By Dr. Joshua Gonzalez
As a sexual medicine specialist, I spend a good deal of time talking about erections. Erectile dysfunction (ED) is actually a pretty common problem. Estimates of the prevalence of ED range from 9% to 40% of men by age 40, and generally increase by 10% with each decade thereafter1. ED affects approximately 30 million American men and it is estimated that 1 in 4 men will experience ED at some point2. Thankfully most cases of ED can be overcome.
Before I discuss treatment options with my patients, I do my best to educate them on their problem. The first hurdle is to get men to understand that ED is, in fact, a problem. It’s not just a normal function of aging. To fully appreciate what ED is and what can cause it, men need to first understand how a normal erection works. Normal erectile function includes the ability to obtain an erection sufficiently rigid for vaginal penetration and to maintain that erection long enough to complete satisfactory sexual intercourse1. I should pause for a moment to highlight two points. First, the original consensus definition of ED is based on a vaginal penetrative model and essentially excludes a whole host of alternative sexual practices. Second, normal erectile function involves not just getting an erection but being able to keep it. That’s very important and I have had patients tell me they never thought they could have ED just because they couldn’t maintain an already achieved erection. Therefore, I routinely define ED for my patients a little more loosely, as a consistent inability to achieve or maintain the necessary rigidity to complete whatever they define as a satisfactory sexual practice. And it’s my job to figure out why ED may be happening to them by reviewing certain factors that influence the way erections work. What follows is an overview of how I typically approach ED, identify problems contributing to erectile dysfunction, and fix them.
Every man who seeks my help for ED undergoes a comprehensive hormonal evaluation. Testosterone is an important factor in regulating the hemodynamics (or blood flow) of erections. As men age, we make less and less testosterone so there’s an increasing potential for ED problems as we get older. Testosterone declines gradually after age age 40 between 0.4 and 2.6% per year3,4. But testosterone is only part of the picture. There is a whole slew of hormones that can influence testosterone production and its use in our bodies. And it’s important to make sure all these parameters are optimized, not just “normal.” Many men who I’ve treated have been told previously by other physicians that their testosterone is normal. The problem with that view is that erections function better at healthier levels of testosterone. The normal range of testosterone is also very wide and if you’re at the lower end of normal and suffering with ED, then you would probably benefit from a treatment to boost your numbers to a healthier level (but still within the normal range).
Depending on a man’s age, there are a few options available to improve testosterone levels. Traditional testosterone replacement therapy (TRT) involves replacing the body’s own production through administration of external testosterone. This comes in the form of topical gels, intramuscular injections, and even implantable pellets. Each delivery method is effective and I try to help patients decide which option works best for their particular lifestyle. In younger men or any man interested in preserving fertility, TRT isn’t a great choice. TRT stops testicular production of testosterone and sperm, which usually results in infertility. I can’t tell you how many times I’ve seen young men on TRT who have no idea of this fertility risk and have never been given another treatment option.
Thankfully there are fertility sparing alternatives in the form of clomiphene or HCG, which will stimulate testicular production of testosterone instead of replacing it. With any hormone treatment, patients are expected to check in with me within a few weeks to update me on their progress and to monitor their hormone levels closely. If things remain under (or sometimes above goal) then adjustments to medications are often made until serum testosterone levels remain steady at the upper end of normal.
Penile erection requires the presence of a pressurized and closed hydraulic system within the corpora cavernosa (i.e. erectile tissue). Thus ED occurs when there is a consistent inability to either obtain and/or maintain that closed system. As part of my evaluation, I routinely investigate any potential blood flow issues using a penile Doppler ultrasound. During the study we examine the quality of the erectile tissue and measure the velocity of blood entering the penis during the erect state. Patients often find this evaluation useful because they can see in real time whether they are getting adequate blood into their erections and whether they are able to maintain a closed system or “trap” the blood in their penis. Those patients who cannot perfuse the erection tissue with an adequate amount of blood are deemed to have cavernosal arterial insufficiency, while those who cannot “trap” are diagnosed with veno-occlusive dysfunction or venous leak. The Doppler is useful for clinicians because it allows an objective assessment of the severity of any potential blood flow issues, which becomes important when considering treatment options.
