The safest treatment for impotence is not on the NHS. Robert Nurden reports
Joan Lyon flinched as she watched her husband, Ian, plunge a syringe into his penis for the first time. Nor did Ian enjoy the experience, which he would have to repeat every time they wanted to make love.

Yet Ian, aged 73, was only following the prescribed treatment meted out to most British men suffering from impotence - a self-administered injection to induce an artificial erection. "It was a savage method and we soon abandoned it," he said. "My wife couldn't bear to look."

Many retired couples would, at this point, have given up on sex and contented themselves with the warm companionship of old age. But the Lyons had always had a "superb" sex life and wanted it to continue.

In his sixties, Ian had started to suffer from epilepsy. A side-effect of the drugs he took to control attacks was partial erectile dysfunction.

"We were so desperate. I even went to a sex shop to see if they had anything for me," Ian says. Eventually, he heard about external vacuum tumescence therapy. Out of curiosity, the Lyons ordered a device through the post for pounds 250. Much to their surprise, they became immediate converts. It restored their sex lives and they now make love every day. Joan is happy to join in the preparation stage. "It's part of foreplay," she says.

Vacuum tumescence therapy is extremely simple. A large glass tube is placed over the flaccid penis and air is extracted with a hand-pump. Blood rushes into the penis and vascular enlargement ensues, leading to erection. With the kit comes a flexible constriction band, which is put on the base of the penis before penetration to prevent blood flowing away from the penis, enabling sex to take place for about 30 minutes.

The Lyons were doubly lucky. Not only could they afford the device, they were also lucky to have stumbled across it at all. In the United States, the vacuum is on the Food and Drug Administration's prescription list, and more than 40,000 men use it as the main treatment for impotence. About 80 per cent report a high degree of success, and there is a 40 per cent chance of improving natural erectile capability.

But in Britain, where an estimated 2.3 million men suffer from impotence, the method is not available on NHS prescription, even though it is the cheapest, least invasive and safest treatment. The disadvantages are possible slight bruising, a technique that is initially tricky to master and rather cumbersome equipment. In the male mind, it is often wrongly linked with tacky advertisements for penis enlargement, which also uses a vacuum principle.

Three years ago, for financial reasons, the Department of Health made it difficult for any new products to get on to part nine of the drug tariff list (the section devoted to appliances available on the NHS), preventing the vacuum device being added to it. Patients now have to buy one, unless they are lucky enough to be referred to more enlightened urology departments, such as those in Leeds or Glasgow hospitals, where consultants have been able to circumvent DoH regulations by using their hospitals' own appliance budgets.

More commonly, on summoning up the courage to go to their GP (fewer than 5 per cent with a problem seek help), men are told that "at their age, a certain amount of erectile dysfunction is only to be expected" and nothing can be done. Urologists are likely to recommend self-injection with vasodilator drugs such as papaverine or prostaglandin E1. At pounds 9.95 a time, it cost the NHS pounds 1,500 for one man to use the technique three times a week for a year. This disregards the added cost of treatment for side-effects such as penile fibrosis and priapism (persistent, painful erection without sexual arousal).

The other, more drastic solution is a surgically implanted prosthesis, an operation carried out at a cost to the taxpayer of more than pounds 3,000. This, too, may have dangerous side-effects, the worst of which is gangrenous infection.

"Impotence has been hijacked by surgeons and drugs companies," says Dr Richard Petty of the independent WellMan Clinic in London. "It's a disgrace. They see a dysfunction and only think about restoring that function by the easiest means possible. The pressure is on to get the patient out of the surgery as fast as possible." By contrast, he combines a degree of counselling, advocating the vacuum method and administering a testosterone supplement.

Misconceptions about impotence being "all in the mind" abound, but overwhelmingly the disorder is organic, not psychogenic. The cause can be hormonal, vascular, neurological, or iatrogenic (caused by drug treatment) - and diabetes may play a part. Psychological problems usually occur later, when discord with a partner may exacerbate the problem.

Dr Tom McNicholas, consultant urologist at the Lister Hospital in Stevenage, believes British males are getting a raw deal. Unlike on the Continent, there are few andrologists (the equivalent, for men, of gynaecologists) to give good advice about sexuality. "I am often forced to prescribe self- injection when vacuum therapy would be better," he says. "If the patient can't afford to buy a device, what's the point? But the whole range of treatments should be available on the NHS - the Italian male demands nothing but the best, and so should the British."

Nick O'Hare, director of Osbon Medical UK, has asked the Department of Health to make the ErecAid vacuum system, which he markets, available on prescription. "The tragedy is that two-thirds of patients I see on clinical demonstrations in NHS urology departments are on income support, disability benefit or state pension," he says. "What makes the situation really absurd is that the current licensed method of treatment costs four times more. But the DoH told me not to bother applying unless the system saves lives."

The ErecAid System, with booklet, video and telephone counselling service, is available for pounds 250 from Osbon Medical UK, 29 Pattison Road, London NW2 2HL, on 0171-431 7003.