What is Erectile Dysfunction?

AUTHOR: DR. JOSHUA GONZALEZ
ILLUSTRATIONS BY EVA HILL

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As a sexual medicine specialist, I get asked questions about erectile dysfunction (ED) all the time. How do I know if I have erectile dysfunction? Does one disappointing boner experience mean there’s a serious problem? Is ED permanent or can it be fixed? Is this thing physical or something in my head? Let me break down the facts:

  • ED is very much a common problem. The prevalence of ED ranges from 9% to 40% of men by age 40, and generally increase by 10% with each decade thereafter.

  • ED affects approximately 30 million American men and it is estimated that 1 in 4 men will experience ED at some point.

  • Even though it’s more common as men age, ED can happen to individuals at any age and it can happen for a variety of reasons. Just because you’re young, doesn’t mean you can’t have ED.

To understand what ED is, you have to understand how a normal erection works. Normal erectile function involves the capacity to achieve an erection sufficiently rigid for penetration, AND to maintain that erection long enough to complete sexual activity. I can’t tell you how many times I’ve had patients sitting across the desk from me who assume they don’t have erectile dysfunction because they have no problem getting hard. Sure, their member goes limp halfway through sex, but surely that doesn’t mean they have ED. Well technically, they do. A good erection gets hard and stays that way till you’re done.

A problem that the above consensus definition brings up is that not everyone has vaginal sex. So what about those non-vaginal penetrators out there, can they not have ED? This is where historical medical concepts sometimes fall short. That’s why I like to think about ED a bit more liberally, as a consistent inability to achieve or maintain the necessary rigidity to engage in whatever a person defines as satisfactory sex.

It may take years for a person to seek help for ED. Even when they do, the process may be a frustrating one. Too many times, people are dismissed or simply given a pill to fix the problem, but don’t understand why they have this problem in the first place. Just because you’re not of a certain age or you aren’t the typical ED patient, doesn’t mean you can’t have a problem. Not appreciating the cause of ED can leave one questioning if they have a real physical problem or if it is all in their head. That’s where I come in.

The most important part of treating a patient’s ED is educating them on why they are having the issue in the first place. Not everyone’s ED is created equal and it’s important to understand specific nuances to truly fix the problem. As a doctor, I take time to review certain factors that influence the way erections work to better understand why a particular person may be experiencing ED.

Is it all in your head?

We like our penises (most of the time) and we like them to get hard when we want or need them to. When they don’t work the way we want them to, it causes us worry, stress, and anxiety, which can compound the problem. ED can also lead to depression, low self-esteem and relationship issues. Data on erectile dysfunction demonstrate that the problem is strictly psychological in only a small fraction of cases. This doesn’t mean your head isn’t getting the best of you. (Both heads!) I explain to every person I treat for ED that it is totally normal to have some psychological component to their erection issue. It is also important to keep in mind a person’s religious and cultural beliefs about sex and sexuality, which can sometimes have a negative impact on erections. As a physician, I primarily focus on the physical but work closely with mental health specialists to help address psychological issues as well.

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Your Penis, The Love Pump

A good erection is all about blood flow, so understanding how your love pump is flowing is important. The erect penis is basically just a pressurized hydraulic system, kind of like a tire. It’s a unique part of the body in that way. Most other areas of our bodies see a constant movement of blood, with the arteries dropping off oxygen and the veins removing the waste. Your penis has the ability to do quite the opposite. During an erection, blood is delivered into the penis and then, for the purposes of staying hard, trapped in place until sex is complete. The problem is that things don’t always work out that way.

If you have ED, you could have a blood delivery problem or a trapping issue. Sometimes it is both, which is why it’s important to understand which kind of flow problem you might have so it can be properly treated. Thankfully, we have futuristic scientific ways of doing just that. As part of my routine ED evaluation, I investigate any and all potential blood flow issues using a penile Doppler ultrasound. During the study, we examine the quality of the erectile tissue and measure the movement of blood in your penis during an erection. Needless to say, it makes for an interesting visit to the doctor’s office.

Patients often find this evaluation useful because they can see in real time whether they are delivering enough blood into their erections and whether they can trap it appropriately. Let’s go back to the tire analogy. Those patients with a blood delivery problem cannot fully inflate their penis because the pressure of air entering their tire is insufficient. Patients who cannot trap or maintain their erection basically have a tire filled with holes. That means that even if they deliver an adequate amount of blood into their penis, it’s leaking out and their tire will never fully inflate.

