Erection: how it works

Nitroglycerin Gel For Erectile Dysfunction Treatment

Erection: how it works


Falling flat in the bedroom? A new gel you rub on your penis might give you just the boost you need, according to research published in the Journal of Sexual Medicine.

In the study, 232 men with erectile dysfunction participated in two separate, four-week trials. In one, they used a new topical gel called MED2005—containing 0.2 percent glyceryl trinitrate, or nitroglycerin—before sex. In the other, they used a placebo gel.

In each trial, they rubbed a pea-sized amount of the gel onto the head of the penis right before sex.

The researchers discovered that nearly 1 in 4 men reported a significant improvement in their sexual functioning score—a questionnaire including measures confidence getting and keeping an erection, hardness of erections, and satisfaction with sex—after the treatment with the nitroglycerin gel, compared to just 14 percent of men who used the placebo gel.

What’s more, the nitroglycerin gel worked fast: 70 percent of men noticed the start of an erection within 10 minutes, and 44 percent reported an erection in five minutes or less.

That’s much faster than the time it generally takes for oral erectile dysfunction drugs to work. In fact, if you’re taking Viagra or Cialis, you need to wait an hour before getting busy, since that's how long it takes for the drugs reach their peak effectiveness in your system, Jacob Rajfer, M.D., professor of urology at the David Geffen School of Medicine at UCLA told us previously.

Related: 10 Myths About Erectile Dysfunction You Must Stop Believing

Now, part of the reason the drug works so quickly might be due to the fact you’re massaging it directly onto the head of your penis, the researchers say.

And even that short amount of stimulation (15 seconds), can help boost arousal.

But since the guys using the nitroglycerin drug showed more improvement in their erections than the men using the placebo gel did, that shows something about the drug itself is responsible, too.

It’s ly due to how nitroglycerin works, by boosting a neurotransmitter called nitric oxide in your body, the researchers believe.

This relaxes the smooth blood vessels in your penis, helping you get and maintain an erection (A few outlets have referred to this as a 'dynamite' gel because nitroglycerin is traditionally associated with its use in explosives.

But nitroglycerin in small, diluted doses has been used as an active ingredient in many medications, including blood pressure meds, as The Telegraph reported).

The nitroglycerin gel was most effective in guys with mild forms of erectile dysfunction. So more studies using different dosages of the meds are necessary to see how the gel can help men with moderate or severe ED more, too, the researchers say.

6 Things Every Man Should Know About His Penis:

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Still, there are some pretty big plusses to this new ED treatment, besides the fact it works quickly. Since the drug is topical, you don’t have to worry about one of the big drawbacks of oral ED meds—the fact that eating a big, fatty meal beforehand can mess with its absorption, leaving you unable to get hard.

Because Viagra and Cialis work best on an empty stomach, you should wait two to three hours after a big meal to take them, as Dr. Rajfer told us previously.

With this new topical drug, you can get right down to business as soon as dinner’s done (Want to keep your erection strong for life? Check out The Men's Health Guide to Erectile Dysfunction).


The Anatomy of an Erection – Erectile Dysfunction Center

Erection: how it works

Most of the time, and for most men, erections come naturally and with little or no effort.

But a number of physical and emotional factors are involved in the process of getting and maintaining an erect penis long enough to achieve satisfaction for you and your partner during sexual intercourse. When one or more of these processes aren’t working, the result can be erectile dysfunction (ED).

Anatomy of the Erect Penis

The penis has three main structures: the corpora cavernosa, the corpus spongiosum, and the tunica albuginea. The corpora cavernosa, which is filled with sponge- tissue, extends the entire length of the penis. The tunica albuginea is the membrane that covers and protects the corpora cavernosa.

The corpus spongiosum, in the middle of the penis, houses the urethra, the opening at the end of the penis through which a man urinates and ejaculates.

There is also a network of tissues, muscles, arteries, and veins running through the penis, which allows it to fill with blood and stiffen for an erection.

