2009-08-28 NYTimes - For E.D., Hope Beyond a Pill

[Joseph]

Let's see, where are the "studies" that measure the incidence of ED in circumcised vs. intact men?

The silence is deafening.

Not a single consideration that it could be the missing 20,000 nerves and leathered glans.

http://www.nytimes.com/2009/08/29/health/29patient.html

Patient MoneyFor Common Male Problem, Hope Beyond a Pill

By LESLEY ALDERMAN
Published: August 28, 2009

IF you watch enough television, you’d think that treating erectile dysfunction was as effortless as popping a pill and then whirling your partner around the living room in a romantic dance. Correcting erectile dysfunction, alas, is not so simple — and it can be rather costly. One Viagra pill, for example, the most common way to treat erection problems, costs about $15.

Dr. Andrew McCullough is an associate professor of urology and director of Male Sexual Health and Fertility at the Langone Medical Center at New York University.

Insurers can be chary of reimbursements. And despite the fact that E.D., as the dysfunction is known, becomes increasingly common after men reach 65, Medicare Part D does not cover drugs for it.

An estimated 30 million men in this country experience erectile dysfunction. Nearly a third of men in their 50s experience E.D., whereas more than half of those in their 60s have the problem.

If you’re hoping to have Viagra-aided sex twice a week, your bill for the entire year could run around $1,500. If you’re fortunate enough to have insurance that covers the medications, your co-pay will be on the high side, around $40 for a one-month supply of six to eight pills — bringing your annual bill to a more manageable $500 or so. There are no generic versions of E.D. meds yet.

Even among the name-brand drugs, which also include Cialis and Levitra, the medications do not work for about half of the men with E.D., says Dr. Ajay Nehra, professor of urology at the Mayo Clinic in Rochester, Minn. He is also president of the Sexual Medicine Society, an association of health care professionals.

And yet, as it turns out there are other treatments for E.D. And some of them are more cost-effective than the brand-name pills advertised on television.

“There is not a man out there that cannot be helped in some way with his E.D. — even if money is an issue,” says Dr. Andrew McCullough, an associate professor of urology and director of Male Sexual Health and Fertility at the Langone Medical Center at New York University.

The first step is to see a doctor who specializes in E.D. (usually a urologist) and have your overall health checked out. If your primary care physician can’t make a recommendation, contact the Sexual Medicine Society and ask for a referral.

In many of cases, E.D. is the sign of an underlying disorder like diabetes or hypertension. In fact, in younger men, erection problems are often the first symptom of cardiovascular disease.

“Erectile problems may show up about three years before a cardiovascular event such as a heart attack or stroke,” says Dr. Ira Sharlip, clinical professor of urology at the University of California, San Francisco.

That’s because plaque will start to clog the small arteries in the penis before the wider coronary arteries. Your doctor will also try to determine whether your E.D. is the result of a psychological issue, in which case he will refer you to a therapist. Depending on your policy, your insurer may cover a set number of visits. (One way for you to check on your own whether your issue may be psychological or physical is try the postage stamp test, also known as nocturnal penile tumescence test.)

By adopting healthier habits, you may be able to improve your overall well-being and restore your erectile function.

“There is increasing evidence that we can reverse erectile dysfunction with lifestyle changes,” says Dr. Drogo K. Montague, director of the Center for Genitourinary Reconstruction in the Glickman Urological and Kidney Institute at Cleveland Clinic.

In a recent study of men with E.D., or at risk for developing it, researchers in Italy found that the men could improve their erections by losing weight, improving their diet and exercising more frequently. After two years of significant lifestyle changes, 58 percent of the men had normal erectile function, according to the study, which was published in The Journal of Sexual Medicine in January.

But lifestyle changes, while basically free, can be difficult to make and may take months to take effect. In the meantime, your doctor will probably prescribe a phosphodiesterase type 5 inhibitor, also called a PDE-5 inhibitor, like Viagra, Cialis or Levitra. These drugs enhance the effects of nitric oxide, a chemical that helps to increase blood flow in the penis. The three drugs work in the same way, but differ in how quickly they take effect and how long they last. If the PDE-5 drugs don’t work for you, don’t give up quickly, says Dr. McCullough, who theorizes that “in over 40 percent of drug failures the problem is with the user, not the drug.” Dr. McCullough adds, “it’s important to take these medications as directed, like on a totally empty stomach, rather than a full one, and not less than 60 minutes before sex.”

If the pills don’t work for you, you might want to try self-administered injections of alprostadil, a drug that helps blood vessels expand and facilitates erections. Granted, this may sound onerous, but the shot, which is sold under the brand names Edex and Caverject, is done with a fine needle, feels no worse than a pinprick and produces an erection that can last up to four hours, according to doctors who recommend it.

The shots cost about $35 per injection and are covered by most insurers, but not by Medicare.

But ask your doctor about an injection that’s a cocktail of generic forms of alprostadil, papaverine and phentolamine.

