Figure 3 The damage to your arteries from aging
Erectile dysfunction is the inability to keep the penis hard enough, long enough for satisfying sex. It wasn’t all that long ago that the topic of erectile dysfunction, or ED, was relegated to “don’t ask, don’t tell,” principally because we docs didn’t want to talk about it since we really didn’t understand it and there wasn’t much we could do about it. Sadly, when medical conditions are not well understood we sometimes blame the patient, telling him “It’s all in your head.” But fortunately, in the 1980s we started to figure it out, and we realized that most of the time erectile dysfunction actually wasn’t just “in your head.” The discovery of Viagra and its various spin-offs provided an easy-to-prescribe, effective remedy. Now patients and doctors can’t shut up about ED, not to mention every other commercial on any given Sunday.
Now that’s not to say that erection problems are only physical. Your biggest sex organ is actually between your ears—it’s your brain. It takes in visual and other sensory erotic stimulation and converts it into a signal to your penis. Your brain is where it all starts, and it’s where it can all end too. Thoughts alone can release adrenaline, which can short-circuit the penis and prevent it from getting or staying hard. Pornographic images can change our brain structure and chemistry for the worse. Fortunately, skilled behavioral health specialists have techniques that can help refresh the mind and restore confidence and satisfaction to the owner of a less-than-peppy penis.
How do you know if you are experiencing erectile dysfunction or just a little off your game? There is a questionnaire we doctors use to help sort that out. It’s a series of five questions that are scored from 1 to 5, with a total of 22 to 25 considered normal.
The questions are regarding your experience over the past 6 months. The first question asks how you rate your confidence that you could get and keep an erection. Answer options are 1: very low, 2: low, 3: moderate, 4: high, or 5: very high.
The second question asks how often your erections were hard enough for penetration when you were sexually stimulated. Answer options are 1: almost never, 2: a few times (much less than half the time), 3: sometimes (about half the time), 4: most times (much more than half the time), or 5: almost always/always.
The third question asks how often you were able to maintain your erection during intercourse after you penetrated. Answer options are 1: almost never, 2: a few times (much less than half the time), 3: sometimes (about half the time), 4: most times (much more than half the time), or 5: almost always/always.
The fourth question asks how difficult it was to maintain your erection to the completion of intercourse. Answer options are 1: extremely difficult, 2: very difficult, 3: difficult, 4: slightly difficult, or 5: not difficult.
The last question asks how often sexual intercourse was satisfactory for you. Answer options are 1: almost never, 2: a few times (much less than half the time), 3: sometimes (about half the time), 4: most times (much more than half the time), or 5: almost always/always.
A score of 12 to 21 is considered mild erectile dysfunction. A score of 12 to 16 is considered mild to moderate erectile dysfunction. A score of 8 to 11 is considered moderate erectile dysfunction and a score of 5 to 7 is severe dysfunction.
So why might the flag fly at half mast? The most common reason is a problem with bloodflow due to narrowing of the arteries. Many conditions can lead to this, including diabetes, high blood pressure, and heart disease. In fact, having trouble getting an erection may be your first and only warning sign of a looming heart attack or stroke. Some medications that treat high blood pressure can make erections worse! So this can be a case of damned if you do and damned if you don’t. Nerves are critical too, and diseases or injuries of the nerves to the penis prevent normal bloodflow. Spinal cord injury, neurological diseases such as multiple sclerosis, certain surgeries in the pelvis, and medications such as antidepressants all can short-circuit the ability to switch on. Low testosterone puts the penis on Snooze, and some medical conditions and medications can lower testosterone. Cigarettes, drugs, and alcohol all are a buzzkill for your penis.
The most common cause of erectile dysfunction, however, is a disease with no cure: aging. As men get older, erection problems pop up. Now, some guys are less affected than others, but by and (not so) large about 40 percent of men will have some degree of problem by age 40. In most cases the problem is mild—occasional difficulty getting it hard and/or keeping it hard. Just a little off your game now and then. But for a small percentage of guys, it’s quite severe. As the decades pass, the percentage of men with erectile dysfunction goes up in lockstep. So 50 percent of men have some degree of problem at age 50, 60 percent have some degree of problem at age 60, and so on. Furthermore, the severity worsens with age.
Time is like a lumberjack sawing away at your mighty oak. Eventually the blood vessels that pump up your penis become more brittle and narrow. At only 1 millimeter in diameter, these arteries are a fraction of the size of the coronary arteries that supply blood to your heart muscle or the carotid arteries that supply blood to your brain, so the penis can be the first to go, well before a heart attack or stroke.