A man achieves an erect penis from stimulation, such as touching or rubbing the penis, or seeing or thinking about something sexually stimulating and exciting. When stimulation occurs, the brain takes over and works with the nerve endings in the penis. The brain and nerves send messages to the penis to relax, resulting in increased blood flow to the veins and arteries in the penis.

The blood fills the penis, leading to pressure that is contained and supported by the tunica albuginea.

Blood entering the penis is essentially locked in by the supporting tissues and membranes, which allows the pressure to be maintained, creating and holding an erection.

The testicles also release the hormone testosterone, which play a role in determining when an erection happens and how firm it is.

An erection goes away when the penile muscles tighten up and stop blood from flowing into the penis. This usually happens after orgasm or once the stimulation is no longer present.

Why Erectile Dysfunction Happens

Erectile dysfunction can occur for many different reasons, including nerve sensitivity, poor circulation and other problems with blood flow, a slowed heart rate, and low testosterone production.

If you have a neurological problem that affects the messages between the brain and the nerves of the penis, erectile dysfunction may occur.

If you have high blood pressure or are taking medications to treat high blood pressure, blood flow and circulation can be affected, making it difficult to achieve an erection because there’s not enough blood flowing in to fill the penis.

Diabetes can cause circulatory problems that inhibit blood flow and damage nerves that receive messages from the brain signaling the penis to relax and fill with blood.

Psychological issues depression, fear, and anxiety about sex and sexual performance can also affect the process of sexual stimulation and the messages sent to the brain.

In order to achieve an erection, your mind and body have to work together. When a breakdown in communication occurs — whether physical or emotional — working with your doctor to find exactly where the problem occurs is key to treating erectile dysfunction and, just as importantly, its underlying cause.


Erectile Dysfunction (ED) | Impotence | Causes, Treatment & Medication

Erection: how it works

Most men have occasional times when they have problems achieving an erection. For example, you may not get an erection so easily if you are tired, stressed, distracted, or have drunk too much alcohol. For most men it is only temporary and an erection occurs most times when you are sexually aroused.

However, some men have persistent, or recurring problems with sexual function. It can occur at any age but becomes more common with increasing age. About half of men between the ages of 40 and 70 have ED. About 7 in 10 men aged 70 and above have ED.

There are several causes which tend to be grouped into those that are mainly physical and those that are mainly due to mental health issues.

About 8 in 10 cases of ED are due to a physical cause. Causes of ED include:

  • Reduced blood flow to the penis. This is, by far, the most common cause of ED in men over the age of 40. in other parts of the body, the arteries which take blood to the penis can become narrowed. The blood flow may then not be enough to cause an erection. Risk factors can increase your chance of narrowing of the arteries. These include getting older, high blood pressure, high cholesterol and smoking.
  • Nerve damage. For example, multiple sclerosis, a stroke, Parkinson's disease, etc. can affect the nerves going to the penis.
  • Diabetes. This is one of the most common causes of ED. Diabetes can affect blood vessels and nerves.
  • Hormonal causes. For example, a lack of a hormone called testosterone which is made in the testicles (testes). This is uncommon. However, one cause of a lack of testosterone that is worth highlighting is a previous head injury. A head injury can sometimes affect the function of the pituitary gland in the brain. The pituitary gland makes a hormone that stimulates the testicle to make testosterone. So, although it may not at first seem connected, a previous head injury can in fact lead to ED. Other symptoms of a low testosterone level include a reduced sex drive (libido) and changes in mood.
  • Injury to the nerves going to the penis. For example, spinal injury, following surgery to nearby structures, fractured pelvis, radiotherapy to the genital area, etc.
  • Side-effect of certain medicines. The most common are some antidepressants; beta-blockers such as propranolol, atenolol, etc; some 'water tablets' (diuretics); cimetidine. Many other less commonly used tablets sometimes cause ED.
  • Alcohol and drug abuse.
  • Cycling. ED after long-distance cycling is thought to be common. It is probably due to pressure on the nerves going to the penis, from sitting on the saddle for long periods. This may affect the function of the nerve after the ride.
  • Excessive outflow of blood from the penis through the veins (venous leak). This is rare but can be caused by various conditions of the penis.

