Dr. Aimee Paik is an experienced dermatologist who is passionate about men’s health and the ability to improve one's quality of life. She completed her dermatology residency at University of California Irvine, where she was elected Chief Resident and received the Resident Teaching Award, and has been in practice for 10 years.
Dr. Daniel Lanzer is a well known Australian Dermatologist and Cosmetic Surgeon who features prominently on TV and in the media. He has pioneered many new developments in Dermatology and Cosmetic Surgery over the last 30 years.
Jacqui is an experienced health writer with an academic background in pharmacology and marketing. Jacqui aims to make complex science accessible to consumers and to help people become empowered owners of their health.
Problems getting it up can be a serious downer, and more guys have it going than you think, including younger blokes.
One of the reasons guys let erectile dysfunction (ED) erode their masculinity and ruin their sex lives is that they buy into unrealistic social norms around sex and don’t know much about how their issue can be managed.
Sure, there’s that little blue pill, but that’s not always a silver bullet.
This guide will empower you with all the knowledge you need about ED, how to treat it, and how to get your mojo back.
So let’s dive in, head first.
In this chapter, we define ED and describe the signs and symptoms. It can be more complicated than you think.
We also look at the stats around ED, its impact on your manhood, and how that little blue pill changed the world.
ED, also known as impotence, is a man’s inability to get or keep an erection firm enough for sexual activity with penetration.1 Some men are completely unable to get an erection and others may get one that doesn’t remain rigid enough for intercourse.2 That means somewhere between a 1 and 3 on the erection hardness score.
Penis is large but not hard.
Penis is hard but not hard enough for penetration.
Penis is hard enough for penetration but not completely hard.
Penis is hard and completely rigid.
Despite the despair you may experience about your 3.5-inch floppy, ED is not a disease, but rather a symptom of another problem. It might be due to a physical problem (such as a heart condition), a psychological issue (such as stress), or a mixture of both.
For simplicity’s sake, think of getting an erection like conducting an orchestra – there are a lot of moving parts. Your brain, nervous system, blood vessels and hormones all have a role to play. If one or more of these parts are out of sync, the whole performance can be ruined.
Outside of death, nothing worries us blokes more than losing our stiffies.
Erections are an integral part of our identity. Starting with the pleasant sensations experienced in adolescence with masturbation and self-exploration, to our first sexual experience, and then the intimacy of a long-term relationship, getting it up is a key part of our manhood.
Failing in the hard-on department can be a significant blow to both you and your partner. It can trigger a loss of confidence, low self-esteem, anger, anxiety and shame.
If that doesn’t make you want to withdraw from sex altogether, it might make you search for a solution, like the little blue pill.
In 1998, a little blue pill for ED was introduced to the world, and it’s fair to say the world hasn’t been the same since.
The availability of ED medication has prompted more blokes than ever to seek medical advice for their hard-on issues and a prescription from their doctors.
As one London-based Cardiologist, Dr Carl Shakespeare, said, it “unlocked the ability of men to communicate with a doctor because it offered them hope.”
Whilst ED medication has helped to break down the stigma associated with sexual dysfunction, it’s also served to make ED, as a sexual issue, become socially unacceptable, which has put a lot of pressure on us guys.
Today’s society would have us believe that a ‘real man’ has sexual prowess, is untiring, masterful and dominant, and can always get it up. But we all know that’s not the case.
Having limp dick once – or even several times – doesn’t mean your sex life is over forever.
Most cases of ED are treatable – or at least manageable – no matter what your age.7 So, parking your car in the garage needn’t be a problem forever.
Understanding what’s causing your ED, however, is the first step to treating it, so keep reading.
ED is usually caused by an underlying health problem, or a combination of problems, which if treated, can reverse your ED.
In this chapter we explore all the possible causes – from physical illnesses to psychological issues, medications and recreational drugs.
Doctors once thought that ED was primarily in a man’s head, but we now know that physical illness is actually behind most cases of ED,7 with psychological problems causing only one in ten cases of persistent ED.1
Commonly, though, a guy with ED will have a combination of both physical and psychological causes.
These range from heart and blood vessel problems to hormonal issues, obesity and even physical damage to the penis.
When the erection orchestra plays sweet sexy music and you’re able to get it up, it means blood is flowing freely into the shaft of the penis.
