Archive for March, 2022

Erection Issues: What to Do Before Seeing a Urologist

March 26, 2022

Andrew Siegel MD  3/26/2022

Our (amazing) blood functions to transport oxygen, carbon dioxide, nutrients, hormones, and waste products; clots to stop bleeding; and regulates our body temperature.  Man — lacking the bone in the penis (baculum) that is present in many mammals — uses blood as a hydraulic fluid that gets pressurized to enable bone-hard erectile rigidity.  Body magic!  

A rigid erection is a symphony that is dependent upon many parts working together in concert — unrestricted penile arterial inflow, erectile chamber smooth muscle relaxation, trapping of venous outflow, and pelvic floor muscle (ischiocavernosus muscle) engagement and contraction. Any deficit with arterial inflow, erectile chamber smooth muscle relaxation, venous trapping, or pelvic floor muscle function will result in decreased erectile rigidity and durability.  It’s as simple as that. 

These local mechanisms are strongly influenced by systemic health issues including any disease process that compromises arterial flow (atherosclerosis, diabetes, hyperlipidemia, etc.).  Arterial inflow can also be compromised by medications used to reduce blood pressure, particularly the beta blocker class. Local mechanisms are also affected by one’s psychological and emotional state, the brain being the dominant and master sex organ. Nervousness results in the release of adrenaline by the adrenal glands and constriction of blood flow to the penis, which explains why “stage fright” dooms the erectile capability of a perfectly healthy young man who simply has performance anxiety. The mind-body connection is profound!

Paralleling the incidence of essential hypertension (a stiffening of the arterial walls that increases with aging), there is also a stiffening of the smooth muscle within the erectile chamber sinus tissue that imperils the ability of this tissue to relax and engorge with blood, negatively impacting venous trapping and leading to erections that are less rigid and less sustainable. Pelvic floor muscle weakness that occurs with aging and pelvic surgery can be detrimental to the process by which the penile blood is pressurized, resulting in less rigid erections.

The bottom line is that erections have everything to do with a healthy vascular (blood vessel) system, pelvic floor integrity, and a mind free of worry, concern, and anxiety.  Vascular health is optimized by a healthy lifestyle.  This translates to maintaining a “fighting” weight and adopting a heart-healthy and penis-healthy diet: nutrient-dense, calorie-light foods including plenty of vegetables, fruits, whole grains, legumes, seeds, nuts, water; moderate intake of meat, dairy, seafood; and avoidance of processed and junk foods, sugar, sweets, and sweetened beverages. Additional healthy lifestyle components include exercising regularly, adequate quantity and quality of sleep, tobacco cessation, alcohol moderation, and stress minimization.  Aside from general exercises (cardiovascular, core, strength and flexibility training), specific pelvic floor muscle exercises (“man-Kegels”) are beneficial to improve the strength, power and endurance of the superficial pelvic floor muscles referred to above, the penile “rigidity” muscles.

Erectile function is a barometer of cardiovascular health, a “canary in the trousers.” The presence of rigid and durable erections is a gauge of overall good cardiovascular health and the presence of erectile dysfunction a clue to the possibility of impaired cardiovascular health and an indicator that a more pervasive underlying medical problem might exist.  Since the penile arteries are generally small (1-2 mm diameter) and the coronary arteries larger (4 mm), it stands to reason that if blood vessel disease is affecting the tiny penile arteries, it may affect the larger coronary arteries as well—if not now, then at some time soon. For this reason, men with erectile dysfunction should undergo a basic medical evaluation seeking arterial disease.

So, if you are experiencing erectile dysfunction, what should you do before seeing a urologist (the experts at managing this problem)?

First, make every effort to improve your lifestyle as discussed above.  If a healthy lifestyle can be adopted, sexual function will often improve dramatically, in parallel to overall health improvements. Since many medications have side effects that negatively impact sexual function, a bonus of lifestyle modification is potentially needing lower dosages or perhaps eliminating medications (blood pressure, cholesterol, diabetic meds, etc.), which can result in further improvement of sexual function. 

Second, if you are dealing with psychological/emotional stress (often perpetuated by concern over the erectile issues, becoming a vicious cycle), it is important to try to manage this as best as possible.  Relaxation techniques such as meditation, exercise, massage, hot baths, aromatherapy, etc., may prove helpful as can seeking the counsel of a psychologist or other mental health specialist.

Third, it is a prudent idea to see an internist or cardiologist to be checked for general vascular disease, since the erectile dysfunction may possibly be just the “tip of the cardiovascular iceberg.”

If you are still experiencing erection issues after adopting a healthy lifestyle, optimizing stress management, and obtaining internal medicine/cardiology consultation, it is clearly time for a urology consultation. We have the wherewithal to help you.

Bottom Line: If you are having issues achieving or maintaining an erection, try to get into the best shape possibleboth physically and mentally/emotionally — and strongly consider seeing an internist or cardiologist for a cardiovascular evaluation.  This is precisely the first-line advice you would be given at the time of a urological consultation for erectile dysfunction.   If the problem persists after enacting healthy lifestyle measures, employing stress reduction techniques, and seeking internal medicine or cardiology consultation, I welcome you to our office to pursue diagnostic evaluation and management options.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro AreaInside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.  He is the co-founder of PelvicRx and Private Gym.  His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families. 

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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

PROSTATE CANCER 20/20 is now available at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health


MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity