chapter 7
Erection Problems
Problems with erections are currently called male erectile disorder (MED), or erectile dysfunction (ED). Some therapists and writers still use the older term for the problem, which is impotence. According to the DSM, erectile dysfunction is “persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection.”
What’s Normal?
Erection is the filling of the small blood vessels in the penis that occurs in the excitement stage of the sexual response cycle. There are two types of erection, based on the cause or source of the erection: reflexogenic erection and psychogenic erection. A reflex is a very basic automatic bodily response that you don’t have to learn. When a man’s penis is touched, it triggers an impulse in a sensory nerve in the penis. The impulse travels into the spinal cord through an interneuron, and back to the penis through a motor neuron, causing an erection. For an erection to be triggered, the smooth muscle at the base of the penis (PC muscle group) has to be relaxed. A reflex erection occurs very quickly because the erection reflex arc is located very low in the spinal cord. A reflex erection doesn’t require input from the brain. Teenage boys are likely to have unwanted reflex erections with very minimal stimulation, such as the touch of clothing on their penis.
Psychogenic erections involve mental input. A man has a fantasy or some type of sexual thought, and the nerve impulses travel from the brain down the spinal cord, gather at a nerve center in the mid-back area, then travel down to the pelvic (sacral) section of the spinal cord, and trigger the smooth-muscle relaxation and the activity of the motor neurons that cause erection.
The reality for most men is that their erections are not strictly reflexogenic or psychogenic; they’re usually a combination of both. For example, a man might have some time on his hands and lie in bed and start to stroke himself or masturbate. This will usually trigger a reflex erection. But he’ll usually start to fantasize also, which will give his erection a psychogenic boost. It works the other way around, too. A man might have an unbidden sexual thought, and if he’s alone he’ll probably reach for his penis, triggering the erection reflex arc.
Another factor in erections involves the sleep cycle. It’s normal for healthy men with no disease processes to have several erections during the course of a night’s sleep. To understand this, you need to know something about sleep. Sleep is not an all-or-none phenomenon. It progresses in a series of stages characterized by different types of electrical activity in the brain. In stage 1 sleep, you experience drowsiness but are easily awakened. In stages 2 and 3 you go deeper into sleep. Stage 4 is extremely deep sleep. After stage 4, you cycle back through stages 3 and 2 and into rapid eye movement (REM) sleep, in which your body is asleep but your brain shows characteristics of alert wakefulness. REM sleep is also called dream sleep. The significance of this for erections is that during dream sleep most healthy men have some degree of erection, whether or not their dream has sexual content.
Each full sleep cycle lasts about ninety minutes, meaning that if a man sleeps for seven hours a night, he will probably have four to five nighttime erections. These nighttime erections are called nocturnal penile tumescence, or NPT. I’m going into all this detail because NPT is very important for diagnosing erection problems. If you wake up in the morning in the middle of an REM segment of your sleep cycle, you may wake up with an erection. Some men call this a “piss hard-on,” based on the misunderstanding that they have an erection because they have to urinate. This isn’t really true; they have an erection that is a remnant of NPT from being awakened during an REM stage. Scientists don’t really know why men have erections during REM sleep. It just seems to be the body’s way of checking out the plumbing. (Women have them too; the clitoris engorges with blood, and the vaginal tissues swell and lubricate.) The absence of NPT can indicate a physical cause for erection problems. The REM sleep/erection phenomenon generally begins around puberty, but children as young as infancy appear to have reflex erections.
Levels of Erection
Like sleep, erections are not an all-or-none phenomenon. There are varying degrees of erections. It’s helpful to think of the erection process as having several stages—initiation, filling, rigidity, and maintenance. Initiation is the phase that occurs in the brain. It usually involves a sexual thought as well as the awareness that it’s okay to have an erection. This is the same as a psychogenic erection. Filling involves the first stages of blood flow into the penis. The penis thickens and becomes fuller and warmer. Rigidity occurs when enough blood has entered the penis to give it a “spring back” quality. Rigidity occurs because there are five valves in the blood vessels at the base of the penis that close and press up against the body, holding blood in the penis. This also accounts for maintenance, which is the ability of the penis to stay at a certain level of hardness.
Throughout this book, I’ll describe erections using a simple 1-to-10 scale. A level 1 is no erection. Levels 2, 3, and 4 reflect filling. Levels 5 through 10 reflect increasing degrees of rigidity, with a level 10 being an extremely hard erection that is almost painful.
One of the problems with the DSM definition of erectile dysfunction is that it talks about a man’s failure to have an “adequate” erection, but it does not define what an adequate erection is. This is because it does not describe erections in terms of different levels. In my experience, anything that is about a level 5 or above is adequate for intercourse, depending on the person. Some men are better at having intercourse with a relatively flaccid penis than others are. In my view, a man has erection problems if he cannot have or maintain some degree of rigidity. Having said that, there are other ways in which we can describe different degrees of erection problems.
