Archive for Erectile Health

Male Sexual Anatomy


Delayed Ejaculations

There are a variety of reasons that men may be unable to orgasm and ejaculate, a condition known as delayed ejaculation (DE) or ejaculatory delay. DE is defined as the inability to orgasm and ejaculate within a period of time that seems reasonable to you and your partner. This doesn’t mean just 2 or 3 minutes, but if you find that you’re going on much longer than usual, you may be experiencing DE.

Here are some of the most common reasons for DE, and what you can do about it:

1. Use of anti-depressant medication (any that affect serotonin reuptake). These medications slow down your neurological response to stimulation, making it harder to kick off the orgasm response. In fact, some doctors use these drugs to help men who ejaculate more quickly than they’d like (see next column, Eager Ejaculation).

If you think your medication may be causing your DE, you have a couple of options. First, you can change medications to one that does not have this effect (Wellbutrin, for example). However, if the medication is working well for you, you may instead want to try adding more stimulation to see if that helps. Vibration is an effective type of stimulation; you might wear a vibrating erection ring or hold a vibrator on any sensitive areas on your penis, scrotum, or perineum. You could also add prostate stimulation by inserting a prostate stimulator (vibrating or not) into the anus so that it rubs the prostate.

Some men report that mental stimulation is also helpful; this could be erotic talk with a partner or fantasizing about something that is a powerful turn-on.

2. Longer recovery period needed, caused by frequent masturbation (or other sexual play), or aging. Some men may need to decrease the frequency of self-pleasure or other sex play if they struggle with DE. Also, as men get older, they may need more time in between ejaculations before they are able to have another orgasm or ejaculate again. They may be able to get erections, but find that they just cannot get enough stimulation to have an orgasm. If this is the case for you, you could either continue the same level of sex play as before, but with added stimulation as described above, or you could decrease the frequency of your orgasms until you find the right balance.

3. Stress, distraction, or inability to stay focused and present in the body. These are the most common reasons for DE, particularly in this era of cell phones, stressful jobs, and busy lives. If you find yourself unable to keep from thinking about work or your to-do list, this may be what’s happening for you. The best way to address this is to turn off your phone, practice letting go of the lists in your head, and concentrate on the sensations you are enjoying during your sexual play. Some find it easier to focus on sensations by using a blindfold or even ear plugs. Others try erotic talk with a partner as a way to stay focused on the sexual encounter. Consider taking a class in meditation or other stress-reduction techniques. Taking a brisk 30 minute walk before sex will also help; it increases your blood flow (which in turn increases your ability to get aroused) and can help you clear your mind.

Eager Ejaculation

In books and movies, our culture glorifies the mad, passionate rush to intercourse as the ultimate sexual experience.  Unfortunately, frenzied sexual experiences can sometimes be unsatisfying and difficult to control.  If ejaculation occurs before either partner wishes, it is often called “premature ejaculation.”

This makes it sound like a medical disorder, but it’s not.  Even the fastest ejaculation isn’t a problem if both partners prefer it that way.  Partners who are not particularly fond of intercourse, for instance, may prefer orgasm through oral sex or a vibrator, and may look forward to the fastest draw in the West.

The key is satisfaction, not endurance.  That said, you can learn to work with your arousal and gain more control  over when and how often you ejaculate, so that you can have prolonged, slow-to-climax interludes, “quickies,” or anything in between!  It’s a great opportunity to expand your sexual repertoire.

Things NOT to try.

Some folk remedies that don’t work very well:

Men sometimes drink alcohol to slow themselves down.  Alcohol can slow responses, but it may also make it difficult to get or keep an erection.

Some men’s partners take a hands-off approach, hoping that a lack of caressing and touching will allow their mates to last longer.  But if touching is not allowed, what’s the point of having sex?

Some men try to dissociate themselves by reciting baseball statistics or all 50 states in their heads.  This “focus-on-something-else” approach doesn’t take into account that arousal is an involuntary response.  Involuntary responses are nearly impossible to consciously control.  Think of what happens when someone asks you to stop focusing on your nose: if someone makes you think of your nose, it’s tough to focus on anything else!

All of these solutions can take you away from what you are doing and feeling, and are veryunlikely to lengthen your sexual experience or heighten your pleasure.

In some cases, your doctor might prescribe an SSRI (Selective Serotonin Reuptake Inhibitor;commonly used as an antidepressant) to delay ejaculation.  Studies show that some SSRIs can delay ejaculation by about a minute, which gives you enough time to begin using the techniques explained here.  A word of caution: when you stop taking the SSRI, you may experience a quicker ejaculation than you did while you were taking it.  Be patient, and stay with it; the practice you gained while taking the medication can help you continue to work with and learn about your arousal levels.

What exactly happens in arousal?

Arousal is actually a part of our every moment.  Arousal keeps us breathing, increases when we need to concentrate on something important, and calms down to let us sleep.  The arousal system even has its own neurological pathway (the autonomic nervous system), separate from the nerves that make your fingers move.  But arousal cannot be controlled directly.  For instance, your heart beats without you deciding to make it beat.  Although you can slow your heart rate a little bit by thinking about it, it’s impossible to control your heart rate entirely with conscious thought.

Likewise, during sexual arousal, any person has room to tinker, particularly in the early stages. However, one may reach the “point of no return”–the brink of the orgasmic threshold when it is no longer possible to slow down and delay orgasm.  Learning how to finesse your personal arousal is the key to choosing the satisfying sexual experiences you desire.

In men, it’s often assumed that orgasm and ejaculation are one and the same.  That’s not quite the case.  There are two stages of a man’s orgasm: the cognitive awareness of pleasure, and ejaculation.  These events happen two or three seconds apart.  During the contractions of the prostate gland, the arousal system sends pleasure feedback to the brain, which is experienced as an orgasm.  Men may experience the prostatic contractions as a pleasant fluttering or throbbing sensation.  The second stage, ejaculation, occurs as stronger muscle contractions propel semen down the urethra and out the tip of the penis.  The “point of no return” actually happens after the first part–the pleasure–and before the second part–the ejaculation.

