Male Sexual Anatomy
RELIABLE ERECTIONS
EVERY MAN’S GUIDE FOR LIFE
Until age 51, I never had any erection difficulties, not even on the few occasions I overindulged in that notorious erection-killer, alcohol. Then things began to change—slowly at first, but over time, noticeably. My erections didn’t rise as rapidly as they once had, and I needed more stroking to stay hard. I couldn’t take my erections for granted anymore. My middle-aged erections required work.
When I first noticed these changes, I’d been a sex educator and counselor specializing in men’s sexuality for almost 30 years. In hundreds of articles, seminars, and media interviews, I’d explained how erections typically become balky in men over 50, and that older men need more direct stimulation to raise and maintain them. I knew I didn’t have “erectile dysfunction” (ED), the post-Viagra term for what was once called “impotence.” ED involves a persistent inability to raise and/or maintain an erection sufficient for intercourse. A major tip-off is not waking with morning erections. I woke with morning erections. I could get it up, keep it up, and enjoy intercourse. But my erections were different. And I didn’t like it.
A medical cause seemed unlikely. I didn’t have any risk factors for ED. I didn’t smoke or have diabetes, heart disease, or high blood pressure. I wasn’t overweight. I drank less than I had earlier in adulthood—no more than a couple of drinks a week. I took no medication with erection-impairing side effects. I exercised regularly, ate a near-vegetarian diet, and usually slept at least 7 hours a night.
A psychological cause also seemed unlikely. I don’t claim to be a paragon of mental health, but I wasn’t depressed. My marriage was solid, affectionate, and communicative. I had some family stresses—teens in the house, aging parents, a mother-in-law with Alzheimer’s—but nothing severe enough to raise a red flag. My career was in decent shape. I had friends. I enjoyed sex with my wife. I was also well aware that I didn’t need an erection to satisfy her, so I didn’t feel performance pressure. Life was good—except that suddenly, I had balky erections. The evidence pointed to one inescapable conclusion—normal, age-related erection changes. No big deal.
Only, it was a big deal. It didn’t matter that my erection changes were normal. I found them distressing. I flashed on that old joke: Fear is the first time you can’t get it up the second time. Panic is the second time you can’t get it up the first.
I complained to my wife, a family physician who deals with ED in her practice. “Get a grip, Mike,” she replied. “If anyone should know this is normal for a man your age, you should.”
“Right,” I said. “This is normal. I know that. I’m not alarmed.” And I wasn’t. But I was concerned. Who wouldn’t be?
THE NEW WORLD OF ERECTILE DYSFUNCTION
The world of erection impairment changed dramatically on March 27, 1998, the day the Food and Drug Administration approved the little blue pill, Viagra, for treatment of ED. Viagra was not the first drug treatment for erection impairment, but it was the one that captured the public’s imagination. Viagra took the country—and the world—by storm. During its first month of availability, U.S. doctors wrote more than 300,000 prescriptions, making it the fastest-selling new drug in history. Within 6 months, doctors wrote repeat prescriptions at the rate of 100,000 a month—a figure that has increased in the years since. Today, Viagra is one of the most successful drugs ever marketed. More than 10 million men have taken more than 125 million tablets. Annual sales approach $2 billion. And with millions of male Baby Boomers in their 50s and getting older every day, the little blue pill’s future looks bright—and many drug companies are scrambling to develop their own erection-enhancing medications.
Viagra not only changed ED treatment, it also changed the way we think about the condition. Since the drug’s arrival, ED has been transformed from something rarely discussed in public into a multi-billion-dollar-a-year industry, with celebrity spokesmen all over the media enthusiastically touting Viagra’s benefits. Vitamin V, as grateful users sometimes call it, also changed the traditional terminology used to discuss erection impairment. For a good 20 years before its approval, sexuality professionals (myself included) had been waging a futile battle to retire the term “impotence,” with its derogatory implications, and replace it with the more neutral term, “erectile dysfunction.” Within a year of Viagra’s approval, “impotence” was out and ED was in.
Ironically, Viagra proved controversial among some sex therapists, who feared that the “medicalization” of ED would cost them clients. “In fact,” says Janet Hyde, Ph.D., a professor of psychology at the University of Wisconsin in Madison, and a past president of the Society for the Scientific Study of Sex, “Viagra has been a boon to sex therapy. It put ED in the news. It gave men permission to admit they had the problem and get help, which often included sex therapy.”
Sex therapists also feared that Viagra would reinforce the widespread—but mistaken—belief that erection equals sexual satisfaction for both men and women. And, in a way, it has. It perpetuates the pornography-inspired notion that sticking an erection into erotic openings is all there is to sex. “In fact,” says Great Sex advisory board member Marty Klein, Ph.D., “it’s quite possible to have a rock-hard erection and still have lousy sex.”
Viagra is not the answer to every man’s erection problem. And it certainly doesn’t resolve the relationship issues that often contribute to erection impairment. But it has transformed ED from a private agony into a public issue less likely than ever to cause shame or embarrassment. And because of the new frankness Viagra has inspired, we now know that erection difficulties are common in men of all ages.
Before Viagra, erection problems were by no means rare, but they were not considered particularly common. The pre-Viagra view was that ED affected the elderly, and men with such chronic or debilitating medical conditions as diabetes, heart disease, depression, and spinal cord injuries.
Today, the picture looks very different. It started changing several years before Viagra arrived, when researchers with the Massachusetts Male Aging Study, an ongoing investigation of 1,709 men over 40, published a report on ED among study participants. Overall, more than half the men (52 percent) reported at least some erection difficulty, notably the balkiness common in middle-aged men. Here’s how the problem broke down by age group.
Erection Difficulties (%)
| Age | Mild, Occasional | Moderate, Frequent | Severe, Constant | Total (%) |
| 40 | 18 | 17 | 5 | 40 |
| 50 | 18 | 19 | 8 | 45 |
| 60 | 18 | 27 | 11 | 56 |
| 70 | 18 | 32 | 15 | 65 |
These findings make ED look surprisingly prevalent. Other recent surveys have shown that erection problems are less common—the result of different survey techniques and other definitions of ED. But all recent studies agree that erection difficulties are fairly common and not confined to elderly men.
▢The 1996 University of California survey (described in the Introduction), which measured persistent ED, not occasional balkiness, found this prevalence:
| 18-29 | 3 percent |
| 30-39 | 5 percent |
| 40-49 | 7 percent |
| 50-59 | 12 percent |
| 60-69 | 16 percent |
| 70+ | 25 percent |
▢The 1999 University of Chicago survey (also described in the Introduction), which asked if ED had been a problem in the previous year, found this prevalence:
| 18-29 | 7 percent |
| 30-39 | 9 percent |
| 40-49 | 11 percent |
| 50-59 | 18 percent |
▢And a 2002 University of North Carolina survey of men over 40 showed that 22 percent experienced erection difficulties “at least sometimes.”
It seems that, until Viagra, many younger, healthy men with ED suffered in silence, according to Stanley Althof, Ph.D., a psychologist at Case Western Reserve University and codirector of the Center for Marital and Sexual Health in Cleveland. Their penises may not have been stiff—but their upper lips certainly were. Viagra provided hope that erection difficulties could be resolved quickly and easily. As a result, it encouraged men to be more forthright, particularly about mild, occasional problems now increasingly called “erection dissatisfaction.”
“No one really knows how much ED is out there,” Klein notes. “Even today, post-Viagra, many men won’t admit that they have problems. But this much is certain: Many, many men experience erection dissatisfaction. They believe they are entitled to firm erections every time they feel sexually aroused, and if that doesn’t happen for any reason, they get upset.”
YOUR SEXUAL BODY AND HOW IT WORKS
Before we go into the reasons why ED exists, let’s take a look at the parts of your body that help create an erection in the first place.
You look between your legs and you see everything, right? What’s to explain? Actually, what you see is only a fraction of what’s down there. Take the penis, for instance. It’s twice as long as you think it is. About half of it is hidden inside your lower abdomen. Along with the part of your penis that you can see, your internal penis also becomes blood-engorged and firm during erection, providing the structural support that allows the external part of the penis to enter erotic openings without buckling.
The pudendal arteries that supply blood to the penis are surrounded by smooth muscle tissue. So are the three major columns of erectile tissue inside the penis (the two corpora cavernosa and the corpus spongiosum). When the penis is flaccid, this smooth muscle is contracted and not much blood circulates through the organ. But with sexual stimulation, the nerve cells in the penis release nitric oxide, which triggers the production of a substance called cyclic guanosine monophosphate (cGMP). As cGMP levels rise, arterial smooth muscle tissue relaxes, and more blood flows into the penis. The smooth muscle tissue in the corpora cavernosa and the corpus spongiosum also relaxes, and they fill with the extra blood. Like a balloon filling with air, the penis lengthens and becomes firm.
Make no mistake, the penis is not a balloon—blood circulates in and out of it no matter whether it’s flaccid or erect. But as the penis swells, the veins that carry blood out become somewhat compressed. Less blood leaves the penis, which encourages blood to pool in the organ’s erectile tissues.
The length of your external penis is the shaft. The end, which resembles a mushroom cap, is the head or glans. At birth, the glans is covered by a flap of skin called the foreskin. In some men, this flap is removed surgically shortly after birth (circumcision). There is no compelling medical reason to perform circumcision. In noncircumcised men, the foreskin retracts during erection, exposing the head of the penis. However, in some men, the foreskin does not retract completely, which may cause pain during erection. In such cases, doctors often recommend circumcision.
If your foreskin is intact, be sure to retract it by hand and wash its inner lining thoroughly every time you shower. If you don’t, dirt and bacteria can accumulate, increasing your risk of spreading sexually transmitted infections—not to mention that your penis doesn’t taste as good during fellatio. Poor hygiene is a major turn-off for women.
After ejaculation, erection subsides. The older you get, the faster this happens. In young men—from teens through the 20s—the penis may remain firm for a while after ejaculation, and erection may subside slowly. But in older men, erection fades quickly. This is normal, and not a sign of erectile dysfunction.
Male Sexual Anatomy
After ejaculation, young men may be able to raise another erection within an hour or so. But as men age, the time lengthens between orgasm and the ability to become erect again. Older men may require 12 hours—or longer. This, too, is normal.
