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“So how does diabetes put the brakes on my sex life?”

“For the most part, the ED is induced by vascular disease caused by the diabetes, which results in blood vessel blockages, including the arteries of the penis. Nerves can also be damaged by the disease, which is another factor that hurts your erection capabilities.”

“So, can you fix my problems?” he asked hopefully.

“First of all, control of your diabetes is your most critical health issue right now,” I said. “That means you must make a serious effort to lose the extra weight you have put on over the last few years. And you can do that through regular exercise and adjustments in your diet. As for your erection problem, I can tell you this: while your specific type of ED is not curable, because it’s caused by diabetes, which is a chronic disease, it may be able to be successfully treated with a new oral medication.”

I explained to Jim that in the future Viagra would be_ one of the new medications available to him and that it had a great likelihood of being effective despite the strong biological impact of diabetes on his erectile performance. At the present time, I was using Vasomax in my study. Although it is less effective for men with moderate to severe dysfunction, it can work well for those with either mild to moderate dysfunction or ED caused by psychological reasons.

1 told Jim it was certainly worth trying Vasomax because it was well tolerated, with an excellent safety profile. I explained how the Vasomax study worked and offered him the opportunity to enroll as long as he met all the criteria. He did and three weeks later he called me. “I’m a private kind of guy, but I just had to tell you what happened,” he told me. “It’s been great, being able to really feel again and give Emily pleasure. It just made us grow even closer. I’m a complete man again. I can’t thank you enough. It’s a miracle—and I never thought I’d live to see it.”

Jim’s response gave me two reasons to be thrilled.’ One, I knew that the quality of Jim’s life had improved. And, two, the fact that he had responded to Vasomax pointed out that his diabetes was not as advanced as I had feared. Jim has since shed the extra weight, his diabetes is under control with Glyburide, an oral diabetes treatment, and he still takes his ED medication. The beauty of both Viagra and Vasomax is that they are compatible with drugs most commonly prescribed by physicians.

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The best aspect of these medications is the unique way in which they react biochemically as facilitators and amplifiers of erections. But there must be normal sexual stimulation in order for an erection to occur. In other words, emotion and caring play a big part in how they work successfully. But one thing is certain: they will help a man achieve the best possible combination of desire and physical functioning.

Their expressions mirrored their skepticism, but Mark and Lucy were ready to try anything. After Mark and Lucy signed the necessary papers required for the study and I took a blood sample, I gave him a Vasomax pill to swallow. I noted his blood pressure and heart rate over the course of the next hour. A possible side effect of Vasomax is a sharp decrease in blood pressure and an associated rise in pulse. If his blood pressure dropped by more than 30 points over his predose reading, Mark would be ineligible to use the drug. His blood pressure dropped only 10 points, with no other noticeable change to him. His pulse went up 10 beats per minute, which was to be expected. Mark was eligible for the trial and I supplied him with a month’s worth of the drug.

Several days later,’ I received a fax from patient with just two words: “It worked!”

And a few months later, my patient was not only his old self, he was even better. He was surprised to find that on some occasions he no longer required the medication to achieve an erection. His job performance was stronger than before and he was drinking moderately, if at all. Most importantly, he understood how his ED had developed and hoped that soon he would not need the medication at all. But should his ED recur—for whatever reason—he felt confident knowing that he could go back on the medication under my supervision.

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All adults are entitled to a fulfilling sex life. An active component of complete health, the ability to have satisfying sex is a marker signifying that all the elements which define us are working together seamlessly. By this I mean not only the physical, but the very important psychological and emotional factors as well. What it comes down to is this: sex is good for you.

As an internist in New York City, I see patients who represent a cross section of the population, from every background and of every age. They come to me for a range of reasons, from yearly checkups to follow-ups to surgery, and everything in between. Increasingly, however, my male patients are coming in to discuss their sex lives and, more specifically, their inability to consistently have erections. Whether they are in their thirties, forties, fifties, sixties, or older, this vital part of their being can sometimes falter, for any number of reasons. Wanting to be the best they can be, at every stage of their lives, they ask about the options available to them.

My goal is to give them the best that medical science has to offer to help restore erections. Today, there are extraordinary new additions to the world of prescription medicine which, without a doubt, rank among the most exciting discoveries in recent medical research. Drugs which accomplish what millions of men, and their partners, have been waiting for are finally available.