Path One: Come and Come Again!

One strategy is to have a whole bunch of orgasms, rather than just one.  Who wrote that “only one” rule, anyway?  This is your sexual pleasure we’re talking about, and no one else decides when the curtain goes down on your party.  It’s okay to accept what is and have fun the way you are.  Does it have to mean the end of everything because someone ejaculates?  Nope! Sometimes, it’s helpful to give yourself permission to have a big, long sexual session.

The multiple orgasms and multiple ejaculations technique is probably the easiest to learn.  The idea is to focus very consciously on the sensations that are arousing to you, do exactly what arouses you most, and don’t hold anything back.  Play around, and if you want to ejaculate again, go for it.  If you need a toy like a dildo or vibrator to increase the intensity of your erotic play, consider investigating the possibilities rather than holding back.

Having trouble getting an erection after ejaculating?  Try using a cock ring.  Cock rings are great when your body says “not yet,” but your desire is still flowing.  A cock ring is a flexible strap that can be secured around the base of the penis.  It works by allowing blood to flow into the penis, but not out.  You can put a cock ring on when you are soft or after you’ve gotten another erection. While you shouldn’t leave one on for more than 30 minutes, there’s a lot you can do in that amount of time.

The major drawback to multiple ejaculations is that it can be hard to avoid post-ejaculatory stupor.  With several ejaculations, your arousal system will have exhausted itself, and you might not have the energy to go on without some sleep.

Path Two: Multiple Orgasms without Ejaculation

It’s possible to learn to stop every orgasm before ejaculating, and to orgasm several times without ejaculating at all.  Interestingly, it’s the ejaculation itself that is often experienced as exhausting, and some men who experience multiple orgasms without ejaculation notice an energizing effect.

The technique described below is essentially a prolonged session of playing “faster-slower.”  The goal is to stay somewhat aroused while you manipulate your arousal level.  Enjoy the feelings of both decreasing and increasing arousal.

Once you can do this, try masturbating to orgasm, and concentrate on the sensations of the prostate.

You need to learn what it feels like to experience the orgasm (for most men, the prostate fluttering) before you can know when to hold back from ejaculation.  Focus on the sensations, and see if you can experience the orgasm separate from ejaculation.

Next, you will need to become aware of your personal arousal and orgasmic cycle.  It’s helpful to rate your arousal on a scale from 0-10, with 9 or 10 indicating the point of no return.  Start by choosing a number in the middle, like 4 or 5, then practice masturbating to a fever pitch and slowing down as you reach that number.  You will still be aroused with minor stimulation, and you will learn what it feels like to be aroused to a 4.

Then, pick a slightly higher number on the scale–say, a 7.  It’s a little trickier here, but you really want to focus on lower arousal.  One thing to try is to take long slow breaths in, and let the breaths out quickly in a couple of bursts.  This helps disperse your sexual energy and take the tension out of your spine and lower back.

Another arousal-slowing technique is contracting your pelvic floor muscles.  Contract these by squeezing the muscles that run from your tailbone, around your anus, and all the way forward to the base of your penis.  When you are contracting correctly, the base of your penis will bob up and down slightly.  Next, incorporate pelvic floor contractions into your masturbation play.  Masturbate up to a 5, then contract for two seconds.  Slow and speed your self-play, and work on incorporating this PC flex into the ups and downs of your arousal cycle.

Similarly, you can control your ejaculation by pressing firmly on the perineum–the area between your scrotum and anus–while contracting your PC muscles.  This helps delay ejaculation by refocusing your attention on your arousal and interrupting the ejaculation reflex.

Perineal massage can be quite pleasurable, and some men think that it’s the greatest sexual technique they’ve ever experienced.  Perineal massage can be done by yourself or your partner, and can be performed at any time during self-play or penetration.

Okay, I’m having a blast here, but what about my partner?

With increased awareness of sexual arousal and physical cues, you can expand your practice to include partners. With a partner involved, you might have to relearn most or all of your cues. Why?  Because it’s one thing to stop your hand, or turn off your vibrator when you need to ease off, but it’s a much greater task to communicate to your partner where you are on the arousal scale.

Fortunately, most couples report that the process of talking is in itself very satisfying, because they feel more connected than when they are silent.  Also, all of the techniques that you’ve been practicing work with partners, because none of them require that you pull out from penetration. Your partner will have fun playing with you and your arousal, pressing your perineum and practicing your breathing techniques with you.  Learn more about your and your partner’s responses to sensation and practice expressing yourself.

Pelvic Floor Health for Men

What is the Pelvic Floor?

The pelvic floor is a group of muscles that forms a supportive sling in the lower pelvis. This sling, made up of 14 different muscles arranged in three layers, attaches to the pelvic bones. In a man’s body, these muscles surround the urethra, the area beneath the prostate gland, and the anus. Click here for a diagram of the male sexual anatomy. In addition to keeping the pelvic organs in place and the pelvic bones stable, these muscles are also responsible for:

1. The pleasurable muscle contractions felt during orgasm. Orgasms feel bigger and stronger when the pelvic floor muscles are strong. Some men are able to learn to separate their orgasm from ejaculation, partly by flexing their pelvic floor muscles. This allows a man to choose how long to experience sexual pleasure, rather than have his ejaculation end the experience.

2. More forceful ejaculations.

3. Keeping urine inside the bladder at moments of unexpected belly pressure (laughing, coughing, lifting, sneezing, jumping).