While your penis is certainly important to your sexual function and pleasure, there’s much more to your sexual body. The scrotum is where your genital tract begins. It’s the fleshy sack that hangs between your legs and houses your two testicles, or testes. Each testicle contains millions of tiny tubes, the seminiferous tubules that produce sperm, or male sex cells. Sperm production begins at puberty and, barring severe illness or injury, continues for a man’s entire lifetime.
The optimal temperature for sperm production is a few degrees cooler than normal body temperature. That’s why the scrotum evolved to hang outside of the trunk of the body—to keep sperm cool. Chances are you’ve noticed that when you feel cold, for example, in a chilly locker room, your scrotum seems to hug your body; but when you’re warm, say, after a shower, your scrotum hangs much lower. That’s the body’s way of keeping the testicles at the best temperature for sperm production. When testicular temperature falls below optimal for sperm production, muscles in the scrotum contract and pull it up close to the body for warmth. But when testicular temperature rises, those same muscles relax, dropping your testicles away from your body to keep them cool. High temperature kills sperm, so men with low sperm counts should avoid hot tubs and sitting for extended periods with their thighs pressed together. Both of these warm the testicles to the point where sperm may die from heat damage.
Inside the scrotum, adjacent to each testicle, is a tightly coiled tube called the epididymis (plural: epididymides), where sperm are stored during the few months they need to mature. If you like, when your scrotum is relaxed, you can feel your epididymides. First gently feel for your testicles. Right next to them, you may be able to feel something spongy. That’s the epididymis.
Once mature, sperm travel up and out of the scrotum through the vas deferens (plural: vasa deferentia), a tube attached to each of your epididymides. These are the tubes that a doctor cuts during male sterilization surgery, or vasectomy. Sperm account for only about 2 percent of the volume of semen. So, while vasectomy eliminates sperm from semen, you notice no difference in your ejaculations after vasectomy. Each vas tube arches around your pubic bone, a hard structure you can feel by pressing on your lower abdomen near the base of your penis. You can use this bone to increase a woman’s likelihood of orgasm during intercourse using the coital alignment technique discussed in chapter 8.
Beyond your pubic bone, each vas deferens tube passes your seminal vesicles, tiny glands that secrete a yellowish fluid that becomes part of semen. This seminal vesicle fluid nourishes sperm on their long journey out of the penis, into the woman’s vagina, through her cervix, through her uterus, and into her fallopian tubes, where conception takes place. It’s a long swim for microscopic sperm, and they need all the help they can get.
Then, both vas deferens tubes merge with your urethra in the prostate gland. The prostate produces most of the fluid that makes up semen. Both urine and semen flow out of the body through the urethra, but they don’t mix. A valve activated by erection allows only urine to flow when the penis is flaccid, and only semen to flow when it’s erect.
The prostate is located toward the back of your body, above your anus. The prostate’s size is a key sign of its health. The easiest way to check this gland’s size is by inserting a lubricated finger into your anus. That’s why doctors perform rectal-finger exams on men—to check the size of the prostate. In young men, the prostate may develop a bacterial infection (prostatitis), in which case it swells, feels tender, and the finger exam hurts. Doctors treat prostatitis with antibiotics. The prostate may also become chronically tender and painful without infection (chronic prostatitis or prostadynia). This is often caused by lower abdominal muscle tension. Relaxation regimens (hot baths, meditation, biofeedback) often help. Some doctors prescribe muscle relaxants.
Until age 50 or so, your prostate is about the size of a walnut. After that, because of normal, age-related changes in the male sex hormone testosterone, the prostate begins to grow, a condition called benign (noncancerous) prostate enlargement (medically, benign prostatic hypertrophy, or BPH). The urethra, the tube that carries urine from the bladder out of the penis, runs through the prostate. As the gland swells, it pinches the urethra, causing BPH symptoms: trouble starting to urinate (medically, urinary hesitancy), trouble finishing (dribbling after you think you’re done), and the most annoying, having to get up at night to urinate (nocturia). Although all men develop prostate enlargement as they age, risk of BPH symptoms is highly individual. Some men need treatment. Others don’t. According to a recent Dutch study of 81,000 middle aged men, by age 75, about half opt for BPH treatment.
Getting up once or twice a night doesn’t bother most men. But if you experience classic symptoms by your 60s, you may have to get up three or more times. That’s when men consult their doctors for treatment. Currently, there are two ways to treat BPH—drugs and surgery. The drugs (and one safe medicinal herb, saw palmetto) slow prostate enlargement and may even reverse it, relieving the pinching that causes nocturia. But medication benefits may be temporary. Prostate surgery (medically, transurethral resection of the prostate, or TURP) offers benefits that typically last about 10 years. This surgery involves inserting a tiny special catheter into the urethra at the tip of the penis, threading it up into the prostate, and then using a cutting tool attached to the catheter to snip away excess prostate tissue, which widens the urethral passage. More than 300,000 TURPs are performed in the United States each year. The operation requires up to a few days of hospitalization, and about a week’s recovery time at home. Afterwards, you maintain normal sexual function, except that orgasm no longer involves ejaculation of semen out of the penis. Instead, you ejaculate backwards into your bladder (dry orgasm, or medically, retrograde ejaculation). Dry orgasm is not harmful and does not diminish the pleasure of orgasm. Your semen mixes with urine and leaves your body when you urinate.
The Cowper’s glands are located along the urethra just beyond the prostate. When you’re sexually aroused, these glands secrete additional fluid into semen.
THE MANY CAUSES OF ERECTILE DYSFUNCTION
Until the 1980s, most sex experts held the Freudian view that erection impairment was caused by deep-seated, unconscious neuroses (read: psychological problems). Today, sexuality professionals have largely rejected Freud’s view. Few men with erection problems have deep psychological problems. According to Althof, “Pure cases of psychogenic (that is, neurotic) ED are the exception, not the rule.” The majority of cases are caused by a combination of sexual misinformation, relationship problems, other life stresses, aging, cardiovascular problems, depression, and drug side effects.
THE MYTH FACTOR
In young men, the main cause of erection problems is emotional stress created by sexual misinformation, belief in the myths perpetuated by pornography and locker-room “experts” who are usually clueless about sex. Here are the most common erection-deflating myths, and the truth about them.
Myth: Erection is something a man “achieves.”
Truth: The American Urological Association (AUA) defines ED as “persistent (at least 3 months) inability to achieve or maintain erection sufficient for satisfactory sexual performance.” The word “achieve” makes an erection seem like something a man must work to produce, as though he were constructing a building. But how do you do this work? For most men, erections just happen and they take them for granted—until, for whatever reason, their penises don’t spring to attention. Then men have no idea how to “achieve” one. “You can’t will an erection,” explains advisory board member Louanne Weston, Ph.D. “The struggle to ‘achieve’ erection is actually counterproductive. It’s distracting. The man loses his erotic focus. And the quest to ‘achieve’ erection generates considerable stress. The smooth muscle tissue in the penis stays contracted, which limits bloodflow into the organ and keeps the man flaccid.”
Penises don’t become erect through work. In fact, erection results from the complete opposite of work—the kind of deep sensual relaxation described in chapter 1. The more sensual your lovemaking, the more likely you are to rise to the occasion. As I’ve mentioned in the preceding chapters, leisurely, whole-body, massage-inspired sensuality is critical to women’s sexual arousal—and arousal is contagious. The more turned on she is, the more turned on—and erect—you’re likely to become.
Myth: Sex is a “performance.”
Truth: The AUA definition of ED mentions “satisfactory sexual performance.” Like the word “achieve,” the term “performance” has troubling implications. It makes men feel like they’re being judged, that women are rating them as lovers. When you think of sex as a performance, you’re likely to fall into the trap of what sex therapists call “spectatoring.” Instead of feeling relaxed and fully engaged in lovemaking, you’re mentally observing and judging your performance like a spectator at a sporting event.
People tend to judge themselves and their actions more harshly than others ever would. Spectatoring invites this kind of self-criticism—and the stress that accompanies it. Stop thinking of sex as a performance to be watched and judged. Think of it instead as a form of adult play. It’s best when the two of you feel deeply relaxed, when the focus is entirely on giving and receiving pleasure. There’s no performance, no audience cheering or booing, no reviews. It’s just you and your lover enjoying each other’s intimate company.
Myth: Men are sex machines, always ready, always hard.
Truth: The assumption is that men are so easily aroused that any female attention produces a bulge in their pants. Many young men—but by no means all—can raise erections whenever an attractive woman comes into view and can have sex at a moment’s notice. But after age 30—often earlier—things change. Like women, men develop a set of conditions that need to be met before they can raise erections and enjoy sex. The conditions vary from man to man, but include such things as: privacy, relaxation, a feeling of emotional closeness with the woman, a romantic setting, no interruptions, and specific types of sexual stimulation.
It’s perfectly normal to have conditions for sex. In fact, it’s unusual not to. Say you love professional football. You’d do almost anything to attend games. But if the game is outdoors and it’s 10 below zero and snowing, you might decide not to go. Sex is similar. You can love sex, but still need certain conditions to enjoy it. If your conditions are not met, your penis might not be interested. “Men’s belief that they’re supposed to be sex machines is one of the biggest burdens men carry into the bedroom,” Great Sex advisory board member Dennis Sugrue, Ph.D., says. “All it does is generate stress, which contributes to erection problems.”
Myth: During each sexual encounter, you get only one shot at erection.
Truth: “Many men have the mistaken idea that they get only one chance for erection,” Weston explains. “If it subsides, they think the sex is over and they’re failures.” No so. Some young men stay rock-hard the whole time, but as the years pass, even those who were once the Washington Monument experience some waxing and waning. For most men, erections go from firm to less firm—or even flaccid—and then back to firm several times during lovemaking. As men grow older, they need more and more direct penis stroking to raise and maintain erection. This is normal, natural, and no cause for alarm.
Unfortunately, when men who believe the “only one chance” myth begin having erections that occasionally subside, they become anxious, which is self-defeating. Anxiety deflates erection. If your erection subsides during sex, don’t tense up and decide it’s all over. Instead, breathe deeply, keep the faith, and ask your lover to caress you in a way that you enjoy. Chances are, your erection will return.
