Erections, Complicated? Come and See How They Go Wrong and How We Fix Them!
- Kenneth jackson DeLay
- Apr 4, 2023
- 3 min read
Erections are a complicated event yet when they occur without difficulty its easy to assume they are simple. Yet they are anything but. They are a complicated interaction between our nervous, vascular, endocrine systems acting on the penis to bring about an increase in blood flow and thus rigidity. Understanding how this all works together allows us to better understand how things can go wrong and what the treatments are when they do.
The first event is stimulation of the nervous system at either the level of the brain, spinal cord or both. In response to emotional, visual, olfactory(smell), and touch parasympathetic nerves from our autonomic nervous system cause the release of nitric oxide from specialized nerve terminals.
This nitric oxide causes vasodilation of both blood vessels and smooth muscle in the corporal bodies of the penis. The corporal bodies are cylinders which are lined with smooth muscle which fill with blood during an erection. When this smooth muscle relaxes it it allows for this space to fill with blood and create an erection.
In addition to the nervous and vascular systems the male endocrine system and the production of testosterone needs to be normal. When testosterone is low there is less desire for sex and less vasodilation of those blood vessels and spaces which need to fill with blood in the penis.
The nervous system can be impacted by a number of processes including strokes, brain tumors, disorders of the peripheral nerves(like multiple sclerosis) as well as surgeries affecting these nerves. One of the surgeries which can have the most profound impact on is radical prostatectomy for prostate cancer. Urologist Patrick Walsh pioneered the identification of the cavernosal nerves which were normally damaged during removal of the prostate and developed techniques for sparing them. Even with this innovation it is common for these nerves to be affected and damaged even in the best surgical hands. Data suggests robotic surgery has not significantly improved this aspect of the surgery.
Men also need healthy vascular systems. In fact erectile dysfunction if a predictor of cardiovascular disease. This is because atherosclerosis, the process of plaque build up which narrows blood vessels affects all arteries throughout the body. As the arteries feeding the penis are affected men can develop erectile dysfunction.
Declining testosterone levels as we age are very common. This process can be worsened by obesity, diabetes, and certain medications. If you have erectile dysfunction you should have a morning testosterone level drawn to rule out an issue here. When testosterone is low oral medications for ED are less likely to work.
Our medical treatments for erectile focus on increasing blood flow to the penis. Oral medications(Viagra, Cialis, Levitra) do this by indirectly making nitric oxide work better by increasing a molecule called cGMP. Anywhere from 30-50% of men will find these medications are ineffective. In some cases they will be effective when first tried but become less effective in time.
When pills do not work there are other options. These include penile injection therapy, MUSE(urethral suppository), vacuum erection devices and penile implants.
Penile injection therapy involves injecting vasodilators(molecules that relax blood vessels) directly into the penis. This is effective in approximately 70% of men. Complications can include penile bruising, injection site pain, and the build of scar tissue with long term use. It is generally advised that men with Peyronie's disease should not use penile injections.
MUSE or the insertion of a suppository into the urethral is rarely effective and can cause significant pain and dizziness.
Vacuum erection devices are pumps which suction blood into the penis. While they can create an erection a ring must be used to trap blood in the penis and many men complain it feels "cool" and unnatural.
There are experimental therapies than many men read about including shockwave therapy and platelet rich plasma. These regenerative therapies are still considered experimental the Sexual Medicine Society of North America says they should not be offered outside of a clinical trial.
When these above therapies are not desired are not effective a penile implant can be a good option. A penile implant is placed during an outpatient procedure. It is a hydraulic device which is made of a silicone polymer. While many men become fearful and reluctant when a penile implant is mentioned satisfaction rates are high (>95%) and many men say they wish they had pursued it earlier. It consistently provides are a firm erection but it not designed to enlarge the penis(it also does not shorter the penis). As with any surgery there are complications which should be discussed with your surgeon.
The bottom line is most men who want to return to sexual activity will be able to do so. Find an expert in your area.
Dr. DeLay is a board certified urologist who specializes in male sexual dysfunction, penile implants, and Peyronie's disease. He is one of the only urologists in South Carolina with fellowship training in these areas.
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