4. Keeping stool inside the rectum until you consciously relax your pelvic floor to allow it to pass.

Pelvic Floor Problems

A healthy pelvic floor is strong and flexible, and can contract and relax easily. Pelvic floor strength and flexibility vary from person to person. Some people go through life without problems, while others experience troublesome symptoms because their pelvic floor muscles are too weak, too tense, too inflexible, poorly coordinated, or a combination of these. Pelvic floor problems can be divided into two broad categories: Low Tone Pelvic Floor Dysfunction (weakness of the pelvic floor), and High Tone Pelvic Floor Dysfunction (painful, tense pelvic floor). There are concrete steps you can take to prevent and/or treat either type of problem.

Low Tone Pelvic Floor Dysfunction

Low Tone Pelvic Floor Dysfunction occurs when the pelvic floor muscles are weak from disuse, or stretched or damaged by surgery. When this happens, the muscles are not strong enough to sufficiently hold up the pelvic organs and hold in urine and stool. Orgasms feel weaker, and the muscles tire more easily.

Who is at Risk of Developing Low Tone Dysfunction?

• People who have had pelvic surgery, particularly with access through the perineum
• People who do not have regular orgasms, because orgasmic contractions help keep the pelvic floor strong
• People who carry a lot of body weight, which can stress the pelvic floor muscles
• Athletes who experience injury to the perineum from water-skiing, bicycling, or equestrian sports
• Men after prostate surgery
• People who have had radiation treatment to the pelvic region

What are the Symptoms of Low Tone Dysfunction?

• Weak or absent orgasms
• Stress incontinence (losing urine or stool when you sneeze, laugh, cough, lift, or exercise)
• Weak ejaculations

How can I treat or prevent Low Tone Dysfunction?

Whether you are trying to treat symptoms of a weak pelvic floor, prevent them from occurring in the future, or increase sexual pleasure, learning to do Kegel exercises will help. These exercises, named Kegel exercises after the doctor who developed them, are designed to increase the strength of the pelvic floor muscles by intentionally contracting and relaxing them in a series of repetitions.

First, Find the Muscles:

For some men, finding the correct muscles to contract and feeling them respond can be challenging. To tighten your pelvic floor muscles, think of pulling your testicles up into your body. If you’re contracting the correct muscles, your penis will rise when you tighten, and fall again when you relax your muscles. This is more noticeable when your penis is erect, but you should still be able to feel the movement when soft. You may also be able to feel the subtle lifting of muscles in your perineum–the area between the scrotum and anus–by placing a hand there and then contracting. This is easiest to do lying on your side.

If you are unsure that you are contracting the correct muscles, or are not able to make the muscles respond, contact a Pelvic Floor Therapist who can teach you how to do this correctly and effectively. There are tools available to help you do Kegel exercises. Some are also prostate massagers, but anything that is designed for anal insertion, whether or not it stimulates the prostate, can help you feel and identify your pelvic floor muscles more easily. This allows you to strengthen more effectively, especially at first. Some men choose to use a tool, others feel confident exercising without tools. One way is not better than another; as long as you’re doing the exercise as outlined below, you can do them however works best for you.

If you choose to use a tool, you’ll also need some lubricant. Use only water-based lubricants if your tool is made of silicone, but any lubricant is fine with plastic and stainless steel. Many men prefer a thicker lubricant to provide extra cushion for anal skin.

Step-by-Step Kegels

1. Lie down on your back in a comfortable place, with your knees bent. If you are using an exercise tool, coat it with lubricant, relax and gently insert it into your anus.

2. Contract your pelvic floor muscles. It will feel like you’re pulling up and in toward your belly button. Do not push out—imagine that you are pull in your testicles. If you’re using a tool, you should feel it rise a bit or, if it’s curved, nudge your prostate. Try to keep your leg, buttock, and abdominal muscles relaxed, and remember to breathe normally throughout the exercise.

3. Hold the lift for a count of 5. Again, remember to breathe!

4. Relax your muscles. You may notice your penis moving as you tighten and release your pelvic floor muscles.

5. IMPORTANT: After each Kegel, take a deep belly breath. Inhale deeply then gently blow out the air while you relax your pelvis completely. This deep relaxation is just as important as the other steps, because the deep breath relaxes the muscles that are not under your conscious control.

6. Congratulations, you have just done one Kegel.

Important Points to Remember:

• If you forget to do your exercises for a few days, don’t fret—just get back to them when you can.
• If you have any pain in your pelvis or genitals that feels worse when doing this, STOP, and contact your health care provider.
• If there’s no improvement in your symptoms after a month, contact a Pelvic Floor Therapist. It’s not uncommon to think you’re doing Kegels correctly but are actually contracting your buttock or abdominal muscles instead, or pushing out rather than pulling up. If you think this might be the case, a Pelvic Floor Therapist can help you do them correctly.

Common Questions

How many Kegels should I do every day?

Start out doing 2 sets of 5 twice a day, holding each for 5 seconds. Gradually increase the time until you can hold each contraction for 10 seconds. Next, increase the number you do each time until you can do 2 sets of 10, holding each for 10 seconds. It would go like this: contract and hold for 10 seconds (while breathing normally), and then relax for 10 seconds (while taking a deep belly breath). Then, repeat the sequence until you have completed 10 exercises. Next, rest for a few minutes and then do another set of 10 in the same way. Repeat this entire sequence again later in the day.

But I read I should do 100 Kegels really fast. Why do you recommend only 5-10?

The pelvic floor is made up of two kinds of muscle fibers: slow-twitch (70%) and fast-twitch (30%). Slow-twitch fibers respond best to slow, step-by-step engagement like we have described. If you only do fast ones, you are not strengthening the majority of the muscle fibers. So it’s important to learn to do the “hold” as described above.

