Barbara E. Kaplan, MHDL

Counseling for Individuals, Couples, Partners, Marriages, Families



For additional information about counseling regarding erection difficulties or for counseling in general, please call 704 333-1510.


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Erectile dysfunction (ED) is the persistent inability to obtain and/or maintain a penile erection that is firmly adequate for sexual activity. The outdated term for this condition is impotence. ED may occur when by self, when with others, not with all partners/situations or each time there is sexual activity. It may co-exist with other sexual problems (e.g., low sex desire) and with first attempt at obtaining an erection or acquired any time later on in life. According to the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health, "ED is very common.  It affects about 30 million men in the United States.1" Worldwide, it's about 150 million!

It is not unusual  for a male, at times, to experience an inability to achieve an erection such as with excessive alcohol use or following an argument with a significant other or spouse.  However, if chronic, it warrants professional attention. Please note, that although it is thought to be a condition attributed to old age, it is not a normal part of aging.  In other words, it is not inevitable that a male will have ED when age 55 years or older.  It can occur at a young age, even with the first attempt at intercourse!

An erection occurs:

…when blood flow increases into the penis, making it expand and become firm. Two long chambers inside the penis, called the corpora cavernosa, contain a spongy tissue that draws the blood into the chambers.  The spongy tissue contains smooth muscles, fibrous tissues, blood-filled spaces, veins, and arteries.  A membrane, called the tunica albuginea, encases the corpora cavernosa. ...

An erection requires a precise sequence of events:

  • An erection begins with sensory or mental stimulation, or both.  The stimulus may be physical—touch, sound, smell, sight—or a sexual image or thought.

  • When the brain senses a sexual urge, it sends impulses to local nerves in the penis that cause the muscles of the corpora cavernosa to relax.   As 
a result, blood flows in through the arteries and fills the spaces in the corpora cavernosa like water filling a sponge.
  • The blood creates pressure in the corpora cavernosa, making the penis expand.  The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining the erection.
  • The erection ends after climax or after the sexual arousal has passed.  The muscles in the penis contract to stop the inflow of blood.  The veins open and the extra blood flows out of the spaces and back into the body. 

There are numerous possible causes for this erectile dysfunction such as medications (e.g., benzodiazepines, antidepressants, antihistamines, diuretics), surgery (e.g., for prostate and bladder cancers,), diseases (e.g., heart disease, types 2 diabetes, Peyronie’s disease, Parkinson’s disease, Multiple Sclerosis), high blood pressure, atherosclerosis (clogged blood vessels), alcohol and other drug intake (e.g., cocaine, marijuana, opiates), sleep disorders, tobacco use, obesity, depression and anxiety and/or other psychological issues (e.g., stress, fear of failure regarding sexual activity, guilt, low self-esteem, relationship conflicts).  It may also be due to a combination of physical/emotional and psychological issues.  However, these possible causes for ED may not be a given for everyone.  For instance, not everyone who is depressed experiences ED and a particular medication may for one person result in erectile dysfunction but not have the same effect on another person.

A mental health professional who is certified in sex therapy as a Diplomate of Sex Therapy or Certified Sex Therapist (https://www.aasect.org/referral-directory) may be consulted first to determine if a medical check up is even necessary.  For instance, if a male is consistently able to achieve and maintained erections during masturbation, then a medical checkup may not be warranted.  If warranted, a physician may rule out an underlying medical problem to account for ED.  Aside from taking a medical/sexual history and conducting a physical exam by a physician, there are tests that may be performed such as blood tests, imaging tests (e.g., Doppler ultrasound to determine penile blood flow), nocturnal erection test to determine if erections occur during sleep, and an injection test.  The injection test consists of introducing a medication into the penis or urethra to cause erection to determine the fullness and duration of an erection.  The tests may be performed by a specialist such as a urologist.  It’s important that the treating physician be knowledgeable about erectile and other male sexual dysfunctions.

There is a wide variety of treatment for ED: sex therapy, prescription medications, changing lifestyle behaviors (e.g., obtaining adequate amount of sleep, exercising, healthy diet), pumps and surgery.  They may be provided separately or in combination of 2 or more treatment options that may reduce symptoms, manage the problem or eliminated the dysfunction. 

Cialis, Viagra, Stendra, Levitra (also referred to  as phosphodiesterase type 5 inhibitors (PDE5 Inhibitors)) are medications that may be effective in treating ED by relaxing the smooth muscles of the penis and increasing penile blood flow with sexual stimulation.  However, for one of these medications to work, there needs to be sexual arousal for the release of nitric oxide.  The nitric oxide then stimulates a specific enzyme (cyclic guanosine monophosphate (cGMP)) in the body and the medication maintains this enzyme in the smooth cells to relax the penile smooth muscles cells permitting penile arteries to dilate and allow for blood flow to the penis.

Cialis, Viagra, Stendra and Levitra may not be a pharmacological choice for all males.  For instance, a male may be taking a nitrate drug for heart disease and when in combination with one of these PDE5 Inhibiter medications, may result in a dangerously sudden drop in blood pressure.  The same result may also occur with alpha-blockers when taken with these PDE5 Inhibiter medications. Therefore, it is important that the treating physician know what medications, herbs, supplements, drugs (alcohol/illicit drugs), over-the counter medications are being taken currently and in recent and remote past.  These medications also may not be warranted if there is a specific disease (e.g. severe liver disease; kidney disease) or other medical condition such as hypotension and uncontrolled hypertension.

