Note: Dr “C” is a We Gotta Thing listener, a medical doctor AND in the lifestyle.  This blog post is the second in a series on this topic and a new content feature we intend to expand upon in the future.- Mr & Mrs Jones
In our last article, we examined the physiology of erections.  Now I would like to outline five mechanisms of ED, from the least common to the most common causes.  These are not the only possible causes, but most other problems (for example, chronic diseases such as diabetes or hypertension) actually cause ED through one of these mechanisms.  I will only briefly touch on treatment here, although establishing the cause of the problem sometimes makes treatment self-evident. I also should issue that universal disclaimer that you always see in health care articles:  if you have problems with ED, especially if it is long-lasting or severe, then you should see your doctor.

5. Neurological damage.  The least common cause of ED in this list, although important in some cases, is neurological pathology.  Men who have had certain kinds of spinal injuries, damage to the prostate, or various neurologic diseases sometimes have damage to nerves leading to the penis which can cause sexual dysfunction including ED.

4. Hormonal imbalances.  Listening to many popular advertisements, one might think that “low T” (low testosterone) is the plague of the modern age.  Let me say one thing about that: THEY ARE TRYING TO MAKE MONEY OFF OF YOU. Now, having said that, decreasing testosterone as we age is a simple and unavoidable fact of life, and it can influence your sexual function.  However, the effect of testosterone directly on erectile dysfunction is relatively low, and in most cases is corrected more safely and effectively by improved lifestyle than by any supplements or medications. When I do put men on testosterone supplements, I find that only about 30% report any improvement, and this is usually improvement in energy rather than in libido or ED.  Nevertheless, for a small number of people, correction of hormonal deficiencies may improve sexual function.

3. Vascular problems.  Now we are getting to the major contributors to ED.  As mentioned above, a very important component of the mechanism of an erection is the blood flow into and out of the penis.  If the ability of the arteries leading to the penis to open up is compromised, then that can cause difficulty in getting an erection.  Many modern medical problems, including hypertension, diabetes, high cholesterol, and smoking are extremely damaging to arteries, causing hardening of the arterial walls (atherosclerosis), obstructive cholesterol plaques, or both.  These problems may cause the arteries to be stiff and unable to dilate, preventing sufficient blood flow into the erectile tissue to cause an erection. These types of arterial problems are also what can cause devastating events such as heart attack and stroke; therefore ED is often considered a “canary in the coal mine” in medicine because it can sometimes predict who might be at risk for such devastating illnesses.  This is a major reason for the disclaimer above; if you have ED which is severe or long-lasting, see your doctor. However, even for men who do not have this severe degree of arterial problems, they may still cause issues with ED.

2. Medications and substances.   Many chemicals which are external to the body may cause ED, usually through changes in vascular or neurologic function, but sometimes in the long term through changes in hormones.  Prescription medicine, over the counter medicine, supplements, and especially alcohol and tobacco are all implicated here. Alcohol, which is particularly at fault in many lifestyle ED issues, causes both sedation of the mind (more on that in a moment), sluggish neurologic responses, and dilation of blood vessels all over the body, directing blood away from the erectile tissue of the penis.  The best approach to this is moderation of intake. Smoking cessation is also critical if you want to maintain your ability to get an erection due to its long term damaging effect on arteries. Among prescription medications, blood pressure medication, sedatives, and some antidepressants are particularly known for their negative effect on sexual function. If you think your medications may be contributing to ED, discuss it with your doctor.  In many cases a simple medication change or instructions for stopping the medication for a few days can improve function.

1. Psychology.  By far, especially in the situations presented by the lifestyle, the most important contributor to ED is the brain.  In the the previous post describing the mechanism of erection, the very first step occurs in…the brain. There are of course many reasons that a man’s thoughts may negatively influence his erections, easily enough for many more articles.  In brief, however, some topics to consider might be the following. First, is the relationship with his long-term partner secure and safe? Any uncertainty in this regard is likely to interfere with sexual function. Second, is the environment of the playtime safe, both physically and emotionally?  Third, is there an appropriate connection of trust and understanding with all play partners, especially in new partners? And fourth, are there issues from the man’s past, including but not limited to religious beliefs, pornography, abuse, or previous relationships that might interfere with the current situation?  These issues may take a great deal of reflection and communication to overcome, and if persistent may require professional help from a therapist.

In the next article, I will touch on the treatment of ED, especially as it has changed over the last couple of decades with the introduction of medications such as Viagra and Cialis.  We will also discuss how to talk about this issue with both your spouse and lifestyle partners.
May you always keep both heads operational in the bedroom,
Dr. C