Letter to the Editor

To the Editor:

I report herein an interesting case study of non-pharmacologic treatment of erectile dysfunction in an otherwise healthy 57 year old man.

The patient was referred to me by his primary care provider for evaluation and treatment of erectile dysfunction (ED). The PCP had prescribed 50 mg of sildenafil citrate (Viagra) and while it was effective, the patient did not like the side effects (dizziness, flushing, headache). At a lower dose of 25 mg the patient still complained of side effects and had poorer quality erections. He was then referred to me for evaluation.

Past medical history was unremarkable except for a varicocelectomy at age 23. The patient subsequently fathered two children whilst in his thirties. The patient denied any ongoing medical problems including diabetes, hypertension, respiratory difficulties or neurologic changes. The patient was not taking any prescribed medications. OTC he takes omeprazole (Prilosec) and an occasional acetaminophen for headache. He denies use of recreational drugs. He does not smoke. He admits to social alcohol consumption. Physical examination was grossly normal.

Sexual history: patient is in a longstanding and loving marriage of 32 years. His wife is healthy. They have sex one to two times per week, usually initiated by the patient. Patient stated that he did not always achieve a full erection which seemed to disappoint and, at times, displease his wife. Upon further questioning, patient admitted to daily masturbatory activity, usually in private. Typically, he masturbated to orgasm using only his hand.

Based on my evaluation, I concluded that his regular masturbatory habit was likely interfering with his erections when he desired to have sex with his wife. Given that he had negative sequelae with sildenafil citrate, I doubted that a trial of tadalafil (Cialis) would be any more effective or acceptable to the patient. Thus I suggested a period of abstinence from self-stimulation and orgasm. I explained to the patient that he did not need to abstain from sexual activity, only from daily masturbation and orgasm, either alone or with his wife. I further explained that this abstinence could be accomplished voluntarily although some men opted to use a mechanical device to prevent them from touching their genitals and achieving erection and orgasm. Lastly, I explained that the process might require several weeks to evaluate its success as opposed to minutes when using a phosphodiesterase type 5 inhibitor. The patient verbalized understanding and agreed to a trial. Follow-up was scheduled for three months.

Upon his return to my office, the patient informed me that he had, in fact, purchased a commercially made “chastity device” (CB-6000s, manufactured by A.L. Enterprises, Inc., Price, Utah). He subsequently purchased a second device (the “Jailbird,” manufactured by Mature Metal, Midland, Texas) because his wife found the polycarbonate of the CB esthetically displeasing. His initial period of abstinence from orgasm was 60 days. Note that I did not suggest this time interval. This was a decision made by the patient and his wife.

Upon release from the device, the patient was able to achieve an erection and orgasm although he rated the quality of the erection as “average” and the intensity of the orgasm as “mediocre.” He attributed this to personal stress as well as unrealistic expectations from both his wife and himself as to what they would experience after such a lengthy period of denial. After a 24 hour period of release he returned to wearing the metal device on a continuous basis.

After a 20 day period of abstinence from orgasm the patient was awakened from his sleep by his wife who was stimulating his genitals with her hand. He noted at this time he was wearing a locked cock ring which provided total access to his penis. As an aside, he noted that his wife had become quite enamored of his chaste state and had requested that he wear a device on his genitalia at all times except when she determined otherwise. He had agreed to this. It was at this time that the purchase of the cock ring, also manufactured by Mature Metal, was made.

On the morning in question, the patient was successfully stimulated to orgasm by his wife, although they used a technique colloquially known as a “ruined orgasm.” This was a mutual decision as his wife was menstruating and unable to have intercourse. A ruined orgasm, for those not familiar with the term, is one in which the man ejaculates but does not have the explosive release and subsequent sexual satisfaction as with a traditional orgasm. Still, the patient reported that the experience was quite pleasurable and he would be interested in repeating it. More importantly, he reported that the quality of his erection was “excellent.” He estimated his penis to be 5.5″ in length and 1.5″ in diameter. He was able to maintain his erection through his entire time of stimulation and beyond. He did note that the cock ring might have some effect on his erectile quality and wondered if he would be able to wear it during intercourse without injuring his wife. I demurred to answer that question.

In addition to being able to achieve and maintain an erection, the patient noted that overall, the quality of his sex life had improved dramatically during the three month trial. He reported increased sexual activity, greater intimacy, improved communication, and in general, greater feelings of affection, tenderness, and closeness with his wife. He reports that she is also experiencing these same feelings and seems pleased with their experience with abstinence and denial. The patient and his wife have voluntarily agreed to continue with a “chaste lifestyle” (his term) for the indefinite and foreseeable future.

To conclude, in healthy men with no organic basis for ED, I suggest abstinence and orgasm denial, collectively known as “male chastity,” as an effective and novel intervention. Further research is warranted to confirm or refute the findings of this single case study.

Yours most sincerely,

Victor Y. E. Rection, MD
Saratoga Springs, NY