The Crude Mechanics of Treating Impotence

So here we are, sitting on the veranda having a beer after work. I’ve made a mobile out of some bleached chicken bones and fragments of coral, tied together with fishing line. When the wind blows it makes a pleasing sound, although, when I canvass his opinion, Dan says he doesn’t care for the thing.

Dr Dan is like that. He can usually be relied on to come out with the opposite view from the one you expect. In medicine and in life he has a passionate distaste for orthodoxy, something you might guess at from the course of his medical career. Shortly after finishing his house jobs he joined a street circus for a year. Afterwards he worked in paediatrics for a while on a family therapy unit, and then as a GP with Aboriginal communities in the outback. And somewhere along the line, to make a bit of extra cash, he worked part time for what he now refers to as the dick clinic in Newcastle, Australia.

Well, it was an impotence clinic to give it its correct name, but we’re off duty here, passing the time of day, talking about impotence.

Impotence means the inability to get an erection.

The received wisdom is that, in the great majority of cases, this particular symptom is due to psychological factors. However, no one wants to be told their illness is all in their head, especially when it is lying limply across their lap. These men want a firm diagnosis. Ideally they want to be told they have a problem which can be fixed by medicine or surgery.

To cater for this demand there has grown up a fairly substantial private industry in the investigation and treatment of impotence, with its own jargon, its own shorthand and its own battery of weird tests, such as the cavernosogram, the penile artery angiogram and the erectometer.

I’ll get to these in a minute. First of all you have to know how the miracle of the male erection comes about, which Dan and I will now explain.

The penis, Dan decides, as we sit on the veranda with the coral chiming above our heads, is best described as a sort of damp loofah. With a central tube along the underside which carries the urethra and two great spongy pods above. When these spongy areas (the corpora cavernosa as they’re called) become pumped up with blood, the penis swells and becomes erect. When the blood drains out it becomes limp. This simple hydraulic mechanism supports all sorts of hopes and expectations of both parties in the sexual act.

To function correctly it requires the arteries going into the penis to dilate and increase the blood flow. It also requires the veins leaving the penis to constrict and stop the blood leaking out. These blood vessels dilate or constrict in response to nervous stimuli, so the whole apparatus is under the control of the nervous system, which is itself controlled by the conscious brain to a greater or lesser degree depending on the individual.

Somewhere the male hormone testosterone comes into the picture as well, although even Dr Dan, who has worked in this field, doesn’t know exactly what part it plays in the process. What we do know is that castrated men have difficulty raising an erection, so there is more to the phenomenon than just nerves and blood vessels, etc. Of course you didn’t need me to tell you that.

Essentially how you get an erection is a mysterious process, as witnessed by the fact that most men will occasionally fail to get one when they’re expecting it. This generally comes as a profound blow to the average male ego, which is an unstable, tumescent thing, and very vulnerable to knocks. If, for some obscure reason, the penis fails to perform, this sets in motion a psychological chain reaction which tends to compound the problem. In truth there’s no such thing as purely physical or purely psychosomatic impotence, they almost always coexist.

But the way you distinguish broadly between the two is to ask the patient if they are having ‘accidental’ nocturnal erections. If so you can reassure them that their equipment actually works when their brain takes a rest. The problem with recognizing these nocturnal erections is that the owner might well be too fast asleep to appreciate them, which is where the erectometer comes in. This is a device you wear around the base of the penis, which registers the happy event even if no one else does. Total physical inability to get an erection can be a temporary side-effect of drugs – commonly alcohol and other mind-altering substances, and the drugs taken to lower blood pressure. Then again it may be that the nerves to the penis have been damaged by, say, long-standing diabetes or multiple sclerosis. Or it may be that the arteries and veins of the penis don’t connect up properly. There’s now a whole new range of tests for this type of disorder. Generally they involve injecting X-ray-opaque dye into the arteries (angiograms) or veins (venograms) of the penis to outline the pattern of flow. If you spot an abnormality, then, occasionally, vascular surgery can rectify things.

You may not require anything quite so drastic. The simplest device for achieving and maintaining an erection is a simple rubber band, worn at the base of the penis to impede the venous drainage. This is the trick used by male pin-ups in order to achieve a suitably provocative state of semi-tumescence.

Alternatively there are several drugs which the patient can inject into a penile vein when required. The very thought of this would make most men wilt but I suppose you can get used to anything. For cases of totally intractable impotence there are various surgical implants which can stiffen the organ artificially. The most basic implants are semi-rigid things, which you bend downwards when you need to tuck your penis in and bend up again when the need arises.

The more sophisticated models are inflatables – such as two little plastic pontoons sewn inside the corpora cavernosa – which can be pumped up with silicon gel. The pump, Dan tells me, is stitched in underneath the skin at some convenient point, either just above the groin or inside the scrotum, so you reach down and squeeze one of your testicles when you want to get the pressure up. This sounds to me like a pretty impressive piece of bioengineering, but Dan, typically, disagrees. He has read a study of patient satisfaction with this device, and says that about half the patients who get one are less than impressed with the result.

So our conversation wanders off the subject, swinging this way and that in the sea breeze, like my mobile made of coral and fishing line. We stop talking about the crude mechanics of treating impotence and discuss the more interesting question of why it should be a problem. Most of the men who came to see Dan at the dick clinic said they were not too bothered for themselves – it was for their wives’ sakes that they wanted treatment. If you accept this at face value it begs the question whether men really need sex as much as we suppose. Not having sex won’t make you ill. Is the male sex drive just a reflection of different sorts of want, which can be satisfied, if necessary, in other ways – the simple need for intimacy, the need for affection?

This is a subject close to Dan’s heart. He has been living here on his own for the past year. I tell him that one evening a while back – it was an evening such as this – I was sitting on the veranda listening to the sound of the surf and talking to one of the local Catholic priests about celibacy. He said: ‘Of course priests have sexual desire, but you learn not to dwell on it. You can say to yourself, ‘Now there’s an attractive woman’, and experience a brief frisson of pleasure, but it’s quite possible to leave it at that.

It’s possible just to recognize desire and move on.’

The other interesting thing he said was that actually the benefits of not having sex with anyone outweigh the advantages. If you make a point of being celibate as a man it gives you an access to women that most men are denied. You can become intimate in the extraordinary way that gay men are intimate with women. And priests, and doctors, I suppose. Being celibate has that advantage.

I suggest this to Dan. He’s looking up, squinting through his glasses at the mobile I have made. There’s a long pause and I’m waiting for him to say something typically provocative and debunking. But the silence just goes on.

I think he’s sleeping.

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