Education - Erection and Erectile Disfunction

Erection / Erection Problems

In many ways, erections sum up the whole male way of doing things: They appear with dramatic and swashbuckling suddenness (at least in younger men), they look like tools or weapons, their use involves aggressive action rather than passive acceptance -and underlying the whole performance is the constant fear that they won't work.

Men's worries often take the form of concern that their erections are too small. But such fears are highly overrated, because no matter how much penises may differ in the flaccid (non-erect) state, studies have shown that they are amazingly similar when they're erect. A penis that's relatively small when flaccid will swell proportionally more than one that’s a little more impressive in its un-aroused state. Erection, you might say, is the great equalizer of penis size. Just for the record, the average size of the erect human penis is about 6 inches, although it can vary from 4 to 8 inches.

But more to the point - at least if you're concerned mainly about pleasuring your partner, not about outshining your male competitors - an additional inch or two makes almost no difference at all.

"The part of the vagina where a woman experiences sexual pleasure is still an area of controversy -but at the very least, it's fairly well agreed that for most women, the greatest pleasure comes when the first [outer] third of the vagina is stimulated," says Ted Mcflvenna, Ph.D., president of the Institute for the Advanced Study of Human Sexuality in San Francisco. "Going in deeper doesn't give most women any extra pleasure."

The Body’s Erector Set

Actually, male erections are the most dramatic manifestation of one of the most basic processes of sexual arousal-vasocongestion (the concentration of blood in the

genitals and the female breasts). Vasocongestion causes the clitoris to become erect, too (as well as the multiple lips that surround it), and although clitoral erections are equally pleasurable, they're not nearly as noticeable as the male variety.

There are still some mysteries surrounding the actual mechanics of a man's erection, but basically it goes like this. Due to the nature of the nerves that supply the penis, the whole show can be touched off in only one of two different ways: by physical touch (so-called reflexogenic erections) or by erotic thoughts (psychogenic erections). Just as you cannot control what arouses you, you also cannot get an erection just because you want one, no matter how hard you try. This is not a personal failure. It's just the way your motor and sensory nerve pathways work.

The penis itself is composed mainly of three cylinders that lie side by side along the length of the shaft-two big ones lying on top (the corpora cavemosa) and a smaller one underneath (the corpus spongiosum), which contains the urethra, or urinary drainpipe. These cylinders are wrapped in a sheath of tight-fitting though stretchable skim Once stimulated by thought or touch, the nerves respond by opening up millions of tiny sphincters along the walls of these cylinders, and fantastic amounts of blood pour in, filling up the millions of tiny sinuses, or balloon like sacs. Once these sacs are filled and distended, the cylinders squeeze off the veins that normally drain blood out of the penis. The result is that eight times the normal amount of blood is trapped inside the penis, creating (ideally, at least) a rigid, towering erection.

Stabilizing the Tower

Rigid as it may be, how come a man's erection doesn't wobble all over the place, or even buckle, during intercourse? Because the rigid corpora cavernosa extend all the way down to the bone that you sit on, giving the erection a rocklike, foundation, explains urologist and micro surgeon Sherman J. Silber, M.D., in his book The Male. Whales, bears, walruses and other creatures have solved the "wobble" problem by means of a bone that runs right up inside the penis, giving their amorous intentions some support. But the human erection, gays Dr. Silber, "is more exquisitely refined than that of any other animal."

The late Dr. Alfred Kinsey, who never seemed to tire of studying even the smallest details related to sexuality, found a great variety in the angle of men's erections. Most men of all ages reported they usually had erections very slightly above the horizontal, but some (15 or 20 percent) said theirs were fully 45 degrees above horizontal, and a few (8 or 10 percent) reported their erections were practically vertical, almost flat against their bellies. Dr. Kinsey also found that with increasing age, the angle of a man's erection tends to gradually droop.

It's also been known since 1945 that most men will have three to five good, unused erections during the night. These nocturnal salutes usually correspond to the dream or REM (rapid eye movement) phase of sleep and generally last 20 or 30 minutes a piece. Interestingly enough, they're usually not triggered by sexy dreams. Instead, it's now believed that dreaming itself causes erections because it induces a state of heightened physiological arousal.

Dr. Kinsey found that most men averaged a little more than one morning erection a week, with the greatest frequency (twice a week) reported by men between 31 and 35. Some guys ascribe this morning surprise to having a full bladder (morning erections are sometimes called "piss-hards"), but a fun bladder has nothing whatsoever to do with having an erection. More likely, they're a last hurrah left over from your final dream of the night.

