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In erectile dysfunction, an individual is unable to develop or maintain an erection during sex. This disorder is also called impotence and like other sexual dysfunction, this condition becomes more common with age. Sex can be important within relationships, so erectile dysfunction often carries with it emotional and psychological stigma. In both males and females,, sexual activity involves a sequence of events called the sexual response cycle. This cycle has four phases, excitement, plateau, orgasm, and resolution. During the excitement phase, muscle tension, heart rate, and blood flow to the genitals increases. In males, this is called an erection. When these reach the maximum level, it’s called the plateau phase. Next, the accumulated sexual tension gets released during orgasm, causing ejaculation in males. Immediately after orgasm comes the resolution phase, where the body slowly returns to its original, un-excited state. Alright, let’s take a closer look at the penis which is made of three long cylindrical bodies: the corpus spongiosum that surrounds the penile urethra, and the two corpora cavernosa made of erectile tissue. The corpora cavernosa are wrapped in a fibrous coat called the tunica albuginea, and each corpus cavernosum is made up of blood-filled spaces called the cavernosal spaces. These areas are lined with endothelial cells surrounded by smooth muscle. Running down the centre of each corpus cavernosum is a large artery called the deep artery which gives off smaller arteries that supply the cavernosal spaces. Next, blood get drained from these spaces by small emissary veins, which drain into the deep dorsal vein. This vein then carries the blood back into the systemic circulation. Now, the penis receives both somatic and autonomic innervation through the cavernous nerves, which innervate both the corpus spongiosum, and the corpora cavernosa. Hypertension causes wear and tear in the endothelial cells, and decreases their ability to produce nitric oxide. Another vascular condition that can damage the arteries is diabetes mellitus. High glucose levels can cause hyaline arteriolosclerosis in the small arterioles in the penis. This is where the arteriole walls develop hyaline deposits, which makes it harder for them to dilate. It also builds up in the capillaries causing the basement membrane to thicken which makes it harder for oxygen to efficiently move from the vascular space to the tissues, causing hypoxia and death of the smooth muscle cells. Hypoxia also causes the parasympathetic nerve fibers to die off, and damaged parasympathetic nerve fibers can’t release acetylcholine, so there’s less nitric oxide synthase activation, and less nitric oxide is produced. Another leading cause of erectile dysfunction is surgery, either on central nervous system structures, like the brain and spinal cord, or on the genital structures themselves, like prostate surgery. Also, conditions like stroke, multiple sclerosis, and back or pelvic trauma can directly damage the nerves, leading to erectile dysfunction. Next, endocrine dysfunctions that causes testosterone levels to fall, like hypogonadism, can cause erectile dysfunction. This happens because low testosterone levels are associated with lower levels of nitric oxide synthase, which causes less nitric oxide to be produced, and less smooth muscle relaxation. Since testosterone production decreases with age, it’s normal for erections to become more difficult to achieve and maintain later in life. Finally, many medications can cause erectile dysfunction as a side effect. These include diuretics because they leave less fluid in your circulation, making it difficult to achieve an erection, and medications like antidepressants and methadone, but those mechanisms are not as well understood. There is no specific test to diagnose erectile dysfunction, so the diagnosis largely relies on the sexual experiences of the individual. Careful questioning of psychological stressors as well as blood tests to check for testosterone and glucose levels, a neurological assessment, and duplex ultrasound to evaluate blood flow and atherosclerosis can be done to investigate the cause of erectile dysfunction. Treatment of erectile dysfunction largely focuses on addressing the underlying cause. In terms of medications, PDE-5 inhibitors, like sildenafil can be used. These medications inhibit the PDE-5 enzyme in endothelial cells which normally breaks down cGMP, leading to higher levels of cGMP. That allows for more smooth muscle relaxation which facilitates an erection. Sometimes, vacuum erection devices can be used. These devices apply negative pressure around the penis which can help draw in blood to achieve an erection. Finally, surgical procedures like prosthetic implants can be embedded into the penis. They does not cause erections but it could help keep the penis rigid.

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“Is my penis a normal size?” and “How can I make my penis bigger?” are two of the most common questions patients ask me at my men's health clinic. I made this video to answer the questions on every guy's mind. If you found this helpful, give it a like, subscribe for more evidence-based men’s health content, and drop a comment with your questions or thoughts. Mentioned in this video: RestoreX Penile Traction Therapy Device: https://rshealth.com.au/shop/p/restorex-penile-traction-device The Penis Project Podcast, Episode 196 – “Penis Enlargement, Girth Goals & Urology Innovation” with Dr. Amy Pearlman: https://www.podbean.com/ew/pb-ym22q-188ca9b Want personalised solutions to your men's health concerns? Book a confidential telehealth appointment with Restorative Health Clinic: https://rshealth.com.au/ In this video, Melissa Hadley Barrett, Urology NP and Clinical Sexologist at Restorative Health Clinic, discusses medical information supported by published research. References: • International Society for Sexual Medicine: What is “normal” when it comes to the penis? https://www.issm.info/sexual-health-qa/what-is-normal-when-it-comes-to-the-penis • Study: Women’s Preferences for Penis Size (PLOS ONE) https://doi.org/10.1371/journal.pone.0133079 • Efficacy of RestoreX After Prostatectomy (BJU International) https://doi.org/10.1111/bju.16033

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