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Your Guide to Understanding Erectile Dysfunction

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20 Minutes

“Almost all men have [Erectile Dysfunction] at some point. It’s how they deal with it that counts.” says Mark L. Held, PhD, a clinical psychologist.

While Erectile Dysfunction (ED) solely affects men, it is both women and men who are impacted by this condition. It is rarely the man who seeks help for this condition alone, but it most frequently the woman who encourages the man to seek out help for this condition. The knowledge and understanding of ED can make all the difference in your relationship – and perhaps be the key to enabling genuine sexual chemistry to prevail.

What is Erectile Dysfunction?

As silly as this question may be, this is not a laughing matter. It is a very important question because while it may seem that everyone knows what erectile dysfunction is, it is always important to clarify the terms. Erectile Dysfunction, according to the Urology Care Foundation, is “trouble getting or keeping an erection that's firm enough for sex.”

For a man to perform the act of sexual intercourse, the penis must become very firm and erect. To become erect, the penis needs sexual arousal to produce chemical and biological changes. Dr. Burnett, professor of urology at Johns Hopkins Medicine, says the “release of the chemical nitric oxide, a neurotransmitter that is produced in nerve tissue, triggers an erection by relaxing muscles that allow blood to fill the penis.” This allows the penis to become hard and rise up, which is called an erection. This erection lasts until the sexual arousal dies down or a man ejaculates and the trapped blood slowly returns to the rest of the body.

For a man struggling with ED, the penis does not become engorged with blood and neither does it become erect in position. This may happen occasionally to some men and they are able to resolve it in a few moments, and others are not able to have an erection at all.

What Causes Erectile Dysfunction?

There are a number of stigmas and misconceptions attached to erectile dysfunction. For example, you may have heard that impotence is purely a sign of a man's age or that it is related to a man's lack of sexual prowess; perhaps you've read somewhere it is due to a porn addiction or that it is caused by a lack of attraction. Some may say that it is caused by medications, and others blame poor diets and a lack of exercise. The cause and reality of ED is much more complex than one simple answer.

Medical Conditions

The Mayo Clinic lists 16 possible medical causes of ED in men. Here they are:

  • Heart disease
  • Clogged blood vessels (atherosclerosis)
  • High cholesterol
  • Diabetes
  • Obesity
  • Metabolic syndrome – a condition involving increased blood pressure, high insulin levels, body fat around the waist and high cholesterol
  • Parkinson's disease
  • Multiple sclerosis
  • Certain prescription medications
  • Tobacco use
  • Alcoholism and other forms of substance abuse
  • Sleep disorders
  • Treatments for prostate cancer or enlarged prostate
  • Surgeries or injuries that affect the pelvic area or spinal cord

So as you can see from the above list, there are many possible causes. But go back to the list, and pause for a few moments. How many of these can actually be seen by your eyes? Sure, as a woman, you may see that your man has gained some weight, or that he uses tobacco or alcoholic beverages. And for sure, you would probably know if he is in the later stages of Parkinson’s Disease or Multiple Sclerosis – but the early stages may not present with traditional symptoms.

High blood pressure and high cholesterol have very few recognizable traits. Type II Diabetes is rarely recognized in its early stages, and is only found if other problems are seen or if a General Practitioner (GP) performs a physical. Medications come with a very long list of side effects, and most people do not read the entire lists, and ED may be a side effect. The point here is this: the medical causes of ED are often hidden in men.

Psychological Causes

Sexual intimacy requires a man to mentally present to the situation. The mental stimulation is vital for the body to respond with the right chemical responses. There must be some kind of incitement in the man’s mind before the penis changes into a full erection. A man’s mind will not be fully present if he is struggling from depression or anxiety.

Depression is a confusing condition when combined with ED. Men who are already struggling with symptoms of sadness, low self-esteem, hopelessness may begin to have erection difficulties as a result of their depression. On the opposite side, men who already have ED, may start to show symptoms of depression because they are unable to sexually perform. Unfortunately, either way you look at depression as the cause of erectile difficulty or a side effect of depression.

Anxiety is similar to depression in that it can be a causing factor or a side effect. However, anxiety around intimacy can begin to be a greater issue. In depression, the man may have a reduced desire to be physically intimate. Anxiety can quickly turn into performance anxiety where sex becomes something to be feared or dreaded.

Past sexual problems or abuse can also interfere with obtaining an erection in men. Sometimes the problems may have occurred many years ago, but over time the memories start to resurface. A triggering event (such as a comment, a certain smell, a similar situation, or visiting friends) can cause a man to remember something that he had forgotten for a while and instead of being able to be intimate, his mind is focused on the event. These triggering events can come from trauma.

However, traumatic events do not have to relate to serious past traumas, sexual or otherwise, and they may simply relate to painful arguments or recent stresses in life that the man is dealing with at that moment. Traumatic events can be something as little as a painful argument or an inappropriate touch from years ago.