Any condition that affects blood flow to the penis, however, can result in ED.8
Blood vessel and heart conditions are the most common medical causes of ED,7 and are often linked to:
The nervous system is another key player in the erection orchestra.When you get turned on – whether by your partner, a sexual thought, or just porn – your brain sends chemical signals to specific nerves near the penis that cause the blood vessel walls to relax, allowing blood to flow into the penis.10 That’s when you get an erection.
Men with conditions that cause nerve damage, such as multiple sclerosis (MS), Alzheimer’s disease, Parkinson’s disease and spinal cord injuries, may often experience ED. It’s because there is an interruption in the transmission of nerve impulses between the brain and the penis.9
Pelvic or prostate surgery and radiation therapy (usually to treat prostate cancer) can also result in the same problem.
And commonly, diabetes can cause nerve and artery damage, making it difficult to get an erection. In fact, between 35% and 50% of men with diabetes experience ED.9
If your hormones are out of whack, it can interfere with your libido and your erections.
The hormone that naturally comes to mind is testosterone. But whilst low testosterone may affect your desire for sex, it is less commonly the cause of ED.11
According to the American Urological Association, testosterone treatment has not been shown to improve erections in men with normal testosterone levels. And studies show that it does not help men with low testosterone levels if ED is their only symptom.11
If hormonal imbalance is the cause of ED, it’s most likely to be from:6,12
Whilst there isn’t any scientific evidence to show that being obese is directly linked to ED, it’s link to heart disease, diabetes, high cholesterol and atherosclerosis – which are all closely linked to ED – make it a major risk factor for ED.13
One Italian study showed that about a third of obese men with ED were able to cure their problem by making lifestyle changes and losing weight,14 and a more recent Australian study14 backed these results, with similar findings.
Penis’ come in all shapes and sizes – big, small, straight, thick and thin – but for men with Peyronie’s disease, it’s curved.
Whilst having a curved erection isn't necessarily a cause for concern, Peyronie's disease causes a significant bend or pain in some men, which can result in trouble having sex.16
The condition is thought to develop after trauma to the penis, such as bending or hitting, which can cause bleeding and scar tissue build-up.17 Peyronie’s can also happen without a prior injury, in which case it’s more likely due to genetics or age.17
Your mental state holds your penis like a marionette string, so as soon as you start to over analyse things, it can be game over.
Psychological ED is pretty common too, with 90% of teenagers and young men experiencing it at some point, usually due to nervousness and anxiety.18
Note, we said ‘at some point’, which means it’s not likely to be permanent.
Older men can experience psychological ED too, but as men age, it’s is less likely to be from nervousness and more likely to be from professional or relationship stress, loneliness, or loss of a loved one.18
Whether you’re stressed about work, money, or you’re going through a rough patch in your relationship, chronic stress and anxiety will affect not only your libido, but your erections too.
Physiologically, the stress hormones cortisol and adrenaline supress production of the sex hormones making it more difficult to get or sustain an erection.19 Stress and anxiety can also interrupt how your brain sends messages to the penis to allow extra blood flow.18
Here’s a scenario that commonly plays out in a man’s life:
You’ve had a stressful day at work and you get home late. You’re tired and still pissed off about the argument you had with a colleague. When you try to have sex it’s really hard to get it up because your mind is elsewhere.
Your partner senses there is something wrong, which only makes you try even harder to get that erection, but it doesn’t work.
The next time things get hot and steamy, you’re reminded of what happened last time and, of course, you fail again. The harder you try the worse it gets, and so begins the vicious cycle of performance anxiety.
For millions of men, ED is nothing more than a stress response that triggers a mind-body phenomenon.18 And because we have no conscious control over our erections, the performance anxiety cycle can be really debilitating and make us want to avoid sex altogether.
We’ll talk about ways to help you manage sexual performance anxiety in the treatment section.
It’s common in men with ED to feel angry, sad, frustrated, unsure of themselves or even less ‘manly’. These feelings may lead to lack of self-esteem and, in severe cases, to depression.
On the flipside, a man with depression rooted in other causes is more likely to lose interest in activities, including sex, which can lead to ED.21
Research published in the Journal of Sexual Medicine showed that the risk of ED increases by 39% in patients with depression, and that the incidence of ED is 1.39 times higher in patients with depression than in those without depression.22
Because of the link between the two conditions, doctors commonly screen men for ED when they present with depression, and vice versa.
As famous sexuality expert and therapist, Esther Perel says, much of our adult sexuality, our current desires, the way we relate to others and how we perceive our self-worth, is the product of the way we were raised and the environment in which our sexuality developed.23
For many people, sexual education was shaped by moral and religious forces, which means they grew up believing, for example, that sexual desire outside of a monogamous, heterosexual relationship is immoral and that masturbation is a sin.
