As someone who works in the sexual health space, I get asked about erections and erectile dysfunction more than anything else. It’s amazing how little men know about their hard-ons. Erections are something that, when things are working right, we take for granted and don’t appreciate the dynamic environment at work during sexual arousal. Men also tend to be equally misinformed about erectile dysfunction (ED).
Before we launch into our accelerated course on everything erections below, let’s take a minute to highlight some key facts. First, did you know that ED is a pretty common problem? Estimates of the prevalence of ED range from 9% to 40% of men by age 40, and generally increase by 10% with each decade thereafter (Cohen). It is a condition that affects approximately 30 million US men and it is estimated that 1 in 4 men will experience ED at some point in their life (Nunes). Also, ED can happen to men of any age. It’s not just an issue for older guys.
One of the most challenging issues men face when their erections aren’t working is uncertainty. It often takes years for a man to seek help for ED. And even when he does the process can be a frustrating one. Too many times, men are dismissed or reflexively handed a “little blue pill,” but may not understand why they have this problem in the first place. This can leave men questioning if they have a real physical problem or if it is all in their heads. That’s where I come in.
Educating a man on why he may be having ED is the most crucial part of his treatment. All erectile dysfunction is not created equal and it’s necessary to understand the nuances particular to an individual to truly fix his erection problem. In my office, I often take time to review specific factors that influence the way erections work so that my patients can better understand why they may be experiencing ED.
Defining ED
Many men do not even know what truly qualifies as ED, so let’s set the record straight. Normal erectile function involves the capacity to achieve an erection sufficiently rigid for penetration and to maintain that erection long enough to complete sexual activity. Too many times I’ve had patients who assume they don’t have ED because they have no problem getting hard. Well sorry to burst your bubble, but a good erection gets hard and stays that way till you’re done. If you go limp halfway through sex, you technically have ED also.
Blood Flow
A healthy erection requires a healthy amount of blood flow. The erect penis is essentially a pressurized hydraulic system similar to a car tire. It’s a unique part of the body in that way. Most other tissues see a continuous movement of blood in and out, with the arteries delivering oxygen and the veins cycling out waste. Your penis has the ability to do the exact opposite. During an erection, we deliver blood into the penis and then trap that blood in place until sex is complete.
If you have ED, you could have a blood delivery problem (what we call arterial insufficiency) or a trapping issue (termed venous leak). Sometimes it’s a little of both. And it’s crucial to appreciate which kind of flow problem you might have so that it can be properly addressed.
Thankfully, we have objective ways of doing just that. When I am evaluating a man with ED, we often perform a penile Doppler ultrasound to evaluate the hemodynamics of his erection. During the study we measure the movement of blood into the penis through the cavernosal arteries and assess for leakage of blood, which should not be present in a fully functioning system. We also examine the quality of the erectile tissue and look for areas of scarring or damage.
Hormones
Hormones are paramount to the health of your erection. Testosterone, often thought of as the male hormone, is probably the most significant of these affecting your erections. In addition to making you horny, testosterone is involved in regulating the blood flow to your penis (see above).
Our bodies weren’t designed to live beyond our reproductive years so as men age, we become less equipped to produce testosterone. On average, testosterone declines gradually after age 40 by about 1% per year, and as testosterone declines the risk of ED increases. This is one reason why ED is more common in older guys. But younger men can also have testosterone issues for a number of reasons. A few additional factors are known to interfere with testosterone production:
- Obesity
- Diabetes
- HIV
- Chronic stress
- Lack of sleep
- Genetic disease
- Environmental factors
There are a few other hormonal factors to consider. First, low testosterone is clearly bad for erections, but so is too much. Elevated levels of testosterone seen in men who use anabolic steroids have been linked with short duration and longer-term sexual dysfunction, including erectile dysfunction (Armstrong, Moss). Secondly, it’s not always helpful to discuss testosterone levels in terms of normal or abnormal. The range of values that qualify as normal can vary widely throughout a man’s life and if you fall in the lower part of that normal range, you may still benefit from boosting your numbers. When I speak to patients about hormones as they relate to their erections I prefer the word optimal. Lastly, testosterone is only one component of a complex hormonal milieu. There are several other hormones that can influence testosterone production and affect its use in our bodies. Estradiol (the body’s primary estrogen), thyroid hormone, and prolactin are just a few.
