fiber optics. Flexible glass fibers transmit light over great distances at any angle. If the fiberglass is enclosed in a telescopelike instrument, it can be passed into the lower bowel to examine the entire large intestine. Whereas the older sigmoidoscope is a rigid instrument, the colonoscope is flexible.

If you are being examined for anemia or bleeding from the large bowel and the cause has not been found, colonoscopy may be necessary. Sometimes small tumors that are seen on a barium enema X-ray can be removed through the instrument without the need for surgery. At other times, a barium X-ray may not reveal a tumor that is seen during colonoscopy. The test, which takes forty-five minutes to an hour and a half, requires that your bowel is cleared with special cleansing fluids, laxatives, and enemas beforehand. It is somewhat uncomfortable. Usually, a gastroenterologist or a surgeon specializing in diseases of the bowel will perform the test.

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In the past little attention was paid to the amount of radiation that patients were exposed to during X-ray procedures. It took years before it became clear that there was a potential danger of disease or birth defects from excessive radiation. Technical advances have reduced the amount of radiation needed for X-rays and measures can be taken to decrease the amount of exposure that is received by parts of the body that should be protected from radiation.

The question is often raised about whether the danger of X-rays is greater than that of the illness for which they are being done. In children and in young adults there is no doubt that it is important to minimize the amount of radiation. In older people the danger seems to be less pronounced because birth defects are not an issue.

Whether or not X-rays cause cancer in older people is still not completely clear. If X-rays are done carefully and with proper supervision, they do not appear to pose a particular threat to the health of the older person. In most cases any danger from the X-ray is outweighed by the beneficial information that is obtained.

Some X-rays have no real danger other than that related to the amount of radiation received. Other X-rays require special chemical substances that are either swallowed or injected, and they may pose some hazard, especially in the older person. Even when the risk is not particularly great, some X-rays require preparation that can be uncomfortable and difficult for older individuals. These factors must be taken into account before an X-ray is ordered. Sometimes physicians modify the procedure to make it easier for the older person. If you had a difficult time with an X-ray procedure in the past and your physician orders a similar X-ray again, let him know so that appropriate steps can be taken to avoid discomfort and danger.

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Penicillin is also used to treat bacterial infections. Many medications in this family are manufactured synthetically and are effective against many types of bacteria. They are called broad-spectrum antibiotics. Most penicillins end in -cillin, such as ampicillin, cloxacillin, and amoxicillin. In general, if you are allergic to one type of penicillin, you will be allergic to the others. Some allergic reactions are mild, resulting in an itchy rash. Others are more serious, causing difficulty in breathing. Sometimes the allergy risk may have to be taken if the illness is severe and if a penicillin is the only drug available. However, precautions can usually be taken to avert a serious reaction. You should obtain a Medic-Alert® bracelet that says you are allergic to penicillin, and always tell your doctor about allergies to antibiotics.

Another group of antibiotics closely related to the penicillins are the cephalosporins, also broad-spectrum antibiotics. People who are severely allergic to penicillin may also be allergic to these as well.

There are other types of antibiotics known as the aminoglycosides, including streptomycin, gentamicin, tobramycin, and netilmicin. They are usually reserved for serious infections and the medication is given by injection. Another important group is tetracycline, also a broad-spectrum antibiotic, which is used for less serious infections and is usually taken orally. This group can cause intestinal problems and may have to be stopped because of diarrhea. Erythromycin and chloramphenicol are medications that inhibit certain types of bacteria. The former is very useful for certain kinds of pneumonia but the latter must be used cautiously because it can cause a rare but severe disorder of the bone marrow.

Antibiotics can be very effective in treating infections of the respiratory system, urinary tract, intestinal system, and heart. They should not be used indiscriminately, and they should never be taken without medical supervision.

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