Editor's Note: The following letter, though lengthy, is printed in its entirety because we feel it illustrates the complexities that individuals sometimes face with issues of sexual health. A quick answer is not the cure for this reader's concerns, and our sexual health experts recommended that we speak to a range of specialists in answering them fully. We also feel other readers will identify with at least some of the situations described here - and will benefit from the answers.
Q. I am a healthy, active 73-year-old widower. I have coronary artery disease and had a 5-way coronary artery bypass in 1986, but no heart attack.
My wife of 46 years died in 1988 after fighting ovarian cancer for two years. We had what I would characterize as a routine sexual and loving relationship for the first 33 years. After that, it deteriorated to an almost non-sexual condition because of emotional reasons (anger, resentment on both sides). I had discovered that I was becoming occasionally impotent in about 1982, but under the circumstances of my marriage it made little difference. During those latter years, I resorted to only occasional masturbation and did achieve climaxes. But by 1988 some stimulation with a hand vibrator was required.
By late 1989 I had gotten my life back together and was very fortunate to meet a lovely lady, a widow of eight years. We both fell in love. She is a loving, caring and passionate person. I told her of my problem with impotence, and she was very understanding. We made love using methods other than intercourse. After such a long period of abstinence, I was thrilled even without the ability to have intercourse or climax. (My last ejaculation was in November 1989 after a long attempt with masturbation.)
In December 1989, I consulted a urologist specializing in potency problems and subsequently got a penile implant. It works great and my lover and I are delighted. She is wonderfully passionate and has multiple orgasms, which gives me great pleasure and satisfaction. Now, life would be even sweeter if I could climax at least occasionally. I took this matter up with my urologist, and as a result received a series of testosterone injections. They did not improve my situation.
If my understanding is correct, testosterone is intended to increase libido, the desire to make love. I have more than enough of that, given the wonderful support of my partner. My problem is that I get little or no erogenous sensation from caressing and fellatio of my penis, and even the expected erogenous feelings from passionate kissing do not materialize.
The closest thing to erogenous feeling for me is when my partner stimulates my nipples in the early part of lovemaking. But even that sensitivity fades after a short time. In addition, very infrequently, I sense upon arising in the morning that I might have the erotic feeling. I have tried masturbating then and found initially some of the old sensations, but these fade after a very short time. We have tried making love at that time period when I have that urge but get the same disappointing results.
I have told my urologist about the lack of erotic sensation. I described the fact that there is very little sensation in the head of my penis (I am circumcised). But the area just underneath the head, where it joins the shaft, is more sensitive to stroking. I stroke there when I have to stimulate the start of urination since I have mild BPH (benign prostatic hyperplasia). However, there is no erotic feeling when my partner and I attempt to stimulate this area during lovemaking. My urologist had no suggestions, and opined that the "nerve endings were burned out." Is there some hope that I can overcome this deficiency? If so, what should I do?
(Note: In a subsequent telephone conversation with Sex Over Forty, the writer of this letter mentioned that he no longer sees the urologist who gave him the implant surgery and later suggested his nerve endings were "burned out." He has started seeing another urologist regarding his prostate enlargement but has not yet discussed his difficulty in experiencing erotic sensation. He also suggested to Sex Over Forty that part of his problem may be psychological, perhaps involving "guilt feelings" about getting involved in a relationship after the death of his wife. He is now married to the partner he speaks of in his letter.)
A. Since your problem is long-standing and multidimensional, involving an array of physical and psychological factors, there is probably no one simple solution. You were right to stop seeing your former urologist, who was clearly dismissive of your problem. You should discuss the situation with your current urologist and probably consult other health professionals, including a sex therapist, as well. But before you do, it is to your benefit to be as well-informed as possible.
To help provide you with information about the possible causes of your problem, as well as its resolution, Sex Over Forty spoke with several medical doctors and psychotherapists, all of whom have expertise in dealing with sexual dysfunction. They are: Steven Auerbach, MD, a urologist in Newport Beach, CA; Steven Morganstern, MD, an Atlanta urologist and co-author of The Prostate Sourcebook; Paul Salkin, MD, an attending psychiatrist at Beth Israel and Lenox Hill Hospital in New York City; Seth Prosterman, PhD, a certified sex therapist in San Francisco, and Michael A. Perelman, PhD, a psychologist and acting co-director of the Human Sexuality Program at New York Hospital-Cornell Medical Center. Their suggestions are incorporated into the following information.
