Erection Problems and Delayed Ejaculation: how to solve this problem
The causes of male erection problems fall into two general categories: physical and psychological. In the early 1970s, psychological impotence was believed to be by far the most common.
The noted sex therapy experts Masters and Johnson reported that 90 percent of men’s erectile dysfunction came from psychological issues.
However, after twenty-five years of advances in the understanding of neurogenic and vascular physiology, we have much better knowledge of the mechanisms of erection problems. Although the psychological component remains a very important factor in diagnosis and treatment, we now know that at least 80 percent of men who seek medical care for erection problems will have primary physical problems.
On the other hand, it is virtually impossible that ED, even with an underlying physical cause, won’t have an impact on a man’s psychological well-being. Any man who has failed to initiate or maintain an erection on one occasion will tend to think “what if my erection fails next time I have sexual intercourse?”
Also, it is worth comparing erectile dysfunction with delayed ejaculation, a condition where an erection is maintained for an extended period with the man reaching orgasm.
No matter what the causes of erection problems, we need to keep in mind the basic principles of the nerve and blood vessel mechanisms. Factors that tend to prevent initiation of an erection usually involve the nerve supply or psychological issues.
Factors that prevent the erectile tissue from fully filling with blood usually have to do with problems of arterial blood flow to the penis.
Factors that lead to the loss of the erection before orgasm and ejaculation tend to involve failure of the venous occlusive mechanism that traps blood in the penis and thus maintains the erection.
A breakdown in any of these areas can result in erection problems or erection problems.
Blood vessel abnormalities and erection problems
Problems with either the arteries carrying blood to the penis or the veins draining blood from the penis can easily prevent a satisfactory erection. The most common of these problems is blockage of the arteries carrying blood to the penis. The small arteries carrying blood into the penis at the time of an erection must dilate from five to ten times their normal resting diameter. Even as little as 15 % percent occlusion of the small blood vessels is enough blockage to cause a problem with erectile function.
Such partial arterial blockage is the most common cause of “organic erectile dysfunction” and is usually associated with risk factors such as cigarette smoking, diabetes, hypertension (high blood pressure), or even marked elevation of blood cholesterol and fat levels.
Other risk factors associated with reduced arterial flow are a history of blunt pelvic trauma or pelvic radiation.
The majority of men who have erection problems as a result of reduced arterial blood flow will also have more generalized cardiovascular problems throughout the body.
Frequently, impotent men also have a history of coronary artery occlusive disease with or without a history of prior heart attacks. Some men with erection problems also have a history of poor blood circulation to their feet and legs, resulting from arterial occlusive disease.
Occasionally, a patient has a focal isolated blockage of one of the arteries carrying blood to the penis. This is usually seen in young patients, in their twenties, who have sustained blunt pelvic trauma such as a past pelvic fracture.
Diabetic men can have impotence secondary to both effects on the nerve supply to the penis, as well as the vascular supply. Diabetic men, as well as older men, have an increased amount of scarring, or fibrosis within the walls of the arteries to the penis. Plaque buildup on these different areas further reduces the inside diameter of the arteries.
Patients with hyperlipidemia, or marked elevation of lipid (fat) levels in the blood have a definite well-described risk for arteriosclerosis. The extra lipid builds up in the wall of the artery and eventually causes a significant degree of blockage. High blood pressure (hypertension) is another established risk factor for arteriosclerosis.
A recent study reported that in one series of men with ED about 45 percent had a history of hypertension. In patients with hypertension, it is not the increased blood pressure itself that contributes to erection problems. Rather, the associated arterial stenosis found in patients with hypertension is thought to be the cause of the erection problems.
Failure of the mechanism that clamps down on the veins that drain blood from the penis has been proposed as one of the more common causes of vasculogenic ED. Some men may develop large venous channels that are never quite fully occluded as the arterial blood flows into the penis during the beginning phase of erection.
Often, this problem is seen in relatively young patients who have experienced erection problems over their entire life. Such patients may report relatively normal initiation of an erection, but within a few seconds or up to a minute or so lose the erection without ejaculation. These venous leak type problems may be surgically corrected.
In Peyronie’s disease, non-elastic scar tissue forms, primarily along the surface of the tunica albuginea, resulting in inadequate compression of the veins below the tunical surface, therefore preventing entrapment of the arterial blood in the normal fashion.
On the other hand, if the trabecular smooth muscle and the vascular spaces of the penis are unable to relax sufficiently, the sinusoidal expansion will be inadequate and the subtunical veins will not be compressed enough to maintain an erection.
This may occur in the overanxious individual with excessive adrenaline and excitement. Alteration of the neuro receptors in the smooth muscle may give an adverse response and, in effect, impair relaxation of the smooth muscle in response to the usual nitric oxide stimulation.
Interestingly cigarette smoking, in addition to causing generalized arterial blockage, may also cause the cavernous smooth muscle to lose its ability to dilate. Again, the net effect is the same – not enough clamping of the penile veins to allow for the heightened intracavernous arterial pressures necessary for an erection