Many women also expect erections to remain hard throughout the entire sexual encounter. If your erection subsides, your lover may feel unattractive, or think she’s a sexual failure. Reassure her that erection changes are normal during lovemaking. When it happens, both of you should understand that you need more direct caressing.
Myth: I blew it last time. I’ll never get it up again.
Truth: This myth is similar to the previous one—and equally false. Of course, it feels strange not to become erect during sex. But it’s a big mistake to over-generalize a single experience to a lifetime of ED. If you miss a shot playing hoops, does it mean you’ll never make another? If you lose at cards one week, does it mean you’ll never win again? Sometimes things go your way, sometimes they don’t. “One negative sexual experience doesn’t mean your erections are history,” Sugrue says. “Thinking so can generate enough stress to cause a self-fulfilling prophecy.”
If you can’t get it up, don’t flip out. Instead, take a careful look at the situation. Here are some possible reasons why things might not work: You were tired. You had too much to drink. You felt stressed by job problems, money troubles, family problems, relationship hassles. You were physically uncomfortable. You wished you were doing something else. You felt distracted by people in the next room, or a party next door, or jackhammers in the street. If you can’t give sex the undivided attention it deserves, your erection may decide to wait until next time. Work to eliminate stresses and distractions. Invest some extra time and effort in relaxation and sensuality. Your penis will thank you with a tall salute.
Myth: If I can’t raise an erection, she can’t be sexually satisfied.
Truth: Erections are not necessary to satisfy women. Even without an erection, you can still help your lover express orgasm by providing loving, whole-body caresses and eventually direct clitoral stimulation with your hand, or tongue, or with a sex toy. Men who believe this myth put way too much pressure on themselves to get hard and stay hard to satisfy the woman. That stress can impair erection. This may come as a surprise, but the vagina is not well endowed with nerves that respond to sexual stimulation, and the deeper inside your penis goes, the fewer of those nerves it finds. Most women enjoy intercourse for the physical closeness it involves and because it’s such a turn-on for so many men. But vaginal intercourse is usually not the key to women’s sexual satisfaction. Most women’s main source of sexual pleasure and satisfaction is the clitoris, located outside the vagina and above it, under the junction of her vaginal lips.
THE STRANGE WORLD OF PORNOGRAPHY
By the time they drop their pants, every man in porn sports a major boner. Many men figure they should, too. But few men can. Those who can’t often feel inadequate, and the stress can contribute to ED. However, there’s a dirty little secret about the erections you see in pornography. Before Viagra, the men in porn—all young, healthy, buffed studs—often had trouble raising erections.
Who wouldn’t? Porn sex is completely nonsensual, which contributes to erection problems, and the pressures most men feel to get it up are nothing compared to the pressures the men in porn face.
Richard Pacheco, a porn star during the 1970s and early 1980s, recalls his first day at work: “I was nervous about acting, nervous about having sex in front of the crew, and nervous about my penis getting hard. Driving over to the shoot, I practiced getting hard in my car. I felt terrified. I had no idea who I’d ‘work with,’ as they say. I was told to arrive at 8:00 A.M. Then they told me I’d go on at 11:00 A.M. I spent the entire morning sick with anxiety, getting made up and fitted for my costume, a doctor outfit. At 11:00 A.M., wearing a white coat, I was called to the set and very briefly introduced to a young, airhead girl. We didn’t say two words to each other. Then the director tells me: ‘Okay, you get it up,’ and to the girl, ‘Suck him.’ She dropped to her knees, and I actually got hard. I was amazed that my plumbing worked. After a while, I noticed that the girl was totally bored. It was the first time in my life any woman had seemed bored while sucking me. It was a rude introduction to the difference between personal and professional sex. About 30 minutes into it, the director tells me: ‘Now come.’
“All of a sudden, I lost my erection. Everything stopped as the director and crew waited for me to get hard again. Only I didn’t. I panicked. The girl kept sucking me, but nothing happened. I had never experienced any sexual dysfunction before in my entire life. But there I was, limp as a wet noodle in front of 30 people with bright lights and cameras, and the director looking impatiently at his watch, saying, ‘Time is money, kid.’ Talk about performance anxiety. After about a half hour the director told everyone to break for lunch. They all ate a fancy catered spread, and I was alone in the bathroom trying to get my penis to work.
“After lunch, I still couldn’t get it up. Two o’clock passed, three o’clock. Everyone was standing around waiting for me to get hard so we could shoot the come shot. Finally, around 4, I flashed on my very first makeout experience. There was still magic in those memories. I raised an erection. My leading lady woke up and started sucking, but as soon as she touched me, I lost it. This happened a few times. Finally, the director told her: ‘Don’t touch him until he’s squirting.’ So I basically masturbated to orgasm, and she got in there at the very end. But I was convinced that I’d never hear from the film company again.”
Pacheco had no idea that his experience was typical. He went on to make more than 100 X-rated videos during a 10-year career. But even after he became a star—winning three Best Actor and five Best Supporting Actor awards from the Adult Entertainment Association—he had trouble raising erections on the set. “It’s unnerving having sex in front of others. For me, I need a connection with the woman—if not love, at least friendship. You rarely have that in porn sex. I stuck with it because I became a star and made good money. But my problem plagued me my entire career.”
After making about a dozen films, Pacheco met another actor who gave him some tips about raising and maintaining erections on the job: “His name—I kid you not—was John Seeman. During the 1970s, John was a porn legend. He could get it up during an earthquake, and often worked as a ‘stunt cock.’ Producers hired him to be there just in case another actor totally pooped out. John would step in and they would substitute his penis for the other guy’s. John and I became friends, and he told me his trade secrets. He said, ‘You’ve got to please yourself. Don’t take orders. Give them. Instead of letting the director order you around, you’ve got to say: ‘Here’s what I need to get it up.’ Believe me, he’ll be grateful. He wants you to get hard, or he has no movie.’” Pacheco still had erection problems on porn sets after embracing Seeman’s advice, but he says, “John helped me a lot. In porn sex or in real sex, you have to get your needs met or else your penis doesn’t work.”
Today, porn actors routinely use Viagra—and some still have erection problems. Meanwhile, the vast majority of men who view porn have no idea that film crews can stand around for hours waiting for the actors to get hard. All viewers see is reliable, rock-hard erections every time. And if their own are not as reliable and as hard, they’re convinced something must be wrong with them.
Myth: When I can’t get hard, she says it doesn’t matter. She must be lying.
Truth: In surveys that have asked women how they feel about men with erection problems, most say they wish men wouldn’t become so obsessed with the situation. For most women, a man’s lack of erection is less of a problem than his anxiety, depression, anger, confusion, and emotional withdrawal because of it. Erection matters to women, largely because it matters so much to men. Women know that if a man can’t get it up, he’s going to be miserable, which affects her. “When a woman says a man’s lack of erection ‘doesn’t matter,’”Weston explains, “what she usually means is that the couple can still have sensual fun without one, that she can enjoy sexual satisfaction without one, and that things are likely to be better next time.”
Myth: If I can’t get hard, she’ll leave me.
Truth: “Women rarely walk out on men because of erection problems,” says Great Sex advisory board member Linda Alperstein, M.S.W., L.C.S.W. “They’re more likely to feel the problem is their fault, that they’re unattractive, or undesirable, or that the man has lost interest and is having an affair.” Couples rarely break up solely because of sex problems. If you develop an erection problem, chances are she won’t leave you. She’s more likely to want to help you resolve it.
Myth: With age, all men develop ED.
Truth: Aging brings erection changes, but that doesn’t mean ED is inevitable. Review the studies cited earlier in this chapter. Erection balkiness is common, but even among men over age 70, severe ED affects only a minority. On the other hand, as men age, their penises generally require direct stroking to become and remain erect. Erections take longer to rise and need more fondling to do so. “With age,” Sugrue insists, “men often develop medical conditions that can impair erection. But ED is not a normal part of aging.”
IT’S OKAY TO RECEIVE PLEASURE
Recently, a 30-year-old writer for New York magazine recounted his 6-month battle with ED. It began when he bedded a new lover, which can be stress-provoking for anyone. They’d just met and he hardly knew her, which added to his stress. She also happened to be a sex columnist for a woman’s magazine, which triggered horror fantasies that she would write about him, review his sexual “performance,” and demolish him in print. He was a nervous wreck.
They undressed, got into bed, and started rolling around, but his penis went nowhere. She asked, “What would you like me to do for you?”
The writer considered her question, and decided it was absurd. “There was nothing I wanted her to do for me. All I wanted was to please her.”
A century ago, sex was something men “did to” women, or “took” from them. Today, it’s more likely to be something they hope to “deliver.” Many men believe the “goal” of sex is to satisfy the woman, that it’s their “job” to orchestrate sex, lead her through it, and “give” her a fabulous orgasm, or several.
It’s great for a man to care enough about his lover’s pleasure to create the erotic context in which she feels relaxed and aroused enough to enjoy herself and express orgasm. But it’s a mistake to consider it your job to deliver her pleasure on an erotic silver platter. Sex is not a job—it’s play. You’re supposed to have fun. Ask how she would like to play. Take her requests seriously and do your best to provide the caresses she wants. Ask for what you want, too. Sexual satisfaction emerges from deep within each of us. It’s not your responsibility to satisfy her, or hers to satisfy you.
The New York magazine writer saw doctors. There was nothing physically wrong with him. He considered Viagra, but before trying it, he consulted a sex therapist who told him: “By trying so hard to please her, you forgot about yourself. You ignored your own sexual needs. You took the pleasure out of sex, and turned it into a ‘project.’ You don’t have an erection problem. What you have are mistaken ideas about sex. Just relax and let yourself receive pleasure as well as give it.”
He did, and all was well.
“Everyone has a right to be a little selfish in sex,” Althof explains. “It’s okay to spend some of the time focusing on your own relaxation, your own arousal, your own pleasure.”