Quite a few drugs, both illegal and medicinal, can hinder a man's ability to get erections. And occasionally, a man's erections will be painful or noticeably crooked, a condition that is sometimes caused by Peyronie's disease.

Effects of Aging

As a man ages, it usually begins to take more time, and more physical stimulation, for him to become erect. As a teenager, he could get a substantial erection in 10 seconds flat, but at 60 it may take 10 minutes of special attention before he comes to attention.

This was demonstrated by two researchers at the University of Southern California who showed the same erotic movie to two groups of men while monitoring their responses. The younger men (19 to 30) got erections almost six times faster than their elders (48 to 65).

A man's erections also tend to become a little less firm as he gets older, and after orgasm, he tends to lose his erection more quickly. Dr. Kinsey found that teenage boys could maintain an erection (before ejaculation) for nearly an hour, but men between 66 and 70 could keep it up for only 7 minutes.

The last and perhaps most noticeable erectile change brought on by age is an increase in the amount of "downtime" that must occur between erections. This refractory period may be as little as 5 to 15 minutes in an 18-year-old, but by the time you reach 60, it may take as long as 18 to 24 hours before the body can repeat the performance.

All of the changes are quite predictable, but they're not necessarily a curse. They're completely normal and natural, for one thing. And for another, slowed- down sexual responses can open up a whole new world of love making that's all the sweeter because it lasts longer. For men who, in their younger days, tended to pop off so quickly that it was all over before it began, getting older can be a genuine blessing.

The Penis/Heart Connection

With all this talk of hydraulics and refractory periods, it's easy to begin thinking of erections as some kind of remarkable machine, completely disconnected from the body. But it's important not to forget that "the penis is connected to the heart," says Stephen B. Levine, M.D., medical director of the Center for Human Sexuality at University Hospitals in Cleveland, Ohio.

"Men believe that they're supposed to be able to have intercourse with anybody, at any time, even somebody they don't particularly care for - but it's a sign of our own alienation from ourselves that we believe this," Dr. Levine says. We're not robots, and our bodies are not machines. "If you occasionally have trouble getting an erection, that doesn't mean you're a wimp or a homosexual," he says. "That means you're just like everybody else."

Some therapists even argue that when it comes to male sexual performance, entirely too much attention has been focused on the erection. Bernie Zilbergeld, Ph.D., a clinical psychologist in the Human Sexuality Program at the University of California, San Francisco, has written that "the erection is considered by almost all men as the star performer in the drama of sex, and we all know what happens to the show when the star performer doesn't make an appearance."

But by focusing so much attention on that little fellow who's supposed to snap to attention at the slightest provocation, we put an almost unbearable burden on men. After all, there's no way he can fake an erection, and it's virtually guaranteed that there will be times when he can't get one. The penis is not the only sexual part of the body, says Dr. Zilbergeld. And besides, it's possible to have a delicious sexual encounter without an erection - and even without intercourse.

There are times, however, when happy talk from therapists is just not enough. The man wants an erection, and he can't get one. Thankfully, there are an amazing number of treatments now available.

Erection Problems

If this were a medical textbook, you'd find the following discussion under the heading "impotence" - an unpleasant medical term for men who have trouble getting an erection or keeping it long enough to make love. But impotence is such a terrible word, implying that a man is feeble, powerless, washed up, over the hill (it actually derives from the Latin impotentia, meaning "lack of strength"), that we'll try to refrain from using it too much here.

A man having trouble getting an erection is just that: a man having trouble getting an erection. In most other ways, he's probably every bit the man he ever was - in fact, since erectile difficulties tend to crop up after the age of 40 or so, it's likely his worldly career and earning power are peaking at the same time this loneliest of problems makes its first appearance.

Just to clarify: Virtually every man has trouble getting an erection from time to time, and although this can be extraordinarily distressing, it's only natural. What's unnatural is the idea that a man should be able to produce a towering erection at the slightest provocation, with any partner, at a moment's notice. Unrealistic expectations only set the stage for disappointment.

"In any other part of a person's life-running a race, hitting a ball - you'll have some days when you can just perform better than other days. But men rarely realize that this is equally true of their sexual lives," says Richard E. Berger, M.D., professor of urology at the University of Washington and coauthor of BioPotency: A Guide to Sexual Success. "If you lose an erection, or can't get one, the best thing to do is try to understand why it happened. Often there's something else going on, like chronic tiredness, stress, alcohol, nicotine or drug use -things you can do something about."