From the day you enter this life, your cells are under attack from a process called oxidation. This is the same process that causes steel to rust. The attack comes from molecules called “free radicals.” The natural balance of smooth muscle and collagen in your blood vessels is destroyed over time by free radicals, as smooth muscle cells disappear and get replaced by more and more collagen, making your blood vessels stiff and narrow Fortunately, your body has a defense mechanism. Molecules known as antioxidants are naturally produced to block those free radicals from doing their damage. One of the key antioxidants is nitric oxide (NO). It is produced from the very innermost lining of the blood vessels, the endothelium.1 As you age, your ability to both produce nitric oxide and to benefit from it declines. Scientists call this “endothelial dysfunction.” Poor food choices, bad habits such as smoking and being sedentary, as well as toxins in our environment all dump more free radicals into our systems. Add to this natural decline disease states such as diabetes, high blood pressure, high cholesterol, and low testosterone, and erection problems become even more severe.
Some aspects of aging seem to be inevitable. Your nerve endings atrophy over time, and so your penis will become less sensitive over time as well. Use it before you lose it!2 This should come as no surprise, considering that all our senses dim as we get older. The drop-off is gradual so most of us don’t really notice it as it is happening, but over time it’s normal to require more stimulation to get and keep an erection. If you have other medical causes for your erectile dysfunction, the decreased sensitivity adds insult to injury. This may be why you can get away with certain lifestyle behaviors when you are young that you can’t handle as you approach and pass middle age. A guy in his twenties could go off on a bender and still rise to the occasion, but men in their fifties or sixties may find it hard to pop their cork after a couple glasses of wine.
Age also steals your testosterone. Not all, but most men will make less and less testosterone over time. The testicles start to wind down, and more and more of the testosterone they do make gets bound up by certain molecules that stick to the testosterone and prevent it from doing its thing.
Good nutrition and exercise are key to slowing the ravages of time. Eating a diet rich in nitrates can sustain your youthful cellular balance longer by providing a source of NO. Fresh, unprocessed, plant-based foods such as vegetables, fruits, nuts, legumes, and grains are the best source of nitrates and thousands of other molecules, many of which are key antioxidants that counteract the aging process. Wouldn’t you rather enjoy some fresh berries than swallow handfuls of medications? Regular exercise also triggers the release of NO and other antioxidants. Excess fat releases toxic free radicals, so staying lean is key as well. Most of my very-advanced-age patients are skinny old men. Excess fat can also reduce testosterone by turning it into estrogens, the female hormones. The sooner you put into practice good nutrition and exercise, the sooner you claw back some time. It’s never too late, but the fact is that the body takes some time to repair itself, and some degree of deterioration is simply not reversible. A 40-year-old who starts to notice some mild inconsistencies with his erection can improve his diet and exercise and, within months, may notice improvements. A 70-year-old with more severe erectile dysfunction may not be able to get back to normal but could prevent a bad problem from getting worse, and may actually respond better to pills like Viagra than he used to. An 18-year-old who eats well, exercises from a young age, and avoids cigarettes, drugs, and excess alcohol may go his whole life without a significant problem, assuming no other illnesses crop up to interfere with his circulation and bloodflow to the penis.
Not everyone who ages gets sick, but over the course of your life, odds are greater than even that you will develop a medical condition that causes erectile dysfunction. Furthermore, erectile dysfunction may be your earliest warning that you are developing a life-threatening condition. Men with erectile dysfunction have a greater than 50 percent chance of developing cardiovascular disease. This means more than 40 percent of men with ED will go on to have a heart attack and almost the same percentage to have a stroke.3 So if you develop ED, seek treatment not just for your love pump, but for your heart pump too. If you can’t get it up you better bring it up with your doctor because not only will you save your sex life, you may save your whole life. Many factors contribute to cardiovascular disease including elevated cholesterol, diabetes, hypertension, smoking, obesity, poor diet, and a sedentary lifestyle. Prevention is better than treatment, but in all cases, there are remedies.
Figure 3 The damage to your arteries from aging
Elevated cholesterol leads to injury of the endothelial lining of blood vessels, resulting in rupture of the lining and plaque buildup, narrowing of the arteries, and eventual loss of bloodflow to the penis. A class of medications known as statins reduces cholesterol but can cause some sexual side effects in some men. Nonetheless, statins can help men with poor erections due to cholesterol plaques recover their sexual function.4 Men with ED due to cardiovascular disease can improve their erections with medications such as Viagra or Cialis, which increase the bloodflow through the narrowed arteries. If the condition is too severe, pills won’t work, but other remedies still can.
