Myth of the On-Demand Hard On

Erectile function, for real

For many people with penises, at a certain age erections come when they are not wanted or welcome. Cue the memories of awkwardly holding books, bags, and lunch trays in front of crotches and frantically thinking about baseball. And then at a certain age they don’t come when they are wanted or welcome. Cue the feelings of frustration and potentially challenging conversations with partners. Either way, the illusion of control is just that…an illusion. The body doesn’t always consider what is wanted or welcome, in fact it rarely does.

So what factors contribute to erectile function and how does one make peace with the uncertainty of it all?

How do erections work?

The long answer is quite complicated and the truth is there are things about erectile function that we don’t understand.

The short answer is that when a person is in a relatively calm state (cue the parasympathetic nervous system) and they become aroused (through visual imagery, touch, smell, thought, etc) the smooth muscle inside the blood vessels in the penis relax, allowing them to fill with blood. Then the pelvic floor muscles surrounding the base of the penis contract around the deep vein of the penis keeping blood in the shaft and supporting the base.

If there are issues with the nerves sending messages to the blood vessels and muscles, lack of blood flow, or weakness in the pelvic floor muscles an erection will not happen. Or if there are psychological or emotional issues that don’t allow the person to reach that relaxed nervous system state an erection won’t happen. Or if there aren’t enough sex hormones to keep the tissues of the penis healthy and promote desire, an erection won’t happen. Or if there is not enough stimulation be it physical, mental, or visual, an erection won’t happen. So, as you can see, there are many puzzle pieces to put together when considering why erections aren’t happening.

Why do erections change?

Because there are so many factors involved in achieving and maintaining an erection, there are many reasons why erectile function may change. Here are a few…Lifestyle Factors: All the things that impact ALL aspects of your health ;)

Lack of good sleep/Sleep apnea :

When you sleep well and breathe well while you sleep, nitric oxide levels in the blood increase. Nitric oxide dilates your blood vessels allowing for better blood flow. Guess what PDE-5 inhibitors (ED drugs like Viagra and Cialis) do? They enhance the effect of nitric oxide in your system, relaxing blood vessels in the penis, allowing them to fill with blood.Chronic stress: Arousal and all the things that come with it (in this case erections) happen in a more parasympathetic (i.e. relaxed) state. It is hard for the body to “come down” when it is in a state of chronic stress and this can negatively impact erections. (Read more about nervous system states here: https://papaya-gold-z4sr.squarespace.com/config/pages/66d0d01345fe453540fca99a.)

Lack of physical activity and exercise:

If you are sensing a trend here, you may be on to something. Erections require blood flow! And lots of it! You know what else gets your blood pumping? Exercise! Cardio exercises keeps your heart and vessels happy while strength training keeps your pelvic floor and core muscles strong and supple. And don’t skip mobility work - hip and back tension can lead to pelvic floor tension which does not help with sexual function.Poor diet: Diet impacts hormone production, energy levels, and gut health all of which are important for erectile function. Nothing feels less sexy than GI issues and in the pelvic health world we call constipation the root of all evil. Chronic constipation, straining to have bowel movements, and gut inflammation are bad news for erectile health.

Smoking:

I’ll say it again - blood flow! Smoking causes cardiovascular problems, which cause erectile problems. Enough said.Heavy drinking: Heavy drinking, like diabetes, leads to peripheral neuropathy or nerve damage. Good function of the nerves in the pelvis and the genitals are imperative for erectile function and sensation. Heavy drinking can also lead to cardiovascular issues and kidney disease.

Physical Health Factors:

• Chronic conditions that impact erectile functionCardiovascular issues - Changes in erectile function may be the canary in the coal mine for undiagnosed cardiovascular problems. Because the blood vessels in the penis are small, they can be affected by high blood pressure, heart disease, high cholesterol, and arterial disease before other symptoms show up. It is HIGHLY recommended to see a cardiologist when experiencing consistent changes in erectile function to rule out underlying cardiovascular issues.

• Diabetes (type 2) -Because diabetes impacts small blood vessels and causes nerve damage, type two diabetes can be a root cause of erectile difficulties. High blood sugar over a long period of time can also cause hormone imbalances which may lead to erectile issues.

• Kidney Disease - Similar to diabetes, kidney disease leads to poor blood flow and nerve damage which have a negative impact on erectile function. Kidney disease may also cause a decrease in testosterone production impacting libido and erectile function.

• Medication - There are a number of medications that can negatively impact erectile function. Here are a few: SSRIs (depression and anxiety), diuretics and beta blockers (blood pressure), antihistamines, finasteride and dutasteride (BPH), anti-androgens (cancer), and opioids (pain).

Psychosocial Factors:

Issues related to emotional, mental, and social factors.

