Why Can’t I Get It Up?

Erectile dysfunction affects a large number of men of all ages, and is a common public health issue. The consequences of this problem can have a significant impact on one’s quality of life, intimate relationships and mental health (Salonia et al., 2024).

In the UK, it’s estimated that 1 in 10 men experience erectile dysfunction in their life. It becomes more common with age, affecting up to 50% of men aged between 40 and 70 years old.

Erectile dysfunction (ED) is defined as the recurring inability to reach or maintain an erection that is sufficient enough to permit a satisfying sexual encounter (Salonia et al., 2024). This definition implies that the problem is regular (lasts several weeks or months) and causes distress for the individual and/or couple. This is therefore not a one-off problem that can be linked to fatigue, stress or a temporary decline in desire.

ED’s can have an organic (physiological) origin, a psychological (psychogenic) origin, or a mix of the two. A clinical assessment will help to identify which factors are in play, thus ensuring appropriate care.

An erection is a complex process. It’s simultaneously neurological, vascular, hormonal and tissular. It involves psychogenic stimuli (subjective perception, thoughts, images, fantasies) and reflexes (genital stimulation, activation of the parasympathetic nervous system), relaxation of sympathetic tone and penile arterial vasodilation. This is all controlled by a neuro-hormonal process, meaning erections are therefore the result of a combination of anatomical and psychological factors.

At the tissue level, the key lies in the production of Nitric oxide (NO), that allows for the smooth muscle fibres to relax. This relaxation allows blood to flow into and fill the corpora cavernosa, which is essential for the penis to increase in size and become rigid (Salonia et al., 2024 ; Pyrgidis, 2021).

To make it easier to understand, we can compare this mechanism to a sponge (Bondil, 1991). When you squeeze a sponge, liquid is pushed out and the sponge itself becomes smaller in size. Inversely, when we let go, the sponge fills with liquid and increases in volume. Erections work in exactly the same way: when the tissues relax, the blood vessels fill up and the penis grows bigger.

At the neurological level, there is a dual system of cerebral control, allowing for stimulation or inhibition. Inhibition is our natural state (it’s a normal adaptive mechanism), so that the penis is resting most of the time. For an erection to happen, the brain has to remove this inhibition at the same time as it experiences forms of stimulation that produce sexual desire and physiological arousal.

In summary, an erection occurs as a result of sexual desire, and stimulation of the penis allows the mechanisms that control the reflex erection to maintain it until ejaculation.

There exist 3 types of erection:

1. Psychogenic erections, secondary to sexual desire, fantasies, mental images, erotic thoughts…
2. Reflexogenic erections, take place after stimulating sensory receptors (testicles, head of the penis, shaft, anus)
3. Spontaneous erections, particularly present during REM sleep, that allows for oxygenation of the tissue in the penis.
   

• Refractory period: there’s a moment of rest that takes place after a sexual encounter/orgasm, called the refractory period. Depending on age, this period can last a different amount of time from person to person. Erections can’t happen during this time.
• Vascular: Atherosclerosis, hypertension, dyslipidemia and diabetes can all cause ED. 52% of men who suffer from diabetes also have ED (Kouidrat, 2017). This is why erectile dysfunction needs to be taken seriously, as it can be a sign of an underlying issue such as a cardio-vascular problem or diabetes.
• Endocrine: Hypogonadism (low levels of testosterone), hyperthyroidism, hyperprolactinaemia (Mulhall et al., 2018).
• Neurological: peripheral neuropathies (diabetes), spinal cord injuries, neurodegenerative diseases.
• Medication and substances: antihypertensive drugs (certain beta blockers), antidepressants (SSRI type), antipsychotics, antiandrogens (prescribed in certain cases of prostate cancer), alcohol, drugs, tobacco (Salonia et al., 2024).
• Penile tissue: fibrosis, Peyronie's disease, penile trauma, surgery (prostatectomy).
  

• Depression (a drop in desire, motivation and the side effects of antidepressants).
• Relationship stress: arguments within the couple, difficulty with intimacy, pressure from a partner.
• Psychosexual trauma: previous cases of abuse, psychiatric problems and struggles with body image.
• Personal stress: performance anxiety, low sexual self esteem and fear of failing sexually.