Cardiovascular disease can be reversed gradually over time with diet and exercise, especially a primarily plant-based diet with minimal simple carbohydrates, minimal simple starches, minimal animal products, and minimal oils. I know, delicious, right? Well it can be, and it’s a lot better than the alternative. In fact, a long-term study at the Cleveland Clinic demonstrated that the most severe cardiovascular “cripples” became healthy and lived for decades if they adhered to such a diet.5 Regular exercise is key as well, but make no mistake, diet is probably more than 70 percent of the equation.
Diabetes attacks your penis from multiple fronts. The fundamental problem is sugar molecules floating around in your blood instead of being packed away into your cells, where they belong. This wreaks havoc on all your body tissues, and some parts show signs of damage before others. Diabetes causes endothelial dysfunction, ruining the ability of blood vessels to release normal levels of NO. This leads to plaque buildup and clogging of the arteries. The damage is particularly serious for smaller blood vessels and capillaries. The poor bloodflow through these very small blood vessels results in damage to the nerves that they provide oxygen to, especially the smaller nerve endings. Guess what has small blood vessels and small nerve endings? Look down if you need a clue. The nerve damage decreases the sensation in the penis. Even worse, it short-circuits the signal to pump up the bloodflow for an erection. Finally, if the signal gets through, the blood vessels of the penis are too damaged to pump up the erection fully. There is also weakening of the muscles at the base of the penis that help trap the blood in the penis. Diabetes also damages the nerves that allow you to ejaculate. You may be left shooting blanks. Your semen may shoot backward into the bladder because the bladder doesn’t close properly due to nerve damage. Diabetes often runs hand in hand with low testosterone production, weight gain, increased cholesterol, and high blood pressure—all of which create the perfect storm to sink your love boat.
Although diabetes can cause erectile dysfunction, the damage can be prevented or slowed down with tight control of blood sugar. Put down the candy bar and pick up the celery stick. Not only does cutting out simple carbohydrates decrease the damage, boosting your intake of fresh vegetables may actually reverse some of the damage done. Sugar is hiding everywhere in the food we commonly eat. Cut out sugary sodas—that’s a no-brainer. Also, fat-free foods are laced with sugar to make them taste better than they should. Sugar is hidden in the form of starches just as often as it’s turbocharged in the form of high-fructose corn syrup. Exercise helps as well, boosting antioxidants in real time and burning off the excess fat that also results from diabetes. In fact, exercise has been shown to decrease the chances of developing diabetes by up to 50 percent!6 If you cannot control your diabetes with diet and exercise, adhere closely to your medication protocol. The key is keeping the fasting sugar level close to 100 milligrams per deciliter (mg/dl) and the hemoglobin A1c (a longer-term measure of sugar control) under 5.7 percent. For every percentage point increase in hemoglobin A1c, there is a 55 percent increase in the chance of having erectile dysfunction.7 Also make sure your testosterone level is normal because testosterone helps your body respond better to insulin.
High blood pressure can give you low penis pressure. Over time, under abnormally high pressure, blood vessels react, increasing the amount of smooth muscle to handle the pressure. This makes the artery walls thicker and less elastic, which narrows the passageway for the blood to flow into the penis. The blood vessels can become damaged and then develop plaques, blocking the blood vessels even more.
| STAGES | SYSTOLIC READING (TOP NUMBER) | DIASTOLIC READING (BOTTOM NUMBER) | |
| Prehypertension | 120–139 | OR | 80–89 |
| High blood pressure Stage 1 | 140–159 | OR | 90–99 |
| High blood pressure Stage 2 | 160 or higher | OR | 100 or higher |
To make matters worse, some of the most commonly prescribed medications to treat high blood pressure actually cause erectile dysfunction because of their effects on the blood vessels and on the brain. The worst culprits are medications known as beta-adrenergic receptor blockers, aka “beta-blockers.” The most common one is propranolol, but most medications ending in –olol are in this category. These medications decrease the flow of blood into the penis, interfere with the relaxation of the small blood vessels to open up and accept the blood, and interfere with brain signals that normally switch on the penis. One commonly prescribed medication, atenolol, can lower testosterone levels. Thiazide and clonidine interfere with erection-stimulating hormone signals from the hypothalamus in the deep brain.
Even though blood pressure medications may cause erectile dysfunction to some degree, they help more than they hurt. When high blood pressure is brought under control with medications, better erections can occur in as little as 6 months.8 Some blood pressure medications affect your penis less than others. Nebivolol is a beta-blocker with fewer side effects. Blood pressure medications known as ACE inhibitors (angiotensin-converting enzyme inhibitors) and angiotensin receptor blockers do not affect erections, but they don’t work for everyone with high blood pressure. When blood pressure medications are necessary, prescription pills such as Viagra can still restore erections, and these medications are usually safe to take together. The medication that is dangerous to take with these “boner” pills is nitroglycerine or medications that contain nitroglycerine. The combination can cause a lethal drop in blood pressure, leading to cardiac arrest.
Proper diet and exercise can prevent or cure high blood pressure and restore good erections. Added salt and sugar both increase blood pressure. Caffeine raises blood pressure, so maybe think twice about that second cup of coffee, or third, or fourth. Exercise improves erections in men with hypertension in as little as 8 weeks.9 Exercise turbocharges the effectiveness of NO and other nutrients to heal the blood vessels.
Smoking used to be very sexy, but most people have wised up. Cigarettes aren’t just bad for your lungs, they are poison for your pecker. The smoke contains free radicals and heavy metals that damage the blood vessels to your penis and choke off the essential NO. Smoking dramatically accelerates the damage done by high blood pressure and diabetes. Men who smoke have a 50 percent chance of developing erectile dysfunction. Men who smoke and quit still have a 20 percent chance.10 Even secondhand smoke gives you a 1 in 3 chance of flaming out in bed.11 Vaping and nicotine patches are better than inhaled smoke, but the nicotine still squeezes off your bloodflow, so completely quitting is the best. The good news is that quitting can result in improvements in as little as 8 weeks.12
Being fat is bad for your fatty. Excess fat releases toxins that continuously assault the blood vessels with free radicals. Furthermore, the excess fat sucks up testosterone, converting it into estrogen, the female hormone. With low T and higher E, you get a weaker erection with a side of man boobs. Combine diet and exercise to lose weight and bump up the NO, and you can see a difference.
The good news is that you really can turn things around.13 The improvements won’t come overnight, but studies indicate that close to a third of men with erectile dysfunction may get back to normal without medications.14
The brain is your biggest sex organ, organizing all the sensual sensations coming in from the penis and other nerve endings, as well as the naughty thoughts bouncing around inside it, and orchestrating an appropriately naughty response that it sends down the spine back to the penis. So conditions that affect the nervous system from the brain to the spine to the nerves of the penis can cause erectile dysfunction.
Parkinson’s disease causes dopamine-producing cells of the brain to die off. This, along with stiffness and difficulty moving, depression, and dementia, all contribute to poor sexual function. Other forms of dementia due to Alzheimer’s disease and stroke damage brain cells and weaken the signals to the penis. Multiple sclerosis affects the brain and the spinal cord and can attack normal sexual function from both levels.
| DRUG CLASS | DECREASED DESIRE | DECREASED ERECTION | ORGASM OR EJACULATORY DIFFICULTIES |
| Antidepressants | amitriptyline clomipramine fluoxetine imipramine paroxetine pheneizine sertraline |
amitriptyline citalopram clomipramine doxepin fluoxetine imipramine nortriptyline paroxetine pheneizine sertraline tranylcypromine |
citalopram clomipramine doxepin excitalopram fluoxetine fluvoxamine imipramine nortriptyline paroxetine sertraline tranylcypromine venlafaxine |
| Other Psychotropic Drugs | alprazolam chlorpromazine fluphenazine haloperidol lithium risperidone |
chlorpromazine fluphenazine lithium risperidone |
alprazolam fluphenazine haloperidol risperidone |
| Cardiovascular Drugs | clonidine digoxin hydrochlorothiazide methyldopa spironolactone |
beta blockers clonidine digoxin hydrochlorothiazide methyldopa perhixilene spironolactone |
|
| Other Drugs | cimetidine | antihistamines cimetidine cyproterone disulfiram gonadotrophin-releasing hormone agonists propantheline pseudoephedrine |
Viagra and similar medications that increase bloodflow to the penis can help these men. Furthermore, medications that treat these underlying diseases may also improve sexual function. In fact, some men with Parkinson’s can become hypersexual because their Parkinson’s medication can raise the levels of dopamine in their brain too high.