• Relationship issues/dynamics - Not feeling safe, at ease, and accepted with the person you want to have sex with can signal to your body that something is off. This doesn’t automatically mean that if erections are difficult, it’s because you aren’t attracted to your partner. You can still have erectile issues with a partner whom you are attracted to and feel safe and secure with. However, if there are underlying issues within a relationship, it can show up in your body’s response to sex.

• Poor self-esteem or negative self talk - The biggest sex organ is indeed the brain. If your brain is telling you messages about your self worth that aren’t congruent with feeling sexy and desired, it’s hard to convince your body to respond.

• Depression - This one is a bit more complicated. Depressive states often lead to a lower sex drive (libido) which can impact sexual function. Additionally, SSRIs commonly prescribed to treat depression may cause erectile difficulties, low libido, and difficulty climaxing. The relationship between erectile function and depression can also go both ways with changes in erectile function causing depression, poor self-esteem, and relationship issues.

• Anxiety - Anxiety impacts your nervous system in a similar way to chronic stress. It makes getting to that calm, parasympathetic state challenging and becomes a cycle where the anticipation of anxiety and the sexual side effects of anxiety creates more anxiety. Like a snake eating its own tail, it is self perpetuating.

• Lack of sex-ed - I’ve had people tell me that they think something is wrong with them because they can’t have sex 5+ times in one night like their friends do. Firstly, let’s not imagine that a man has never exaggerated his sexual experiences. Secondly, everyone has a refractory period (the time following ejaculation when the body can’t produce another erection) and the length of the refractory period is different person to person, changes with age, and varies depending on the sexual activity. This is NORMAL. It is also normal for erections to wax and wane during a single sexual encounter. Porn, movies, and media will have us believe that a person with a penis gets hard as soon as they think about sex and that their rock hard erection lasts until the moment they cum. That is not how the body works. Sometimes a person needs mental stimulation, sometimes physical or visual. Sometimes erections come and go. Sometimes one time in a day is all the body wants. All of the factors that we have mentioned so far are in constant flux - they change moment by moment, day by day, so why should erectile function be exactly the same every time.

• Trauma - Experiences are stored in our bodies through our nervous system. Our brains and nerves are constantly taking in information about our bodies and our surroundings and using it to assess how safe we are. If experiences around sex have not felt safe in the past, the body remembers and acts accordingly. Even if the current situation is perfectly safe and the desire to engage is strong, the body may not be able to register this.

• Cultural/Social Drivers - If the idea of masculinity is tied to an erection and that erection falters, even slightly, it may seem like a heavy blow. Again, it is NORMAL to have occasional changes in erectile function and this does not mean you have “erectile dysfunction”. Sometimes the mindset inherent in equating masculinity, sexuality, and self-worth with an erection can create a self-perpetuating cycle caused by the pressure to “perform” + the fear of being unable to “perform”. This is a deadly cocktail for erectile function. Sometimes erections and orgasms are like watched pots, they can’t happen with all eyes on them.

Why does erectile function change over time?

Whew, that is a long list. And that’s not even every single thing that can impact sexual function! So why do we see changes in erectile function with age? Let me ask you this - how many 20 year olds do you know with high blood pressure, diabetes, or cardiovascular disease? Or a long history of drinking and smoking? Or 20 years of a sedentary job and little physical activity? Or a long term relationships with complex dynamics and the stress of raising children? I could go on…Life is a big part of the equation. Things accumulate. Things change in the body, in the mind, in the spirit, between people. We are changing moment to moment, day by day and the list of things that could potentially impact erectile function gets longer as the years go by. Understanding and acknowledging that change is inevitable, even embracing it at times, makes the experience less painful and the nervous system less reactive.

So what can be done?

Unsurprisingly, supporting good erectile health in a physical sense requires all the same things that support the rest of your physical health. This means consuming a diet that includes water, whole grains, fruits and veggies, and healthy fats (nuts, fish, avocados) and limiting alcohol, caffeine, sugar, and excessive animal protein intake.

It means exercising - whatever you like to do to get your blood pumping and keep your muscles strong. There is no one-size-fits-all activity for this! I recommend that people start with what they like to do because it is much more likely they will actually do it and keep doing it. Swim, run, bike ride, hike! Check out resistance training classes at the gym or the Y, take yoga or Pilates classes, play tennis or pickle ball or basketball, dance! Whatever suits your fancy :)

It means getting good, quality sleep. Again, there is no magic bullet here but finding a bedtime routine that is consistent and making sure you are getting to bed at a time that allows you to get 8ish hours of sleep is a good start. Also to note, eating a lot before bed, drinking alcohol, or heavy workouts in the evening and a lot of screen time prior to bed can be enemies of good sleep. Guided meditation or yoga nidra can help with relaxation before bedtime. The app Insight Timer has a TON of guided relaxation, meditation and soundscape recordings designed to help with sleep.