In most cases due to physical causes (apart from injury or after surgery), the ED tends to develop slowly. So, you may have intermittent or partial ED for a while, which may gradually become worse.

If the ED is due to a physical cause, you are ly still to have a normal sex drive apart from if the cause is due to a hormonal problem. In some cases, ED causes poor self-esteem, anxiety and even depression.

These reactions to ED can make the problem worse.

Mental heath (psychological) causes

Performance anxiety can cause or contribute to ED. For instance, many men have occasional times when they cannot get, or maintain, an erection. If you have one episode where you can't have sexual intercourse as a result, you may get anxious that it will happen again. This anxiety can be enough to stop you getting an erection next time, leading to more anxiety.

Various mental health conditions may cause you to develop ED. They include:

Typically, the ED develops quite suddenly if it is a symptom of a mental health problem. The ED may resolve when your mental state improves – for example, if your anxiety or depression eases.

However, some people become even more anxious or depressed when they develop ED. They do not realise it is a reaction to their mental health problem.

This can make matters worse and lead to a vicious circle of worsening anxiety and persisting ED.

As a rule, a psychological cause for the ED is more ly than a physical cause if there are times when you can get a good erection, even though most of the time you cannot. (For example, if you can get an erection by masturbating, or wake up in the morning with an erection.)

A referral to a specialist is sometimes needed. However, GPs are now treating more cases than previously, as the treatment options have improved in recent years. Your GP is more ly to suggest referral if you have been found to have a hormonal problem, if the cause is related to another condition circulatory problems, or if you are young and the condition started after an injury.

The following gives a brief summary of treatment options. There is a good chance of success with treatment.

As mentioned, some medicines can cause ED. Check the leaflet that comes with any medication that you take to see if ED is a possible side-effect. Do not stop any prescribed medication but see your doctor if you suspect this to be the cause. A switch to a different medicine may be possible, depending on what the medicine is for.

Medication (tablets taken by mouth)

In 1998, the first tablet to treat ED was launched. This made a huge impact on the treatment of ED. For treating ED, there are now four different tablets licensed in the UK:

  • They work by increasing the blood flow to your penis. They do this by affecting cGMP, the chemical involved in widening (dilating) the blood vessels when you are sexually aroused (described above). They are sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®) and avanafil (Spedra®). You take a dose before you plan to have sex. Because of the way they work, these medicines are called phosphodiesterase type 5 (PDE5) inhibitors.

So, even if the nerves or blood vessels going to your penis are not working so well, a tablet can cause the blood flow to increase in your penis and cause an erection. Tablets can treat ED caused by various underlying conditions.

Note: none of these tablets will cause an erection unless you are sexually aroused.

There is a good chance that a medicine will work (about an 8 in 10 chance of it working well). However, they do not work in every case. There are pros and cons for each of the above and your doctor will advise.

For example, you may not be able to take certain tablets for ED if you have certain other medical conditions or take certain other medicines.

For example, you should not take a PDE5 inhibitor if you take nitrate medicines (including glyceryl trinitrate (GTN)) which are often used to treat angina.

Also, if you have high blood pressure for which you take a certain type of medication, called alpha-blockers (doxazosin, indoramin, terazosin or prazosin), you need to wait until you are on a stable dose. This is because combining alpha-blocking medication with a PDE5 inhibitor can cause a sudden blood pressure drop.

Cream applied to the penis

Topical alprostadil may be prescribed. The cream comes with a plunger. It is applied to the tip of the penis and the surrounding skin. It should be used 5 to 30 minutes before you have sex.