RELATIONSHIP PROBLEMS AND OTHER LIFE STRESSES
Many men notice that they can raise erections solo, but develop problems during partner sex. One reason is that men typically feel the woman is rating their sexual performance, which causes anxiety. “Most golfers notice that they swing better on the driving range than they do on the first tee,” Sugrue explains. “Sex is similar. In masturbation, you’re entirely focused on your own pleasure, like a golfer on the driving range. That’s not the case in partner sex. Many men feel their partners are judging them, as other golfers might, so partner sex is more stressful. Masturbation also has a marvelous built-in sensory feedback system. You can make little adjustments instantaneously based on how you feel. You can’t do that in partner sex.”
Relationship issues may also contribute to partner-sex erection difficulties. “Even good relationships can suffer chronic annoyances and festering resentments,” Klein notes. “They can cause erection difficulties in partner sex that you don’t have during masturbation.”
If relationship problems contribute to erection impairment, it doesn’t necessarily mean your relationship is on the rocks. But Althof explains, “The penis is attached to the heart. When considering the causes of an erection problem, look deeply into your feelings about your relationship.”
The penis may be attached to the heart, but the connection can be confusing. Sometimes your erection may go limp immediately after relationship trauma, for example, learning that your lover has been having an affair. Other times, erections are so sensitive to relationship stress that your penis realizes something is wrong before your head does. And sometimes erections seem impervious to chronic relationship stress. But then months after bickering has become the hallmark of your interactions—boom, ED.
Because ED’s relationship connection can be elusive, it’s a good idea to take a careful look at yours. Have you been fighting more lately? Have you become stuck on any issues? Do you still find your lover interesting? Attractive? Has anything changed in either of your lives during the past year that has driven a wedge between you? Have you recently become aware of traits in your lover that you find upsetting, disappointing, or maddening? Are you interested in anyone else, and considering breaking up? Are you afraid that she’s losing interest in you? All these issues—and others—might contribute to erection problems. You may be able to explore them on your own, but you might also need professional counseling. Sex therapists are trained in relationship counseling, and they specialize in issues that have sexual dimensions.
Other life stresses can also cause or contribute to erection impairment—everything from disasters such as job loss, a loved one’s death, or your house burning down, to chronic hassles like car trouble, or the neighbor’s dog barking at all hours.
GETTING OLDER
Erection problems can develop at any age. But the research clearly shows that risk increases as men grow older. After age 50—often earlier—erections typically become balky even if you’re in a happy relationship, have not fallen victim to the erection myths, have no significant risk factors, and have no unusual stresses in your life.
With age, the nervous system becomes less robust. The sexy sights, talk, and touch that once produced a major bulge in your pants lose some of their power to arouse. With age, even if you don’t have cardiovascular disease, your arteries lose some of their elasticity. They don’t relax and open up as fully as they once did, so the pudendal arteries can’t carry as much blood into the penis. And with age, testosterone levels decline, possibly to a level low enough to affect sexuality (though low testosterone is more likely to deflate libido than erection).
This is not to argue that erections are doomed when you hit age 50, or 60, or 70. A healthy man can raise an erection at any age. But aging takes a toll. As I discussed in detail in chapter 2, a healthy lifestyle delays the effects of aging.
Don’t expect your penis to stand up if you cannot. Any illness or injury—a cold, the flu, allergies, tennis elbow, low back pain, you name it—can decrease libido and impair erection. Decreased sexual interest is the body’s way of directing its energy toward healing. Illnesses, particularly painful conditions, are also anxiety-provoking and distracting. They may prevent the relaxation, sensuality, and undivided attention necessary for great sex.
The body is not a machine that can be quickly fixed when it’s broken, like a car that needs a brake job. It’s a living organism, one that takes time to recover from illness. How much time? Usually much more than you’d expect. Musculoskeletal injuries can take months to heal. Viral illnesses, especially the flu, can leave you feeling lethargic and wasted for up to 10 days after you’re back to normal activities. After injuries or illnesses or surgery, don’t rush back into sex. If you do, your penis may rebel. Give yourself time to fully recover. During that period, there’s no need to refrain from physical closeness with your lover. Massage and other forms of sensual play can feel like ends in themselves if you let them. But don’t expect your penis to become erect until you’re healthy again.
As early as the fourth century B.C., Hippocrates speculated that long-duration horseback riding might cause impotence. His observation was largely forgotten until reports began circulating of erection problems in healthy young men who had no risk factors—except extended bicycle riding.
Subsequent studies suggested an unusually high risk of erection problems in elite, long-distance bicycle racers. Danish researchers surveyed 800 bicycle racers. More than 300 of them (38 percent) reported difficulty raising erections for a few days after races.
The researchers involved in the Massachusetts Male Aging Study mentioned earlier in this chapter investigated cycling and erection dysfunction among the study’s 1,709 participants. Riding less than 3 hours a week was not associated with erection difficulties. In fact, occasional or short-duration riding significantly reduced the risk of erection problems. However, bicycling more than 3 hours a week raised the risk 72 percent above average.
Why would cycling cause erection impairment? Straddling a narrow bicycle seat compresses nerves involved in erection and the pudendal arteries that supply blood to the penis. As a result, cyclists are at risk for numbness in the penis and decreased bloodflow into the organ. What’s worse, compression of the pudendal arteries can actually injure them over time, causing the development of deposits (plaques) that narrow them, limiting bloodflow. Elite cyclists have few plaques in their other arteries, but often have significant plaque formation in their pudendal arteries. Even recreational cyclists can develop localized plaques from a pudendal artery injury sustained from slipping off the pedals and falling onto bicycle crossbars.
If you ride less than 3 hours a week, you’re unlikely to develop persistent numbness of the penis, localized plaques, or erection difficulties. But if you ride more than that, good bike fit can often help prevent problems. Consult your local bike shop for assistance and make sure that when you’re seated on the saddle, your knees bend slightly when you downpedal. Also, consider switching to a saddle designed to support your weight on your buttocks, not your penis. Angle the nose of your seat down and your handlebars up to reduce pressure on vital nerves and arteries. And leave the saddle and stand about every 10 minutes or so.
CARDIOVASCULAR DISEASE (INCLUDING HIGH CHOLESTEROL AND HIGH BLOOD PRESSURE)
Cardiovascular disease is a major risk factor for ED. As I described in chapter 2, a healthy cardiovascular system—your heart and blood vessels—is necessary for good bloodflow into the penis. The clogged arteries that result from high blood pressure, high cholesterol, smoking, obesity, and diabetes limit this bloodflow and cause erection problems. University of South Carolina researchers studied 3,250 men aged 26 to 83 for 4 years to observe the relationship between their sexual functioning and cholesterol levels. As their cholesterol increased, so did their risk of ED. Compared with men whose cholesterol levels were 180 or less, those at 240 or more had almost twice the risk of ED.
Danish researchers studied 101 men with high blood pressure. The higher their pressure, the more likely they were to suffer ED. High blood pressure damages the arteries and interferes with bloodflow into the penis. Researchers in Saudi Arabia found similar results when they studied 388 men with ED. High blood pressure significantly raised their risk. So did lack of exercise, which is associated with high blood pressure.
SMOKING
Smoking damages the blood vessels and accelerates arterial narrowing, limiting bloodflow into the penis. Researchers with the Centers for Disease Control and Prevention studied 4,462 Vietnam veterans, aged 31 to 49. The more they smoked, the more likely they were to experience ED. Compared with nonsmokers, those who smoked the most had double the risk of ED—and these were all fairly young men. In the Saudi study just mentioned, smoking also greatly increased risk of ED.
OBESITY
Obesity means you’re more than 20 percent heavier than the weight recommended for your height and build. It usually results from a high-fat, high-cholesterol diet and lack of exercise—both risk factors for ED. Obesity also raises blood pressure. An analysis of men in the Massachusetts Male Aging Study shows that as participants’ weight increased, so did their risk of ED.
Other studies support these findings. Korean researchers evaluated 325 men with ED. As their weight increased, so did the severity of their ED. Other studies show that weight loss and exercise also protect against ED (see chapter 2).
DIABETES
Diabetes damages both the cardiovascular and nervous systems. Men with diabetes are not condemned to ED, but the disease increases risk. Wisconsin researchers surveyed 365 diabetic men who had been diagnosed at least 10 years previously. Overall, 20 percent reported erection difficulties, with incidence rising from 1 percent in those aged 21 to 30, to 47 percent among those 43 or older.
North Carolina researchers surveyed 246 diabetic men and found that about one-third experienced erection impairment.
NEUROLOGICAL DISORDERS
Multiple sclerosis, spinal cord injuries, and other neurological conditions can damage the nerves involved in erection.
HORMONAL IMBALANCES
ED might result from an endocrine disorder. Hormones released into the bloodstream by several glands are crucial to sexual function and general well-being. The one that concerns most men is a low level of testosterone. If you’re experiencing ED, ask your physician to order a testosterone blood test. But most men with ED have normal testosterone levels until late in life.
Some young athletes take androgenic anabolic steroids to bulk up. These hormones increase muscle mass, but often cause erection problems (see chapter 2).
CONGENITAL ABNORMALITIES
The main one is hypospadias (high-poe-SPADE-ee-as). In men with this birth defect, the urethra opens on the underside of the penis, instead of dead-center on top of the head. Hypospadias is one of the most common male birth defects. It affects one man in 200. In a mild case, the urethra opens a fraction of an inch below where it should. In more severe cases, it opens several inches down the shaft of the penis. Hypospadias is rarely discussed outside of urology journals. Hypospadias, per se, does not cause ED. But men who have it often suffer considerable anxiety over their “mutant” genitals, which may contribute to ED. In a related, rarer condition, epispadias, the urethra opens off-center on the topside of the penis. (For more on hypospadias and epispadias, see chapter 11.)
GENITAL AND URINARY TRACT CONDITIONS
Infections include: bladder infection, gonorrhea, chlamydia, nongonococcal urethritis, and prostatitis. None of these cause ED directly. However, some cause pelvic or genital pain, and others cause a discharge from the penis. Plus, the pain and anxiety of having a genital or urinary tract infection can contribute to ED.
Genital diseases include priapism and Peyronie’s disease. Priapism involves prolonged, painful erection unconnected with sexual arousal. Its cause is unknown, but it is associated with sickle-cell anemia, leukemia, some other cancers, and the supposed aphrodisiac Spanish fly. ED is common after priapism. Peyronie’s disease involves fibrous tissue growth in the penis that reduces the organ’s elasticity and may impair erection. Both diseases are rare.