Lifestyle Causes

Stress is one of the worst causes of erectile difficulties in men. If a man is overly stressed with work, family life, finances, or health concerns – he will be less inclined and able to perform sexually. We know that we all face increasing amounts of stress each day, and while we wish that there was a turn-off switch in our minds to be intimate, men don’t have that ability anymore than most women.

The impact of pornography in a sexual relationships is one that scientists are trying to establish and many studies seems to contradict each other. In one Italian study of 28,000 men, it was found that “Men are suffering from 'sexual anorexia' and are unable to get erections because of Internet porn use that started in their mid-teens”. On the other side, Nicole Prause, PhD, a sexual psychophysiologist and licenced psychologist at the Sexual Psychophysiology and Affective Neuroscience Laboratory states that “In one case, the study found stronger sexual arousal in men who reported viewing more sex films at home.” The men who did had erectile dysfunction were “those whose personal values contradict with viewing sex films may be experiencing general shame around sex that also influences their erectile functioning.”

What scientist do know about pornography viewing and men is this: pornography usage can stimulate a man’s appetite for vivid sex, and it can be difficult to be aroused if not exposed to that same level of stimuli with a partner.

What Treatments are Available?

Self Care

Like most conditions, the first step in treating a problem is to ensure that you are in the best health possible. Here are some excellent ways to improve your health:

Non-Medical Helps

Acupuncture and natural supplements have been found to be helpful for some men. Supplements such as L-arginine, Propionyl-L-carnitine, Yohimbe, Red Ginseng, and Maca have been studied by scientists, and while some are more beneficial than others, they should only be taken with the proper permission. L-arginine, according to the Mayo Clinic, can interfere with Viagra and should never be taken together. Supplements, like all medications, can have interactions and negative side effects such as diarrhea, acne, stomach pain, increased anxiety, and an irregular heartbeat.

Other non-medical helps that a man might use would be a penis ring or a vacuum pump to enhance penile size. Both of these can assist in increasing the blood supply to the penis and allowing it to become engorged with blood to become erect.


Available by prescription only, there are specific medications that can help create an erection for a man.

Viagra / Sildenafil: The most popular of all erectile medications is Viagra. It is also available in its generic form Sildenafil. The generic form is cheaper, but they both work to increase blood flow to the penis.

Benefits: Improve the man’s ability to get and maintain an erection; this medication works in approximately 60 minutes and can last for 4 hours.

Cons: Does not enhance sexual arousal. Medication has to be taken prior to planned intimacy. Excessive alcohol mixed with this medication headaches, dizziness, or an unsafe drop in blood pressure. Possible side effects are headache, dizziness, upset stomach (nausea), back pain, and muscle pain.

Spedra / Avanafil: If you are wanting a quick medication for impromptu intimacy, then speak to your GP about this medicine. Avanafil is similar to Sildenafil; they both work the same way to increase blood supply to the penis, but this medication works much faster.

Benefits: Body can absorb this medicine in as little as 15 minutes. The medicine lasts up to 5 hours.

Cons: A large meal can slow down absorption. The penis will not harden without sexual intimacy; this medicine must be used in tandem with intimacy.

Levitra / Vardenafil: Like Viagra, this medicine helps men achieve an erection.

Benefits: Works faster than Viagra, and often has fewer side effects. It is also considered safer for men who have diabetes, high blood pressure, or high cholesterol. The medicine also has a shorter half-life, which means the body is able to remove the medicine faster.

Cons: The shorter half-life means it does not work as long as Viagra

Cialis / Tadalafil (as needed): This medicine works just like Viagra and Spedra, but it has the ability to last much longer in the man’s body.

Benefits: Can be taken up to 36 hours prior to intimacy. This medicine has been approved for men who suffer with high blood pressure.

Cons: Similar to Viagra

Cialis / Tadalafil (every day): While this medicine is almost identical to Cialis (as needed), it is a much smaller daily dose. This daily dose allows the man to be sexually active without the need to remember to pre-dose on medication prior to intimacy.

Vitaros / Alprostadil: Is the only approved medication that is not a pill, but it is a cream that is applied to the penis. The medication permeates the skin of the penis and relaxes the blood vessels just like the other medications work.

Benefits: Works in as little as five minutes, and not have to taken orally

Cons: The medicine needs to be stored in a refrigerator, and can lose potency if kept in a warm place for more than a few days. Additionally, the cream may be irritating to your partner; a latex condom should be placed over the penis and cream to protect them from the irritation.

What is the Psychological Impact of ED?

