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Friday, December 19, 2014

Dr. Pegs Prescription

Disclaimer: Names and details have, of course, been changed to protect confidentiality. This patient is not real but he is representative of many patients I have seen with the same problem.

The nurse’s note said, “Will not disclose.” This happens when the patient doesn’t want to talk to the nurse about their problem, preferring to wait for the doctor. We respect this choice, although what you tell the nurse is as confidential as what you tell the doctor. Still, some people just don’t want to have to talk about it more than once, whatever it is. Often, “will not disclose” means something about sex.

Sliding open the door, I saw a young man perched on the edge of the exam table, arms and legs crossed, one foot bouncing. His smile was hesitant, his eye contact brief. I asked him some basic questions to put him at ease. His name was Ethan. He was a law student. He moved here from Maine to go to school and was in his second year.

“I’m worried. I think I have a problem. I don’t know; it’s never happened before. See, last weekend, Saturday night, my girlfriend and I were, well, you know…”

“Having sex?” I prompted. Sometimes plain speaking works best.
“Yeah.” Ethan visibly relaxed a little and proceeded to tell me that everything had started off fine, but after only a few minutes of intercourse, he had lost his erection. He was mortified, and left his girlfriend’s apartment shortly after that. She had been kind about it but he was in shock.

“I was wondering if maybe I should get some Viagra or something. Or some tests. What could be wrong?”

We talked some more, and Ethan explained that he had been dating his girlfriend for almost a year. Things were going well, he thought. They were happy together. She was a student too. They were both busy, with full schedules and jobs, but they usually managed a date night on the weekends, and had satisfying sex often. She was taking birth control pills, and they used condoms as well just to be safe. Last Saturday they went out with some friends, had a few beers, and then went back to her apartment.

“I don’t know what happened,” he said, grimacing. “I feel terrible.” He worried that he had let his girlfriend down, that she would think he wasn’t attracted to her, that she would see him as less of a man. After all, he saw himself as less of a man.

“What kind of guy can’t keep it up? I mean, at my age? I’m only 24.” He wanted to have sex with his girlfriend again but he dreaded a repeat performance.

I asked him more details about his health and his life. He is basically healthy. He takes no medications. He has no trouble urinating and he usually wakes up with an erection (that is reassurance that the equipment can function). He eats too much junk food and doesn’t exercise as much as he’d like, both of which he blames on the demands of law school. He doesn’t smoke or use any recreational drugs. Further discussion revealed that he had a big exam coming up, that his grandfather back in Maine was very ill, and that he had consumed more than his usual amount of alcohol last Saturday.

“Well, there you go,” I said. “Triple whammy.” Pardon the pun.

Stress is by far the most common cause of erectile difficulties in young men. It can be stress in the moment, like the worry that you’ll lose your erection again, or more distant stress, like Ethan’s sick grandfather and his upcoming exam. It’s not like Ethan was consciously thinking of either of those things while he was with his girlfriend, but both were there in the background creating a subtext of anxiety. Add alcohol, the second most common reason for erectile failure, and the evening was practically doomed from the fourth beer.

This happens. It happens to more young men than you might think.

When they come to see us in the clinic, we usually ask a lot of questions, do a physical and genital exam to make sure all is normal, and treat with plenty of education and reassurance. If we suspect a physical problem we might do some tests, but for most young men erectile failure is a transient problem — more mental than physical. Alcohol, smoking, recreational drugs and some medications can certainly contribute, and I did advise Ethan to back off the beer a bit, but the main culprit is stress, which is compounded by worry that it will happen again.

Having an understanding and supportive partner who will not take it personally is a huge help. It is usually not about them. A partner who reacts with blame or self-pity just makes it all worse. Of course, sometimes the relationship itself is the source of the stress, in which case that needs to be addressed.

By the end of his visit, Ethan had uncrossed his arms and was looking at me as we spoke. He said he was going to go make an appointment for counseling to help manage his stress. Then he planned to call his grandfather, call his girlfriend to arrange a date, and go study for his exam. He promised to come back and see me if the problem didn’t resolve. I think he is going to be okay.

If you have a problem, SHAC is here to help. Call (505)277-3136 for a medical appointment, (505)277-4537 for a counseling appointment.

Peggy Spencer is a student-health physician. She is also the co-author of the book “50 ways to leave your 40s.” Email your questions directly to her at pspencer@unm.edu. All questions will be considered anonymous, and all questioners will remain anonymous.