DEPRESSION
Everyone occasionally gets the blues. But when sadness persists for months without returning to gladness, that’s serious (“major” or “clinical”) depression. About one person in eight suffers depression at some point in life. In men, depression may cause the classic symptoms: deep melancholy, weepiness, and an inability to get out of bed. But it also might cause anxiety, angry outbursts, and alcohol or drug abuse. And it might impair both libido and erection.
To make matters worse, the most popular medications used to treat depression, the selective serotonin reuptake inhibitors (SSRIs), including Prozac, Paxil, Zoloft, Luvox, and Celexa, cause sexual side effects in about half of those who take them (see “Drugs,” opposite). About 10 percent of men taking SSRIs report ED.
To preserve your sexual function while taking an antidepressant:
Take less. Ask your doctor about the possibility of reducing your dose. You might find a dose that treats your depression without causing sexual side effects.
Switch drugs. Ask your physician if you might switch to Wellbutrin. This effective antidepressant may cause erection problems, but compared with the SSRIs, it carries a substantially lower risk.
Try Viagra. Ask your doctor about taking Viagra in addition to your antidepressant. University of New Mexico researchers worked with 76 men who complained of sex problems—libido loss, ED, trouble ejaculating—after taking SSRIs for an average of 2 years. They were given either a placebo or Viagra (50 or 100 milligrams, as needed). After 6 weeks, those who took Viagra reported significantly improved libidos, erections, ejaculation, and overall sexual satisfaction.
Take a “drug holiday.” Anthony Rothschild, M.D., a psychiatrist at McLean Hospital in Belmont, Massachusetts, studied 30 couples, each with one member taking an SSRI and reporting sexual side effects annoying enough to consider going off the medication. Rothschild advised them to go drug-free on weekends, from Thursday morning to Sunday at noon. Half reported better sexual functioning and more desire over the weekend, and only two said they felt more depressed. If you’d like to try a drug holiday, consult the physician who prescribed your medication.
ALCOHOL
In Macbeth, Shakespeare wrote that the substance used worldwide to coax reluctant lovers into bed “provokes the desire, but takes away the performance.” How true. The first drink is “disinhibiting.” People are more likely to accept sexual invitations. But if people of average weight drink more than two beers, cocktails, or glasses of wine in an hour, alcohol becomes a powerful central nervous system depressant that interferes with erection. The more you drink, the more likely you are to experience ED.
DRUGS
Some drugs impair erection directly, for example, narcotics, tranquilizers, sedatives, and many psychiatric medications collectively known as “downers.” They are all central nervous system depressants. Take them, and your penis stays down, too.
Other drugs have side effects that may cause ED. The key word here is “may.” If you take any of the drugs listed below, you’re not necessarily fated to go limp. Sexual side effects are highly individual. If you believe you’re experiencing erection-deflation from any medication you take, consult the physician who prescribed it. Perhaps another drug, one with a lower risk of sexual side effects, can be substituted. And be aware that if a label says, “may cause drowsiness,” as many antihistamine labels do, the drug may cause erection problems.
This list of erection-impairing medications has been adapted from a 1997 article in the Journal of Family Practice by authors who combed the medical literature for reports of drugs with sexual side effects. Drugs frequently associated with ED are starred (*).
Over-the-counter drugs: Aleve (pain and inflammation), Benadryl (antihistamine; sleep aid), Dramamine (antihistamine; motion sickness); Naprosyn (pain and inflammation), Pepcid (stomach distress), Tagamet* (stomach distress), Zantac (stomach distress).
Narcotics: Codeine, Darvocet, Darvon, Demerol, Dolopine*, Methadone*, Morphine*, Oxycontin, Percodan, Percoset, Roxanol, Vicadin.
Tranquilizers: Anafranil*, Atavan, Barbiturates, BuSpar, Librium, Mitran, Thorazine*, Valium, Xanax.
Sedatives: Dalmane, Halcion, Phenobarbital*, Restoril.
Blood pressure medications (antihypertensives): Adalat, Aldactone*, Aldomet*, Apresoline, Arfonad, Blocadren, Calan, Cardizem, Catapres, Demser, Dilacor, Esidrix*, HydroDiuril*, Hygroton*, Hylorel*, Inderal*, Inversine, Ismelin*, Isoptin, Loniten, Lopressor, Lotensin, Lozol, Midamor, Minipress, Normodyne*, Oretic*, Prinivil, Procardia, Propranolol, Regitine, Reserpine, Tenormin*, Thalitone*, Toprol, Trandate*, Vasotec, Verelan, Visken, Wytensin*, Zestril.
Antidepressants: Ascendin, Aventyl, Celexa, Effexor, Janimine*, Ludiomil, Luvox, Nardil, Norpramin, Pamelor, Parnate, Paxil, Pertofrane, Prozac, Tofranil*, Vivactil, Wellbutrin, Zoloft.
Antianxiety and psychiatric medications: Anafranil, Compazine, Equanil, Eskalith*, Haldol, Lithium*, Lithonate*, Mellaril*, Miltown, Navane, Orap*, Permitil*, Prolixin*, Serentil, Sulpitil*, Supril*, Thorazine.
Seizure medications: Atretol*, Carbatrol, Diamox, Dilantin*, Epitol, Mysoline*, Primidone*, Tegretol*.
Other prescription drugs: Akineton (Parkinsonism), Amen (female sex hormone), Anaprox (pain and inflammation), Antabuse (alcoholism), Antivert (nausea and vertigo), Anxanil (antihistamine), Artane (Parkinsonism), Atarax (antihistamine), Atromid* (lowers cholesterol), Atropine (various uses), Axid (ulcer), Azulfidine (ulcerative colitis, Crohn’s disease, and rheumatoid arthritis), Banflex (muscle relaxant), Bentyl (irritable bowel syndrome), Bonine (nausea and vertigo), Cogentin (Parkinsonism), Compazine (nausea and vertigo), Cordarone (cardiac arrhythmia), Cycrin (female sex hormone), Daranide* (glaucoma), Diamox* (glaucoma and seizure), Digitek (congestive heart failure), Digoxin (congestive heart failure), Di-Spaz (irritable bowel syndrome), Ditropan (bladder leakage), Fastin (obesity), Flexon (muscle relaxant), Furoxone (protozoal dysentery), Inapsine (anesthetic), Indocin (pain and inflammation), Interferon (immune stimulant), Kemadrin (Parkinsonism), Ketoconazole (fungal infections), Klonopin (seizures), Lanoxin* (congestive heart failure), Lioresal (muscle relaxant), Lopid (lowers cholesterol), Matulane (Hodgkin’s disease), Methadone (heroin addiction), Methotrexate (rheumatoid arthritis and cancer chemotherapy), Mexitil (cardiac arrhythmia), Mintezol* (parasitic infection), Naprosyn (pain and inflammation), Neptazane* (glaucoma), Niacor (fungal infection), Nizoral* (fungal infection—oral, not the cream), Norflex (muscle relaxant), Norpace (cardiac arrhythmia), Parlodel (Parkinsonism), Phenobarbitol (sedative), Prilosec (ulcers), Pro-Banthine (gastrointestinal spasms), Provera (female sex hormone), Quarzan (ulcers), Reglan (nausea, vertigo, and heartburn), Sansert (migraine headache), Transderm-Scop (motion sickness), Trecator (tuberculosis), Vistaril (antihistamine).
Recreational and illegal drugs: Amyl nitrate, amphetamines, cocaine, heroin, MDMA (Ecstasy).
While this list contains the drugs most frequently associated with erection impairment, other drugs may also cause it. In addition, if you take two or more medications at the same time, their interactions in the body might also contribute to ED. If you develop erection difficulties shortly after starting any medication, it’s likely the drug has something to do with your situation. Consult the prescribing physician.
PROSTATE CANCER TREATMENT
Male sex hormones spur the growth of prostate tumors. To minimize this, some prostate cancers are treated with female sex hormones. As a man’s sex-hormone balance tilts more toward the female, his erections may suffer. Another common treatment for prostate cancer is removal of the gland (radical prostatectomy). Unfortunately, the operation often damages the nerves involved in erection. Researchers at the Fred Hutchinson Cancer Research Center in Seattle followed 1,291 men who had radical prostatectomies. Eighteen months later, 60 percent of them had severe ED. Some surgeons suggest “nerve-sparing” prostatectomy for erection preservation. In this study, it helped—but not much. Among those receiving standard prostatectomy, 66 percent wound up with ED. In men who had nerve-sparing surgery, the figure was 56 percent.
Surgery for benign prostate enlargement may, on occasion, contribute to ED. But a recent British study suggests that this is rare, and that the operation for benign enlargement (transurethral resection of the prostate, or TURP) is more likely to improve erection than harm it.
HOW TO VISIT A DOCTOR FOR AN ERECTION PROBLEM
Before Viagra, some physicians were reluctant to deal with erection problems. No longer. The new openness about ED, plus demand for Viagra, has spurred doctors to take erection impairment seriously. It’s a good idea to begin investigating any erection problem by having a check-up. Review the potential physical causes of ED, then use the following guide to obtain a thorough exam.
Describe your situation in detail. How long have you had the problem? When did it begin? How? Did it develop suddenly or gradually? Has it ever improved or suddenly worsened? Under what circumstances? What was happening in your life around the time the problem began? What was happening during the year before it began? Can you raise an erection during masturbation? Do you wake with morning erections? Are you happy with your relationship? If not, why not? What has happened in your relationship because of the problem? Have you withdrawn from sex? Has your partner?
Review your medical history. Relevant items include: your age, weight, cholesterol level, blood pressure, smoking, drinking, over-the-counter and prescription drug use (see here), recreational drug use, any recent acute illnesses, and any history of depression, anxiety, heart disease, stroke, diabetes, prostate surgery, pelvic injury, hormonal problems, multiple sclerosis, sickle-cell anemia, spinal cord injury, priapism, Peyronie’s disease, or exposure to toxic chemicals.
