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You Me and ED

Men, your partner lies before you in a dimly lit room, completely enticed by your pre-mating seduction ritual. Marvin Gaye, just barely audible in the background, whispers “Let’s get it on.” Following a trail of rose petals littered across the floor, you advance to the silk-covered bed where your lover awaits. Minds and spirits already entwined, the time comes for bodily connection when, as though pressing a soft gummy worm against the keyhole of the doorway to your love life, you find yourself locked out … and no one can let you in.

There are over 600,000 new cases of erectile dysfunction in the United States annually.{1} Erectile dysfunction is defined as the consistent or recurrent inability of a man to attain or maintain an erection sufficient for sexual intercourse and is considered a symptom, not a disease.{2} This article will identify the physiology of penile erections, risk factors of erectile dysfunction, and ways to maintain a healthy erection.

So, what do you know about how the male erection works? Engorgement of the penis with blood appears to be common knowledge, but how does that blood get to your “tower of power”? Does one just “will it” to the penis?

To start, there are three types of erections: those that occur during deep sleep, those caused by direct physical genital stimulation, and those caused by any of the other four senses or by mental imagery.

Let’s pretend for a second that you are with a partner and the erection process has been initiated. For the first phase of your erection, varied hormones will begin to circulate in the penis. The hormones stimulate relaxation of penile arteries and smooth muscle—a type of muscle similar to that found in the stomach lining- which will increase blood flow to the penis. Simultaneously, penile veins contract, preventing that blood from leaving the penis. For increased rigidity (hardness) of the penis and ejaculation, the ischiocavernosus and bulbospongiosus muscles—similar in composition to muscles that move your arm or leg—contract around the bottommost portion of the penis and “sit bones.”{3} Now that you know how erections are supposed to work, let’s look at the risk factors of erectile dysfunction.

The risk of developing erectile dysfunction has been shown to increase sharply beyond the age of 40.{4} There is not much we can do to combat Father Time, and accident or illness can happen unexpectedly at any age; however, more manageable risk factors of erectile dysfunction for those over 40 include heart disease, high cholesterol, and high blood pressure.{5} For those under 40, psychological risk factors such as anxiety and depression have been shown to be the most prevalent.{6} Regardless of age, I think many of us will agree that a healthy erection is ideal. Here are some ways to keep your flag at full staff through the ages.

Unrestricted passage of blood to the penis is ideal for a healthy erection; thus, decreased fat accumulation along arterial walls is essential. Brisk walking for an average of an hour a day has been shown to promote healthy arteries and significantly decrease the onset of erectile dysfunction.{7} In addition, people following a Mediterranean-based food pyramid have been found to demonstrate a lower onset of erectile dysfunction.{8}

Sustained occlusion of blood flow to the penis for more than three hours per week (common in cyclers) has also been shown to have a negative impact on erectile function.{9} While more research is required to identify the best bike seat cushion for the prevention of erectile dysfunction, pressure mapping studies have shown that gel-padded and air seat cushions provide the most even weight distribution.{11}

Finally, performance anxiety may be avoided through positive and open communication with your partner. From the start, try to incorporate phrasing such as “it would feel better if you…” versus “I do not like it when you….” {11}

These are all great ways to address risk factors before they become evident. But what if you want to put a little more “pep” in your pepperoni?

In The 40-Year-Old Virgin, Steve Carell’s character asked, “Is it true that if you don’t use it, you lose it?” We all laughed at his droll question, but he may have been onto something. Remember, the rigidity of a penis during arousal is increased and maintained by two pelvic floor muscles similar to the muscles in your arms and legs. Just like those muscles, the pelvic floor muscles may increase and decrease in size and strength with exercise.{12}

To maintain a healthy erection, it may help to lie on your back with hips and knees bent so you can comfortably keep your feet in full contact with the floor. Place your dominant hand on the buttock muscle on the same side (for example, if you are right-handed, put your right hand on your right buttock). From here, contract your pelvic floor the same way you might contract to stop or slow the flow of urine. The dominant hand’s role during the contraction is to make sure that the buttock muscle stays relaxed. For increased resistance to the muscles at play, perform the exercise with an erection.{13}

It is paramount that the pelvic floor muscle is engaged in isolation. If you are having a difficult time isolating the pelvic floor muscle, another way people think of engaging it is by trying to make the penis “jump.” However, if you use this cue, be careful that the penis does not jump too far away because then we have a whole other issue.