Injection treatment

This was the most common treatment before tablets became available. It usually works very well. You are taught how to inject a medicine into the base of the penis. This causes increased blood flow, following which an erection usually develops within 15 minutes. (Un with tablets, the erection occurs whether of not you are sexually aroused.)

You can place a small pellet into the end of the tube which passes urine and opens at the end of the penis (the urethra). The pellet contains a similar medicine to that used for the injection treatment. The medicine is quickly absorbed into the penis to cause an erection, usually within 10-15 minutes.

Vacuum devices

There are several different devices. Basically, you put your penis into a plastic container. A pump then sucks out the air from the container to create a vacuum. This causes blood to be drawn into the penis and cause an erection.

When erect, a rubber band is placed at the base of the penis to maintain the erection. The plastic container is then taken off the penis and the penis remains erect until the rubber band is removed (which must be removed within 30 minutes).

Penile implants

Penile implants can be permanently into the penis by a surgeon. The most sophisticated (expensive) type can be inflated with an inbuilt pump to cause an erection. The more basic type has to be straightened by hand. 

Treating an underlying cause

For example, treating depression or anxiety, changing medication, cutting back on drinking lots of alcohol, or treating certain hormonal conditions may cure the associated ED.

Lifestyle and other advice

As mentioned above, ED is often a marker that heart disease or other cardiovascular diseases may soon develop. Therefore, you should review your lifestyle to see if any changes can be made to minimise the risk of developing these problems.

Also, your doctor may prescribe a statin medicine to lower your blood cholesterol level if your risk of developing cardiovascular disease is high.


Sometimes couple counselling, or sex therapy is useful. These are most useful if certain mental health (psychological) problems are the cause of, or the result of, ED.

In some cases, sex therapy is used in addition to another treatment option.

In England, Scotland and Wales sildenafil is available on NHS prescription from GPs as well as specialists, for all men who have ED. In Northern Ireland, a specialist has to assume responsibility for prescribing it.

Tadalafil, vardenafil and avanafil are only available to those patients who have one of the specified medical conditions listed below. Other men can receive a private prescription from their own GP.

The specified medical conditions are:

A specialist can also prescribe treatments using medication on the NHS if your condition causes severe distress in your life. Examples would be relationship breakdown, social problems or effects on mood or behaviour.

It is best to see your GP. They are ly to discuss the problem, go over any medication you may be taking and do a physical examination. This can help to identify or rule out possible underlying causes. Before treatment your GP may suggest some tests.

Depending on your symptoms, ly cause of the ED, age, etc, your doctor may suggest that you have some tests. These are mainly to check up on any risk factors listed above which increase the risk of developing narrowing of the arteries. Tests may include:

If you have a low sex drive, or if you have had a previous head injury, ED may be due to a hormonal problem. In this situation a blood test to check the level of the hormone testosterone (and sometimes prolactin) may be advised.

In a small number of cases, tests to check the way the blood circulates through the penis, using scans or drug injections, may be done in hospital clinics.


Erectile Dysfunction: Symptoms and Treatment

Erection: how it works

Erectile dysfunction (ED), sometimes called impotence, is the inability to get or keep an erection firm enough for sexual intercourse. The condition has become highly visible in recent years, but that doesn’t make it any more welcome for the 5 to 15 percent of American men whose sex lives are affected.

The disorder can occur at any age, but is more common in men over age 75, according to the American Academy of Family Physicians (AAFP). In middle aged men, ED can signal risk of a heart attack, said Dr. David Samadi, the chairman of urology and chief of robotic surgery at Lenox Hill Hospital in New York City. 

The same cholesterol plaques that can build up in the arteries surrounding the heart can also affect arteries that go through penile tissue. Once doctors rule psychological causes, “they need to do a cardiac workup to make sure that this guy is not on the verge of getting a heart attack,” Samadi told Live Science.