The other 30% of muscle fibers are important too, so once you’re comfortable with the Kegel “hold”, you can learn “flicks.” To do these, tighten your pelvic floor muscles the same way as before but more quickly, then relax. The entire cycle should take about 3 seconds, and you should breathe normally and keep the rest of your body relaxed throughout. Do about 20 twice a day, and finish each set with the deep belly-breath. Doing more would just overwork the muscles, and can lead to poor technique that compromises your progress or leads to other problems.

Once I have my routine of two sets of 10 Kegel “holds” and 20 “flicks,” how should I progress from there?

If you began by using a tool, now is the time to learn to contract your pelvic floor muscles without the tool. Once you have mastered holding for 10 seconds without the tool and without involving your buttock or abdominal muscles while lying down, the next step is to do your exercises sitting up, and after that, standing. You can eventually build up to doing them while you do functional tasks like lifting, walking up stairs, jumping, etc. It’s important to make sure you’re able to contract and relax your pelvic floor muscles without involving other muscles in your body, and while breathing normally, so don’t rush the process. If you’re not sure if you’re doing them correctly, check with a Pelvic Floor Therapist.

If you want to do more advanced exercises, you can add weight (resistance) while you do your exercises. Once you have mastered doing the exercises lying down, the next step is to use a tool and hold it with your hand and pull slightly outward on it at the same time as your muscles work to hold it in. Once you can hold for 10 seconds, still using good technique (not involving other muscles, remaining relaxed, breathing normally) you may try it while standing. Or try hanging a light towel over your erect penis while doing the exercises as another way of adding resistance. The weight of the towel can be increased over time. Another method is to use weighted anal tools, such as those made by Njoy, first lying down then standing, while allowing the weight of the tool to provide resistance.

High Tone Pelvic Floor Dysfunction

High Tone Pelvic Floor Dysfunction occurs when the pelvic floor muscles are overly tense, inflexible, or in spasm. The muscles are unable to move and stretch easily with daily activities. This causes uneven stress on the bones where the muscles attach, as well as discomfort of the muscles themselves. The term “high tone” refers to the presence of high tension in the muscles. This can occur with either strong or weak pelvic floor muscles, and can cause a wide range of problems.

Who is at Risk of Developing High Tone Dysfunction?

• People who do a lot of Kegels without adequate relaxation both during and in between exercises.
• Athletes, gymnasts, and Pilates enthusiasts who work out with a focus on core strength without adequate focus on relaxation.
• People with high-stress lifestyles and/or difficulty coping with stress who carry their tension in their pelvis.
• People who have had trauma to their pelvic floor from surgery or sexual abuse.

What are the Symptoms of High Tone Dysfunction?

• Pain as sexual arousal builds
• Pain with orgasm
• Pain in the penis, testicles, or perineum
• Constipation and/or pain with bowel movements
• Painful urination and/or increased frequency of urination
• Ache in the pelvis from constant muscle stress on the lower spine and tail bone
• Incorrect diagnosis of prostatitis, or prostatitis that is resistant to medical treatment over a period of months or years

What should I do if I think I have High Tone Dysfunction?

There are many conditions that are easily confused with High Tone Dysfunction, so we recommend you start by seeing your health care provider to obtain an accurate diagnosis. Once a medical diagnosis of pelvic floor dysfunction is made, a Physical Therapist (PT) or Occupational Therapist (OT) who specializes in the pelvic floor can do a thorough assessment and determine the exact portions of the pelvic floor that need attention. The therapist can perform treatment as well as teach you a series of individualized exercises you can do at home, either alone or with the help of a partner, to help facilitate normal coordination and flexibility of pelvic floor muscles. We recommend working with a therapist rather than attempting to treat this condition on your own.

Erectile Dysfunction

What is Erectile Dysfunction?

What causes Erectile Dysfunction?

Rehabilitation Techniques for Erectile Dysfunction

Erectile Dysfunction (ED) in men is defined as an inability to achieve and maintain a penile erection sufficient for penetration. There is a broad range of erection troubles including:

•  the inability to become hard at all,
•  becoming hard only briefly,
•  becoming only half-hard, and
•  only occasionally becoming hard.

No matter your level of current function, this article can:

•  help you understand what’s happening in your body,
•  give you the information you need to make sure your erection problems aren’t a sign of something more serious, and
•  give you some ideas of steps you can take to improve the health, strength and duration of your erection.

Increasing focus on rehabilitation techniques for ED can also improve sexual function for men without ED. Some men want harder erections or for their erections to happen faster and/or last longer.

Why is erection capacity important?

Beyond sexual penetration, penile erections are a simple, elegant indicator of overall health and well-being. This is because the formation of erections relies on healthy physical systems and mental processes. When any part of that combined system is ill or not maintained, erections can become much harder to have or maintain.

How do erections happen?

Think of sexual arousal as a collaboration between the mind and body. When medical conditions, trauma or surgery changes structure or function, or the mind is overcome with anxiety, it is hard for the whole system to work together.

The process of becoming sexually aroused with an erection includes several types of nerves, the penile clitoris (aka corpus cavernosa) and small blood vessel function. Having an orgasm further tests the neural system, and experiencing ejaculation relies on yet another nerve system. The whole sexual system isn’t complicated, but does require many sections to work together for sexual arousal to fully develop.

There are two ways to consciously initiate penile erections. One is to physically massage the penis which causes blood flow to be released into the caverns of the clitoris. When this blood swells the caverns, the penis enlarges (mostly sideways, but also makes the penis a little longer), and traps the blood inside the caverns. The other way is to allow or create sexual thoughts or arousing ideas in the mind. The brain will translate these ideas into sexual arousal, and when the nerve impulses reach the genitals, blood flow will release into the caverns. Most men use some combination of both the direct stimulation and cognitive sexual arousal (mental) pathways to sexual arousal, and vary their techniques depending on their individual circumstances. Read this article about Erectile Function to learn more.

