KEN BADER: A 50-year-old fellow from Ohio writes to ask, "What treatments are effective for erectile dysfunction for diabetic men with circulatory problems and/or neuropathy?"

DR. GOLDSTEIN: Yeah, unfortunately, diabetes is not a great disease to have in terms of the ability to get penile erections. It's extremely common to have erection problems with diabetes. And we advise you to have visits to a doctor and be managed in a way very similar to non-diabetics. You would undergo a history, physical examination, laboratory tests and probably managed by first-line therapies such as Viagra. Should these fail, then second line therapies, which would involve the pellet or the injection, or if those fail, third line therapies such as implant would be advised. We have had success with diabetics, with circulation problems, and nerve damage with Viagra.

KEN BADER: A 39-year-old male listener writes from Virginia, "Would consumption of alcohol cause a decrease in erection firmness?"

DR. GOLDSTEIN: That's an excellent question. It depends on the degree to which the alcohol is consumed. In the Massachusetts Male Aging Study, which was a large-scale, randomized, community-based sample of men who were assessed for what predicted erectile function, in addition to how often erectile function existed, which would be prevalence, ethanol use or alcohol use was actually not a statistical indicator of erectile dysfunction unless and until the alcohol consumption was fairly excessive. There are lots of reports that minor use of ethanol actually prevents vascular disease, which turns out to be probably the basic underlying dysfunction in the majority of men with erectile problems. So I guess the message is, you can drink minimally, but not excessively, and still maintain erectile function.

KEN BADER: This is an interesting question from a 45-year-old man from New Hampshire. He writes, "I have no problems achieving an erection, nor do I have problems sustaining it, but I do have trouble reaching an orgasm. Is this a sign of impotence?"

DR. GOLDSTEIN: It's a similar question to one we've just answered. Orgasm, ejaculation and erection are real separate sexual functions in men. Of course, another sexual function is drive, what we call libido. There are several reasons for men to have delayed orgasm, or diminished orgasm. And the most common, I would think, is just simply aging, changes in sensation. Since orgasm ultimately is a sensory event, sensation must reach a certain part of the brain in sufficient quantity as to then release what we call a propagating wave, which spreads in a portion of the brain resulting in the pleasure of orgasm. If you don't reach this ultimate sensation event in the brain, orgasm won't happen. Also medications prevent orgasm. Medications for example, such as things like Prozac, drugs that are for depression, we actually use for men who have premature ejaculation to slow down their orgasm ejaculation reflex. I would strongly encourage you to see a doctor. One of the best t herapies we now have is vibration therapy, to enhance the amount of stimulation to the important part of the brain that orgasm is happening.

KEN BADER: Here's a question from a 31-year-old woman in Ohio. She writes, "My husband is 31 and has suffered from impotence for about six months. We are at a loss for a reason why this has occurred. He is not able to achieve and maintain an erection. However, he is able to achieve orgasm and ejaculate through masturbation, during which he still does not achieve an erection." Her question is, "Do you have any explanation for why this may be occurring?"

DR. GOLDSTEIN: This is a great question and one that speaks of many different topics. So let's do the best we can in a short period. The fact that he has an erection problem that is consistent for six months meets the actual definition of impotence. We don't include men who have impotence with one night of activity. The second issue that this question addresses is the orgasm. Ejaculation clearly can happen normally in men without erections. You can actually have wonderful quality, well maybe not wonderful quality, but less forceful orgasm and ejaculation without good quality erections, but at least you can have them and get the sexual release. So they're not related. The young person aspect, that he's only 31, is a fascinating discussion in erectile activity, because by and large this is a disease of aging, and of aging blood vessels secondary to cigarette smoking and diabetes and high cholesterol. What we're finding more and more is that the young impotence is due to the same vascular damage, but that vascular damage is due to trauma. And I just wonder if we can ever speak to the other side of this. That this man is not a bicyclist or is a karate person, has been kicked in his crotch or has fallen on a fence post or fallen on a piece of concrete in his crotch, because that is likely the explanation if you think about it. I would strongly encourage this individual to see, in particular, a urologist, where specialized testing can be taken.

KEN BADER: Here's an interesting situation described by a 43-year-old male listener from Florida. He says, "Recently, I have experienced difficulty in sexual arousal. What effect does a geographical relocation, such as moving from 3,800 feet elevation to sea level, that's number one. Number two, gaining approximately 20 pounds, and number three, having an increase in stress related to job change, have to do with this?" Three interesting situations.

DR. GOLDSTEIN: Well, gaining weight, having stress, and geographic location, are great reasons for having arousal problems. Arousal is very much related to how one feels, how one is comfortable, how one -- it's as much psychologically as an indicator of psychological health as anything is. So simply waiting this one out or actually seeing a psychologist to gain more control over your situation, your psychologic stress, would be useful. There are other reasons for poor arousal and that of course is related to hormones. And that is another possibility for this individual, to get tested for hormones. The most common reason for arousal when you have an erection problem is the erection problem. Because if you're, you know, if you can't perform, your arousal situation diminishes greatly.