William Aiken

The middle-aged man with the large 'beer belly' and sedentary lifestyle, who smokes a pack of cigarettes per day, bragging to his friends at the bar on a Friday night about his prowess in the bedroom is being economical with the truth.

Contrary to his being able to exhibit any sexual prowess, it is far more likely that he is having problems with his erections and an unsatisfactory sex life. Of course, we can't be absolutely sure about this but, based on his big belly and lifestyle, it is likely that he has derangements in his metabolism, circulation and hormones which would negatively impact on his ability to get or maintain an erection of sufficient rigidity for the completion of satisfactory sexual intercourse.

What's an erection?

An erection is a hydraulic event which requires a pressure head of blood flowing through pliant, open blood vessel channels which are responsive to and under the direction of nerve impulses. This, of course, occurs on a background of normal sexual desires which in turn is related to normal levels of testosterone secreted into the blood by the testicles.

The relational and psychological context is also important as these factors do impact upon the ability to get an erection as the brain is indeed the most important sex organ. Factors such as stress, anxiety, fear, anger, conflict, guilt, and bereavement will negatively influence the brain centres which control the nerve impulses and hormones that facilitate erections.

The man described above is likely to have elevated levels of glucose and fats in his blood, due to impaired metabolism of these substances. Over time, this facilitates the narrowing of his blood vessels. Apart from the physical narrowing, his blood vessels carrying blood to the penis don't relax and expand very well because the chief chemical messenger responsible for this, nitric oxide, is diminished by the metabolic derangements. Furthermore, the tissues of the penis which also relax and expand under the influence of nitric oxide and nerve impulses don't relax much resulting in a soft erection.

The nerve impulses are impaired because the sustained high level of glucose has affected the metabolism of the nerves and their ability to transmit impulses. The tissues of the penis begin to shrink over time as it is deprived of oxygen-rich blood which is needed to nourish its cells. Cigarette smoking aggravates all of this by facilitating narrowing of the blood vessels in the short and long terms.

Soft penetration

When his erection has failed him on the first occasion he worries and is anxious over it happening again when he attempts to have sex. The hormones released into the bloodstream from anxiety and worry further aggravates the problem when he attempts to have sex. The erection is now too soft for penetration to occur and he starts avoiding his partner sexually and becomes increasingly withdrawn from her. His partner may think he is having an affair and is no longer interested in her sexually, which results in a further deterioration of the relationship.

He visits his doctor who does a proper evaluation, checking his urine for glucose and protein, checking his blood pressure and doing tests to determine the level of lipids (fats) and glucose in the blood. The doctor advises him to stop smoking, puts him on a programme of exercise and weight loss, refers him to a dietitian and may put him on medication to decrease his cholesterol or glucose depending on how high they are.

He invites the patient to bring his partner with him on the next visit so that he may get her perspective, enlist her support in the treatment and advise them both. Finally, he suggests that Viagra, Levitra or Cialis may be helpful until the metabolic derangements have been improved and he cites recent evidence confirming the benefit of exercise and weight loss in improving the quality of erections in men with erectile dysfunction.