Psychology and erections
In treating men with ED, I find myself functioning as a therapist during many of our interactions, trying to explain that it is totally normal to have some psychological component to their erection issue. Men tend to like their penises and like them to perform well. When they don’t rise to the occasion it causes us worry, stress, and anxiety, which can compound the problem. But if you look at data on erectile dysfunction, they suggest that only a small fraction of men with ED (around 15%) have a strictly psychological problem.
ED can both lead to and be the product of depression, anxiety, stress, low self-esteem, and relationship issues—all psychological factors I have to consider when evaluating someone with erectile dysfunction. It’s also essential to keep in mind a person’s religious and cultural beliefs about sex and sexuality, which can sometimes have a negative impact on erections. If I don’t have the time or expertise to delve into these areas alone, I tend to lean on my mental health colleagues to help identify and address these other psychological factors.
Other factors
As we go through life, bad things happen. And sometimes those things can affect our erections and it’s useful to take those into account. Some examples include:
- Prostate, bladder, or pelvic surgery
- Chemotherapy or radiation
- Heart attacks, stroke
- Cognitive decline
- Illness, disease, pandemics
- Trauma — psychological, sexual, physical
Asking for help
Every case of ED can be a little different, but don’t hesitate to seek out evaluation if you’re concerned. If you aren’t getting regular morning erections or notice a considerable change in how often you’re waking up hard, it may be a sign that something isn’t working right. If you’re having a problem with your erections most of the time (not just that one time you drank too much), you might want to see someone. If even masturbation is difficult because you can’t get it up or you find yourself avoiding sex because you’re worried about your performance, you might have ED. In other words, if you’re not having enjoyable sex and you think your erection is the reason why then bring it up with your doctor. If they don’t take you seriously, try to find a sexual health specialist that will.
Make a change
You don’t have to wait to see a specialist before taking steps to improve your erections on your own. You know all those things your doctor tells you about leading a healthy lifestyle to prevent heart disease? The same is true for your erection. Cigarette smoking (including vaping), alcohol intake, and decreased physical activity have all been associated with erectile dysfunction. So quit or cut back on the bad stuff and increase your hours at the gym. A healthy diet is also crucial to optimizing your erections. Increasing intake of fruits, vegetables, and flavonoids has been shown to decrease the risk of erectile dysfunction in young men (Mykoniatis). So has the Mediterranean diet (La). Obese and overweight men can appreciably improve their erectile function simply by adjusting their diet incorporating a structured exercise training program.
Medical interventions
Sometimes lifestyle modifications aren’t enough and you may need to consider (along with your health care provider of course), a number of medical treatments to help with your erections. If your hormones aren’t optimal, discuss hormonal therapies to boost your performance. There are numerous oral medications that help to improve blood flow. There are injections for those men who need something a little stronger than a pill. Newer, regenerative therapies like low-intensity shockwave therapy and platelet-rich plasma are showing promise in the treatment of ED. And there is even penile implant surgery to help those who don’t respond to other non-surgical therapies. For guys who have encountered relationship issues related to their ED or those whose problem is primarily psychological, psychotherapy or focused sex therapy can be very helpful. There’s a solution out there for every man and every problem. You may just need a push in the right direction.
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Armstrong JM, Avant RA, Charchenko CM, Westerman ME, Ziegelmann MJ, Miest TS, Trost LW. Impact of anabolic androgenic steroids on sexual function. Transl Androl Urol. 2018 Jun;7(3):483-489.
Cohen D, Gonzalez J, Goldstein I. The Role of Pelvic Floor Muscles in Male Sexual Dysfunction and Pelvic Pain. Sex Med Rev. 2016 Jan;4(1):53-62.
La J, Roberts NH, Yafi FA. Diet and Men’s Sexual Health. Sex Med Rev. 2018 Jan;6(1):54-68.
Moss HB, Panzak GL, Tarter RE. Sexual functioning of male anabolic steroid abusers. Arch Sex Behav. 1993 Feb;22(1):1-12.
Mykoniatis I, Grammatikopoulou MG, Bouras E, Karampasi E, Tsionga A, Kogias A, Vakalopoulos I, Haidich AB, Chourdakis M. Sexual Dysfunction Among Young Men: Overview of Dietary Components Associated With Erectile Dysfunction. J Sex Med. 2018 Feb;15(2):176-182.
Nunes KP, Labazi H, Webb RC. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens. 2012 Mar;21(2):163-70.