a man is sexually stimulated by sight, thought, or touch, the brain sends
signals that relax the smooth muscles around the arteries that supply blood
to the spongy and cavernous bodies. The veins draining the bodies can't keep
up, resulting in swelling. As the swelling reaches the limit of the penile
skin, the penis becomes firm. The pressure of the spongy and cavernous bodies
against the skin partially closes the veins, helping to maintain the erection.
Erection continues until the signals from the brain stop, but erections are
not consistent; waking and waning are normal, even during intercourse.
Erection can occur throughout life, happening before birth and into the 90's
in healthy men. Nocturnal erections occur during all male dreams
(regardless of what the dream is about), unless the man has physical problems
(this is the easiest way to determine if impotence is physical or emotional in
nature). The so called "morning erection" is the result of being wakened
during, or just after a dream; and it can be a very persistent erection.
While a morning erection is not a sign of arousal, it's presents and the
pleasurable sensations it can create may result in arousal.
have only very limited control over their erections. During puberty the young
man is often embarrassed by erection in public settings, but he gradually
becomes able to suppress erections when the stimulation is mild. Likewise, it
is impossible to "will" an erection, although sexual thoughts can cause
erection. During prolonged foreplay a man's erection may go away; this is
normal, and is not a sign of lessening interest.
health and physical exhaustion can affect erection; when very tired, a man may
be able to have only a partial erection, but still be able to climax. Erection
is lost in two stages; the initial stage is very quick, but usually leaves the
penis firm enough to continue intercourse. The second stage is somewhat
slower and is effected by a variety of things including age (which tends to
speed it), and arousal level before climax, with higher (or longer) pre-climax
arousal generally resulting in slower lose of erection
the head (or glands) of the penis is very sensitive to touch, touch alone does
not bring about an erection. The epicenter responsible for such essential
arousal is actually within the brain. Only after the brain receives visual,
audio or mentally stimulating input will it transmit (via the central nervous
system) instructions to the smooth muscles along the penis to relax.
the release of nitric oxide in the corpora cavernosa
relaxes the smooth muscles. At the same time, the artery to the penis widen to twice
its diameter, increasing the blood flow sixteen-fold, and the veins which
carry blood away from the penis are blocked. As a result, the two
spongy-tissue chambers in the shaft of the penis fill with blood and the penis
becomes firm. The corpora cavernosa, acting like a sponge, fill with
In fact, the corpora absorb up to eight times more blood than when the
penis is flaccid. As your penis swells and lengthens, the filled corpora
cavernosa press against the veins. The veins surrounding the chambers are
squeezed almost completely shut by this pressure. The veins are unable to
drain blood out of the penis and so the penis becomes rigid and erect. This
condition normally keeps this erection firm enough for intercourse.
most basic level this function is considered to be normal if a man is able
to maintain his erection sufficiently long to engage in satisfying intercourse
and the subsequent ejaculation. The length of time a man might stay
continuously erect can be on the average be about 30 - 45 minutes. Of course
the duration of his erection vary greatly, in which case it may be a shorter
or a great deal longer. After ejaculation or cessation of further stimulation to the penis itself or
to the brain excess blood will be allowed to drain away, while the level of
blood flow into the penis returns to normal. The penis once again becomes
flaccid as it loses the built up pressure.
quality or intensity may depend on the nature in which the brain is
stimulated. Acts as simple as kissing or "petting" are at times sufficiently
arousing to bring about an erection. Viewing a sexually titillating movie or
photographs will arouse most men to erection. Beyond this the particular
nature of erotic images will have varying effects, as men tend to have a broad
range of sexual tastes and desires. While some men may become highly aroused
by mundane stimulation, others thrive on fetishes.
