Getting up, staying up: Why can’t I get an erection?

Some men may experience a condition where they are unable to engage in sexual intercourse due to not being able to have a normal erection. Erectile Dysfunction can be detrimental to a relationship. It is a good thing there is treatment for this condition. Erectile dysfunction is basically a disease where a man is unable to sustain an erection firm enough to have sex. Some symptoms of this that are undesirable to men may be not being able to get an erection, not being able to sustain an erection and not having or having a low level of sexual desire. Erectile dysfunction has a low incidence rate for men that are under 40 years old. As men grow older, they will gain more medical conditions that will eventually contribute to having erectile dysfunction. Some individuals may think erectile dysfunction happens due to age but that is not the case, it’s due to the medical conditions that arise with age. This is reinforced by the fact that 50% of diabetes patients develop erectile dysfunction.

Goals of Treatment

In terms of goals of treatment, we want to address any underlying conditions that are causing the erectile dysfunction, assess whether it’s safe to have intercourse, discuss realistic expectations that the patient can achieve with therapy and keep current relationships intact with no disruption.


Possible Causes

A brief list of possible causes is heart disease, diabetes, obesity, tobacco use, substance abuse and low testosterone level. Another condition that may have a similar outcome to erectile dysfunction is premature ejaculation. Male sexual arousal is very complicated and there are many different aspects of this process that can go wrong. This process consists of the blood vessels, nerves, muscles, emotions, hormones and the brain. There can be psychological causes to erectile dysfunction too such as depression or anxiety that impair sexual excitement.


Diagnosing Erectile Dysfunction

There are many ways to diagnose erectile dysfunction. Doctors can do a quick physical check to see if they can see any issues with the testicles or the nerves that are responsible for sensation. Doing a blood/urine test can pinpoint the more underlying conditions that may be causing the disorder like heart disease or diabetes. The blood flow going to the penis could also be checked using an ultrasound. Different types of medications can be used, via injection, to see if it stimulates more blood flow to the area to cause an erection. A psychological examination is also important if that may be a factor.


Treatment Options

The first step in terms of treatment would be to address the underlying medical conditions causing the erectile dysfunction, then after those conditions are treated and controlled, the next step would be to treat the erectile dysfunction.


Phosphodiesterase type 5 inhibitors

There are various oral treatments available such as Levitra, Cialis and Viagra. These medications mainly act on nitric oxide’s effect in the body. This will increase blood flow to the area to cause an erection and this will be relative to having a sexual stimulus, without a sexual stimulus you can’t have an erection. A sexual stimulus will cause the necessary steps to release the nitric oxide. These medications will only enhance that nitric oxide signal to the penis. Some side effects that may occur due to these medications are headaches, backaches, nasal symptoms and stomach upset. Be cautious of other medications which can have a serious reaction with these erectile dysfunction treatments such as nitrate containing drugs (nitroglycerine for angina). This can seriously affect heart function or decrease blood pressure significantly. Phosphodiesterase type 5 inhibitors such as sildenafil, vardenafil and tadalafil are usually the first choice to treat erectile dysfunction. This will also be the first choice for individuals who have antidepressant medication causing erectile dysfunction. It is important to note that this medication only works to enhance an erection that is already developed through sexual stimulation or mental arousal.

Tadalafil is the one that lasts the longest which will work up to 36hours. The other products have a shorter duration of action which is up to 12 hours. There are similar receptors in the eyes, and this may cause visual symptoms if the medication binds in the eye. Sildenafil in particular is affected by high fat meals, so it is important to keep this in mind if taking it as treatment. In terms of an overall picture, sildenafil works the best and tadalafil has the least side effects. It is important to understand that other medications such as alpha blockers may benefit erectile dysfunction or cause serious drop in blood pressure depending on if the medication is selective to receptors or non-selective.



There are other options available if these oral options are not effective. There is an injection that can be self-administered called alprostadil and this is positioned into the base of the penis or the side. This injection has a very fine needle and will cause very minor pain. This medication will prolong an erection. If the erection lasts for more than 4 hours, that is a urologic emergency and the individual should seek medical attention immediately or there will be damage to the penis.This is why it is important to increase the dose slowly and gradually to prevent a priapism from happening. The alprostadil intracavernosal injections will cause an erection even if there is no sexual stimulus or arousal. The mechanism that this medication works by is completely different from the other medications. Another form of alprostadil is a suppository format that could be inserted into the penis inside the urethral opening and this usually takes around 10min to start working. It can last up to 1 hr.



It is important to check blood work to see if testosterone level is normal since testosterone replacement therapy is also an option to manage erectile dysfunction. This should usually be the first option before beginning other options


Alternatives to Medication:

Penis Pump

There are alternatives to medications that may be tried too. A penis pump is a device that is battery powered and used to create a vacuum to encourage blood flow into the penis. A ring is used to maintain the blood inside the penis that will keep the erection firm. The ring can be removed after intercourse.



Last resort is surgery. Doctors can surgically implant inflatable rods into the penis which can be controlled to create an erection and deflated to go limp.


Other Non-Medication Methods

In terms of non-pharmacological treatments, there are many options. Exercise can help improve symptoms experienced by erectile dysfunction. Speaking to a psychologist or counselor may also help with psychological reasons to the erectile dysfunction.


Premature Ejaculation:

Stop/Start Technique

There are methods to treat premature ejaculation without drug therapy. There is a technique called stop/start technique. This is done where the partner gives low level stimulation to the individual (maybe start off with using just hands). When the stimulation is getting overwhelming, the partner can stop and give the individual time to gather themselves again. Then the stimulation can increase in intensity and stopped again. The stopped duration should be minimum 1 minute. This can be done multiple times with a minimum of 4 times until the individual can move on to ejaculation. This method puts the most pressure on the partner since they have to be patient with the process and sacrifice their own desires and pleasures.


Squeeze Technique

Another method that can be used is called the squeeze technique. This technique is not generally recommended by most clinicians since there are negative and possibly painful outcomes with using this technique. This method requires the individual to squeeze a certain part of the penis to decrease excitement as well as stop the stimulus. This will follow the stop/start technique in the sense that the erection will be stopped and restarted multiple times to prevent an ejaculation early on.


Quiet Vagina Technique

The third option is called the quiet vagina. This method requires a partner. Ejaculation is induced by movement of the Vagina. The partner can be told to only sit with minimal movement for the first couple minutes to prevent an ejaculation and gradually increase movement so as to delay ejaculation. This technique requires effort from the partners end because it will require the partner to be cooperative with the process, as mentioned before, sacrificing their own desires.


Medical Treatment

There is medical treatment with medication for this condition. There is a significant increase in time to ejaculation with daily doses of medications such as citalopram, paroxetine, sertraline and clomipramine. If a daily routine is not preferred, then it can be used as needed 3-6 hours before engaging in sexual activity. In terms of which option is more effective, it is the daily option and it usually takes 2-3 weeks to show its full effect. Combination treatment is also an option with PDE5 inhibitors and SSRIs. This combination is the most effective way to delay ejaculation. Numbing the penis with local anesthetics is also an effective way to delay ejaculation but the issue with this is that the individual still has the problem of not recognizing a low level of sexual arousal. Using tramadol off-label is an option too but shouldn’t be recommended since patients can get addicted to it.

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