Anybody who believes that the way to a man's heart is through his stomach flunked geography. Robert Byrne

The impact on men

If I as a writer and a registered nurse had one wish, it would be this: slow down and read this section very carefully. Erection difficulty is not a problem that can be fixed by one call to the GP or one visit to a therapist. The answer could be as simple as your partner purchasing new lingerie, a fancy date night, or a prescription, but that often does not address the whole issue. ED is not merely a penis problem. Here’s why:

  • Men identify with their penis much like women identify with their breasts.
  • The penis (specifically the size) is a symbol of manhood.
  • The level of perceived success in the bedroom equals the level of self esteem for a man.
  • It’s embarrassing for a man to not be able be sexually intimate on demand.
  • A man may feel less-than, humiliated, and painfully vulnerable in his life when he struggles to obtain an erection.
  • It can make a man “fear that their breakdown in penile functioning will result in their being unwanted by a partner and their resulting fears of loneliness, isolation, and impotence.” (Morris Psychological)

Some men, due to the above issues, could eventually obtain an erection with help – but would that be good enough? Would they be able to accept an erection with help? For some men, the answer is no. Obtaining an almost-normal erection will not deal with the “underlying existential anguish” that Dr. Daniel Watter, Board Certified Sex Therapist, addresses. In simple terms? The erection is just a symptom of a greater problem in a relationship. If a man does not feel safe, connected, loved, empowered, and free to express himself in a true way, he will not change if he can get an erection momentarily with help.

The impact on relationships

The impact of feeling connected in a relationship versus feeling isolated must be acknowledged. Men want to feel connected and important in a relationship in many of the same ways that women do, and if they do not feel connected, isolation can start to come into the relationship. If the man feels isolated, the relationship quickly begins to suffer.

Women are also affected by erectile dysfunction in a relationship, and it’s not solely because their partner is unable to get an erection. Andrew McCullough, MD, director of sexual health and male infertility at NYU Medical Center says that women “think when a man can't get an erection is that it's her fault, and nothing could be further from the truth." After blaming herself, the woman often begins to wonder if the man is cheating within the relationship or (even worse) thinking that he does not find her sexually appealing anymore. Before too long, arguments begin to develop all based on erroneous thoughts when none of it may be true.

So You’ve Got the RX, But Now What?

Understand the treatments limitations

A prescription for medication is just one of many possible treatments for Erectile Dysfunction. As you can see from the above lists, there are many options available and each of them have varying benefits and side effects. The medications are not the only answer, they are merely a tool in a toolbox to assist a man to be intimate. They will not create or produce intimacy within a relationship – that part is up to you and your partner.

Focus on romance and lovemaking versus intercourse

Focusing on romance does not mean that the partner should just stroke the man harder or pull out more lingerie. When the spotlight is merely on traditional penis-in-the-vagina intercourse, it puts a lot of pressure on the man to perform. ”There are lots of different ways to be sexual, and if one way becomes difficult or even impossible, you have to explore, together, the things you can do with each other than are sexually exciting," says Jennifer Downey, MD, a psychiatrist at New York State Psychiatric Institute suggests.

Keep communicating

The morning after the first erectile difficulty is not the best time, nor is everyday after it happens. “The best thing to do is to discuss things outside of the bedroom – not right after it happens, but days or even weeks later," Dr Downey suggests. She further encourages the woman to speak about it like other medical issues, and not make the concern bigger and more difficult. Some men may feel more comfortable if the woman attends the doctor’s appointment, and others prefer to by themselves — whichever they choose, it is always good to offer support and encouragement.

Identify stressors that may be causing ED

One of the ways Medical News Today recommends to stop the cycle of performance anxiety, is to “identify what stressor or worry influenced the symptoms of ED. The cause may be simple, such as an upcoming project at work or planning a family trip.” When you are able to shift “the focus to the cause, rather than the symptoms, may help a person reduce the pressure to perform well every time, especially during times of increased stress.”

Consider therapeutic counselling

It’s understandable that you may feel awkward going and talking to a therapist for sexual difficulties, but trained therapist can help you overcome the “underlying emotional and psychological troubles that may be causing ED.” says Everyday Health. Just knowing what happens in therapy can help relieve some stress. Quality therapy happens in a real office with nicely appointed chairs; there is no sexual contact nor does the client get undressed. Some offices may offer teletherapy using video conferencing so you do not have to leave your phone. If you choose to do this therapy, just make sure they are a qualified, licensed therapist.

Most therapist begin the discussion by asking general questions such as ones about your health, education around sex, and what brought you to the office. Based off of these answers, a treatment plan can be created. One of the unique benefits of therapy is communication strategies, as the International Society for Sexual Health points out. In a session “clients may practice asking for what they want or need sexually or emotionally in a relationship,” and this is crucial because most couples do not know how to ask for intimacy, they just try to do it like they seen on television.

Remember this: real life intimacy requires good communication and learning what the other partner's wants and needs for intimacy to be meaningful.