Dear Dr. Myrtle,
What is ED?
Erectile Dysfunction (ED) in men is defined as an inability to achieve and maintain a penile erection sufficient for penetration. There is a broad range of erection troubles including:
• the inability to become hard at all,
• becoming hard only briefly,
• becoming only half-hard, and
• only occasionally becoming hard.
No matter your level of current function, this brochure can:
• help you understand what’s happening in your body,
• give you the information you need to make sure your erection problems aren’t a sign of something more serious, and
• give you some ideas of steps you can take to improve the health, strength and duration of your erection.
Increasing focus on rehabilitation techniques for ED can also improve sexual function for men without ED. Some men want harder erections or for their erections to happen faster and/or last longer.
Why is erection capacity important?
Beyond sexual penetration, penile erections are a simple, elegant indicator of overall health and well-being. This is because the formation of erections relies on healthy physical systems and mental processes. When any part of that combined system is ill or not maintained, erections can become much harder to have or maintain.
How do erections happen?
(For complete information on the mechanism of erection, see the AWT Men’s Erectile Function Brochure.) Think of sexual arousal as a collaboration between the mind and body. When medical conditions, trauma or surgery changes structure or function, or the mind is overcome with anxiety, it is hard for the whole system to work together.
The process of becoming sexually aroused with an erection includes several types of nerves, the penile clitoris (aka corpus cavernosa) and small blood vessel function. Having an orgasm further tests the neural system, and experiencing ejaculation relies on yet another nerve system. The whole sexual system isn’t complicated, but does require many sections to work together for sexual arousal to fully develop.
There are two ways to consciously initiate penile erections. One is to physically massage the penis which causes blood flow to be released into the caverns of the clitoris. When this blood swells the caverns, the penis enlarges (mostly sideways, but also makes the penis a little longer), and traps the blood inside the caverns. The other way is to allow or create sexual thoughts or arousing ideas in the mind. The brain will translate these ideas into sexual arousal, and when the nerve impulses reach the genitals, blood flow will release into the caverns. Most men use some combination of both the direct stimulation and cognitive sexual arousal (mental) pathways to sexual arousal, and vary their techniques depending on their individual circumstances.
Types of Penile Erections
There are two types of erections in men:
Erections for oxygenation (puff erections).
The blood vessels that lead to the inside of the clitoral structure need routine blood flow for oxygen and nutrition. The body accomplishes this (without effort or awareness from the man) by lightly flooding the clitoris three to six times daily. Morning erections and slight “puff” erections during the day and evening are simply the body’s way of taking care of the genital structures. While this is not related to sexuality, the lack of these “puff” erections is a strong indication that something is disrupted and needs attention. These puff erections are not related to sexual arousal itself, since the blood flows through the clitoris rather than being trapped as it is in penetration erections.
Erections for sexual arousal.
When the blood flowing into the caverns increases at a rate greater than the outflow, the penis becomes stiff because the blood is trapped, causing an erection. When a man wants to use his penis for sexual penetration, he needs this hardness to hold his penis straight. Penetration can occur with softer erections, but the man needs to be careful not to bend the penis, since the elastic/fibrous clitoris can be broken when bent at an angle.
Physical Causes of Erectile Dysfunction
Today we know that physical causes (heart disease, diabetes) of ED are more common than psychological causes. In fact, more than 80% of erectile dysfunction is an early physical manifestation of medical illness. The connection is so strong that early erectile problems are known to precede heart attacks by an average of 3-5 years in men, many of whom never had symptoms of heart problems. For men diagnosed with diabetes, more than 90% have erectile dysfunction.
Men’s erectile function is very similar to the canary in the coal mine. If the canary is having problems, something is wrong in the system somewhere and needs close medical evaluation. Until you know better, always consider a change in erectile function as a meaningful medical event that requires the attention of a health professional.
We strongly recommend that you start with a visit to your health care provider for a physical assessment, and that you not put it off. Make sure you mention your erection difficulties at that visit, so your health care provider will have the information necessary to arrive at an accurate diagnosis. This is no time to be shy; you really need to tell it like it is. But don’t just accept a prescription for Viagra: you need to know if your heart, nerve and metabolic system is having trouble and if your early signs of erectile dysfunction are a dangerous symptom, not just an inconvenience.
Psychological Components of ED
Once your health care provider has evaluated you for physical causes of ED, look also at what emotional, psychological, or relationship issues you have. These may be either a cause of your ED, or have arisen from the experience of having ED. It can be very disturbing to have your body stop functioning as it has all of your life, and can make relationship problems difficult to solve.
You can find a professional who is particularly knowledgeable about sexual issues by going to the web site of the American Association of Sex Educators, Counselors and Therapists (www.aasect.org). On their web page you will find information for the public on how to find a sex counselor or therapist in your area. It might be helpful to see a counselor alone, with your partner, or some of each, but you should decide what is most helpful for you.
Rehabilitation Techniques for ED
With or without a medical diagnosis, most men can increase their hardness by making lifestyle changes. Although making these kinds of changes can take some time, the positive effects on your erections will likely be noticeable sooner than you might expect, particularly if you really commit to the change. Steven Lamm’s book The Hardness Factor (see resources) explains specific lifestyle changes that can increase your firmness noticeably in as little as a week, and impressively in six weeks. Staying with those changes for the rest of your life will help you be able to become erect and stay that way well into old age.
Eat the Good Sex Diet.