Forms of Erection Problems
A man with lifelong total erectile dysfunction has never had an erection in his life. I’ve never heard of a case like this. It probably exists in conjunction with serious congenital malformation of the genitals. In acquired erectile dysfunction, a man functioned fine at some point but can no longer get erections. In generalized erectile dysfunction, a man cannot have an erection in any situation. He goes not have NPT or morning erections, and he can’t get an erection with masturbation or any kind of activity with a partner, including manual or oral stimulation or intercourse. In situational erectile dysfunction, a man can have an erection in one context or with a particular person, but can’t have one in every situation.
Of all of the above conditions, acquired situational erection problems are the most common, as well as the easiest to treat. The most common scenario is a man who has normal NPT and can have an erection with masturbation but has difficulty getting an erection with a partner. Another common problem exists in a man who can get an erection from oral sex but loses the erection at the point of penetration. You can see that both of these situations appear to be psychological. The presence of NPT means that the plumbing is working, which indicates that some psychological factor in the sexual situation is shutting the man down.
In another pattern of erectile dysfunction, a man can get a full erection rather quickly but then immediately loses it. In the absence of NPT, this is usually caused by a problem with leaky valves at the base of the penis. Other men can get a partial erection but not a full one, either during sleep or with a partner. This is usually a sign that the erection problem has physical (also called organic) causes. For a list of possible physical causes of erection problems, read on.
Physical Causes of Erection Problems
The most common physical cause of erection problems is cardiovascular disease. Anything that interferes with blood flow can have a negative effect on a man’s erections. In fact, doctors now use erection difficulties as a warning sign of cardiovascular disease. Diabetes can also cause erection problems by destroying the nerves that trigger erection. Disorders of the nervous system, like multiple sclerosis, can interfere with erection.
Drugs are a huge cause of e
rection problems. Alcohol potentiates estrogen (a female hormone) in men, placing chronic alcoholics at high risk for erection problems. Nicotine and caffeine are stimulants that constrict the small blood vessels in the skin, especially in the lips, fingertips, and genitals. Any medications that lower blood pressure can affect erections, as can medications for ulcers. Even over-the-counter medications like antihistamines can temporarily interfere with a man’s sexual arousal. Some men take illegal stimulants like cocaine and amphetamine because initially these drugs appear to make their erection response stronger, which is true. However, the long-term use of any illegal stimulants that I am aware of eventually destroys erectile tissue and degrades a man’s erection response over time.
Prostate problems can interfere with erections. Benign enlargement of the prostate can cause erection problems, and surgery to remove a cancerous prostate can cause permanent erection problems. Acute infections of the prostate and other genital organs can cause erection problems.
Hormone problems can affect erections. The main male hormone is testosterone. Problems with testosterone usually affect sexual desire rather than erection. High levels of another hormone called prolactin can affect a man’s erections, but this condition is rather rare.
If you are experiencing erection problems, it is important to figure out if your problems are physical, psychological, or some combination of both. In general, if you get nighttime or morning erections that are relatively hard but you have trouble getting or maintaining erections with a partner, your problems are probably psychological and will most likely respond well to the strategies outlined in this book. If you don’t have nighttime or morning erections, your problem may be physical and you will need to see a urologist who specializes in erection problems to find out what’s going on.
What will happen if you go to a urologist? The urologist may be able to diagnose a physical problem based on your description or your responses to a questionnaire. There are also several tests that can be performed to find out if you have problems with blood circulation to your penis. The simplest test is the penile/brachial index. The physician takes your blood pressure in your arm and in your penis and compares the two to see whether the blood pressure in your penis is abnormally low. Another test is also simple but not very pleasant. The physician sticks a small needle into the penis at various locations. This tests for nerve damage, which could be a sign of multiple sclerosis. The urologist will also likely want to perform a digital rectal examination of your prostate to find out whether it is enlarged. He or she will probably also order a prostate-specific antigen (PSA) test to screen for prostate cancer.
If your doctor suspects that you may have cardiovascular disease, he or she may order an angiogram or other diagnostic procedure to screen for it. Specific tests exist to determine blood flow to the penis. One of them is dynamic cavernosography. A dye is injected into the bloodstream and ultrasound is used to see whether the dye fills the erectile tissue in the penis. When a man with no physical problems has an erection, valves at the base of the penis close and press up against the body, holding blood in the penis. Dynamic cavernosography can help the urologist determine if you have a leaky valve. The most common behavioral sign of this complication would be getting an erection but losing it right away.
Some doctors inject special drugs into the penis to test for erection problems. These drugs are fast-acting localized vasodilators like papaverine and phentolamine. They expand blood vessels and draw blood into the penis. If you are injected with a drug like papaverine and don’t get an erection, it could mean that there is damage to your erectile tissue.
Urologists who are very thorough will do many of these tests twice—once with no sexual stimulation, and once while the patient watches sexually explicit materials. During this type of test patients are provided with special glasses that display X-rated visual materials.
