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.
HORMONES.
Evaluation.
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).
Treatment.
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.
BLOOD FLOW.
Evaluation.
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.
Treatment.
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.
PSYCHOLOGICAL FACTORS.
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.
OTHER CONSIDERATIONS.
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.
References:
- 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.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
how may you help me about ED just experience 3 days ago…pls send me your advised
Hi Litz,
It sounds like you may have a pelvic floor disorder. Unfortunately we cannot make specific recommendations without evaluating you. We would be happy to evaluate you in one of our locations or you can use our website to find a pelvic floor physical therapist in your area that can help.
Regards,
Admin
I’m having issues I’ve took 100mg of sildenafil and I’m still not getting and erection
Hello,
We highly recommend you seeing a pelvic floor physical therapist to get evaluated. Without a full history and evaluation, we cannot give direct advice as we do not know the route of the problem. The following links can help you locate a pelvic floor pt near you.
Pelvic Guru Provider Directory
Herman and Wallace Find a Provider
International Pelvic Pain Society Find a Provider