There are many chemical processes in the body that contribute to your erections and orgasms, and they need good building blocks, in the form of the foods you eat, to function smoothly. Truly, eating a healthy diet (a low-carb version of the Mediterranean Diet) can revolutionize your sex life. Avoid white foods (refined grains and sugar), focus on lean proteins (beans & nuts), and lots of deeply colored vegetables and fruits.
Get more exercise.
Thirty to sixty minutes of moderate exercise every day (walking hard enough to make you sweat a bit) makes a big difference to most men’s erections, sexual performance, and libido. When you make your heart work hard, it gets better at working hard and becomes better able to meet the demands of sex. When you fatigue your muscles, your body makes more small blood vessels to carry oxygen to your tissues, which results in stronger erections. Exercise also increases sexual desire, decreases depression, and increases feelings of well being. Taking a 20 minute walk before sexual activity can prime your sexual arousal system for a perkier performance, too.
Anything that reduces your blood vessel health reduces your sexual potential. If you smoke, you can increase your hardness significantly by quitting, and some men notice a difference in as little as two weeks. Smoking stiffens blood vessels, and lowers HDL (good cholesterol) and raises LDL (bad cholesterol), which is exactly the opposite of what you want for prevention of heart problems, and ED.
Keep your alcohol use moderate.
Having more than three alcoholic drinks a day inhibits both erections and orgasms by decreasing production of nitric oxide. Nitric Oxide is the neurotransmitter molecule necessary for relaxing the blood vessel walls in the erectile tissue of the penis. Over time, use of alcohol causes nerve damage that can permanently affect your ability to become erect. Although the relaxation effect of alcohol may feel beneficial to your sexual relaxation, it is a leading cause of soft erections in men.
Don’t use street drugs.
Cocaine, LSD, marijuana, amphetamines and barbiturates all decrease your ability to become hard and stay hard. Sexual arousal is a unique balance between relaxation and excitement, and when you use substances that interfere with one part, the other components are often inhibited as well.
Refine your prescription medications.
Ask your doctor if you can refine your medication choices towards those with fewer sexual side effects. Some medications are more likely than others to support your sexual health, and some combinations of medications could be making your ED worse. Your health care provider may be able to prescribe comparable medications with fewer sexual side effects.
Address emotional and relationship issues.
Maybe emotional issues weren’t originally any part of the cause of your ED, but if you’ve been struggling with hardness problems for some time, chances are emotional issues are present. If ED is affecting your self-image or altering your intimate relationship(s), you owe it to yourself to get help dealing with any emotional issues involved.
Have regular orgasms.
Many men can orgasm without having a completely hard erection: they just have to know that and not let the softness stop their self-pleasuring. Some men use different techniques for arousal depending on what they need in different settings. You can orgasm alone or with a partner; both ways are effective for keeping the system fit. Regardless, we recommend at least two orgasms a week (with ejaculation if possible) as a healthy sexual maintenance routine.
Any recommended devices or sex toys?
There are a number of mechanical devices that may help maintain a stronger erection, including erection rings, erection rings combined with vibrators, and penis pumps.
Erection rings are rings of material that fasten around the base of the penis. They help maintain an erection by restricting the blood flow back out of the penis. Some erection rings are stretchy silicone or elastomer, some are rubber O rings, and some are adjustable leather or synthetic bands that close with snaps or velcro. Only use easily removable or adjustable erection rings (not steel rings), and don’t leave them on for more than 30 minutes; keeping blood trapped in the penis for a long period of time can cause permanent damage. Some erection rings include a built in vibrator.
Vibrators activate the mechanism responsible for blood flow into the penile clitoris. Even if nerves responsible for sexual arousal have been damaged, when the penile clitoris and blood vessels are healthy, a vibrator may help you become hard. You need to experiment with different types of vibration and apply it to the base of your penis, along the shaft, or any other sensitive place that arouses. Use it with or without a erection ring, or choose one with a built-in erection ring. Try your vibrator for self-stimulation, or combine it with partner play.
Penis pumps are very helpful for achieving a harder erection, especially if you are able to become partially erect. Pumps work by using a vacuum to stretch the membrane surrounding the erectile tissue of the penis, allowing blood to flow in freely. A pump is often used in combination with a erection ring. First the pump brings partially oxygenated blood into the penis, and then an erection ring (placed around the base of the penis shaft) holds the blood in. Be gentle when using a pump; mild suction is all that’s needed. It is possible to hurt yourself by pumping too vigorously or for too long. Also, to avoid blood blisters, don’t use pumps if you use blood thinning medication.
For men recovering from pelvic trauma, surgery (prostate or rectal), or radiation therapy, a rehabilitative therapy called penile rehabilitation (PR) has been developed. Many men don’t realize that these same techniques are helpful when recovering function for metabolic ED, too, because maintaining the flexibility and ensuring routine oxygenation is good for the penis no matter the cause of ED.
When used for PR, the goal for using a penis pump is to continue blood flow and flexibility during the healing process, when nerves have been damaged by surgery or radiation. If the nerves recover function and re-establish themselves, then the clitoral structure will be ready for action as well. If blood flow stops (without use of a pump), then anoxic damage to the clitoris may be irreversible.
Effective penile rehabilitation often involves a combination of daily medication and use of a pump daily. Ask your health care provider whether a program like PR is right for you. (For more information, see our AWT Penile Rehabilitation Brochure.)
The Hardness Factor, by Steven Lamm, MD. 2005
The New Male Sexuality, by Bernie Zilbergeld. 1999
Coping with Erectile Dysfunction, by M. E. Metz, PhD. and B. W. McCarthy, PhD. 2004.
Reclaiming Desire:, by A. Goldstein 2009.