male libido is often receptive to a great variety of stimulation. To consider
a man sexually dysfunctional solely by measuring his arousal during
intercourse, with a long term partner, is simply too limited as well as
illogical. Certainly there are men who are not only fulfilled, but thrive in
life-long monogamous relationships. This confirms the notion that there is
great variation between the needs and sensibilities among men. It would be a
mistake however to insist that all men can achieve the same purpose,
blissfully maintaining a long-term relationship, which is both sexually and
if things aren't quite working that way. There are a number of conditions
which may diminish or otherwise influence this process, these are known and
considered under one very general
catch all term: Erectile Dysfunction, which
is technically defined as "the inability to achieve or maintain an erection
sufficient for sexual intercourse". This is one of the most common sexual
ailments in men. Although erectile dysfunction can
be primarily psychological in origin, for most men it's more likely a physical
disorder, often with some psychological overlay. While some men assume that erectile
failure is a natural part of the aging process and tolerate it; others
devastating. Withdrawal from sexual intimacy because of fear of failure can
damage relationships and have a profound effect on overall well being for the
Male Aging Study measured several
health related variables in 1290 men aged 40 to 70 years. Erectile dysfunction
was very common. Fifty two per cent of the men reported some degree of
impotence-mild in 17.1%, moderate in 25.2%, and complete in 9.6%. Complete
impotence was reported by 5% of men at 40 years of age and 15% at 70 years of
Over the past decades, the medical perspective on the causes of impotence
has shifted. Common wisdom used to attribute almost all cases of impotence to
psychological factors. Now investigators estimate that between 70% and 80% of
impotence cases are caused by medical problems.
It is often difficult to determine if the cause of erectile dysfunction is
physical or psychological, or even some combination. The following may be
helpful in understanding the difference.
impotence tends to be abrupt and related to a recent
situation. The invidual may be able to have an erection in some
circumstances but not in others. The inability to experience or
maintain an erection upon waking up in the morning suggests that the problem
is physical rather than psychological.
impotence occurs gradually but continuously over a period of time. If
impotence persists over a three-month period and is not due to a stressful
event, drug use, alcohol, or medical conditions, the individual may needs to
seek medical attention from a urologist specializing in impotence.
In virtually every case of impotence, there are emotional issues that can
seriously affect the man's self-esteem and relationships, and may even cause
or perpetuate erectile dysfunction. Many men tend to fault themselves for
their impotence even if it is clearly caused by physical problems over which
they have little control.
Anxiety has both emotional and
physical consequences that can affect erectile function. It is among the most
frequently cited contributors to psychological impotence. Anxiety over sexual
performance is often referred to as performance anxiety and may provoke an
intense fear of failure and self-doubt. It can sometimes set off a cycle of
chronic impotence. In response to anxiety, the brain releases chemicals known
as neurotransmitters that constrict the smooth muscles of the penis and its
arteries. This constriction reduces the blood flow into and increases the
blood flow out of the penis. Simple stress may even promote the release of
brain chemicals that negatively affect potency in a similar way.
Depression is strongly
associated with erectile dysfunction. In one study, 82% of men who reported
moderate to severe erectile dysfunction also had symptoms of depression.
Depression can certainly reduce sexual desire, but it is often not clear which
condition came first.
Problems in Relationships often have a direct impact on sexual
functioning. Partners of men with erectile dysfunction may feel rejected and
resentful, particularly if the affected man does not confide his own anxieties
or depression. Both partners commonly experience guilt for what they each
perceive as a personal failure. Tension and anger frequently arise between
people who are unable to discuss sexual or emotional issues with each other.
It can be very difficult for the man to perform sexually when both partners
harbor negative feelings.
Socioeconomic Issues like
losing a job or having lower income
or education increases the risk for impotence.
(particularly heavy) is frequently cited as a contributory factor in the
development of impotence.
Alcohol has also been implicated in causing impotence.
In small doses, alcohol releases inhibitions, but in doses larger than one
drink, it can depress the central nervous system and impair sexual function.
Lack of Frequent
Erections deprive the penis of
oxygen-rich blood. Without daily erections, collagen production increases and
eventually may form a tough tissue that interferes with blood flow. The
spontaneous erection men experience while sleeping or awake may be a natural
protection against this process.
The Physical causes of Erectile Dysfunction
Blockage of Blood Vessels The
primary cause of oxygen deprivation is ischemia, the blockage of blood
vessels. The same conditions that cause blockage in the blood vessels leading
to heart problems may also contribute to erectile dysfunction. For example,
when cholesterol and other factors are imbalanced, a fatty substance called
plaque forms on artery walls. As the plaque builds up, the arterial walls
slowly constrict, reducing blood flow. This process, known as arteriosclerosis,
is the major contributor to the development of coronary heart disease.
Diabetes may contribute to as
many as 40% of impotence cases . Between one third and one half of all
diabetic men report some form of sexual difficulty.
High Blood Pressure Erectile
dysfunction is more common and more severe in men with hypertension than it is
in the general population. Many of the drugs used to treat hypertension are
thought to cause impotence as a side effect; in these cases, it is reversible
when the drugs are stopped.
