HEALTH / Second Opinion

Advertisements for medical and surgical treatments have become commonplace in newspapers and magazines recently. People are encouraged to buy self-help manuals on conditions as various as irritable bowel syndrome and incontinence. Many of these advertisements deal with disorders that men find embarrassing, such as baldness, prostate problems and, especially, impotence.

Since the dawn of human history impotence has been a source of anxiety for men and of income for their mainstream medical advisers, as well as for herbalists, counsellors and a variety of charlatans. The sufferer needs an informed guide to help him through the choices available.

The surge of medical interest in impotence began in the United States more than 20 years ago when surgeons, realising that there was a vast potential market for an effective treatment, began the development of a mechanistic solution. The simplest implant is a stiffening rod which is inserted deep inside the penis and provides it with a permanent state of semi-rigidity. More elaborate devices were devised, one involving an implanted cylinder which could be pressurised by an implanted pump, so allowing the penis to be stiffened or relaxed at will. Implants are expensive and good results cannot be guaranteed, but many thousands of customers were reported to have been satisfied.

Meanwhile, however, sex therapists were claiming - with justification - that most impotence has a psychological basis and that counselling techniques were effective for most couples. This claim raised one serious problem: by no means all the men who wanted treatment had a partner prepared to undergo therapy with them. The choice of therapies was then widened by the discovery that an injection of the drug papaverine into the penis will in virtually all cases produce an erection that will last long enough for sex. Various simple self-help devices have also been developed to induce an erection by creating a vacuum around the penis or by blocking the blood flow out of it.

With so many choices available, what the impotent man needs - and may find difficulty in getting - is a proper diagnostic assessment rather than a manual of possible treatments. Every man has an occasional failure but, depending on the circumstances, he may lose confidence and slide down a staircase of failure, less confidence, fear of further failure, and eventually sad belief that his impotence is permanent. He may have a physical cause for his problem: complications of diabetes, narrowing of the blood vessels from atherosclerosis, low sex hormones associated with alcoholic liver disease, and - an important and reversible cause - a side effect of drugs, including some of those used to treat raised blood pressure. A physical problem may be magnifed by the man's psychological response to it.

The advocates of self help point out, quite rightly, that since most impotence is psychological it follows that if confidence can be restored by a mechanical device then there may be no further problems. But psychological problems often need psychological solutions, and with so many different approaches to the treatment possible, surely this is a condition where the sufferer needs advice from a specialist. Free access to specialist opinion used to be the great merit of the NHS, the feature that really did make it the envy of the world. But times have changed, and men worried about impotence may have difficulty getting a referral

to an appropiate specialist, or find that the specialist has a very long waiting list. And so the entrepreneurs step forward.