Psychological causes may be primary, when physical functioning is intact, or secondary to an organic cause (Bilal et al., 2020).

Stress, whether acute or chronic, is one of the major causes of ED’s. It affects erections in many different ways: neurological, hormonal, vascular and behavioural.

In stressful situations, the sympathetic nervous system goes into overdrive. This is what activates our fight or flight reaction. All senses are on high alert, breathing increases, and major muscles contract to prepare for immediate reaction, it’s time to fight or to run, erections are useless… Thus, increased sympathetic tone causes arterial vasoconstriction, which reduces blood flow to the corpora cavernosa, preventing the attainment or maintenance of an erection.

This mechanism explains why periods of stress often impedes the ability to get erect. On a psychological level, performance anxiety can create a vicious cycle: the occasional problem getting it up fuels negative expectations and the fear of failure, reinforcing enhancing sympathetic activation during subsequent intercourse (Xu et al., 2023).

What’s more, chronic stress stimulates the hypothalamic-pituitary-adrenal (HPA) axis, with an increased level of cortisone being released. Constant high levels of cortisone can alter endothelial function, meaning the health of cells, thus reducing the production of NO. This disrupts the vascular metabolism and, indirectly, lowers testosterone production, a hormone that plays a part in sexual desire and erectile function (Mbiydzenyuy et al., 2024 ; Kaltsas et al., 2024 ; Xu et al., 2023).

Stress can also favour behaviours such as smoking tobacco, drinking alcohol, a sedentary lifestyle, difficulty sleeping… which aggravate the vascular and endocrine risk factors for erectile dysfunction. All of these reasons explain why managing these issues often requires an approach that combines biomedical care with psycho/sex therapy.

Certain clinical factors may point to a psychological or physiological cause of erectile dysfunction.

Nevertheless, there are a few common side effects: headaches, hot flushes, tachycardia, nasal congestion, visual disturbances (rare). In addition, certain drug interactions should be noted in cases where treatment is already underway (Pyrgidis, 2021). Thus, it’s important to talk things through with a doctor before taking any form of medication.

In the case of hypogonadism, testosterone replacement therapy may be a possible form of treatment, after an assessment and confirmed doses have been provided. This improves desire levels and can partially restore erectile function when paired with other treatments (Mulhall et al., 2018). However, its prescription requires medical supervision.

Penis ring : use alongside the suction device to help maintain erection.

Psychotherapeutic intervention is essential, particularly in the presence of psychogenic or mixed factors.

CBT that’s adapted to sexual disorders aim to reduce performance anxiety, correct dysfunctional beliefs (eg., “I need to have a strong erection every time”), and gradually reintroduce sexual activity in a pressure free environment (Bilal et al., 2020).

Addressing difficulties within the relationship (communication, intimacy, expectations…) via couples therapy is often a vital move in reinstating a satisfying sex life. In sex therapy, gradually reintroducing intimacy without having performance as an objective thanks to the Sensate Focus, sexual communication and education on sexuality are important steps in improving ED’s.

What’s more, many studies show that although men often consult alone, this problem affects their partner just as much. Feelings of rejection, a decrease in desire, guilt or exclusion concern both partners. Including your partner is therefore vital. It improves sexual satisfaction, relational satisfaction and adherence to treatment (Dean (2008 ; Conaglen, 2008).

A few simple changes can play a key role in improving erections: stopping smoking, drinking less alcohol, losing weight, exercising regularly and controlling diabetes and hypertension. These measures improve endothelial function and reduce the risk of cardiovascular issues, which in turn improve erectile function (Salonia et al., 2024 ; Kaltsas et al., 2024).

Erectile dysfunction results from a delicate balance between vascular, neurological, hormonal and psychological factors. Most notably stress can alter erectile function in the short term or the long term. Optimal treatment consists of a multidisciplinary approach: screening and correcting organic factors, pharmacological treatment (PDE-5 inhibitors as firstline treatment), and psycho/sex therapy to treat performance anxiety and relationship troubles. Finally, adapting your lifestyle can help in long lasting improvement.