Hormonal Imbalance

It’s been said that humans are slaves to their hormones. Well, when it comes to the penis that’s partially true. Hormones, testosterone in particular, are very important to the health of your erection. In addition to making you horny, testosterone is important in regulating the blood flow to your penis. And guess what? Erections are all about blood flow.

As we age, we make less and less testosterone. This is one reason why erectile dysfunction is more common for older individuals. However, many factors can cause low testosterone levels, even in younger patients, including:

  • Obesity

  • Diabetes

  • Genetic disease

  • Cancer

  • HIV

Even without any of these risk factors, we’re all headed down the same path. Testosterone declines gradually after age age 40 between 0.4 and 2.6% per year.

Neither low testosterone, nor high testosterone is good for erections. While still not well-defined, higher (often super-human) levels of testosterone seen in those who use anabolic steroids have been linked with short duration and longer term sexual dysfunction, including erectile dysfunction. Secondly, testosterone is only one component of a complex hormonal milieu. There are a number of hormones that can influence testosterone production and its use in our bodies.

In regards to hormonal parameters, it’s not always helpful to discuss them in terms of normal or abnormal. Before seeing me, many have been told previously by other physicians that their testosterone is normal, so they think their hormones are fine. The problem with that view is that healthier levels of testosterone are associated with improved erectile function. The range of values that qualify as normal testosterone can vary widely throughout a person’s  life but that doesn’t mean nothing can be done. If your erections are failing, and your testosterone is on the low end of normal, you might benefit from a treatment to boost your numbers.

Say Something

So when should you seek help for ED? Every case is different.

If you aren’t getting regular morning wood or have seen a significant change in how often you’re waking up hard, it may be a sign that something isn’t working right. If you’re having a problem with your erections in a majority of sexual encounters, you might want to see someone. If masturbation is difficult, or you have come to rely on “little blue pills,” (aka Viagra) or you find yourself avoiding sex because you’re worried about your performance, you might have ED.  Basically, if you’re not having enjoyable sex and you think your erection is to blame talk to your doctor about it. If they brush you off or doesn’t offer you the answers you are looking for, try to find a sexual health specialist.

Do Something

I get asked a lot about what you can do to prevent erectile dysfunction. It’s pretty easy actually. You know all those things your doctor tells you about leading a healthy lifestyle to prevent heart disease? The same is true for your erection. In fact, there are alot studies out there showing a clear link between ED and heart disease. Men can often present with ED as the first sign of undiagnosed cardiovascular disease.

Cigarette smoking (past and current), alcohol intake, and decreased physical activity have all been associated with erectile dysfunction. If any of those apply to you, quit or cut back on these habits and increase your hours at the gym. A healthy diet is also important. One study found that increased intake of fruits, vegetables, and flavonoids decreases the risk of ED in young men. Another found a lower risk of ED in those who adhered to a Mediterranean diet. If you are obese or overweight and can lose some extra pounds by changing your diet, you are likely to see improvements in your erections. Overweight individuals can significantly improve their erectile function simply by incorporating a structured exercise training program.

Beyond lifestyle modifications, there are a number of medical treatments available to help with your erections, depending on the cause. There are hormonal treatments to boost your performance; oral medications that help to improve blood flow; and injections for those who need something a little stronger than a pill. There is even penile implant surgery to help those who don’t respond to other medical treatments. For people who have encountered relationship issues related to their ED, or those whose problem is primarily psychological, psychotherapy or focused sex therapy can be very helpful. There’s a solution out there for every man and every erectile problem. In most cases, you just need someone to guide you in the right direction.

Key Takeaways on ED:

  • ED happens to a lot people at any age. It’s not necessarily in your head, no matter what you’ve been told.

  • Fixing the issue requires understanding the cause of the problem in the first place.

  • If you think you have ED, seek help soon. The longer you leave your penis limp, the more damage it can do to your self-esteem, your relationship and your overall health.

  • Live heart healthy to live erection healthy.

Finally, and most importantly, if you suffer from erectile dysfunction, remember that there is a solution out there for you!

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