The worst thing you can do, he says, is worry about it too much., Men often begin thinking of their erection as the key part of what amounts to a sexual performance, a kind of Super Bowl of Sex -in other words, something at which it's possible to fail. They begin to worry that they will fail, especially if it's happened a few times already. That initial worry leads to the downward spiral of anxiety, self-doubt and self-observation that William Masters, M.D., and Virginia Johnson, of the Masters and Johnson Institute in St. Louis, called "performance anxiety" - one of the most common psychological causes of erection problems and one that's sometimes difficult to overcome.

A Curable Epidemic

But for a huge number of men, the trouble is more intractable than that. For them, erectile difficulties have become a chronic, long-term problem, and that's the subject of the rest of this chapter. Chronic impotence (if you'll pardon the phrase) is sometimes defined as the inability to achieve and maintain an erection long enough for sexual intercourse in at least 25 percent of attempts. Other doctors say the term simply means that difficulties crop up often enough to be recognized as a problem by a man or his partner. However you define it, such a distressing situation is extraordinarily common: It's estimated that one in every nine or ten American males is chronically impotent - that's ten million men, and perhaps many more. Studies have shown that nearly 20 percent of men are chronically impotent by the time they reach age 55; 30 percent by age over half by age 75.

These huge numbers are no particular comfort to a man suffering from such humiliation -or to the woman who loves him. The man, afraid to "fail" if he attempts sex, often pulls back from his partner, fearful, anxious and ashamed. The woman, for her part, often blames herself, fearing that she is no longer attractive to him, that she no longer turns him on or perhaps even that he’s taken another lover. What is in many cases a relatively minor mechanical problem can

sometimes become a marital catastrophe.

Even so, there's plenty of good news to spread around. In fact, over the past decade, there's been a virtual revolution in treatments for male impotence, and many men who once would have had to resign themselves to a life without sex now have an almost bewildering array of options.

"The real tragedy, though, is that as many as 90 percent of these men may be suffering needlessly," says E. Douglas Whitehead, M.D., a director of the Association for Male Sexual Dysfunction in New York City and an associate clinical professor of urology at Mount Sinai School of Medicine. "Impotence is primarily an epidemic with a cure. Great strides have been made in recent years, not just in diagnosing the causes of impotence but in doing something about them."

How to Head Off Problems

Before we get into a discussion of all the treatments now available, though, let's pause a moment to consider a few ways to prevent the problem in the first place. Chief among the ways men can maintain a "potent lifestyle" are eating a low-fat, low-cholesterol, high-fiber diet and doing regular aerobic exercise. Yes, it's boring, and you've heard it before, but it’s true. The reason is simple: A lifetime of eating fatty foods and not exercising leads to clogged arteries. And clogged arteries mean that blood flow is impeded to the penis as well as the heart. And since erections depend on robust blood flow, "anything that keeps those vessels clean will reduce your chances of developing erection problems," Dr. Berger says. In fact, in one study, researchers found that more than 75 percent of impotent men had at least some problems with arterial blood flow to the penis.

Even though it's usually older men who have heart attacks, heart disease is slow and insidious, and it begins early in life-which is why you're never too young to start protecting yourself. The same is true of sexual potency. In his book BioPotency (coauthored with Deborah Berger), Dr. Berger reports on a Czecho- slovakian study in which doctors examined the penile arteries of a group of deceased men whose ages ranged from 19 to 85. The results showed that all the men 38 years old and older had at least some blockage in these arteries. The message: The time to begin preserving your sexual longevity is now.

Dr. Berger makes these general recommendations.

• Generally, cut back on your intake of fatty meats and eggs, whole milk, ice cream, cheese and butter. Trim the fat off meat and broil or roast instead of trying. Rarely, if ever, eat organ meats like liver or sweetbreads.
• Increase your intake of fish and poultry.
• Keep salty, processed foods to a minimum.
• Eat plenty of fresh, whole fruits and vegetables and whole grains.
• Work out regularly - ideally, for 20 to 30 minutes at least three times a week.

Is It the Body or the Mind

Once you do decide to seek help at a clinic or with a qualified urologist, it's nice to know that your odds of success are extremely high. "Almost everybody can be treated successfully," says Dr. Berger, "because even if we can't fix the underlying problem, we now have ways to go around it."

This is a dramatic turnabout from 20 years ago, when most sex specialists believed that for the vast majority of men, their sex problems were "all in their heads" - and hence very difficult to treat. Today, though, most specialists think precisely the opposite is true: that 50 to 75 percent of men with erection problems have some physical (and usually treatable) trouble that's to blame. In one 1986 study of 1,500 men who visited sex clinics for erection problems, more than 70 percent were diagnosed as having erection problems caused by some physical, rather than psychological, disorder.