Review your psychological history. This includes any symptoms of anxiety, depression, phobias, panic attacks, or a fundamentalist religious background in which sex was considered taboo. Bear in mind that drugs used to treat anxiety and depression may have erection-impairing side effects.
Drugs. Jot down all the medications you take, both over-the-counter and prescription. Take the list with you. Also, honestly declare how much alcohol you drink and any recreational drugs you use.
Get tested. Tests should include:
▢Blood pressure. High readings are associated with ED.
▢Cholesterol. High levels increase risk of ED.
▢Testosterone. Abnormally low levels usually suggest libido loss, but also contribute to erection problems.
▢Glucose tolerance. This tests for diabetes, which increases your risk of ED.
▢Thyroid function. Low levels of thyroid hormone are linked to ED.
▢LH and Prolactin. Low levels of these pituitary hormones may cause ED.
▢PSA. The screening test for prostate cancer.
▢Nocturnal Penile Tumescence. This test involves attaching a strain gauge to the penis to see if you have erections while you sleep. The absence of nighttime erections strongly suggests that physical factors are causing the problem.
While physicians are well-equipped to evaluate the physical causes of erection impairment, they may not be the best professionals to evaluate the extent to which the problem results from the very real issues of sexual mythology, relationship problems, emotional stress, or nonsensual lovemaking. To explore these issues, consult a sex therapist. (See chapter 15.)
Regardless of its cause, erection impairment has a major impact on men’s lives. The University of Chicago survey asked men with and without ED if they felt happy or unhappy. Those with ED were four times more likely to say they were unhappy. “For many men,” Sugrue says, “the ability to raise an erection is the very essence of manhood. As a result, many men consider an erection problem much more than just a sex problem. Many men with ED consider themselves complete failures as men. That can cause tremendous anguish.”
THE MANY TREATMENTS FOR ERECTION DISSATISFACTION AND ED
These days, if you experience any erection difficulty, from minor (occasional erection dissatisfaction) to persistent ED, you might be tempted to ask your doctor for Viagra. It usually helps, but it’s often unnecessary.
The following section presents a step-by-step approach to erection restoration. Viagra and other erection medications are the final step. But don’t skip the others. They’re good for your overall health. And they can enhance your relationship as well as restore lost or faltering erections.
SIX SECRETS TO MORE SATISFYING ERECTIONS
1. Lead a healthy lifestyle. This means, if you smoke, quit. Get regular, moderate exercise. Eat a lower-fat, lower-cholesterol diet, with less fast and junk food and more fruits and vegetables. Control your weight. Limit alcohol. Steer clear of recreational stimulants and depressants. Incorporate a stress-management program into your life. And sleep at least 7 hours a night. (For more on a sex-enhancing lifestyle, see chapter 2.)
2. Identify, then manage, your stressors. Perhaps you’ve taken a “stress test” published in some magazine. The trouble is, most of these self-assessment quizzes are so simplistic they’re useless. For a more usable and relevant analysis of what’s stressing you out, click on www.essisystems.com. For less than $20 you can order an excellent, comprehensive self-assessment tool called Stressmap. For more information, see the Resources section at the back of the book.
The test provides an at-a-glance picture of your stress situation neatly arranged to reveal your problems and strengths. A mental health professional can also help identify your life stresses. One of the best stress relievers is deep relaxation (review the discussion in chapter 1). Other proven stress relievers include: exercising, meditating, getting a massage, laughing, taking hot baths, gardening, having a pet, visualizing relaxing scenes, and spending quality time with friends, family, or a lover. Incorporate one—or more—into your daily life. Ideally, combine them: Exercise with friends. Bathe with your lover.
3. Reestablish intimacy. Men are brought up to take care of themselves, not to turn to others for help and support. As a result, when faced with ED, many men withdraw into a cocoon of silence, sometimes punctuated by angry outbursts. Or they blame the women in their lives for “not being sexy enough.” Over time, men’s silence and tantrums eat away at relationship intimacy—especially because women often blame themselves for men’s erection problems, fearing that they are no longer attractive, or that the man is having an affair or is about to leave them.
Intimacy involves opening yourself up emotionally. If you clam up about what’s bothering you, the intimacy in your relationship evaporates. Silence about erection problems only makes things worse. It contributes to anxiety and depression, which aggravate ED. It often leads both men and women to withdraw from sex. It drives a wedge between you and your lover, which interferes with your ability to work on the problem together.
Don’t withdraw into silence. Talk about your situation. Tell her how you feel. It may be difficult, but you don’t have to be the world’s most articulate man to get your point across. Discuss how you feel to the extent that you can. “Sometimes,” Alperstein says, “all a man can say is: ‘I feel bad about my erection situation and don’t know what to do about it.’ That’s a good start.” Don’t simply dismiss the problem by saying: “I’m tired. I’m overworked.” Maybe so, but that’s rarely the end of the story. If fatigue and overwork are factors, what can you do about them? If you’re in a basically happy relationship, reassure your lover that it’s not her fault and that you’re not about to leave her. Ask how she feels about your situation. Is she thinking of leaving you because of it? Chances are she’s committed to you and as concerned about the problem as you are—for your sake. If your relationship has problems, discuss them. It’s possible that they play a role in your erection problem. If you have trouble saying what you mean, or if relationship issues make discussion difficult, a sex therapist can help.
Reestablishing intimacy also requires you to remain an active participant in your relationship and your sex life. Social connections, especially enjoyable activities with the woman you love, are relaxing, and help produce erection. “Continue to invest time and energy in your relationship,” Weston advises. “Have fun together. Make dates. Go out. Enjoy each other’s company.”
The amount of time you actually have an erection represents only a small fraction of the time you spend with your lover. And you don’t even need an erection to give her pleasure. It’s worth repeating: Fewer than half of women express orgasm during vaginal intercourse even if the guy is the Rock of Gibraltar. Most need direct clitoral stimulation. “Try your fingers, tongue, or a sex toy,” Sugrue suggests.
You may feel strange making love without an erection. You might think: My penis is dead. What’s the point? But your penis is not dead. It’s just taking a little vacation. Withdrawal from sex won’t help the situation, but sensual closeness just might. Not to mention that your lover may need reassurance that you still love her, find her attractive, and want to make love with her.
Another great way to reestablish intimacy is with the couple’s game An Enchanting Evening, developed by Barbara and Michael Jonas of Scottsdale, Arizona (see here).
THE SENSUAL, NONINTERCOURSE SOLUTION
Here’s a standard sex-therapy treatment for erection impairment that you can do without the guidance of a trained professional. Go ahead and have sex. The only catch is that you take a break from intercourse—even if you have an erection. “I usually ask couples dealing with erection problems not to have intercourse for 8 weeks,” Klein says. “It takes the pressure off the man to have an erection, so it’s a good break from performance anxiety. Assuming the man is sexually skilled with his hands and tongue, it shows him that he can get his partner very turned on and satisfy her without an erection. And it allows him to experience all the ways he can enjoy sex without an erection.”
After a few weeks of making love without intercourse, you likely will raise an erection. “I tell men to welcome those erections, and then ‘waste’ them, not use them for intercourse,” Klein says. “That changes how the man feels about his erections. When couples come in for treatment of ED, erection is a scarce resource. But when the couple ‘wastes’ a few erections, the man’s feelings usually change. All of a sudden, his erections aren’t scarce anymore. In fact, they’re so abundant that he doesn’t even need to take advantage of them every time they appear.”Review the discussion of whole-body sensuality in chapter 1. Make dates for sensual exploration. Try some new sensual enhancements: showering together, music, candlelight, bedroom snacks, sex toys, a romantic getaway—whatever you like. Just don’t have intercourse for a while. Explore all the ways you can give and receive pleasure without an erection. When your erections return, continue to emphasize total-body sensuality over genital sexuality. Your penis needs sensuality to become erect and stay that way.
4. Get your needs met. I don’t mean for you to demand she drop to her knees and service you whenever you want, or do anything she truly dislikes. Pleasing yourself simply means recognizing that you have requirements for the kind of arousal that raises an erection and maintains it. It’s okay to have conditions. It’s okay to tell your lover about them. When thinking about the conditions you need to enjoy sex, ask yourself these questions:
Do you really want to make love? This question gets to the idea of whether you simply want to “score” or whether you want to have great sex. Men tend to initiate sex more often than women, making sex something they pursue. The “chase” becomes a game, and winning means getting her into bed. But some men become so caught up in the pursuit that they ignore their own feelings. If you don’t find the woman sexually attractive, why bother? Why jump into bed if you think she’s annoying? Or if your team is in the playoffs and you’d rather watch the game? Or if you’re just not in the mood? It’s okay not to want to bed every woman with a pulse. It’s also okay to decline sexual invitations. If you have sex when you don’t want to with a woman who doesn’t do much for you, your penis may not like the “working conditions” and decide to go “on strike.”
Do your fantasies turn you on? As discussed in chapter 3, great sex depends on a combination of friction and fantasy. Have you come up with any hot new fantasies lately? Or are you still imagining the same tired, old scenes? “After a while, fantasies get stale,” Klein explains. “Use your imagination.”
Does she take enough initiative? In great sex, lovers give and receive pleasure. Some women feel too inhibited to do much initiating. If she’s passive, then you have to do all the work. That’s not fair—and it’s often erection deflating, especially as men grow older. It’s okay to be a little selfish, to spend some time just lying back receiving pleasure. If your lover does not take enough initiative, ask her to. You might do this verbally: “Let’s take turns giving each other back rubs.” Or you might take the less direct—but often preferable—approach of praising anything she does that involves taking initiative or that you particularly enjoy. Many women are unsure of their erotic skills and find praise reassuring. It also enhances intimacy and contributes to women’s sexual self-confidence, which helps them become more sexually assertive.
Are you getting the amount of stimulation you need? As the years pass, most men need increasing amounts of direct penis stroking to raise and maintain erections. As discussed in chapter 1, one key to great sex is whole-body sensuality, as opposed to a preoccupation with the genitals. But embracing whole-body sensuality doesn’t mean you should downplay your need to have your penis fondled—perhaps quite a bit—to have reliable erections. If you want to be stroked early in lovemaking, or if you want more penile stimulation, ask for it. Just don’t expect her to caress your penis every moment you’re in bed together—whole-body sensuality is still important.