Truama, disease, or surgery can injure the spine. A spinal injury interrupts the two-way flow of information from the penis to the brain and back. The sensations from the penis cannot make it to the brain to tell the brain it’s time to start an erection. Furthermore, sexual images, feelings, and thoughts cannot send their stimulating signals down to the penis. If the spinal injury is high enough, the penis can get some signal from a reflex nerve loop in the lower spine. That weaker signal is enough to respond to a pill like Viagra. If the injury is below the level of the spine that conducts the reflex to the penis, then the reflex won’t happen and pills may not work.
Pelvic trauma or surgery can injure the nerves carrying the signal from the penis to the spine and back. These nerves travel from the spine to the penis between the prostate and the rectum, so surgery on either of these structures can cause erectile dysfunction if the nerves get squeezed, crushed, burned, or even severed during the surgery. The injured nerves sometimes heal, but very slowly, taking up to a couple of years. Radiation to the pelvis also injures those same nerves, but not quite as badly. Pills such as Viagra or Cialis may not work if the injury is severe. Instead, injections directly into the penis of a more powerful medication may work, or a vacuum erection device can be used. These are covered in more detail in Chapter 11, Now What? When Pills Don’t Work. Penile implant surgery is also an excellent remedy when the other methods are not successful.
Exercise is great for the penis; however, bicycle riding occasionally can damage the blood vessels or the nerves to the penis because they are situated under the butt bones (ischial tuberosities) and get squeezed by the narrow bicycle seat. This often causes some brief, temporary numbness in the penis and testicles. Sometimes the damage is more extensive and requires days or months to heal. The best strategy when this happens is time off the seat (and finding another sport) and the use of pills like Viagra to allow more blood to flow through the injured/narrowed artery and compensate for the injury. Even more rare is trauma that severs the pudendal artery. This can require surgery to bypass the injury with a new blood vessel connection—like a cardiac bypass, only for the penis.
When the body is really ill, the penis is too. Kidney failure and dialysis result in poor blood vessel health as well as low testosterone, both of which knock out erections. Liver cirrhosis, most commonly from alcoholism, also lowers testosterone. HIV often causes low testosterone levels. Testosterone replacement and penis pills are helpful in these cases.
Sometimes the problem really is all in your head. After all, your brain chemistry and nerve connections are essential for giving the command to hoist the mainsail. Sometimes you lose command of your ship to a mutiny of thoughts or feelings that you don’t really want at that time, in that place. In many cases it’s a quiet insurrection, where a subtle thought gives you just enough anxiety to sink your ship. More and more, the problem is that your brain can be pirated by too much pornographic imagery. This resets your compass, causing you to seek less familiar sexual shores but, in reality, leaving you floundering sexually in a sea of streaming smut.
Adrenaline is the fight-or-flight hormone our body releases when we are faced with danger. Danger makes us feel anxious, and anxiety triggers the release of adrenaline. Adrenaline then shunts our blood to our heart and lungs and away from our smaller parts like fingers and toes and the penis so that we can survive a physical attack without dying from blood loss. This is a critical safety feature that probably saved many a caveman from mauling predators. It’s rare that we have the need to shunt our blood away from our smaller parts in order to survive these days. There are no longer saber-toothed tigers chasing us around, but there certainly are many modern causes of anxiety. But herein lies the rub: If you are anxious because you just lost your job, you may release adrenaline, but your circulation can’t tell if the adrenaline is from a psychological cause or a physical injury and so it shunts the blood away from your penis. Significant stress from daily life can spill over into erectile dysfunction.
But the adrenaline trigger can be even more subtle. Let’s say you were under the weather, but tried to have sex anyway and had some physical trouble. Or perhaps you had too much to drink so you suffered from “whiskey dick.” Either way, you may get distressed by this failure and start to wonder if something is seriously wrong with you. The next time you go to have sex, it can play on your mind and you might ask yourself a very simple but very anxiety-provoking question: “Will I have trouble having sex LIKE I DID THAT TIME BEFORE?” The adrenaline release then prevents your erection and reinforces your anxiety. Now, the next time you have the opportunity for sex, you may experience an even more profound adrenaline surge as you ask yourself the adrenaline-inducing question, “Will I have trouble having sex LIKE I DID THE LAST TWO (OR MORE) TIMES?” And then you do have trouble—again—and then it becomes a vicious circle. Once there is a negative feedback loop set up, performance anxiety sets in. The fear of not being able to perform can become a self-fulfilling, consuming state of mind and body.