Finally, with some men it’s difficult to tell whether or not their erection problems are physical, because they don’t know whether they have nighttime erections. If that’s the case, the urologist can rent you a device called the Rigiscan, which measures nocturnal penile tumescence (NPT). The device consists of a flexible loop that you put around your penis before you go to sleep. It’s connected to a computer, and as you sleep, if blood flows into your penis, the loop stretches and the computer records the activity and prints out a record of it. You get a graphic record that shows the degree of erection and how long it lasted. Patients are usually directed to use this machine several nights in a row to make sure the readings are accurate. A potential problem is that the gauge can fall off the penis in the middle of the night and fail to provide a reading.
Medical solutions for erection problems are described in Chapter 24. In addition to pursuing a medical solution, you may want to try the exercises described in this book even though they are psychologically based. They can’t hurt you, and they’ll definitely create the optimal situation for pursuing medical solutions.
Psychological Causes of Erection Problems
The most common psychological cause of erection problems is anxiety. Remember that anxiety has both physical symptoms (rapid heart rate) and psychological symptoms (worry). The reason anxiety shuts down your erections has to do with the organization of the nervous system, which you read about in Chapter 3. To briefly recap, the sympathetic nervous system helps you disperse energy really quickly when you perceive a threat to your life. In contrast, the parasympathetic nervous system produces your relaxation response. Erection is a function of the parasympathetic nervous system. If your sympathetic nervous system is activated (in other words, you are anxious), it floods your bloodstream with adrenalin and inhibits erection. If you have a tendency to be concerned about erections, you need to learn how to relax and activate your parasympathetic nervous system. The exercises in Chapter 16 will show you how.
There’s a specific type of mental anxiety that interferes with erections. It’s called performance anxiety. I talked about it in Chapter 3. What you need to know for now is that men with erection problems think differently in sexual situations than men who do not have erection problems. Men with erection difficulties usually have a problem with what Masters and Johnson called spectatoring: They mentally watch themselves to see whether or not they are getting an erection.
Another major psychological cause of erection problems is depression. Depression is an overwhelming feeling of sadness, along with a loss of interest in activities that used to give pleasure, like eating and sex. In fact, erection problems are a common symptom of depression. Depression is usually temporary. If you are severely depressed, you may need medication to help you through it. If you are only mildly depressed but it’s affecting your erections, the peaking process described in Chapter 24, on dealing with erection problems, can help. Peaking is an arousal technique that helps the secretion of endorphins in the brain. Endorphins are feel-good chemicals that can often benefit mild depression. One of the problems with depression is that it can diminish a man’s nighttime erections. This could lead him to believe that he has physical erection problems when he really doesn’t. When men who have been depressed start to feel better, their nighttime erections return.
Besides anxiety and depression, there are other psychological causes for erection problems. Sexual trauma or abuse in the past can cause them. So can being unsure of your sexual orientation. Problems in your current relationship or your current sexual situation can also be a factor. Some men don’t receive enough stimulation from their partner and don’t ask for it. As you get older, you generally need more direct physical stimulation of your penis in order to get an erection. Men often expect their bodies to function like machines. They expect to have an erection even when they’re hungry, tired, stressed out, or afraid.
Expectations also shut a lot of men down. Especially harmful is a form of interpersonal expectation called the self-fulfilling prophecy. In this situation, a man worries about having an erection, and the anxiety in turn interferes with his abil
ity to have an erection. This means that even one episode of erection failure can unfortunately set the stage for some major problems.
Remember, men’s erectile ability varies tremendously. What feels like an adequate erection for one man may be a source of anxiety for another. You don’t necessarily have a problem if you don’t have reflex erections. There are many men (even young men) who always need direct physical stimulation in order to have an erection. It’s probably unrealistic to expect that you will have an erection merely from viewing something that is sexually explicit, whether it is pornography or your partner’s naked body. It’s probably also unrealistic to expect that your erection will maintain the same level of rigidity throughout the course of a sexual encounter. It’s normal for a man’s erection to vacillate between several levels depending on the amount of stimulation he is receiving.
Here are a couple of case histories from my surrogate practice. The first illustrates psychologically based erection problems, and the second illustrates erection problems with a physical cause.
Larry
Larry’s story illustrates a typical progression from perceived erection failure to anxiety to actual erection failure. At first, Larry, age forty-two, noticed that sometimes he would lose his erection after several minutes of intercourse with his girlfriend. He would start worrying about this as soon as intercourse started. Then he started worrying about it even before intercourse started, when his girlfriend did oral sex with him. Eventually he found he had a difficult time getting an erection at all. Soon he began to avoid any type of sexual activity or touching because of the anxiety it caused him. After about a year he entered therapy. He followed the program I will describe later in this book and regained the ability to have intercourse with his girlfriend. Their sex life now is better than ever. In therapy, Larry learned how to reduce the anxiety he felt in sexual encounters and how to cope with changes in his sexual response as he aged. He learned to relax his body and allow his natural sexual response to happen instead of increasing his anxiety by working at getting an erection.
Sexual Healing Page 9