Are you getting the kind of stimulation you need? Perhaps you like a tight grip on your penis, but she’s partial to providing feathery, fingertip touch. Or maybe you love having your scrotum cupped in her hand, and you think she doesn’t do that enough. Ask for the kind of stimulation you need. Or show her. One of my most remarkable experiences as a sex counselor involved a guy in his late twenties whose erections started faltering about a year into a relationship with a woman he swore he adored. I asked about his sexual tastes, and he explained that what he liked best was fellatio—but that his lover didn’t provide it. After I asked a few more questions, he revealed that all his previous girlfriends had done it without being asked.
So, I made the obvious suggestion: “Ask her,” I said.
He insisted he couldn’t, so I suggested he start right then and there with a rehearsal of sorts—I told him to ask me for what he wanted, and I would say it back to him. We exchanged the words several times and before he left, I told him to say it aloud (but to himself) several times a day. Finally, the next time he was in bed with his girlfriend, I suggested he say the words to her. He seemed dubious, but said he’d try. A few days later, he called to tell me he’d asked, and she was happy to oblige. His problem disappeared.
“Think about what turns you on and—especially—off,” Weston suggests. “If a sexual experience involves several items from your personal turn-off list, it’s reasonable to expect erection difficulties. Work to create a sexual context that turns you on.”
5. Do Kegel exercises. In addition to enhancing the pleasure of orgasm, preliminary studies suggest that Kegel exercises help men with erection problems. Researchers at the University of Milan in Italy discovered that men with ED tend to have unusually weak pelvic floor muscles. In a later study, Belgian researchers trained men with erectile dysfunction in Kegel exercises. Forty-two percent reported improvement.
Here’s a short course on Kegels. First identify your pubococcygeus (PC) muscle. It’s the one you contract to stop urinating, or to squeeze out the last few drops. For slow Kegels, contract your PC and hold it for a slow count of three, then relax. For quick Kegels, contract and release your PC as rapidly as you can, then relax. Begin by doing five slow contractions and five quick ones three times a day. Each week, increase the number of contractions you do by five. Your goal is to do 50 slow and 50 fast three times a day, for a total of 300 contractions a day. Don’t increase the number of contractions more quickly than recommended, or you may suffer groin soreness.
6. Try sex therapy. If do-it-yourself approaches don’t restore your erections, sex therapy usually works. Studies show that sex therapy helps revive lost or faltering erections in about 70 percent of cases.
Sex therapy for ED typically involves much of what I’ve encouraged you to try on your own, but with personal coaching focused on your specific situation and relationship. It includes:
▢Reducing your anxiety about sex.
▢Correcting any destructive erection myths you might believe.
▢Assessing your stressors and working to minimize them.
▢Helping you and your lover to work out any relationship issues.
▢Helping you both to improve your sexual negotiation skills.
▢Encouraging a more sensual approach to lovemaking, including homework exercises focused on whole-body massage—often with intercourse temporarily prohibited.
▢Encouraging you to be forthright about your sexual preconditions and the amount and kind of stimulation you need.
Sex therapy can produce dramatic relief from ED fairly quickly, even for severe ED. Recently, Australian sex therapists published a study involving 32 men with persistent, moderate-to-severe ED—defined as impairment during 75 to 100 percent of sexual experiences. After just 10 sex therapy sessions, 16 of them (50 percent) regained their erections. For more on sex therapy, see chapter 15.
VIAGRA: EVERYTHING YOU NEED TO KNOW
Thanks to Viagra, ED isn’t a big secret anymore. But what do you really know about the little blue pill? Here are the basics.
How it works. Recall that sexual arousal stimulates release of nitric oxide in the penis, which triggers production of cGMP, which in turn, relaxes the organ’s smooth muscle tissue and lets extra blood flow into the penis’s spongy erectile tissues. Viagra (sildenafil) enhances this smooth muscle relaxation, spurring greater bloodflow into the penis. Viagra comes in 50-milligram pills. The typical dose is 50 to 100 milligrams—one or two pills.
Its benefits:
1. It’s a pill, and Americans love pills.
2. It doesn’t interrupt the flow of sex because you take it 1 to 3 hours before lovemaking.
3. It helps men with ED caused by both physical illness and stress/anxiety problems. Most studies show that it produces erections in 75 percent of cases, with even greater effectiveness among men with only mild or occasional problems.
4. It requires normal sexual stimulation. You don’t have to walk around with an embarrassing bulge in your pants that signals you’ve taken a drug.
5. It’s safe for most men. Its only significant side effects are headache (16 percent of users), flushing (10 percent), upset stomach (7 percent), nasal congestion (4 percent), and rarely, visual disturbances, mostly in men with chronic eye conditions such as macular degeneration. Side effects are more likely with a 100-milligram dose.
6. It’s affordable. The 50-milligram dose most men take costs about $10, a small price to pay for an amorous evening free from erection worries.
ERECTION INSURANCE
Viagra was approved for persistent ED, but once a drug is approved for any reason, doctors are free to prescribe it for other, so-called “off label” uses. Viagra’s main off-label use is as “erection insurance” for men with occasionally balky erections who don’t want to worry about them. If you use Viagra for erection insurance, you might not need 50 milligrams. Try cutting the pills in half. Twenty-five milligrams is often sufficient.
If you have iffy erections or feel anxious about getting it up, should you use Viagra for erection insurance? That’s up to you. If you’re over 40 and you ask for a prescription, most physicians are willing to oblige. Many are happy to prescribe it for younger men. The real issue is what you do with your more reliable erections once you have them. If you use Viagra to imitate pornography—mechanical, all-genital sex with a headlong rush into intercourse—the drug may not work because porn-style sex is often stressful enough to overwhelm Viagra’s benefits. In addition, your lover may experience “Viagravation” (see below). But if Viagra allows you to relax about your erections and focus on whole-body sensuality, then it can enhance lovemaking.
VIAGRA-VATION
WHAT REGAINING YOUR ERECTIONS MEANS FOR YOUR RELATIONSHIP
Human beings are well-equipped to adapt to less-than-ideal situations. And indeed, many couples adapt to erection problems—especially those couples who feel uncomfortable with intimacy. “Lack of erection means they don’t have to deal with their intimacy issues and have an excuse to avoid sex,” Weston explains. “But when men regain lost erections, the sexual equilibrium in the relationship changes. Erection restoration solves one problem, but may cause others.”
“In all my years of treating ED,” says Klein, “I’ve seen very few pure erection problems. But I’ve seen lots of ED accompanied by anxiety, guilt, shame, anger, violence, alcoholism, religious beliefs, and relationship problems. By itself, Viagra can’t resolve these other problems, which often play an important role in the erection trouble.”
To understand why this might cause aggravation for a couple, let’s start by looking at the difference between the way men and women view ED and its consequences. Men tend to consider erection impairment a mechanical problem, with Viagra the quick fix. Women generally see ED as an emotional issue, and want to work on the couple’s intimacy—or lack of it—before they feel comfortable returning to intercourse.
Once the possibility of having intercourse returns, couples face any number of challenges—and may not agree on how to deal with them. For example, if a couple hasn’t been physically affectionate together in a while, they may feel tentative approaching each other for sex. If one or both previously didn’t enjoy sex, now neither has an excuse to avoid it. One partner might harbor unexpressed resentments about the ED or about the other’s withdrawal from intimacy. A woman might have taken comfort in the man’s ED—figuring he couldn’t be unfaithful to her—but now feels vulnerable and scared he’ll cheat. Likewise, a man might feel he is now free to leave his partner and seek another relationship. “By themselves,” says Marian Dunn, Ph.D., director of the Center for Human Sexuality at the State University of New York Health Science Center in Brooklyn, “Viagra and other similar treatments often are not enough to help couples reactivate their sex lives.”
In addition, Alperstein says, if the woman has become menopausal during the time when the man experienced ED, she may have less sexual desire, be less able to produce vaginal lubrication, and have experienced vaginal atrophy from lack of regular intercourse.
Couples returning to sex after ED should proceed slowly. “Don’t rush intercourse,” Althof advises. Instead, work up to it by having nonsexual fun together for a while. Go out on dates. Flirt. Share affectionate touches, nicknames, or routines. Treat your relationship as new because in some ways, it is. Even with restored erections, you can’t have good sex without feeling emotionally close and trusting.
If anger, resentments, emotional withdrawal, or other issues have diminished the intimacy in your relationship, consider couples counseling or sex therapy. “Sometimes, Viagra works fine by itself and sex therapy is not necessary,” Sugrue explains. “But if the man’s ED is associated with relationship problems, or if relationship problems appear after Viagra restores his erections, then I recommend a combination of the drug and sex therapy.”
Its limitations. Viagra doesn’t work in about 25 percent of cases. As the severity of ED increases, its effectiveness decreases. For example, it works well in most men with diabetic ED, but less well in diabetics with considerable cardiovascular and neurological damage. Even in men with mild erection balkiness, Viagra may not work in some situations—such as if you feel particularly stressed, distracted, or alienated from the sexual experience.
The latest studies suggest that some men need to increase their dose over time. University of Alabama researchers tracked 150 men who took Viagra regularly for 2 years or more. During that period one-third of them had to increase their dose from 50 to 100 milligrams.
For men who respond poorly to Viagra, it may help to combine it with the over-the-counter supplement ArginMax (see here). Researchers at University of California, Davis, worked with men with ED who did not benefit much from Viagra. The men took Viagra plus either ArginMax or a placebo. After 4 weeks, erections improved significantly in 22 percent of those taking the placebo, but among men using ArginMax, the figure was 60 percent.
When you shouldn’t take it. Some men should never use Viagra—those taking nitrate medication for heart disease, notably nitroglycerine for angina, or the party drug amyl nitrate (“poppers”). The combination of Viagra and nitrate drugs can cause a drastic drop in blood pressure—and possibly death. Before this problem was identified, the combination of Viagra and nitrate medication killed more than 500 men. If you take any nitrate drug, don’t use Viagra.