Although this generic combination is not F.D.A.-approved as an E.D. treatment, doctors are legally free to administer it — and both Dr. Sharlip and Dr. McCullough recommend it.

“The generic injections clearly work the best,” Dr. Sharlip said, “and are usually less expensive.”

Another cost-effective option is a vacuum erection device or penis pump. It works like this: you place a tube on the penis and then pump the air out of the tube, which pulls blood into the penis. When the penis is erect, you then put a snug ring around the base to maintain the erection, which lasts long enough to have sex.

The cost for the device, which requires a prescription, can run from $300 to $600, but most insurers and Medicare will cover part of the cost and the device should last for years. Even if you spend $300 out of pocket and use the device once a week, you’ll be spending much less per year than on pills or injections. You can also buy a nonprescription pump online (even Amazon carries some) for as little as $30, Dr. McCullough said.

Finally, if all other treatments fail, you could consider getting penile implants, an effective and permanent solution for chronic E.D. The most common type of implant works through inflation: two cylinders are placed inside the penis and a fluid-filled reservoir is implanted under the abdominal wall or groin muscles; a pump and a deflation valve are placed inside the scrotum. To create an erection, you pump fluid from the reservoir into the cylinders. To deflate the penis, you press the release valve.

Most insurers and Medicare cover the surgery, so your out-of-pocket costs will be minimal. This might be the most cost-effective strategy of all since, according to Dr. Nehra, 80 percent of implants last 10 years.

[cloud7]

Originally Posted by Joseph

Let's see, where are the "studies" that measure the incidence of ED in circumcised vs. intact men?

in the african intact verse circumcised study they reported them although they danced around them and mislead them of course, I don't remember the exact numbers but it was something like 99.9% of intact men said sex is pleasurable and they said 98.4% of circumcised men said sex is pleasurable and then used these to say the numbers were almost identical and that circumcision did not reduce pleasure (as if that was what they measured at all, sex without a foreskin is still pleasurable but not as great and that's what they didn't measure). the numbers were similar but to a lesser degree for is penetration possible. anyways the study could have said:

circumcision causes 1600% in men who don't find sex satisfying
circumcision increases male sexual penetration difficulties 500%
circumcision will make sex un-pleasurable for 1.4 out of every 100 men circumcised

[Someone mundane]

It's ALWAYS an amazingly complicated disease or fat lifestyle, isn't it. (Bit of sarcasm there.)

Nevermind that last solution. Yuck yuck yuck... If I ever run into severe E.D. during my own lifetime I would NOT like to have a purely mechanically functioning penis. Those "implants" do not even sound the same as a normal erection. Blood provides for other things, such as oxygen to the tissues. That idea right there just seems like it'd only serve to poorly imitate an erect one... And that's being generous. (Then again I don't know much about it sooo...)

I don't know whether it is because of the thinking that erections can happen more frequently from mental things alone...

Or that missing tissue which probably contains nerves to help trigger, along with it's own blood supply, and keeps things sensitive and supple on the surface of the penis is not given a thought.

Maybe it's just a combination of the two mindsets.

Giving them credit, E.D. CAN probably be more complicated than just a missing foreskin. Think of all the underlying biological processes... There's just so many ways to get an erection. And they also rely on sleep testing to be the lone definitive indicator for if there is a physical problem or mental one in a clinical setting I think...

It's possible that the foreskin missing could make it more difficult in some cases to attain an erection, (Usually being awake probably) but I doubt it's that severe of a factor. The foreskin itself is not even a part of the spongy erectile tissue beneath which is what fills with blood and thus gorges the entire penis. That's the most important thing. I don't know if this could be considered a good thing to be thankful for in our cases, (cut) or a bad thing, because while likely the most factually accurate conclusion, it just helps twist views out of place from the most important things all the more and makes some people lose sight of the arguments against. That it isn't necessary and is merely a subtraction. Which when it comes to this is of pointlessness at best. Also that everyone should get their choice... None has the right to deprive, just the basic stuff.

Overall though I'm not too sure if the anti-circ arguments can really be that easily applied to erectile dysfunction. Consider the foreskin for what it is... Not an essential portion of the whole, but a beneficial one nevertheless. It is desirable to have. Just not the only thing that is important where it concerns an erection. I don't doubt that it could play a part, I'm just saying that it's likely not the most important thing.

Now regions which most frequently use lubricants on the other hand... THAT I can definitely understand and find somewhat difficult to refute by anything really. Intact men have looser skin which slides and has stretch sensation. Lubricants can still be used, but they're really nowhere near as badly needed. It's as simple as that.

[peterpink]

Some have suggested there is a relationship between the sensitivity of the foreskin's ridged band and the initiation and sustaining of erection.