Men raised in such environments often associate sex and masturbation with shame and may experience sexual dysfunction, such as premature ejaculation and ED.
Childhood abuse and sexual trauma can also be at the root of a man’s ED.
Some guys can confuse premature ejaculation or loss of libido with ED.
Premature ejaculation is one of the most common sexual dysfunctions in men, affecting up to 30% of Aussie guys.24 More than you thought, right?
If you fear that your hard on won’t last long enough, it may result in premature ejaculation.25 Or, if you’re worried about ejaculating too soon, it can cause you to have ED.
It’s a bit like like a chicken and egg situation – it’s hard to tell what came first
A doctor can help you determine the cause of the issue so you can seek the right treatment.
Some medications can cause ED or worsen the symptoms of ED.
The common culprits include drugs used to treat:6,26
While it’s normal to want to stop a medication that’s getting in the way of your sex life, you should always speak to your doctor first. They’ll help you find a balance between treating your symptoms and managing the side effects.
Using alcohol or other recreational drugs for a fun night out could actually be the thing that’s keeping you soft.
Recreational drugs can include illegal drugs but also prescription drugs that are misused.
Here’s how some of the common ones can impact you sexually:
Watching porn is enjoyable, and based on the stats, we think most of you would agree.
According to Pornhub, Australians rank 7th in the world for visitors to the site, despite our smaller population.
Whilst watching porn might seem harmless, evidence increasingly suggests that watching too much porn can cause problems with sexual performance, such as ED.35
One Italian study that surveyed 28,000 men found that excessive consumption of porn, starting at 14 years of age and continuing daily into their mid-20s, desensitised them to even the most violent images.36
According to the Italian Society of Andrology and Sexual Medicine, these men develop their sexuality largely divorced from real life relationships, leading to “gradual but devastating” consequences.
Symptoms usually start with lower reactions to porn sites, then a general drop in libido and in the end, it becomes very difficult, or impossible, to get an erection.
The type of porn you watch also matters. Unlike the soft-core porn that used to be available in Playboy and Penthouse magazines, online porn depicts more graphic, kinky and even violent behaviour. The more you watch, the more likely you are to develop unrealistic expectations of sex as well an increased tolerance for sex – much like a drug addiction.35
On a neurological level, you decrease your sensitivity to the pleasure-seeking chemical dopamine. This not only desensitises you to real sexual encounters with a partner, but fuels the addiction and makes it difficult to quit porn.37
The good news is that the condition is reversible with proper assistance.
There’s a lot of good information about ED out there, but there’s also some complete furphies. So, what should you believe?
This chapter will dispel some of the common myths and put your mind at ease about wearing tight underwear!
ED only happens to older guys
It’s true that the prevalence of ED increases with age, but that doesn’t mean younger guys are immune to it.
One study published in the Journal of Sexual Medicine found that one in four men seeking medical help for ED is younger than 40 years.38
And whilst it is common for the cause of a young guy’s ED to be psychological – like performance anxiety – another more recent study found that physical causes may be behind more young men’s ED than previously thought.39
So, even if you’re a young, fit guy who is experiencing ED, your doctor will likely assess you for both psychological and physical causes, just to be sure.
If you can’t get it up once, it means you have ED
Few guys bat a thousand in the bedroom, and an off night or two is usually nothing to worry about.
Most of the time the reason you can’t get it up can be linked to something temporary, like the fact that you drank too much earlier in the day or you had an exhausting day at work and your mind just wasn’t up to the task.
If, however, you’re experiencing ED over a longer period of time – like several months – it may be a more chronic issue which you should speak to a doctor about.
Men with erectile difficulties can’t achieve orgasm
Many people believe if a bloke can’t get it up, he can’t have sex or orgasm. That’s actually not true.
In fact, you don’t need a full erection to be able to ejaculate.7 That’s because two different sets of nerves control erection and orgasm, so if erections aren’t happening, those other nerves can still trigger orgasm.40
If a man has ED it means he doesn’t feel desire
Erection problems and low desire are actually two very different things.
Low desire means you don’t feel like having sex. This could be because you’re not feeling well, you’re under stress, you don’t fancy your partner or your testosterone levels are low.
Erection problems, however, mean you could want to have sex (which means you feel desire), but your penis won’t get hard – or just not as hard as it used to be. Such cases are usually rooted in a physical issue, such as vascular disease or nerve damage.