Since sexual arousal is a complex process involving hormones, emotions, nerves, muscles, blood vessels and the brain, a malfunction in any of these can lead to ED. Stress, exhaustion and psychological issues can also contribute, and anxiety over maintaining an erection can actually make it harder to attain. In short, any condition that inhibits blood flow to the penis can lead to ED.

Aging is a large part of ED, but according to the AAFP and the Mayo Clinic, ED can also be caused by:

  • Heart disease or clogged blood vessels
  • High blood pressure
  • Diabetes
  • Obesity
  • Metabolic syndrome, a grouping of conditions that include high blood pressure, cholesterol and insulin levels and excess fat around the waist
  • Multiple sclerosis
  • Parkinson's disease
  • Low testosterone
  • Peyronie's disease, which is scar tissue inside the penis
  • Certain prescription drugs, such as antidepressants and high blood pressure medication
  • Smoking
  • Alcoholism or drug addiction
  • Prostate treatments
  • Brain or spinal cord injuries
  • Stroke
  • Radiation therapy to the testicles
  • Certain types of surgery on the prostate or bladder

The vast majority of ED cases are caused by disease, according to the National Institutes of Health (NIH), while drug side effects account for 25 percent.

Low libido, which is a low interest in having sex, should not be confused with ED, Samadi added. 

People often have drops in testosterone levels as they age, often called male menopause or “manopause,” Samadi said. 

Diagnosis & tests

Doctors can rule out various systemic causes of ED with a physical exam. Breast enlargement in men, for instance, can indicate hormonal issues, while decreased pulses in the wrists or ankles can suggest blood flow problems, according to the NIH.

Beyond that, several tests can lead to an ED diagnosis. According to the Mayo Clinic, these include:

  • Blood tests to check cholesterol, testosterone and glucose levels
  • Urinalysis to look for signs of diabetes
  • Ultrasound to check blood flow to the penis
  • Overnight erection test to monitor erections during sleep. Physical causes of ED can be ruled out if the patient has an involuntary erection while sleeping (a normal occurrence), breaking a special tape wrapped around his penis.

Medication & treatment

A variety of drugs and treatments are available for ED, from simple pills to complex surgeries. The cause and severity of ED will determine which treatment is recommended, according to the AAFP. Some treatments can have significant side effects.

Psychotherapy is an option to treat anxiety-related ED, according to the NIH. The patient's partner can help in the process of developing intimacy and stimulation.

Oral medications successfully treat ED in many men, Samadi said. These include sildenafil (commonly known by the brand name Viagra), tadalafil (Cialis), vardenafil (Levitra) and avanafil (Stendra). Each works by enhancing naturally occurring nitric oxide, which relaxes muscles in the penis and increases blood flow.

However, these medications should not be taken by men who take blood thinners, high blood pressure medicines, nitrate drugs for angina, or alpha-blockers for an enlarged prostate. According to the NIH, the combination of ED pills with these other prescription medications can cause a sudden, dangerous drop in blood pressure. 

Side effects include nasal congestion, headaches and a flushed face. If one medication doesn't work, another may do the trick. “We don't know why, but the chemistry of it may work differently on different people,” Samadi said. 

It's best to take oral medications on an empty stomach 60 to 90 minutes before having sex. If a person has a large meal, such as a steak dinner, the fatty food may absorb some of the medication and reduce its efficiency, except for Cialis, which stays in the body for a long time, Samadi said.

Other ED medications include:

  • Alprostadil injections, which produce an erection in five to 20 minutes that lasts for about an hour. Patients use a fine needle to inject alprostadil (commonly known by the brand names Caverject Impulse and Edex) into the base or side of the penis. Side effects can include bleeding or fibrous tissue formation at the injection site as well as prolonged erection, according to the Mayo Clinic.
  • Alprostadil penis suppository, which is inserted with a special applicator about 2 inches into the urethra. Side effects can include pain, minor bleeding, dizziness or fibrous tissue formation inside the penis.
  • Testosterone injections to raise low hormone levels.