For every man who is worried about the possible loss of potency —the ability to have a firm erection each and every time he wants to have sex—for every male who has already experienced it, and for every partner who ever wondered what to do, there is not only hope, there is this new medical miracle.

Simply stated, a revolution has begun. Most men, who suffer from erectile dysfunction, or ED, may now restore their virility by taking a prescription pill. The impact on the estimated thirty million men who experience ED cannot be underestimated. Today, ED can be treated successfully more than 95 percent of the time. Nevertheless, fewer than 5 percent of those affected have received treatment.

Effective, and well tolerated, these amazing pharmacological virility remedies are Viagra, the brand name for sildenafil, and Vasomax (phentolamine). For the first time, it is possible to restore optimal sexual function to nearly every man who desires it. And they will put to rest the myth that ED is an irreversible function of aging. In a matter of minutes, the new oral medications can:

• allow a man to have firmer erections to ensure fulfilling sexual intercourse

• renew and strengthen an existing—or even dormant—sex life

• bolster self-confidence

• lift depression associated with ED, thereby positively affecting all facets of a man’s life, including his work

• help to create a relaxed, unhurried window of opportunity to proceed at a couple’s individual pace

• mend relationships torn by frustration

• offer joy in the sexual arena, where little or none had been felt for years

• solidify sexual bonds with a partner

• restore intimacy and thereby deepen relationships

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Talking about man’s reproductive system you know what is on the outside of a man’s body between his legs. In this case imagine he is leaning back rather than lying flat. At the front of his body you can see pubic hair, then under that is his penis. Penises come in a range of sizes, and can look quite small when they are in their normal state. By ‘normal’, we mean when they are not aroused, but are soft and hanging loosely. They have a shaft that is several centimetres long, which starts at the lowest part of a man’s abdomen and ends with a sort of bulb-shaped part that is called the glans. The glans has a different type of skin to the shaft, it is more sensitive, and at the tip of the glans is a little opening to the urethra. Urine, or wee, comes out of here when a man goes to the toilet.

When a baby boy is born he has a fold of skin covering the glans. This is called the foreskin. It is open at the end, just beyond the tip of the glans, so that the opening to the urethra is not covered. The foreskin can be pulled back when the penis is washed, and it moves back to expose the more sensitive skin of the glans when the man has sex. A penis that has a foreskin is said to be uncircumcised.

Some men have been circumcised. That means that their foreskin has been removed. Usually this is done by a doctor, or by a religious elder, when the baby is very young. In some cultures it is done at puberty. Occasionally a man may need to be circumcised later in life for medical reasons.

When a man becomes sexually excited, or ‘turned on’, his penis becomes erect, which means it gets harder and larger. When a man has an erection, it is difficult to tell if he has been circumcised or not because the foreskin pulls back to expose the glans. The penis gets harder and larger because blood flows to spongy tissue in the penis and fills it. The passage from the bladder that carries urine is blocked off so that when he ejaculates, or comes, only semen, which is the fluid containing sperm, is released.

Directly behind the penis is a loose bag of skin called the scrotum. Inside the scrotum are the two testes, or balls, that produce sperm. Sometimes the scrotum hangs loosely, and sometimes it scrunches up tightly close to the body. This generally depends on how the man is built It can also happen because sperm need to be kept at a certain temperature to live, and so when it is hot, the testes may be kept cooler by hanging more loosely away from the body, and when it is cold, they can move up close to keep warmer.

Behind the scrotum, towards the back of the body is an opening, which is the man’s anus. Faeces, or waste from the bowel, comes out here when the man goes to the toilet.

Now let’s look inside the man’s body. This shows the man’s body from the side. Perhaps it would be best to start with sperm production. Look at the testes inside the scrotum. They are about the size of walnuts and are made up of tightly coiled tubes where sperm and hormones are produced from puberty onward. Sperm are really tiny and you can only see them if you use a microscope. You may have heard of testosterone. This is one of the hormones produced in the testes. It is involved in producing male characteristics such as body hair and a deep voice.

Along the back to the top of each testis is the epididymis. The epididymis stores more mature sperm waiting to be fed into the vas deferens when they are needed. The vas deferens is usually just called the vas. One vas leads away from each testis. They are long and narrow and carry sperm to the urethra. The vas loop around the bladder and as they feed into the prostate gland the sperm mix with semen, which is fluid from the seminal glands. The prostate is also where the part of the urethra that is connected to the bladder can be closed off, so that only semen is released when a man ejaculates.