Bike riding causes ED
The research is not conclusive on this one…
Over the last few decades, research has found that some male cyclists develop damage to the main nerve in the perineum (the area between the anus and the penis), which sends blood to the penis.41 Over time, the damage may lead to erectile difficulties.
A 2014 study refuted this, however, finding no link between riding and ED.42
So, whist the jury is still out, it’s worth erring on the side of caution. If you feel any tingling or numbness in your penis after rides, stop riding for a week or two.43
Also, make your ride more comfortable by getting a more padded seat and adjusting the handle bar height. Padded riding shorts could help too.
Wearing tight underwear causes ED
If you’re strictly a tight underwear/briefs kind of guy, you needn’t worry about it causing you ED, but there is something else you should keep in mind – your fertility.
Tight underwear has been associated with infertility because it can increase the temperature of the testicles, and therefore the sperm.44 So, switch it up every so often and give boxers a whirl.
Masturbation causes ED
Most blokes masturbate – it’s natural! It also has many health benefits, like releasing tension and reducing stress.45
But can it directly cause ED? The answer is no.
There is research suggesting that masturbating to porn can contribute to ED by desensitising you to certain imagery and physical intimacy, but masturbation itself does not physically cause ED.
Your bad habits don’t affect your penis
Your vices aren’t just bad for your health overall, but they can affect your erections too.
Lighting up, drinking alcohol and illicit drugs have all been linked to erectile problems, mainly because they affect blood flow to the penis.
If you want to be able to perform, go easy on these activities or don’t do them at all.
Only men feel the impact of ED
This certainly isn’t true.
Both a man and his partner can be affected by ED. Whilst it obviously affects a couple’s sex life, it can also carry over into the rest of the relationship.
Often blokes are ashamed to talk about ED and get help. Instead they pull away from their partner, who in turn feels rejected, worries they’re not attractive enough, and may even suspect an affair.
The best policy is honesty. As uncomfortable as it may be, discuss your ED with your partner and get help, both for your health and the success of the relationship.
ED is a medical condition like any other, and fortunately, it’s very treatable.
In this chapter we explore all the possible treatment options, from natural and lifestyle changes, to medical and surgical interventions.
For most men, ED can be effectively treated, especially if there is a reversible underlying cause.
Read on to find out about all the treatment options.
Get ahead of the game by looking after your everyday health. Your penis – and your partner – will thank you later.
Exercising regularly will give you better stamina and a much better sex life in general.
Firstly, exercise stimulates the release of hormones and boosts libido. Secondly, it stimulates the growth of blood vessels and increases blood flow, which naturally leads to enhanced blood flow to the penis. Thirdly, the awareness of being healthy and fit gives you more confidence overall – and we all know confidence is sexy!19
When it comes to food, studies show that men who eat a traditional Mediterranean diet have a lower risk of ED.46 That means eating lots of vegetables, fruits, whole grains, nuts, fibres, fish, virgin olive oil and having a moderate wine intake.
Amongst other benefits, these foods are thought to raise nitric oxide levels, which helps blood vessel to relax and widen, helping blood flow to the penis.46
Smoking is a risk factor for heart disease, stroke, vascular disease and type 2 diabetes, which means it’s also a risk factor for ED. If you’re a smoker, research says that quitting can improve your ED, and the earlier you quit, the better.47
And you might like to rethink how many beers you’re consuming. Whilst a few drinks can help you kiss your bedroom nerves goodbye, overdoing the booze can cause you to have erectile difficulties.
One study showed that 33% of alcohol-dependent men experience ED long term, and the more they drank, the more sexual difficulties they had.48
Ideally, cap your intake of alcohol to two standard drinks per day.
Stress and erections don’t go together.
If you’re struggling to get or maintain an erection – or even just get in the mood for sex – consider doing stress-relieving activities such as meditation, breathing exercises and yoga to help improve your mindset and libido.19
In particular, mindfulness-based meditation has been shown to be effective as it helps to focus your thoughts intently on the present moment. Just 10 minutes a day can make a difference.49
Also, don’t be afraid to communicate your fears and desires with your partner. Since a lot of sexual issues start with stress and anxiety, simply sharing your concerns with your partner can help take a load of your mind.19
When life gets busy one of the first things we tend to compromise is sleep, but that’s a bad idea for your sex life.
Sleep helps us reduce stress and keeps the immune system healthy, which is essential for energy and a healthy sex drive.19
If you can’t get the normal 7-9 hours of sleep per night, try power napping.