If medications don't work, more aggressive treatments may be recommended, including:

  • Penis pumps, which involve placing a hollow tube over the penis and creating a vacuum that pulls blood into the penis with a hand- or battery-operated pump. According to the Mayo Clinic, a tension ring is placed around the base of the penis to maintain the erection until intercourse is finished.
  • Penile implants, which surgically places rods into the two sides of the penis that are inflatable when desired.
  • Surgery, which can repair arteries carrying blood to the penis or veins that allow blood to leave the penis.


A variety of lifestyle choices can affect the ability to achieve and maintain an erection, so preventing ED is possible in some cases. Men are encouraged to manage chronic health problems with their doctors and to exercise regularly. They also should avoid smoking and excess alcohol and get help for anxiety or depression, according to the Mayo Clinic.

“There are a lot of benefits to healthy sexual function,” Samadi said, “Whether it boosts the immune system or whether it is good for releasing stress. So certainly, you don't need to give up on it just because you're getting older.”

Additional resources

Additional reporting by Laura Geggel. Follow her on @LauraGeggel. Follow Live Science @livescience, & .


***click on underlined links to access PubMed abstracts***

Penile physiology/biochemistry: NO means yes!

Nitric oxide (NO) is the most important factor increasing blood flow into the penis to cause engorgement. Sexual arousal activates the production of NO in the penile nerves. There it activates release of cyclic GMP, which causes the smooth muscle surrounding the penile arteries to relax.

The result is a very large increase in blood flow, giving the man that “turned on” feeling.

Lou Ignarro, a UCLA PhD who shared the Nobel Prize in Medicine in 1998 for the discovery of NO and its role in the erectile response, has co-authored 4 of our reviews and wrote the forword for our book, saying “I have no doubt that this book will help millions of couples around the world by improving male sexual performance”.

Distension and rigidity of the penis also depend on factors that limit outflow of blood. As with a fire hose, if there was no nozzle to limit outflow, the hose would remain limp. However, the penile veins are strategically placed within and adjacent to the fibrous sheath that surrounds the penis.

The distention caused by the large inflow of blood together with the surrounding pelvic floor muscles are therefore able to markedly constrict outflow of blood.

The pelvic floor muscles also put direct pressure on the penile sheath resulting in elevations of pressure within the penis that can be much greater than in the inflowing blood, resulting in maximum erection hardness.(Meldrum, 2014)

A very large increase of blood flow into the penis is absolutely necessary for an adequate erection to occur.

We can't emphasize enough the importance of sexual arousal in stimulating the production of nitric oxide (NO) in the penile nerves and thereby inflow of blood.

However, that topic is clearly an extensive one which we can’t cover here. We suggest couples access the Sinclair Institute’s website to explore that in more detail.

Once NO is sufficiently activated in the penile nerve endings, levels must be high enough and last long enough to relax the penile arteries to carry a large amount of blood into the penis. That in turn causes engorgement to initiate the erection as well as to put pressure on the penile veins to restrict outflow (covered below).

NO is actually a gas, which lasts only a few seconds before being rapidly broken down. It’s startling that the survival of our species relies on such a delicate substance, but fortunately, the body has very effective antioxidant systems that counteract NO breakdown for a lasting effect on blood flow.

Unfortunately, average levels of a principal circulating antioxidant, Pon-1, and of a principal tissue antioxidant, glutathione, are decreased in men with low erectile function (erectile dysfunction, ED).

In a well-designed study, pycnogenol, a fully characterized commercial preparation of antioxidants in blueberries, was shown to markedly improve erectile function scoring by the study participants. Also, chocolate (cocoa), a very potent antioxidant, markedly stimulates NO levels, even in young, healthy men.

These findings together show how critical antioxidants are for maintaining NO levels and action and suggest that antioxidants may also maximize erectile function in men without ED.