In addition, Viagra is associated with a slightly increased risk of heart attack and stroke. It slightly increases the tendency for blood to clot. Internal blood clots trigger heart attack and most strokes. Men with histories of heart attack and stroke should consult their doctors before using Viagra, and consider taking an anticoagulant, like aspirin, to reduce their risk of internal clots.
As this book went to press, a second erection medication was approved, Levitra (vardenafil). Another one, Cialis (tadalafil), already approved in Europe, is in the final stages of approval in the United States. Both Levitra and Cialis work the same way as Viagra, but they last longer. Viagra’s effects last for a few hours, while Levitra and Cialis facilitate erection for about 24 hours, and in some men, up to 36.
OTHER TREATMENTS FOR ED
Yohimbine. For centuries, the bark of the West African yohimbe tree was reputed to restore faltering erections. Scientists scoffed—until the 1980s, when several studies showed that a chemical in the bark, yohimbine, increased bloodflow into the penis. More than 10 years before Viagra, the Food and Drug Administration approved yohimbine as a prescription treatment for erection problems. The herbal extract is available in the products Ahprodyne, Yocon, and Yohimex.
Yohimbine is controversial. Some studies show that it produces no benefit. However, two analyses—a 1996 review of 16 studies at Syracuse University and a 1998 British analysis of 7 studies—both showed that yohimbine is an effective treatment for ED. The British group called it “a reasonable therapeutic option.”
If you’d like to try a yohimbine-based drug, ask your doctor for a prescription. Several yohimbine products are sold over the counter as supplements, but a 1995 FDA analysis showed that many contain not nearly enough to help with erection. Possible side effects include: increased heart rate and blood pressure, fluid retention, nervousness, irritability, headache, dizziness, tremor, and flushing.
Vacuum constriction devices. These devices create a vacuum around the penis that draws blood into the organ, resulting in temporary erection. Models differ, but all include a plastic tube that fits over the penis, fitted with a pump typically operated by a hand bulb. You squeeze the bulb, which sucks air from the tube, drawing blood into your penis. Once you have an erection, you slip a rubber ring similar to a rubber band over it to compress the veins that drain blood from the penis. This helps to maintain the erection.
Most studies of VCDs report 60 to 80 percent effectiveness. Researchers at the University of Texas, San Antonio, provided devices to 216 men with ED. Seventy percent used them, and of those, 85 percent said that they and their partners were satisfied with them. The American Urological Association (AUA) endorses them, saying they result in a “high probability of return to intercourse.”
The downside is that these devices produce only temporary, short-lived erections. They also may cause a temporary bluish discoloration of penile skin, and possibly a feeling of coolness that some men find uncomfortable. Some couples don’t like the way these contraptions interrupt their lovemaking. You can minimize the distraction if you integrate the device into sex, with the woman helping the man use it.
VCDs are available over the counter and by prescription. The over-the-counter models, “penis pumps,” are sold as sex toys by most sexual-enhancement retailers. They are less expensive than prescription models, but may not provide a sufficient enough seal between the device and the base of the penis to create an effective vacuum. The AUA advocates using a prescription model. They cost more (your health insurance may cover it), but they provide a better fit and seal.
Cock rings. Vacuum constriction devices include a rubber ring that fits over the erection to compress the veins that carry blood out of the penis. Sex toys known as “cock rings” work by the same principle. The arteries that carry blood into the penis run through the center of the organ, so cock rings don’t keep blood out. But some of the veins that carry blood out of the penis are close to the organ’s outer skin. As the penis expands during erection, these veins become somewhat compressed, which restricts outflow. Cock rings reduce the outflow a bit more, resulting in greater blood buildup in the penis, and a slightly firmer erection.
Cock rings also have a psychological effect. If a man believes that a cock ring helps his erection, he’s likely to feel reassured and become more relaxed, which helps raise and maintain erection.
I’ve seen no medical reports of cock rings damaging the penis when used as directed. However, bruising is possible if the ring is too tight. If you’re concerned, use an adjustable ring.
L-arginine. L-arginine is an amino acid and the chemical precursor of nitric oxide, a compound crucial to erection. Studies show that L-arginine supplementation increases levels of nitric oxide in the penis. New York University researchers gave 15 men with ED either L-arginine or a placebo for 2 weeks. None of the placebo group improved, but 40 percent of those taking L-arginine did. Israeli researchers worked with 50 men with ED, all of whom had low levels of nitric oxide. The men took either L-arginine or a placebo. About a third of those taking the L-arginine reported benefit. While interesting, these benefits are within the realm that might be expected of a placebo. Still, L-arginine is safe and available over-the-counter at health food stores and supplement shops.
Ginkgo. This medicinal herb improves bloodflow around the body, notably through the brain, where it helps slow the progression of Alzheimer’s disease. It also appears to spur bloodflow into the penis. In one study, 60 men with ED caused by cardiovascular problems were given ginkgo (60 milligrams/day). After 1 year, half regained their erections.
Ginkgo also has been shown to help prevent ED and other sex problems caused by antidepressants. At the University of California, San Francisco, researchers gave ginkgo extract (an average of 209 milligrams/day) to 63 people suffering sex problems as a result of taking antidepressants. The herb helped 76 percent of the men, including quite a few who had erection problems. The men also reported more sexual desire, an improved ability to raise erections, and generally more pleasurable sex.
Ginkgo is available over-the-counter at health food stores and supplement shops. It’s safe for most men. However, ginkgo is an anticoagulant. If you take anticoagulant medication or use other anticoagulants frequently—aspirin, garlic, ginseng, vitamin E—you may experience bruising or bleeding problems. Consult your physician.
Ginseng. For centuries, Asians have considered ginseng a sex enhancer. Korean researchers gave 90 ED sufferers one of three treatments: a placebo, an antidepressant, or ginseng. The placebo and antidepressant groups both showed 30 percent improvement in erection firmness. The ginseng group improved 60 percent. Another group of Korean researchers performed a similar study with 45 ED sufferers. Compared with those taking a placebo, the ginseng group (900 milligrams three times a day) experienced significant erection improvement. Ginseng is safe for most men. Many preparations are sold at health food stores and supplement shops. Follow the package directions for dosage.
Ginseng has anticoagulant action. If you take anticoagulant medication or use other anticoagulants frequently—aspirin, garlic, ginkgo, vitamin E—you may experience bruising or bleeding problems. Consult your physician. Herbalists advise that ginseng must be used regularly for several months before its benefits become noticeable.
ArginMax. ArginMax for Men is an over-the-counter supplement that contains vitamins and minerals found in many one-a-day supplements—plus ginkgo, ginseng, and L-arginine.
University of Hawaii researchers gave either a placebo or the dose specified on the ArginMax label to 52 men with ED. A month later, 24 percent of the placebo group reported improvement. In the ArginMax group, the figure was 84 percent. ArginMax caused no significant side effects, except increased bruising because two of its ingredients—ginkgo and ginseng—are anticoagulants. ArginMax is available at health food stores and supplement shops.
Hypnosis and acupuncture. Scandinavian researchers divided 60 men with stress-related ED into four groups. One received acupuncture twice a week for 6 weeks. Another received sham acupuncture on the same schedule. The third was hypnotized—three sessions for the first week then one a month for 2 months. The fourth was given a placebo. The placebo and sham acupuncture improved erections in about 45 percent of users. Acupuncture helped 60 percent; hypnosis, which is very relaxing, helped 75 percent. Acupuncture and hypnotherapy are both deeply relaxing, so it makes sense that they would help treat stress-related ED.
Alprostadil. Like Viagra, the drug alprostadil relaxes the penis’s smooth muscle tissue and allows extra blood into the organ. The drug can be administered in two ways, by injection or by inserting a tiny pellet into the urethra. The insertion system involves an applicator that pushes the pellet about an inch into the urethra. Half the men who use the insertion system raise erections within 10 minutes and they typically last 30 to 60 minutes, varying from semifirm to firm. Beyond squeamishness about inserting the pellet, the main potential side effect is pain due to pellet insertion.
Injected alprostadil produces an erection within a few minutes. It usually takes a while for men to become comfortable with self-injection in the penis, and the dose must be carefully regulated, otherwise prolonged painful erection (priapism) may occur, which requires prompt medical treatment. Since the arrival of Viagra, alprostadil has become less popular. But Viagra does not help men whose ED is caused by neurological problems, such as nerve damage from prostatectomy for prostate cancer. For men with neurological ED, alprostadil is still a valuable option. If you’re interested, consult a urologist.
Testosterone. Testosterone has more effect on libido than erection. But men with levels low enough to impair libido usually have erection problems as well. At Northwestern University, researchers reviewed 73 testosterone-supplementation studies from 1966 to 1998. In addition to restoring lost libido, testosterone replacement restored erection in about half of the cases. Testosterone benefits only those men who have abnormally low levels. Men in the normal range receive no additional libido or erection boost from supplementation. Testosterone may also accelerate the growth of prostate cancer, so supplementation should be limited to men with abnormally low levels.
Implants. If other treatments don’t provide sufficient benefit and you really want an erection, implants are the treatment of last resort. Implants don’t interfere with urination, ejaculation, or orgasm. But they involve major surgery along with the risk of complications.
Two types are available: flexible rods and hydraulically inflated cylinders. Flexible rods are the simpler option. The surgeon inserts a rod into the penile shaft in place of erectile tissue. Afterward, you have a permanent erection. You bend the rod down so it’s inconspicuous most of the time, and bend it up for sex. A flexible rod is less likely than a hydraulic implant to malfunction or cause complications. However, the surgery may cause scarring, and a flexible rod can be embarrassing if you wear tight clothing or undress in a locker room.
Hydraulic implants involve a set of nested cylinders inserted into the penile shaft, a reservoir of salt water usually implanted in the lower abdomen, and a squeeze bulb hand pump usually inserted into the scrotum. In nonsexual settings, the penis looks normally flaccid, except for the possibility of surgical scarring. For sex, you squeeze the bulb, and fluid flows from the reservoir into the cylinders, which inflate and extend like the hydraulic lift in an auto shop, producing erection. After ejaculation, you hit a release valve. The fluid returns to the reservoir and your erection deflates. Some men have no complaints about hydraulic implants. However, they may malfunction, requiring corrective surgery.
If you’re interested in an implant, consult a urologist.