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Waking up grumpy. Under a microscope, tissue taken from the throat of a man who snores looks just like tissue taken from the hands of a man who regularly uses a jackhammer. It is slack and floppy. All the muscle tone has been vibrated out of it. Snoring makes the soft palate at the back of the mouth vibrate. The more a man snores, the more the palate vibrates and the weaker it becomes. The more it weakens, the harder it is to stop snoring.

It is this progressive loss of tone that can turn a mild snorer into a man with a chronic sleep problem. Over a few decades, it can also turn a relatively nice bloke into a grumpy old man. Grumpy because, without even knowing it, he has not had a decent night’s sleep in years.

Until recently, snoring has been largely ignored. It’s been viewed as an innocuous activity which, at worst, irritates the snorer’s sleeping partner. The insidious damage it causes and the resulting ramifications are only now being fully recognized.

Heavy snoring puts tremendous stress on the body. It generates a huge amount of pressure in the throat and can transform sleep from a restful activity into a struggle for oxygen. The development of new technology in the 1970s showed that snoring has the potential to reduce blood oxygen to levels that were previously thought incompatible with human life.

Chronic heavy snorers often have episodes of apnoea when the soft palate and the tongue relax, due to decreased muscle control, and fall back in the throat, effectively blocking the flow of air in and out of the lungs. When this happens the man chokes and the oxygen level in his blood falls dramatically. An automatic reflex usually jerks him into restarting breathing. During such episodes the oxygen level can drop 80 per cent. Repeatedly these men get a fall in oxygen levels equivalent to going up to the top of Mt Everest and back in twenty seconds. Men with chronic sleep apnoea do this hundreds of times a night.

These repeated falls in oxygen have long-term effects on health. Simply having a history of heavy snoring is associated with an eightfold increase in the risk of stroke, double the risk of high blood pressure and an increased risk of heart attack, probably as high as twentyfold. Throat tissue damage can become evident after just five or ten years of snoring. Even in the early stages, the tissue can become so loose that sleeping becomes a night-long battle to breathe. This can happen without the man even being aware of it. All he knows is that he doesn’t feel restored on waking and that during the day he feels sleepy and performs under par.

Men are more prone to snoring than women. Until the age of fifty, about nine men snore to every one woman. After this, the gap begins closing. It is believed that androgens (male hormones) amplify snoring. Men have a lower voice, their throat tissue is floppier, and their larynx vibrates at lower frequencies. At menopause, women’s hormonal balance changes, androgens rise and so does their predisposition for snoring.

Snoring is not inevitable. It is not something men have to resign themselves to. If recognized early it can be stopped. There are several things even an established snorer can do to minimize it. Sleeping on the side rather than the back is recommended. Keeping weight down is crucial. For many men there is a weight threshold above which they will snore. Often a very small amount of extra weight can make a big difference.

Alcohol is a muscle relaxant and relaxes the throat muscles, making snoring all the more likely, so the consumption of alcohol in the last few hours before going to sleep should be avoided. Nasal obstructions, such as allergies or old football injuries, also can lead to snoring and should be treated.

General fitness helps, too, but there are exceptions. Weightlifting or sports which build thick neck muscles can encourage snoring by putting pressure on internal airways. Genetic inheritance is influential as well. Some men are just born with narrow airways and will become snorers. Those with long necks are less predisposed. Giraffes are unlikely to snore, and looking at Nefertiti, it would be a fairly safe guess that she never snored either.

It is when moderate snoring progresses to heavy snoring and incidents of sleep apnoea begin that the activity becomes dangerous. Studies have shown that 25 per cent of middle-aged men (between the ages of forty and sixty) have an average of five apnoeas per hour of sleep. This is regarded as mild apnoea and most men would not know they had it. Men who suffer chronic sleep apnoea may have between 300 and 500 incidents a night. Over time the lack of good sleep begins to show. Signs of personality change emerge, the men feel grumpy and irritable, their short-term memory starts going, and so does their libido.

Treatment for chronic sleep apnoea includes various types of surgery or using a special mask which was developed in the 1980s by Professor Colin Sullivan, respiratory physician at the University of Sydney. This mask has since become the international ‘gold standard’ for treatment. Lasers are also used to operate on the throat to stop snoring.

If you think you suffer from sleep apnoea and need treatment, first see your local doctor. The doctor can then refer you to a respiratory physician who will decide if you need to go to a sleep laboratory.

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