Earlier I mentioned that erectile dysfunction is a symptom rather than a disease; this means it is a finding that results from another condition.{14} Erectile dysfunction in younger men has often been shown to improve spontaneously, and in older men pelvic floor physical therapy has proven to be very effective.{15} But it may be appropriate to consult a primary care physician to rule out other serious conditions prior to initiating physical therapy.{16}




{1} Catherine B. Johannes et al., “Incidence of Erectile Dysfunction in Men 40 to 69 Years Old: Longitudinal Results from the Massachusetts Male Aging Study,” Journal of Urology 163, no. 2 (February 2000): 460–3, https://doi.org/10.1016/s0022-5347(05)67900-1.

{2} Ian Eardley, “The Incidence, Prevalence, and Natural History of Erectile Dysfunction,” Sexual Medicine Reviews 1, no. 1 (May 2013): 3–16, https://doi.org/10.1002/smrj.2.

{3} Ernst R. Schwarz, Erectile Dysfunction (New York: Oxford University Press, 2013); Pierre Lavoisier et al., “Pelvic-Floor Muscle Rehabilitation in Erectile Dysfunction and Premature Ejaculation,” Physical Therapy 94, no. 12 (December 1, 2014): 1731–43, https://doi.org/10.2522/ptj.20130354; Rany Shamloul and Hussein Ghanem, “Erectile Dysfunction,” Lancet 381, no. 9861 (January 12, 2013): 153–65, https://doi.org/10.1016/s0140-6736(12)60520-0.

{4} Ronald W. Lewis et al., “Definitions/Epidemiology/Risk Factors for Sexual Dysfunction,” Journal of Sexual Medicine 7, no. 4 (April 2010): 1598–607, https://doi.org/10.1111/j.1743-6109.2010.01778.x.

{5} Allen D. Seftel, Peter Sun, and Ralph Swindle, “The Prevalence of Hypertension, Hyperlipidemia, Diabetes Mellitus and Depression in Men with Erectile Dysfunction,” Journal of Urology 171, no. 6 (June 2004): 2341–45, https://doi.org/10.1097/01.ju.0000125198.32936.38; Wesley Ludwig and Michael Phillips, “Organic Causes of Erectile Dysfunction in Men Under 40,” Urologia Internationalis 92, no. 1 (January 2014): 1–6, https://doi.org/10.1159/000354931; Lewis, “Sexual Dysfunction,” 1598–607.

{6} Eardley, “Erectile Dysfunction,” 3–16; Ludwig and Phillips, “Organic Causes of Erectile Dysfunction,” 1–6.

{7} Sidney Glina, Ira D. Sharlip, and Wayne J.G. Hellstrom, “Modifying Risk Factors to Prevent and Treat Erectile Dysfunction,” Journal of Sexual Medicine 10, no. 1 (January 2013): 115–9, https://doi.org/10.1111/j.1743-6109.2012.02816.x.

{8} Glina, Sharlip, and Hellstrom, “Modifying Risk Factors,” 115–9.

{9} Glina, Sharlip, and Hellstrom, “Modifying Risk Factors,” 115–9.

{10} Hirosuke Takechi and Akihiro Tokuhiro, “Evaluation of Wheelchair Cushions By Means of Pressure Distribution Mapping,” Acta Medica Okayama 52, no. 5 (October 1, 1998): 245–54, https://doi.org/10.18926/AMO/31321.

{11} John P. Wincze and Risa B. Weisberg, Sexual Dysfunction: A Guide for Assessment and Treatment (New York: The Guilford Press, 2015).

{12} Lavoisier et al., “Pelvic-Floor Muscle Rehabilitation,” 1731–43.

{13} Lavoisier et al., “Pelvic-Floor Muscle Rehabilitation,” 1731–43.

{14} Shamloul and Ghanem, “Erectile Dysfunction,” 153–65; Michel Millodot, Dictionary of Optometry and Visual Science, 7th ed., s.v. “symptom,” retrieved January 7, 2018, from https://medical-dictionary.thefreedictionary.com/symptom.

{15} Johannes et al., “Incidence of Erectile Dysfunction,” 460–3; Lavoisier et al., “Pelvic-Floor Muscle Rehabilitation,” 1731–43.

{16} Shamloul and Ghanem, “Erectile Dysfunction,” 153–65; Giorgio Gandaglia et al., “A Systematic Review of the Association Between Erectile Dysfunction and Cardiovascular Disease,” European Urology 65, no. 5 (May 2014): 968–78, https://doi.org/10.1016/j.eururo.2013.08.023.