Difficulties sleeping and sleep apnoea (trouble breathing while asleep) can also negatively impact your sex life.50 Speak to a doctor for guidance on how to manage these more serious issues.
If your erectile difficulties are caused by psychological issues such as performance anxiety or depression, therapy from a trained psychologist, doctor or psychiatrist can help. It can also benefit men who have lost their sexual confidence, even if their ED is caused by physical factors.
Counselling can be done individually or with a partner, but if you’re in a relationship, it’s most beneficial when you include your partner. Studies have shown that for men with stress-related ED, including their partner in therapy resolves the problem 50%-70% of the time.51
Kegels are usually associated with women looking to strengthen their pelvic floor muscles during pregnancy, but they can also help with erectile difficulties.52
What’s a pelvic floor muscle?
You can find them by stopping mid-stream two or three times when you urinate. The muscles you can feel activating while you do this are the pelvic floor muscles.
Each Kegel squeeze consists of holding these muscles for five seconds and then releasing them. Work up to 10-20 repetitions per day. You should start to notice a difference after six weeks.
Porn-induced erectile dysfunction is becoming more and more common in young men.
Watching and masturbating to porn too much can desensitise you to sex in real life, leading to erectile difficulties and relationship issues.
Some ways you can tackle the issue include:
If natural medicines are your preference, there are a number of supplements that may support healthy erections, especially if your ED has a physical cause. In all cases, however, more research is needed to prove their safety and effectiveness and they should be taken under the guidance of a health professional.
Australian law prevents us from talking about certain medications for ED until you’ve spoken to a doctor, so our lips are sealed.
What we can say, though, is that there are clinically proven oral medications to treat ED that are effective in the majority of men.1
Also known as a penis pump, this is a mechanical way of producing an erection for men who can’t (or prefer not to) take medications, or find that they’re not working. It’s best for men diagnosed with moderate ED.62
The pump works by placing a cylindrical tube over the penis. As air is pumped out of the cylinder, the pressure build-up helps to draw blood into the penis, causing the penis to enlarge. A rubber ring is then placed around the base of the penis to keep the erection.
The duration of the erection depends on the individual, but approximately 30-minutes can be expected.62
Whilst it’s a drug-free option, many men prefer other treatments for ED due to the lack of spontaneity involved with using a penis pump as well as possible side effects.
These might make you squirm a little, but it’s good to know your options.
Legally, we can’t name this treatment, but there is a medication that can increase blood flow when injected into the penis or when inserted as a suppository into the opening at the tip of the penis.63 It can give you an erection within 5-10 minutes that lasts up to an hour.
This may be an option for men who find oral ED medications don’t work well.
A doctor’s consultation is needed to determine whether this is a suitable treatment for you.
Low intensity shockwave therapy (LISWT) is a fairly new treatment for men whose ED is caused by blood vessel problems.6 Generally men with mild to moderate ED who have had some response to oral medications are ideal candidates for LISWT.64
During the treatment, non-invasive low-intensity sound waves are passed through the erectile tissue. It is thought that the treatment works by clearing plaque out of blood vessels and encouraging the growth of new blood vessels.65
Studies show that it can significantly improve ED,66 but more research is needed before clear recommendations on its use can be made.
It also costs in the thousands of dollars, so it’s not an option for all candidates.
If non-surgical treatments fail to work, surgery may be an option.
This involves a device being surgically implanted into the penis. Prostheses are available as either malleable (bendable) rods or an inflatable device.
With the malleable rod implant, the penis will always be semi-rigid and just needs to be lifted or adjusted into the erect position before sex.67
Alternatively, the inflatable implant makes use of saline, which is pumped into cylinders in the penis to get an erection. It is more natural looking than the rod implant and it allows men to have an erection when they choose.67
However, keep in mind, while penile implants can help men get an erection, they don’t increase sexual desire or sensation, nor will they make your penis larger than it naturally is at the time of surgery.68
This is a major operation and it is rarely used.
It involves surgery on the veins and arteries that supply blood to the penis and is sometimes recommended for young healthy men who develop ED after trauma in the area around the penis.1
This is the bit where we give ourselves a plug, because, well, we think we’re worth it and we’re sure you’ll think the same if you decide to come on board.
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This information is not intended to be a substitute for professional medical advice, diagnosis, or treatment. It should never be relied upon for specific medical advice. If you have any questions or concerns, please talk to your doctor.