Even so, there's no clear line that separates the body from the mind, and both are almost always involved.

"There's seldom such a thing as purely physical impotence, because if a man can't get an erection once, he starts to worry about it, and when it happens again, he worries even more, until he begins to expect to fail," says Dr. Berger. "Even after the initial, physical cause of erectile difficulty has been treated, it's not uncommon for men to still need a little therapy to overcome those fears and negative expectations."

Expect a Few Questions

At the clinic, the first thing a specialist will attempt to determine is the primary cause of your problem. The most basic question is, Is it mainly physical, or is it mainly psychological? (Again, these things are often devilishly intertwined, but one or the other undoubtedly came first.)

Experts say your erection problems probably have some psychological cause if:

• They appeared suddenly, rather than gradually.
• They occur only with certain partners or in certain situations (for instance, if you can get a rigid erection while masturbating, but not with your wife.
• You also feel decreased desire for your partner.
• You have problems ejaculating or reaching orgasm.
• You have other bad feelings, like shame, guilt, hostility or depression.

By contrast, the impotence is probably caused by organic or physical problems if:

• The onset is gradual, with a progressive decrease in hardness and frequency of erections.
• It occurs in all situations - in the morning, during intercourse and during masturbation.
• You can get an erection, but you can't seem to maintain it.
• Your sexual desire is undiminished.

Expect to be asked about all these areas as the doctor tries to determine whether your problem has a mental or physical basis.

The doctor may ask a few other questions about your life and health, too.

Could a prescription drug you're taking be the problem? IVs now believed that as many as a quarter of all cases of impotence are caused or made worse by medications, according to Paul Church, M.D., a urologist at the New England Deaconess Hospital in Boston.

Could it be alcohol? A drink or two can have a mildly aphrodisiac effect, but heavy drinking is one of the most common causes of impotence. Long-term drinking can be disastrous, reducing the blood levels of male hormones and sapping sex drive.

Could it be smoking? Good erections require robust blood flow, but smoking constricts blood vessels, squeezing off circulation. That's probably why a very high percentage of impotent men are heavy smokers. (Quitting may not lead to a sexual renaissance, but it certainly can't hurt.)

Old Reliable: The NPT Test

You could very well ask yourself all those questions without going to a sex clinic at all, of course. But you couldn't move on to the next stage: high-tech medical testing to determine whether the cause (if physical) is centered in the nerves, blood vessels, hormones or somewhere else. Just a few years ago, doctors were only able to distinguish between physical and psychological impotence. Today, armed with a space-age array of testing devices, it's often possible to precisely pinpoint the problem and then target the treatment.

Actually, the test you're most likely to get is one of the oldest and simplest- the venerable nocturnal penile tumescence (NPT) test. Although it's not as reliable as it was once believed to be, many specialists still consider the NPT test to be the gold standard of impotence tests. Its basic premise is simple: Normally while he's sleeping, a healthy man will have erections that last 20 to 30 minutes every 90 minutes or so. The NPT test is just a way of determining whether this is occurring or not. If a man is not having normal erections while he's sleeping, there's probably some underlying physical problem to blame. If he is, the problem is likely psychological. The NPT test can be done in a sleep lab, under carefully monitored conditions, in which both the frequency and rigidity of nighttime erections are measured. It can also be done more cheaply, but with slightly less accurate results, at home.

The Most Common Problems

These and other tests can be used to narrow the search to the primary, underlying problem. A fair percentage of cases turn out to be caused by chronic diseases of one kind or another. The most common cause of organic impotence, it's now believed, is vascular disease, which interferes with the lusty blood flow that’s so critical to producing a rigid erection.

The next most common cause is diabetes, affecting an estimated two million men in the United States. (For more, see "Diabetes.") People with diabetes often suffer from neuropathy (tingling and numbness in the hands and feet due to damaged nerves), which is the most common cause of neurological impotence. Quite a few other men have impotence due to bladder, rectal or prostate surgery or spinal cord injuries.

Sometimes, hormonal problems may turn out to be the cause, but this is really fairly rare (perhaps 5 percent of all cases). Some men believe that their erection problems are due to a gradual decline in testosterone levels caused by aging and that testosterone pigs or shots will restore their sexual youth. In the relatively rare instances in which this is actually true (often due to a condition called hypogonadism, or malfunctioning testicles), the treatment is testosterone replacement, which generally restores both sexual desire and erections. But if your testosterone levels are normal, shots are almost universally ineffective, Dr. Whitehead says.