Types of Penile Erections

There are two types of erections in men:

Erections for oxygenation (puff erections).

The blood vessels that lead to the inside of the clitoral structure need routine blood flow for oxygen and nutrition. The body accomplishes this (without effort or awareness from the man) by lightly flooding the clitoris three to six times daily. Morning erections and slight “puff” erections during the day and evening are simply the body’s way of taking care of the genital structures. While this is not related to sexuality, the lack of these “puff” erections is a strong indication that something is disrupted and needs attention. These puff erections are not related to sexual arousal itself, since the blood flows through the clitoris rather than being trapped as it is in penetration erections.

Erections for sexual arousal.

When the blood flowing into the caverns increases at a rate greater than the outflow, the penis becomes stiff because the blood is trapped, causing an erection. When a man wants to use his penis for sexual penetration, he needs this hardness to hold his penis straight. Penetration can occur with softer erections, but the man needs to be careful not to bend the penis, since the elastic/fibrous clitoris can be broken when bent at an angle.

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Physical Causes of Erectile Dysfunction

Today we know that physical causes (heart disease, diabetes) of ED are more common than psychological causes. In fact, more than 80% of erectile dysfunction is an early physical manifestation of medical illness. The connection is so strong that early erectile problems are known to precede heart attacks by an average of 3-5 years in men, many of whom never had symptoms of heart problems. For men diagnosed with diabetes, more than 90% have erectile dysfunction.

Men’s erectile function is very similar to the canary in the coal mine. If the canary is having problems, something is wrong in the system somewhere and needs close medical evaluation. Until you know better, always consider a change in erectile function as a meaningful medical event that requires the attention of a health professional.

We strongly recommend that you start with a visit to your health care provider for a physical assessment, and that you not put it off. Make sure you mention your erection difficulties at that visit, so your health care provider will have the information necessary to arrive at an accurate diagnosis. This is no time to be shy; you really need to tell it like it is. But don’t just accept a prescription for Viagra: you need to know if your heart, nerve and metabolic system is having trouble and if your early signs of erectile dysfunction are a dangerous symptom, not just an inconvenience.

Psychological Components of Erectile Dysfunction

Once your health care provider has evaluated you for physical causes of ED, look also at what emotional, psychological, or relationship issues you have. These may be either a cause of your ED, or have arisen from the experience of having ED. It can be very disturbing to have your body stop functioning as it has all of your life, and can make relationship problems difficult to solve.

You can find a professional who is particularly knowledgeable about sexual issues by going to the web site of the American Association of Sex Educators, Counselors and Therapists ( On their web page you will find information for the public on how to find a sex counselor or therapist in your area. It might be helpful to see a counselor alone, with your partner, or some of each, but you should decide what is most helpful for you.

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Rehabilitation Techniques for Erectile Dysfunction

With or without a medical diagnosis, most men can increase their hardness by making lifestyle changes. Although making these kinds of changes can take some time, the positive effects on your erections will likely be noticeable sooner than you might expect, particularly if you really commit to the change. Steven Lamm’s book The Hardness Factor (see resources) explains specific lifestyle changes that can increase your firmness noticeably in as little as a week, and impressively in six weeks. Staying with those changes for the rest of your life will help you be able to become erect and stay that way well into old age.

Eat the Good Sex Diet.

There are many chemical processes in the body that contribute to your erections and orgasms, and they need good building blocks, in the form of the foods you eat, to function smoothly. Truly, eating a healthy diet (a low-carb version of the Mediterranean Diet) can revolutionize your sex life. Avoid white foods (refined grains and sugar), focus on lean proteins (beans & nuts), and lots of deeply colored vegetables and fruits.

Get more exercise.

Thirty to sixty minutes of moderate exercise every day (walking hard enough to make you sweat a bit) makes a big difference to most men’s erections, sexual performance, and libido. When you make your heart work hard, it gets better at working hard and becomes better able to meet the demands of sex. When you fatigue your muscles, your body makes more small blood vessels to carry oxygen to your tissues, which results in stronger erections. Exercise also increases sexual desire, decreases depression, and increases feelings of well being. Taking a 20 minute walk before sexual activity can prime your sexual arousal system for a perkier performance, too.

Stop smoking.

Anything that reduces your blood vessel health reduces your sexual potential. If you smoke, you can increase your hardness significantly by quitting, and some men notice a difference in as little as two weeks. Smoking stiffens blood vessels, and lowers HDL (good cholesterol) and raises LDL (bad cholesterol), which is exactly the opposite of what you want for prevention of heart problems, and ED.

Keep your alcohol use moderate.

Having more than three alcoholic drinks a day inhibits both erections and orgasms by decreasing production of nitric oxide. Nitric Oxide is the neurotransmitter molecule necessary for relaxing the blood vessel walls in the erectile tissue of the penis. Over time, use of alcohol causes nerve damage that can permanently affect your ability to become erect. Although the relaxation effect of alcohol may feel beneficial to your sexual relaxation, it is a leading cause of soft erections in men.

Don’t use street drugs.

Cocaine, LSD, marijuana, amphetamines and barbiturates all decrease your ability to become hard and stay hard. Sexual arousal is a unique balance between relaxation and excitement, and when you use substances that interfere with one part, the other components are often inhibited as well.

Refine your prescription medications.

Ask your doctor if you can refine your medication choices towards those with fewer sexual side effects.  Some medications are more likely than others to support your sexual health, and some combinations of medications could be making your ED worse. Your health care provider may be able to prescribe comparable medications with fewer sexual side effects.

Address emotional and relationship issues.

Maybe emotional issues weren’t originally any part of the cause of your ED, but if you’ve been struggling with hardness problems for some time, chances are emotional issues are present. If ED is affecting your self-image or altering your intimate relationship(s), you owe it to yourself to get help dealing with any emotional issues involved.