The medications available to address blood flow work primarily on arterial insufficiency. The most popular and well known treatment is a group of medications called phosphodiesterase 5 inhibitors (PDE5i). These are the “little blue pills” that you’ve probably seen advertised on television, especially during sporting events. The pills are not all blue and they are not equally effective for every man, but they generally work well for patients with mild arterial insufficiency. Many men who I see have already experimented with these medications or been prescribed them by their primary doctors without any real understanding of how they work. PDE5i cause the main arteries supplying the erection tissue to dilate, resulting in an increased inflow of blood into the penis. Unfortunately, because they are absorbed into the systemic circulation they can dilate blood vessels elsewhere or cross react with other enzymes in the body, which can cause unwanted adverse effects.
Men who have more significant arterial insufficiency or venous leak thankfully have other options. Intracavernosal injections involve administering a medication directly into the penis that maximally dilates the arteries. These injections are used at the time of sexual activity just like PDE5i but are much more effective at providing rigidity. Because they are administered directly into the penis, they often have less side effects than the pills. But they need to be used carefully and patients should be educated on how to properly dose these medications. Intracavernosal injections can lead to prolonged erection (priapism), which as exciting as that sounds to some men, can actually lead to permanent damage to the erection tissue. I work carefully with my patients to find their correct dose and even teach them how to administer the antidote should priapism develop. After overcoming the initial fear of using injections for sex, many men find this strategy very effective and are overwhelmingly satisfied with the results.
For those men who have moderate to severe venous leak, injections may be limited in their efficacy. As I mentioned earlier, all of the medications we have for ED work on the arterial system. If your problem is a trapping issue, then even injections may disappoint. However, insertion of a penile implant is the gold standard for men with venous leak. Many men are initially wary of undergoing surgery but in the right patient, penile implants are a great option. In fact, penile implants have the highest satisfaction rate of any ED treatment. Penile implants are easy to use, completely concealed, and 100% reliable.
I explain to every man I see for ED that it is completely normal to have some psychological factors contributing to their issue. As men, we like our penises and we like them to work when we want or need them to. When they don’t work it causes us worry, stress, and anxiety, which can compound the problem. But what I also try to impart on my patients is that in most cases of ED, the problem is not just “in their head.” In fact, in more than 80% of cases there is some physical issue that can be identified and addressed.
Still, it is important to keep psychological factors in mind. Relationship problems, performance anxiety, and even cultural beliefs about sex can have a negative impact on erections. I often work closely with therapists to help address some of these issues when present. Concurrent therapy can be helpful in helping men optimize their erectile function.
In trying to comprehensively evaluate my ED patients, I will often refer them for an evaluation by a pelvic floor therapist. My colleagues at Pelvic Health and Rehabilitation Center have been very helpful in that regard. Concomitant pelvic floor muscle dysfunction is common in men with erectile or ejaculatory dysfunction and there is plenty of evidence that demonstrates potential therapeutic benefit from pelvic floor therapy for men who suffer from these conditions. Check out Jandra Mueller’s blog from last week here for more information.
As with most sexual issues, ED should be approached with a comprehensive strategy. It’s not always a hormone problem, or a blood flow issue, or performance anxiety. Sometimes it’s all three and the greatest successes I’ve had in treating men with ED has come in collaborating with other specialists to tackle each contributing factor. Lastly, it’s time we started moving beyond traditional definitions of ED and started realizing that not all erections are created equal. An erection that works for one man in a particular situation may not be sufficient for another. So let’s work together and start Making Erections Great Again.
- Cohen D, Gonzalez J, Goldstein I. The Role of Pelvic Floor Muscles in Male Sexual Dysfunction and Pelvic Pain. Sex Med Rev. 2016 Jan;4(1):53-62.
- Nunes KP, Labazi H, Webb RC. New insights into hypertension-associated erectile dysfunction. Curr Opin Nephrol Hypertens. 2012 Mar;21(2):163-70.
- Feldman HA, Longcope C, Derby CA, Johannes CB, Araujo AB, Coviello AD, Bremner WJ, McKinlay JB. Age trends in the level of serum testosterone and other hormones in middle-aged men: longitudinal results from the Massachusetts male aging study. J Clin Endocrinol Metab. 2002 Feb;87(2):589-98.
- Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR; Baltimore Longitudinal Study of Aging. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Baltimore Longitudinal Study of Aging. J Clin Endocrinol Metab. 2001 Feb;86(2):724-31.