It means limiting stress as much as possible and coping with the inevitable stressors that life brings. Breathing is by far the most important tool in your tool box for this. It is the original body hack. You can’t control your heart rate or pupil dilation or sweat glands or the other parts of your body that respond to stress but you can control your breathing. It is a two way street between your breath and your nervous system. If you can slow and deepen your breath, it sends a signal to your nervous system to calm down. Super helpful in life and as you prepare for sexy time.

More specifically, what can be done?

When it comes to specifics for erectile support there are a number of options. As a pelvic floor PT, I’m going to start with our friend the pelvic floor specific suggestions.

Pelvic mobility is your friend! Embrace your inner Shakira. Moving your pelvis is helpful for blood flow, muscle function, and happy nerves. This may be harder than it seems, especially when you first try it. It’s like learning to play the piano, when your first start your fingers are clumsy and uncoordinated but it gets better with practice. You can do this lying down, sitting (easier on a yoga ball), or on hands and knees. Technically, you can do it standing as well, but this is harder so maybe not ideal for beginners.

• Move pelvis forward and back - imagine arching and rounding your low back

• Move pelvis side to side - rotate side to side, like a rocking shipMove pelvis up and down, shortening one side of the body and then the other

• Move pelvis in a circle - imagine hula hooping

• Move pelvis in a figure 8 - like an infinity loopLearn how to breathe AND strengthen your pelvic floor

When you breathe in using your diaphragm your pelvic floor moves down, when you breathe out your pelvic floor moves up. This is very important for maintaining pliability, mobility, and blood flow to your pelvic floor muscles.

Practice feeling your whole trunk + your pelvic floor move when you take a breath in. It is common to take too big of a breath and tense up when you start this practice. Instead, think of using 75% effort and soften your belly, back, butt, anus, etc. Tune into the sensation of gently stretching throughout your entire trunk (including the pelvic floor) when you inhale. Then you can start to gently contract your pelvic floor when you exhale. This should feel like a lift of your penis or anus. Again, keep it gentle to start and try to notice how it feels.

Put these steps together - feel a soft expansiveness in your torso and pelvic floor on your inhale and then a gentle lift of your pelvic floor on your exhale. Once you feel comfortable with this, practice it in all the positions you want to have sex in! Lay down, sit, kneel, stand, do a backbend - the sky is the limit!

So now that you’re rocking and rolling with your pelvic floor, what other options are there?

Medically speaking, there are a number of options for increasing erectile function.

The most popular are a class of drugs known as PDE-5 inhibitors. These include Avanafil (Stendra), Sildenafil (Viagra), Tadalafil (Cialis), and Vardenafil.Avanafil, Sildenafil, and Vardenafil all last between 4-5 hours and should be taken 30 min -1 hour before activities begin. Tadalafil can last up to 36 hours and can be taken either as needed prior to a sexual encounter or daily in a small dose to keep more consistent blood flow to the genitals. It is also sometimes prescribed for people with pelvic pain or post-surgically to aid in healing. These all have the potential for side effects and interactions with other drugs so talk to your doctor before taking them.There is a shot called trimix, a combination of alprostadil, phentolamine, and papaverine. These are mixed and injected directly into the side of the penis. They CANNOT be used in combination with oral PDE-5 inhibitors. This is a common option for people who have undergone prostate removal surgery or other pelvic procedures.

The most invasive and extensive medical intervention is a penile implant. These are inflatable or malleable (semi-rigid) devices that are implanted into the penis and either operate via a saline-filled pump in the scrotum or a malleable rod that is positioned manually. The benefit of a penile implant is that it does create an on-demand hard on. The drawbacks are that they are pricey, there is a risk of complications, and they may fail after a period of time and need to be removed or replaced.

One More Thought…

For some people, de-centering an erection as the focal point of sexual activity can go a long way to easy dismay over an unpredictable erection. Pleasure, connection, and even climax are still possible without an erection and without ejaculating. Engaging in partnered sex can be amazingly enjoyable without any erection in sight. Hands, mouths, thighs, butts, and toys are all wonderful pleasure tools and are available at all times without pressure or stress. A conversation about what kind of sex people want to be having, what people like and what gets them off is a great place to start. De-centering an erection can open the door to possibilities you never knew existed. A person with a penis may derive great pleasure (and climax) from penis and testicle massage, prostate stimulation, anal play or nipple play. Use your imagination! An expansive definition of sex and willingness to explore has the power to flip the script when it comes to erectile unpredictability. Rather than be a hinderance to a fun and a raucous sex life, it can be an opportunity for uncovering as yet undiscovered pleasures, experiences, and ecstasies!