One solution for this condition is called “sensate focus.” This is a technique developed by Masters and Johnson, pioneers in behavioral sexual medicine. A behavioral health specialist can guide you through it. The basic idea is to have affectionate contact with your partner in five stages that gradually build up to sexual intimacy.
The first stage of the sensate focus technique is spending 10 minutes simply touching each other’s hands and feet while otherwise clothed. Focus on the pleasure you receive rather than on what you are giving. Stage 2 builds on stage 1, and breasts and genitals are now in play to be touched. You once again each take a 10-minute turn, but you may guide your partner’s hand around to the spots that make you feel good. Stage 3 is where you stop taking turns and touch each other at the same time. Now you can start focusing on your partner’s pleasure. Stages 4 and 5 bring you right up to the edge of sex. You allow your partner to straddle you in a superior position and rub her genitals against yours whether or not you are hard. If you do become hard, your partner can insert you in just a little bit. If you get anxious, you can always drop back to a lesser stage of intimate contact and build back up until you are ready for intercourse. The goals of sensate focus are to help you focus on pleasure instead of performance and also create a closer feeling of connection to your partner to allow you to have sex without feeling anxious.15
Depression can go hand in hand with anxiety and can lead to sexual dysfunction as well. Causes can range from low self-esteem to high stress at work. More serious crises—such as posttraumatic stress syndrome from combat or previous sexual abuse—can be causes as well. Professional treatment for depression and anxiety can improve sexual function in many of these cases. Sometimes men aren’t able to realize they are depressed or anxious because they are so used to keeping their emotions in check due to social norms. Although medications can lift the depression, sometimes they lower the erection. Commonly prescribed antidepressants such as Prozac work by boosting serotonin in the brain. Unfortunately, serotonin suppresses oxytocin, a brain signal that triggers the penis to get hard and triggers sexual climax. Serotonin boosts prolactin, which is another brain chemical that can prevent sexual climax as well as decrease testosterone production. Other antidepressants such as tricyclic antidepressants and monoamine inhibitors can have negative effects on sexual function as well. Fortunately, some antidepressants, such as bupropion, nefazodone, and mirtazapine, have many fewer of these side effects. Medications used to treat psychosis and medications used to treat anxiety often work by lowering dopamine levels. Dopamine plays a key role in the brain in stimulating erections. Fortunately, even while on these necessary medications, oral medications such as Viagra can still work.16
There are other common psychological causes of erectile dysfunction. A guy may suppress feelings he is unable or unwilling to confront with his partner, including lack of intimacy or lack of feeling desired. On the other hand, he may feel less desire towards his partner due to his partner’s physical changes, such as weight gain, or due to a problem the partner may be having with sex. In some cases there may be anxiety over pregnancy, as when one partner wants to have a child but the other doesn’t or when the couple is unable to get pregnant. Guilt can also be a significant cause of anxiety that leads to sexual dysfunction. Religious prohibitions, divorce, and death of a spouse can all work at a very deep level on a guy’s mind. Professional therapy can help to free him up to enjoy sex without the guilt.17
Overexposure to pornography can ruin the real thing. In Chapter 6, we took a deep dive into porno penis and revealed how men who watch pornography excessively—several times a week—are at risk of losing enjoyment of sex in real life. Brain centers that are important to experiencing pleasure and intimacy become desensitized and shrink. These changes mimic those seen in drug addicts. This used to be a rare problem, but since the advent of smartphones and Internet streaming, porn is literally everywhere, all the time.
In many cases of behavioral/psychological causes of erectile dysfunction, prescription penis pills can help. If it’s a matter of a loss of confidence from being unexpectedly off your game, the reliability of a pill-induced erection may allow you to be less anxious. Sometimes a short, deliberate course of these pills will allow you to eventually get back in the saddle without them. In some cases the adrenaline will still overpower the medication. Even in cases that are primarily physical, a psychological component or reaction to the physical problem can throw fuel onto the fire. Working with a behavioral sexual medicine expert can allow medications to work better or lower your need for them.
Routine prescriptions for pills like Viagra or Cialis don’t always work for any of these various causes of erectile dysfunction, whether medical or behavioral. The next chapter will explain how the pills do and don’t work and discuss additional treatments that work when pills don’t, including injections, devices, and surgery. The treatment of low testosterone is often needed as part of the remedy for men with poor erections, and this is covered extensively in Chapter 13. Fortunately, we now live in a time when a man can get effective help for erection problems and no longer be sent home from the doctor’s office in quiet desperation.