Have regular orgasms.

Many men can orgasm without having a completely hard erection: they just have to know that and not let the softness stop their self-pleasuring. Some men use different techniques for arousal depending on what they need in different settings. You can orgasm alone or with a partner; both ways are effective for keeping the system fit. Regardless, we recommend at least two orgasms a week (with ejaculation if possible) as a healthy sexual maintenance routine.

Any recommended devices or sex toys?

There are a number of mechanical devices that may help maintain a stronger erection, including erection rings, erection rings combined with vibrators, and penis pumps.

Erection rings are rings of material that fasten around the base of the penis. They help maintain an erection by restricting the blood flow back out of the penis. Some erection rings are stretchy silicone or elastomer, some are rubber O rings, and some are adjustable leather or synthetic bands that close with snaps or velcro. Only use easily removable or adjustable erection rings (not steel rings), and don’t leave them on for more than 30 minutes; keeping blood trapped in the penis for a long period of time can cause permanent damage. Some erection rings include a built in vibrator.

Vibrators activate the mechanism responsible for blood flow into the penile clitoris. Even if nerves responsible for sexual arousal have been damaged, when the penile clitoris and blood vessels are healthy, a vibrator may help you become hard. You need to experiment with different types of vibration and apply it to the base of your penis, along the shaft, or any other sensitive place that arouses. Use it with or without a erection ring, or choose one with a built-in erection ring. Try your vibrator for self-stimulation, or combine it with partner play.

Penis pumps are very helpful for achieving a harder erection, especially if you are able to become partially erect. Pumps work by using a vacuum to stretch the membrane surrounding the erectile tissue of the penis, allowing blood to flow in freely. A pump is often used in combination with a erection ring. First the pump brings partially oxygenated blood into the penis, and then an erection ring (placed around the base of the penis shaft) holds the blood in. Be gentle when using a pump; mild suction is all that’s needed. It is possible to hurt yourself by pumping too vigorously or for too long. Also, to avoid blood blisters, don’t use pumps if you use blood thinning medication.

Penile Rehabilitation

For men recovering from pelvic trauma, surgery (prostate or rectal), or radiation therapy, a rehabilitative therapy called penile rehabilitation (PR) has been developed. Many men don’t realize that these same techniques are helpful when recovering function for metabolic ED, too, because maintaining the flexibility and ensuring routine oxygenation is good for the penis no matter the cause of ED.

When used for PR, the goal for using a penis pump is to continue blood flow and flexibility during the healing process, when nerves have been damaged by surgery or radiation. If the nerves recover function and re-establish themselves, then the clitoral structure will be ready for action as well. If blood flow stops (without use of a pump), then anoxic damage to the clitoris may be irreversible.

Effective penile rehabilitation often involves a combination of daily medication and use of a pump daily. Ask your health care provider whether a program like PR is right for you. For more information, see this brochure of the Penile Rehabilitation Program.

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Erectile Dysfunction May Indicate Heart Problems

Erectile dysfunction is not just a matter of sexual functioning–it can also point to other health problems.

Studies show that for men with type 2 diabetes, erectile dysfunction is an early warning sign of heart problems, including heart attacks. Why are erectile dysfunction and heart problems linked? It’s because the ability to have an erection depends on healthy blood flow, and if something is going on in your body to hinder healthy blood flow, it can first affect your erections and eventually affect your heart. This article describes research showing the connection between erectile dysfunction and heart problems, related issues, and what you can do about it to protect your health.

Read more here.

Impotence and Men

Impotence is a condition where a man’s penis cannot get or maintain a hard enough erection for penetration. Due in part to cultural messages that suggest that sex equals penetration, many men and their partners feel that their sex life is over if they begin to experience erectile difficulties or impotence.

There are “things he can do,” but it’s wise to back up and ask, “Is there anything he wants to do?” Does the man want to change something for himself, or for his partners? Can he talk to his partner(s) about sex? What does sex mean to him? What it means to him to have “lost sex”?

Sex is intimate contact with oneself and/or between consenting adults. Penetration is one act of intimate contact, and many forms of mutual pleasuring (masturbation being one of them) are available to him that do not involve an erect penis. Sex does not have to stop, and intimate sexual contact can be re-initiated with some forethought and preparation, and less focus on penetration as the most desirable or only sex act available to him and his partner(s).

But what if penetration is really important to him?

If your friend wants to investigate his erectile difficulties, he needs more information. Is the cause medical? Hardening of the arteries (arteriosclerosis), high blood pressure, and diabetes are common diseases in the United States that can have a strong impact on the ability for a man’s penis to become erect. There are medical and surgical treatments for these conditions that can be prescribed by a health care practitioner. Non-pharmacological solutions involve instruction in the use of cock rings or penile vacuum pumps; erection rings work by keeping blood in the penis, while vacuum devices draw blood into the penis using suction. While some might want erections to happen “naturally,” few men will turn down the opportunity to have a fabulous pleasure opportunity with a fun suction device. For some couples, non-drug devices can mean the difference between having “sex” and not.

Sometimes, erectile difficulties do not have a direct medical cause. Is the hard erection of a man’s early life the only “erection” he thinks is real? For these men, understanding changes in the body as we age can make a huge difference in their confidence and erections. Some men and women need extra stimulation with hands or vibrators to maintain their arousal/erections. Accepting the challenge rather than quitting can mean hours of pleasurable play with fluctuating erections.

There’s more to this sex stuff than what we learned as young people. When we make inflexible demands on ourselves and our bodies, we get less pleasure than we could otherwise have. Opening up to new possibilities can make changes happen all through our (sex) lives.

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Penile Rehabilitation after Prostate or Pelvic Surgery or Radiation

Why Do Erections Stop Happening after Prostate Cancer Surgery?