As a risk factor
for impotence, Parkinson's disease (PD) is an under-appreciated problem. It is
estimated that about one-third of men with PD experience impotence.
affects the central nervous system, also precipitates sexual dysfunction in as
many as 78% of males suffering for MS.
and its Treatments can damage nerves needed for erectile
the side effects of radiation therapy include most of
those of surgery, but the risks for impotence and incontinence are
about a quarter of all cases of impotence can be attributed to medications.
Many drugs pose a risk for erectile dysfunction.
Among the drugs that are common causes of impotence are the following:
- Drugs used in chemotherapy.
- Many drugs taken for high blood pressure, particularly diuretics and
- Most drugs used for psychological disorders, including anti-anxiety
drugs, anti-psychotic drugs, and antidepressants.
Physical Trauma, Stress or Injury
: spinal cord injury and pelvic trauma, such as a
pelvic fracture, can cause nerve damage that results in impotence.
studies have indicated that regular bicycling may pose a risk for erectile
dysfunction by reducing blood flow to the penis.
does not cause erectile dysfunction. When
impotence occurs after this procedure, it is often in men whose female
partners were unable to accept the operation.
Abnormalities : Hypogonadism in men is
a deficiency in male hormones, usually due to an abnormality in the testicles,
which secrete these hormones. It affects 4 to 5 million men in the United
Low Testosterone Levels
only about 5%
of men who see a physician about erectile dysfunction have low levels of
testosterone, the primary male hormone. In general, lower testosterone levels
appear to reduce sexual interest, not cause impotence. A 1999 study, however,
suggests that testosterone levels are not an accurate reflection of sexual
Lifestyle changes to help prevent Erectile Dysfunction
Maintain General Health
: Because many cases of impotence are
due to reduced blood flow from blocked arteries, it is important to maintain
the same lifestyle habits as those who face an increased risk for heart
Diet : Everyone should eat a diet rich in
fresh fruits and vegetables, whole grains, and fiber and low in saturated fats
and sodium. Because erectile dysfunction is often related to circulation
problems, diets that benefit the heart are especially important.
: A regular exercise program is
extremely important. One study reported that older men who ran 40 miles a week
boosted their testosterone levels by 25% compared to their inactive peers.
Another study found that men who burned 200 calories or more a day in physical
activity (which can be achieved by two miles of brisk walking) cut their risk
of erectile dysfunction by half compared to men who did not exercise.
Limit Alcohol and Quitting Smoking
who drink alcohol should do so in moderation. Quitting smoking is essential.
Staying sexually active can help prevent
impotence. Frequent erections stimulate blood flow to the penis. It may be
helpful to note that erections are firmest during deep sleep right before
waking up. Autumn is the time of the year when male hormone levels are highest
and sexual activity is most frequent.
The Kegel exercise is a simple exercise commonly used by
people who have urinary incontinence and by pregnant women. It may also be
helpful for men whose erectile dysfunction is caused by impaired blood
circulation. The exercises consist of tightening and releasing the pelvic
muscle that controls urination
Reducing Medications :
If medications are causing
impotence, the patient and physician should discuss alternatives or reduced
Interpersonal, supportive, or
behavioral therapy can be of help to a patient during all phases of the
decision-making process regarding possible methods of treatment. Therapy may
also ease the adjustment period after the initiation or completion of
treatment. It is beneficial to have the partner involved in this process. The
value of sex therapy is questionable. In one study, 12 out of 20 men whose
dysfunction had a psychological basis and who were advised to enter a sex
clinic resisted sex therapy out of embarrassment or because they felt it
wouldn't help. Of the eight who entered therapy, only one actually achieved
Treatment with medication
Viagra : is now prescribed in over
90% of erectile dysfunction cases. Studies indicate that it helps 70% of
patients achieve sexual function. In one 1999 study, overall male satisfaction
was 65%. Not surprisingly, the best results occurred in men who had the fewest
sexual problems before treatment, but even men with severe erectile
dysfunction had a 41% satisfaction rate. A 2000 study of men who had responded
well initially to sildenafil found that 96% of them were satisfied with the
treatment after two to three years.
Administration and Effect
effective within 20 to 40 minutes. The drug works only when the man
experiences some sexual arousal.
Mechanism of Actions
originally developed for heart disease, but was found to have a unique
mechanism of action that targeted only factors in the penis. The drug blocks
the enzyme phosphodiesterase. This action maintains persistent levels
of cyclic GMP, a chemical that is produced in the penis during sexual arousal
and which is the primary chemical that relaxes smooth muscles and increases
Common Side Effects
Common side effects
include the following:
- Muscle aches.