First, you should get a complete medical check-up. Certain medical conditions can cause anorgasmia (lack of orgasm) and loss of sexual sensation. For instance, prostatitis - inflammation of the prostate gland - can lead to decreased sensitivity of nerves in the genital region. A urologist can diagnose the condition by checking the prostatic fluid; once diagnosed, the condition is easily treated. You should also have your testosterone level checked. Although you say that receiving testosterone injections several years ago was ineffective, you do not say whether your testosterone level has been examined recently.
If you are currently producing insufficient testosterone, this could be a factor in your lack of erotic sensation. There are alternatives to testosterone injections, such as receiving the hormone via skin patch. The best source to consult is a urologist who specializes in treating sexual dysfunction. If your current doctor does not, contact a medical center in your area to find a urologist who does. Certain prescription (as well as recreational) drugs can interfere with sexual sensation and orgasm. For example, the antidepressants known as selective serotonin reuptake inhibitors (SSRI's), including Prozac and Zoloft, are known to have this side effect in many users. Let your physician know what medications you take, including the dosage; you may benefit from switching drugs. Heavy consumption of alcohol (more than two drinks a day) is also associated with diminished sexual sensation; if you drink, you may want to consider reducing your intake or quitting altogether.
It is possible that the penile implant you received was not properly fitted, which could be another reason for loss of sensation. However, getting a new implant should only be considered as a last resort. There are other, less invasive measures you might undertake to restore sensation.
Among these are:
Viagra: This may or may not be an option for you because you suffer from coronary artery disease. If you are taking certain heart medications, Viagra could cause serious illness and even be fatal. This decision should be left up to your doctor. Although Viagra is known primarily for treating erectile dysfunction, it also has been shown to increase sexual sensation and restore orgasm in some users. Morganstern recently studied 15 patients (four with penile implants) who were anorgasmic and experiencing little or no sexual sensation for a period of years. After treatment with Viagra, 12 of the 15 were able to achieve orgasm. Improvement took place "fairly rapidly" and without side effects.
MUSE: With this drug delivery system, the medication alprostadil is inserted into the penis via a thin tube placed in the urinary opening. This increases blood flow to the penis, which, in addition to improving erectile function, may enhance sensation.
L-arginine: This amino acid has been shown to be effective in triggering the production of nitric oxide, a substance involved in relaxing muscles inside the blood vessels of the penis - thus helping increase blood flow to the area. Products containing L-arginine, such as Viramex, may help when taken orally. Consult with your physician before you try any L-arginine products.
Sexual experimentation: Trying different techniques during masturbation or activity with your partner may also help. For instance, using your hand to grip the base of your penis and pull back the skin may make the head of your penis more sensitive.
Since you mention that you experience mild sexual sensitivity in certain circumstances (e.g., having your partner stimulate your nipples, using a hand vibrator to masturbate) you may also benefit from "concentrating on and combining those circumstances you find somewhat arousing," suggests Perelman.
Try using a hand vibrator to stimulate your penis while your partner stimulates your nipples. Focus the vibrator stimulation on the coronal ridge of your penis (where the head joins the shaft), which you indicate is more sensitive than other regions. Engaging in all of these activities simultaneously may result in increased sensation. Don't be discouraged if you don't feel much the first time; let yourself get used to making love in this way and give it a number of tries.
Engaging in fantasy, too, can be helpful. Even though you find your partner attractive and desirable, fantasizing about other sexual situations can help distract you from any performance anxiety you may feel during lovemaking. Both men and women engage in sexual fantasy to heighten arousal, during partnered sex as well as masturbation. Such fantasizing is fairly common, and engaging in erotic fantasy does not mean you love your partner any less. Watching adult videotapes or looking at erotic magazines before sexual activity may also heighten your arousal.
Finally, you should seek out a sex therapist or psychotherapist with an expertise in sexual issues. As you noted yourself, you may be experiencing residual anxiety about getting involved in a relationship after your first marriage. A qualified therapist can help you resolve these and other emotional issues that may be interfering with your sexual response. We recommend that you and your partner attend therapy sessions together since this a problem that affects both of you.
For a listing of names of certified sex therapists in your area, you can contact the American Association of Sex Educators, Counselors and Therapists. Write to: AASECT, PO Box 238, Mt. Vernon, Iowa 52314-0238.
Your determination to resolve your problem is admirable. Given the recent advances in the treatment of sexual dysfunction, along with your strong motivation to get more physical pleasure from sex, there is certainly reason to be optimistic.