A common cause of Erectile Dysfunction (ED) is anything that damages, stretches or cuts nerves deep in the pelvis, which commonly happens during surgical or radiation intervention for prostate, colon or rectal cancer. It’s common for men with prostate cancer to have pre-surgical metabolic ED, yet prostate cancer therapies themselves cause ED (radiation therapy 43%; radical prostatectomy 58%), because the therapies damage nerves, blood vessels and/or clitoral components. Minimally-invasive surgical approaches may reduce complications right after surgery but still increase post-surgical ED.

The path of the pelvic plexus–the delicate nerves that carry sexual arousal information between the penis and the lower spine–curves around the prostate, colon, rectum and bladder. When surgery is performed on the prostate, or the prostate is completely removed, some nerves will be cut and some will be stretched. Even the most skilled and careful surgeon cannot avoid stretching the nerves. The stretched nerves become stunned, and although they are complete and in place, they cannot function until they recover. Nerves may return to function soon after surgery, but the time of recovery may take up to three years after the surgery.

In the meantime, when the nerves stop working, oxygen-rich blood will stop flowing to the clitoral body inside the penis, and scarring can occur. It’s important to keep blood flowing to the nerves, small blood vessels, and the clitoral body inside the penis, so that the oxygen exchange still happens and will work when nerve function recovers. Often we can’t tell when nerve recovery will occur, so it’s worth it to help blood flow to the penis for the whole three years after surgery. Fortunately, we have techniques that can help improve oxygen-rich blood flow to the penis even when the nerves can’t do the work.

Men who had trouble getting erections before the surgery will have more difficulty recovering after the surgery. This is a “double-whammy”: erectile trouble before surgery adds to the disturbance of prostate surgery and makes it harder to recover erectile function after surgery. Fortunately, penile rehabilitation helps men with any kind of erectile dysfunction, so even if there was trouble before the surgery, recuperation can be helped by penile rehabilitation.

First experience after surgery

From a man’s perspective, he will go into surgery with the penis length and function he is used to. When he wakes up after surgery, he will see that a urinary catheter has been placed inside his penis, both to help drain urine, but also to help keep the passage from his bladder to the penis open. This catheter also artificially stretches the length of his penis.

The clitoral bodies inside the penis won’t get any oxygen filled blood from the time of his surgery. The lack of oxygen, and the unavoidable nerve stretching, will cause the penis to shrink quite a bit, and when the catheter is pulled out (often right before hospital discharge) the penis will appear sometimes half of its length. Shocking as that is, remember the penis doesn’t have to stay that way, and penile rehabilitation (PR) is the process of regaining erectile function, erectile length and girth, and erectile hardness.

Goals of Penile Rehabilitation

The main goals of penile rehabilitation are to:

  • Increase daily oxygen exchange to the penis, and
  • Maintain length and girth of the penis such that full erection size and hardness are possible once the stunned-nerve period is over.

Regular daily blood flow keeps the erection nerves and blood vessels healthy by bathing them with oxygenated blood, and prevents scarring of the clitoral body inside the penis. If appropriate, medications (see pg. 6) should begin immediately after returning home from surgery. The physical portions of PR should be tried as soon as you feel physically comfortable enough to touch your penis, or by at least 2 months after surgery, whichever is sooner. During early recovery from surgery, there may be discomfort as internal scars heal. If discomfort happens, wait a few days, and start, or restart your program.

However, there should never be any pain with PR. If there is pain, you should stop and consult your health care provider.

It’s important to remember: the sooner PR is started, the better the success. However, men who are within the three-year-from-surgery window will still benefit from PR, particularly if they occasionally have soft erections or erections when they wake up. Penile rehabilitation will help on-demand therapies work better (using PDE5-Inihbitors like Viagra before sexual activity), and can create erections hard enough for sexual penetration even when the nerves have been permanently damaged (Vacuum Erection Devices with constriction/cock ring).

For more information on the AWT Penile Rehabilitation Program, click on the download tab, or call and ask for a booklet.

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Men’s Erectile Function

Understanding the basics of the penis and how it works is an important step in…
Read below to learn about the male sexual anatomy and how erections happen.


The Male Penis

A male penis is made up of 4 basic structures:

  • The soft, hairless outside skin that stretches over the penis.
  • The urethra, a central inside tube where urine and occasionally semen passes out from the body.
  • The spongy paraurethral gland that wraps around the urethra from the bladder to the tip of the penis head (aka corpus spongiosum). This gland secrets drops of fluid into the urethra to keep it lubricated and open. Paraurethral tissue also makes up the head of the penis, giving it a soft, spongy feel. The paraurethra does not change size or texture in response to sexual arousal.
  • The clitoris is the hydraulic, erectile part of the penis, and is also known as the corpora (body) cavernosa (caverns). Just like in women, the male clitoris is shaped like a wishbone, connected at the tip and separating into two legs/shafts inside the body.

Because of higher testosterone levels, the male clitoris is longer (about 5”) than the female clitoris (about 4”), and develops primarily on the outside of the body. Also, one cannot directly touch a male clitoris as you can a woman’s.

The genital blood supply (pudendal artery) and nerve connection (pudendal nerve and parasympathetic nitrergic nerves) are the same in all genders. No bone structure exists within the male penis in humans.

The Hydraulics of an Erection

The clitoral structure is composed of a fibrous, slightly flexible outer layer (tunica) which surrounds multiple inner balloon-like caverns. Blood moves in and out of the caverns, filling them like balloons and naturally flooding them several times per day to provide routine oxygen and nourishment. These floods are the morning erections men notice in the morning and during the day unrelated to sexual arousal. When the caverns are empty, the clitoris is very flexible and floppy like a partly-filled balloon.

What Causes an Erection?

Sexual arousal is a response to stimulation produced by several mind and body systems working together. An erection is one sign of a man’s sexual arousal, when the clitoral body swells with blood and the penis becomes stiff and hard.