- Gastrointestinal distress.
- Nasal congestion.
a potent and highly-selective PDE5 inhibitor and may not affect other parts of
the body, including the brain, heart, kidney and eyes. Clinical trials are
reporting significant success rates in up to 88% of patients. It appears to
take effect in 15 minutes and the effects last up to 24 hours. Improved
results were reported in men suffering from erectile dysfunction of varying
severity and causes. Common side effects include headache, muscle pain,
stomach upset following meals, and back pain.
Vardenafil : is another PDE5 inhibitor currently being investigated. A small
study concluded that it increased penile rigidity and tumescence. Further
evaluation is warranted.
Testosterone Replacement Therapy
Testosterone replacement therapy may be effective in inducing puberty in
adolescent boys with hypogonadism and may also be helpful for some adult
patients with the condition. Some experts believe testosterone replacement
therapy also may be helpful for older men whose testosterone levels are
Other procedures and devices
Vacuum devices, or external management systems, are
effective, safe, and simple to use for all forms of impotence except when
severe scarring has occurred from Peyronie's disease.
Using the Device
- The man places the penis inside a plastic cylinder.
- A vacuum is created, which causes blood to flow into the penis, thereby
creating an erection.
- A band is tightly secured around the base of the penis, which retains
the erection, and the cylinder is removed.
- It takes about three to five minutes to produce an erection.
Drawback: Lack of spontaneity is this method's only major drawback. The erection
involves only part of the penis shaft, and the process will certainly seem
peculiar in the beginning. When these psychological obstacles are overcome,
many couples find the result highly satisfactory.
Success rate: Studies have found that
success with the vacuum device is equal to other methods. Between 56% and 67%
of men using it reported the device to be effective. In one study of men who
had used the vacuum device for many years, almost 79% reported improvement in
their relationships with their sexual partners, and 83.5% said they had
intercourse whenever they chose. Nevertheless, drop out rates are high. In one
1999 study, for example, the overall drop out rate was 65%.
Side effects: include blocked
ejaculation and some discomfort during pumping and from use of the band. Minor
bruising may occur, although infrequently. It is very important to use a
medically approved pump.
Controllers (Cock rings)
Vacuumless devices that trap blood within the penis
are also available. They are called venous flow controllers or simple
constricting devices. These devices are typically rubber or silicone rings or
tubes that are placed at the base of the erect penis to trap the erection.
They can be used by men who can achieve erections but lose them easily. These
devices should not be used for longer than 30 minutes or lack of oxygen can
damage the penis.
Three types of surgical implants are currently being used for the treatment
of erectile dysfunction:
- A hydraulic implant consists of two cylinders placed within the erection
chambers of the penis and a pump. The pump releases a saline solution into
the chambers to cause an erection, and removes the solution to deflate the
- A penile prosthesis is composed of two semi-rigid but bendable rods that
are placed inside the erection chambers of the penis. The penis can then be
manipulated to an erect or non-erect position.
- A third implant uses interlocking soft plastic blocks that can be
inflated or deflated using a cable that passes through them.
Other alternative treatments
Many alternative agents are marketed for impotence. Very few
have been studied and some can be harmful.
Yohimbine (Yocon, Yohimex)
has been used as folk medicine for years. It appears to improve blood flow.
Studies have been inconclusive about its benefits.
Aphrodisiacs are substances that are supposed to increase sexual drive,
performance, or desire. Some examples include the following:
- Viramax is a well-marketed product that contains
Yohimbine and three
herbal aphrodisiacs: Catuaba,
Muira puama, and
Maca. It has not been proven
to be either effective or safe and interactions with medications are
- Foods that some people claim have aphrodisiacal qualities include
chilies, chocolate, licorice, lard, scallops, oysters, olives, and
anchovies. No evidence exists for these claims and certainly no one would
ever advocate eating large amounts of such foods, which in cases such as
licorice and lard, can be dangerous.
- Spanish fly, or cantharides, which is made from dried beetles, is the
most widely-touted aphrodisiac and is particularly harmful. It irritates the
urinary and genital tract and can cause infection, scarring, and burning of
the mouth and throat. In some cases, it can be life threatening.
No one should try any aphrodisiac without consulting a physician.
In one small study, 78% of men who had impotence
caused by impaired blood flow regained erections after taking
research is needed.
Ginseng root is
a traditional Asian remedy for stimulating sexual function, although no
studies have been conducted on its effectiveness.