'Thanks to its ridged band, the inner lining of the foreskin is specialized sexual tissue. The ridged band readily expands and contracts and is obviously designed to detect stretching forces. When penile shaft skin tugs on the ridged band, special “genital corpuscles” in the peaks of the ridges detect movement and trigger ejaculation. Stretching of the ridged band may also trigger and sustain erection.' http://research.cirp.org/func1.html

[Joseph]

I think a good indicator is measuring where E.D. is prevalent.

I think cobra was saying that the facts are that viagra sales are the highest in the US?

[Someone mundane]

Of course, like I said I don't doubt that it could play a role.

However.

I know for a fact that even mutilated as my penis is, all I need to do is clear my mind of lewd thought, grab it, and start massaging it and an erection will trigger, regardless of the ridged bands supposed absence or my mental state.

In light of this, it is HARDLY a requirement to initiate erection or sustain it in my opinion.

Another interesting note: When I tug my shaft skin down towards my scrotal region firmly enough when erect, that can be enough to cause me to ejaculate as well. Whether that's because of some ridged band remnants, pressure on the internal structures, or even pulling the frenulum remnant... I can't really say. Too many possibilities.

I make no claim that this applies to others, only that it could, and that it has been my own personal experience. All I'm saying is to keep proper perspective. Human rights is MORE than enough reason to keep fighting for this. Preserving function is just the icing on the cake.

EDIT: Joseph, you could be right there. I haven't really looked into it that thoroughly myself. BUT, doesn't the US also have pretty high obesity rates? You have to consider that too. That would lead to heart problems which can in turn also contribute to E.D.

[estefan]

this is one thing that never convinced me. erectile problems are generally psychological or have to do with blood pressure and that kind of thing. you don't necessarily need physical stimulation to get an erection, do you? so why would a procedure that desensitizes the penis have any effect on erections?

[rtnt]

Because physical stimulation of the genitals helps increase sexual arousal which helps a male maintain his erection. So the ridged band can play a big part in helping a male keep his erection because of the ridged band giving strong erogenous feelings of pleasure that increases sexual arousal which makes the male more likely to maintain his erection. Usually though if circumcised or not, a male will not have a hard time maintaining an erection unless if he is old or unless if he recently had sex a bunch of times.

[Tally]

Originally Posted by estefan

this is one thing that never convinced me. erectile problems are generally psychological or have to do with blood pressure and that kind of thing. you don't necessarily need physical stimulation to get an erection, do you? so why would a procedure that desensitizes the penis have any effect on erections?

To me the circumcision related ED problems are for guys past 40. By that age, the keratinization is so great that sensitivity typically has fallen drastically. Granted, this does not affect every cut guy. But I think it is more prevalent the older the guy is.

Sure, you can get an erection from purely mental stimulation. Before I started restoring, I could get an erection, but keeping it hard for more than a few minutes became increasingly difficult. Sure, I could fantasize to keep it up, but, hell, that is too much like masturbating with a live pussy.

[1Taoist]

I think what tally is saying relates to the fact that erections are part mental and part physical. ED drugs are for
men whose physical is waning. It effects the production of an enzyme that allows the muscles to relax in a way to better facilitate erection. But the mental thing is more powerful than just the physical, which is why ED drugs are for men screwing the same girl over and over. Put a new pussy in front of a man and I'll show you a man who don't need Viagra. Unfortunately, this is also why so many senators end up ballin other chicks besides their wife- the ED drugs are makin em even better at it.

When we're 20 the erection is mostly physical, some mental. When we're 30 it's less physical, more mental. When we're 40, it's only partly physical and almost all mental (especially if we've been married to the same pussy for years). ED drugs kick in as the physical dwindles, but it's really only meant for monogamous couples in long-term relationships. For non-monogamous couples, it's coke. :-))

This is the connection to circ. Why men who are cut don't "feel" the effects til 40. Until then, the physical still works pretty good, despite the degradation.

When we reach 40, life is more mental, and this can be a problem. When the physical gets "old", we use our mind too much and it dissatisfies us, and the result is waning hard-ons. That's our love/hate relationship with fantasy- it leaves us empty physically. Same with new pussy- makes for great hard-on physically, but leaves us empty. This is why I believe so many report good feelings from restoring, and the release from such mentally-driven erections/orgasms as well as variety-driven erections/orgasms (new partners all the time). The mind plays a role, as does variety, but they must play an integral role and never a dominant one, forsaking the others. Physical is often confused with variety, because variety stimulates the physical to overwhelm the mind.

When we're 40, as opposed to 20, we don't relax as much in the face of sexual situations cuz it isn't as new as it was then, and stimulating situations/temptations tend to be wrong ones, or at least ones we know aren't worth the trouble. When we're 20 we're dumb, and full of cum, so we relax and bam! Hard as hell.

Restoration allows us to have better physical sensation in the face of the right situations, rather than just the wrong ones (if you get my drift). ED drugs help a bit but not nearly as well.

And it's my understanding that Medicare DOES cover Viagra, or at least Medicare part D, and is in fact a huge revenue for Pfizer.