It is possible to have side effects from the PDE5 Inhibitor medications such as headaches, stuffy nose, runny  nose, flushing and muscle aches.  More severe effects may occur such as an erection lasting 4 or more hours, loss of hearing, loss of vision, dizziness, fainting.  This is not an inclusive list of serious side effects.  Although having an erection for 4 or more hours may seem like a blessing for the male with or without erectile dysfunction, it is far from this, as the prolonged erection can cause pain, and damage to the penis.  It is important to receive immediate medical help with any of the severe side effects.  And it is important, as well, to speak with a physician about any of the other side effects.

Aside from medications taken orally, injections and suppositories may be utilized.  Again, the severe side effect may occur of having an erection lasting 4 or more hours.

Some men consider use of alternative medicines (which includes but is not limited to herbs, vitamins and mineral supplements).  However, they may not be safe or even work.  Therefore, it is important to check with a physician about the use of alternative medicines or what may be referred to as natural products.  The Food and Drug Administration has issued a warning about Herb Viagra, advising  not to purchase or use it.

According to National Center for Complementary and Integrative Health of the National Institutes of Health (NIH):

No complementary health approaches have been shown to be safe and effective for sexual enhancement or treating ED. Safety is a serious concern with regard to dietary supplements promoted for ED or sexual enhancement.

Researchers have studied a variety of herbal remedies for ED, but the amount of research on each herb has been small, and much of the research has been done in animals rather than people.  Currently, there is no definite evidence that any herbal products are effective or safe for ED.

A few studies have tested acupuncturefor ED, but the amount of research is too small to allow any conclusions to be reached about whether it’s helpful. …

Many supplements promoted for ED and sexual enhancement—sometimes called “herbal Viagra”—have been found to be tainted with drug ingredients or related substances. Some products include combinations of multiple ingredients or excessively high doses, both of which can be dangerous.  Consumers can’t tell whether a product contains these ingredients because they’re not listed on the product label.  The drug ingredients in some ED supplements may interact with prescription drugs in harmful ways.  …  For example, some of them may interact with drugs that contain nitrates, leading to a dangerous decrease in blood pressure.  People with diabetes, high blood pressure, high cholesterol, or heart disease often take drugs containing nitrates, and men with these conditions frequently have ED.

The U.S. Food and Drug Administration (FDA) warns consumers to beware of ED/sexual enhancement products that:

  • Promise quick results (within 30 to 40 minutes)
  • Are advertised as alternatives to FDA-approved prescription drugs of the hundreds of products FDA has tested contain high doses of undeclared (or hidden) mixtures of different drug ingreduienbts
  • Are sold in single servings
  • Advertise via spam or unsolicited e-mails
  • Have labels written primarily in a foreign language
  • Have directions and warnings that mimic FDA-approved products  ...

Even more troubling is that many of the hundreds of products FDA has tested contained high doses of undeclared (or hidden) mixtures of different drug ingredients.  For example, one of these tainted products included 31 times the prescription dose of tadalafil (the active ingredient in Cialis), in combination with dapoxetine, an antidepressant that is not approved by FDA.

According to National Institute of Diabetes and Digestive and Kidney Diseases of NIH: 

A vacuum device may be utilized for ED,  It works by engorging blood into the penis.  The device may require some practice or adjustment.  Using the device may make your penis feel cold or numb and have a purple color.  You also may have bruising on your penis.  However, the bruises are most often painless and disappear in a few days.  Vacuum devices may weaken ejaculation but in most cases, the devices do not effect the pleasure of climax, or orgasm.

If considering using a vacuum device, speak with a physician first about which one to use.  Another option for ED may be taking testosterone if this hormone is at a low level.  According to the National Institute of Diabetes and Digestive and Kidney Diseases, testosterone may help ED.  However,

it is often unhelpful if your ED is caused by circulatory or nerve problems.  Taking testosterone also may lead to side effects, including a high red blood cell count and problems urinating.

Testosterone treatment also has not been proven to help ED associated with age-related or late-onset hypogonadism.  Do not take testosterone therapy that hasn’t been prescribed by your doctor.  Testosterone therap can affect how your other medicines work and can cause serious side effects.

Surgery may be helpful in the treatment of ED but can be considered the last resort.   Surgery may consist of implants or repairing arteries that block flow of blood to penis.

Sex therapy is demonstrated to be effective in the treatment of erectile dysfunction.  The sex therapist (Certified Sex Therapist or Certified Diplomate of Sex Therapy) may proceed by obtaining a basic intake (e.g., social history) and takeing a comprehensive sex history, rules-out a medical cause for the dysfunction, determines diagnosis and then continues with therapy(ies) deemed appropriate for the diagnosis.  A partner/spouse may or may not be included in the treatment.  Sex theapy may consist of, but not be limited to, Cognitive Behavioral Therapy, Sensate-Focus Therapy, both of which may be utilized separately or in combination with one another and/or other types of psychological and medical therapies.  Cognitive-Behavioral Therapy recognizes that one’s feeling and behavior are largely influenced by one’s thought(s) and that unhealthy thinking may result in disturbance such as sexual difficulties or make them worse.  Therefore, the therapist works with the client to identify these thoughts, test and correct them to change the view of self, others, situations and environment.  It may be tailored in an effort to stop ruminating unhealthy sexual thoughts (e.g., “I’m a failure,”  “I’m not a man,”) and address myths thought to be true.  Sex therapy may also consist of behavioral exercises that the client may engage in, on own, by self and/or with a partner, outside of the therapist's office.

To locate a Certified Diplomate of Sex Therapy or Certified Sex Therapist, both professionally trained to provide sex therapy for the treatment of sexual dysfunctions, please check the American Association of Sexuality Educators Counselors & Therapists (AASECT) website:

This article was written some time between January 1, 2016 and January 22, 2019 with a typographical error corrected in March 2022.