Functionally, there are two main principles to consider: getting blood to flow into the clitoris to stiffen the penis, then keeping blood in.

Pumping blood into the clitoris

Erections require several different functioning systems to work together; the most important being nerves & blood vessels.

The nerves of sexual arousal produce nitric oxide to cause special arteries in the clitoris to relax and open up, allowing blood to flood in. Nitric oxide can also be released by rubbing and massaging the blood vessels themselves, which is why vibrators increase engorgement.

When nitric oxide opens the floodgates, the pressure of the blood in the caverns presses hard against the tunica, and the whole structure stiffens up. High arousal pushes quite a bit of blood into the clitoris, such that the outflow veins are squashed, effectively trapping the blood inside.

During the development of an erection, the other structures of the penis ‘tag along’, but do not contribute at all to the erection. The skin on the outside of the penis stretches tight, while the urethra and paraurethra conform to the new, erect shape. The tip of the penis does not change shape because the clitoris is not in the tip. Overall, the penis changes shape mostly in the wideness/girth, and to a lesser extent in length. It looks much longer because the penis is more obvious when it sticks out away from the body.

Keeping blood in the clitoris

Normally, blood drains out of the clitoris through veins on the very outside of the tunica. Flexibility of the clitoris’ tunica is one key to holding blood into an intact clitoris. To hold erections, the tunica:

  • must be complete, without tears or holes
  • stretch flexibly, and press the outflow veins shut almost completely
  • isn’t scarred from trauma or inflammation, leaving it too small to stop the flow.

The other key is continued arousal. If erotic stimulation stops or non-erotic thoughts interfere, the erection will go away.

What if you lose your erection?

Erections are important for penetration, but they are not necessary for sexual pleasure or orgasm. The sensory nerves that trigger pleasure and orgasm often function even when the clitoral structure won’t hold erections sufficient for penetration. Consider that women’s clitori swell and ebb with different levels of stimulation and arousal, yet experience sexual pleasure and orgasm routinely. This happens because the female tunica covering the clitoris is relatively thin and porous compared to the male tunica.

The male tunica is much thicker. This thickness allows it to both swell and press on the outflow veins to close them off. Thus, with sufficient pressure, men hold erections for a longer period of time than women do. This is what supports penetrative sex play, but men can enjoy arousal and orgasm without erections. If you are experiencing difficulty getting and maintaining an erection, see our article about erectile dysfunction to learn about causes and treatment approaches.

Penis Questions Answered

Here are some answers to your penile questions:

Q: Is there a bone, or not?
A: No, there is no bone in a human penis. All erectile stiffness is from blood pressure inside of the clitoris itself.

Q: Why are penises erect in the mornings?
A: Penises are puffed up in the morning because the body is naturally oxygenating them, and will do so about 4 times per day. This is one of the activities that men with nerve damage notice: they don’t get their usual morning erections because the neural control is damaged. If this has happened, then the man needs to use a vacuum pump 3x daily (just to puff the blood in), so that the clitoris stays functional and doesn’t scar. (For more information, see Penile Rehabilitation.)

Q: Why do they shrink up in cold water or cold weather?
A: Penises shrink in cold weather/water because the body naturally pulls blood into the core of the body to keep warm. Less blood to the penis means that the size will shrink temporarily.

Q: Why do penises float in bath water?
A: Non-erect penises float in bath water because there is more glandular tissue (paraurethra) and air (inside the urethra) than blood in the clitoris. If a man gets an erection, the blood in the clitoris will weigh the penis down, even as it becomes stiffer.

Q: How can you aim your pee when you have an erection?
A: If a healthy penis is fully engorged, a man can’t pee so “aim” is irrelevant. The muscles at the base of the bladder (above the prostate gland) are neurologically designed to hold tight during erections, to allow the alternate semen pathway to take over and permit ejaculation. The man may feel that his bladder is very full, but until he allows the erection to slowly subside, he won’t be able to empty his bladder until the nerves of sexual arousal switch the muscle back off and allow urination.

Men with nerve damage from diabetes, surgery, trauma, etc. sometimes do have problems with urine leakage because the nerve doesn’t function correctly and hold the muscle tight. Each situation is unique, though, and some men recover full bladder holding over time.

Q: How does a cock ring work?
A: A cock ring works by trapping blood in the clitoris. By trapping the outflow veins ever so lightly, we can support an erection by not allowing the clitoris to deflate–similar to a light tourniquet on an arm. We only sell easily removable or adjustable cock rings, because keeping blood trapped for a long period of time can permanently damage the inside lining of the clitoris by depriving it of oxygen. Have a steel-hard erection, but don’t wear steel cock rings.

Q: What techniques can help maintain erections?
A: Any technique or device that wraps around a penis shaft will help hold erections. Rubber bands (watch the pubic hair), cock rings, hands (particularly grabbing at the base and stroking out from the body) helps trap blood in the clitoris. Stimulation of the clitoral nerves with the hands rubbing along the shaft is an added bonus. Just don’t hold on too tightly for too long.

Vacuum pumps help the inflow of clitoral blood dramatically by mechanically stretching the clitoral tunica larger. If blood can flow in, the vacuum pump is making room for it to flow in.

Vibrators activate the neural mechanism that begins blood flow into the penis. Even if the nerves responsible for sexual arousal have been damaged, if the clitoral structure is still functional, you’re still a go. Vibrators cause sheer stress, and sheer stress applied to the inner blood vessels of the clitoris activate blood flow. Therefore, vibrators are a non-drug method for bringing blood into the clitoris.

Viagra (the drug sildenafil) works by keeping nitric oxide working in the clitoris. It does not cause erections, but it allows them to stay once they’ve been started by either erotic thought or manual stimulation.

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