We will discuss how to keep your antioxidant levels high in the page “lifestyle and erectile quality”, and a listing of great antioxidants is to the right of every page. Neural NO release is also prolonged by a Cyclic-AMP mediated mechanism. Cafeine stimulates Cyclic-AMP levels, so a cup of coffee after a romantic dinner may help with later evening pleasures!

Here’s where the Viagra- drugs enter the scene. NO acts to cause relaxation of muscle in the wall of the penile arteries and the tissue within the penis itself through an intermediate substance called Cyclic GMP (Rajfer J, 1992).

These drugs act to block the biochemical pathway (phosphodiesterase 5, PDE-5) that breaks down Cyclic GMP, thereby raising cyclic GMP levels.

These “PDE-5 inhibitors” work reasonably well for many men but remember they will not work if there is very little NO passing from where it is produced (in the blood vessel lining) into the surrounding muscle. Also, it is very important for your health to have lots of NO (see the “Erections and Health” page.

The pressure of the blood entering the penile arteries is a factor, but don’t be fooled. It is actually the exact opposite of what you might think. In someone who has higher blood pressure, blood vessels are constricted, which lowers the flow of blood into the penis.

In men with high blood pressure the chance of having ED is 2-3 times higher (Doumas M, 2006). Of course the pressure of blood flowing into the penis can’t be higher than the pressure in the man’s circulation.

Because pressures up to 2-4 times peak circulation pressure have been measured in young healthy men (Lavoisier, 1986), that clearly shows that something else determines maximum erection hardness (see “Outflow of Blood”/pelvic floor exercises below.

On the “lifestyle and erectile quality” page we will discuss other factors that can increase or decrease NO and inflow of blood.

Outflow of Blood

If there is no nozzle on a fire hose, the hose will remain limp in spite of a large amount of water flowing through it. wise, if the penile veins are wide open, erection will not occur.

The “nozzle” for the penis is created by the penile veins being constricted as they pass through and next to the tough fibrous sheath surrounding the penis, both by the pressure of blood distending the penis, but also by pressure and contractions from the surrounding pelvic floor muscles.

In a remarkably well-structured study of pelvic floor exercises (PFE’s) (Dorey, 2004 and 2005), 40% of men had their ED resolve and in another 35% it was improved. Their sexual partners experienced increased satisfaction and desire (Dorey, 2004).

The benefits were of a similar magnitude compared to those of Viagra. These two approaches to treatment aren’t competitive. They work on entirely different aspects of erectile function and would at a minimum add together to promote better erectile quality.

More than that, there are men whose decreased erectile function will have an inadequate response to Viagra and other PDE-5 inhibitors because the penile veins are too open, and men who will not respond to PFE’s because of insufficient inflow of blood.

Erectile fuction will be maximized and for the highest percentage of men by combining efforts to both increase inflow and decrease outflow. (Meldrum, 2014) It is not surprising that erection hardness is an excellent predictor for men to continue use of one of the Viagra- drugs. (Mazzola, 2013)

The pelvic floor muscles are not only important in constricting outflow of blood, but they also exert pressure on the penis by surrounding and being attached to the penile sheath. That is why pressure in the penis in healthy young men has been measured at levels 2-4 times higher than the peak pressure of the inflowing blood.

Contractions of those muscles are stimulated by distention of the penis and by pressure on the end of the penis (the “glans penis”) (Lavoisier P, 1986) (Shafik A, 2006). Therefore, coital thrusting further increases penile hardness, provided that the pelvic floor muscles are sufficiently developed.

PFE’s are described in detail online by the British researcher who led the above study.

So what do I do to get “George” maxed out?

First, do everything you can to increase NO in your blood vessels and penis, further described in the page “Lifestyle and erectile quality”. The real bonus is that increasing NO by the ways we describe will also increase your general health and your “healthspan” (the number of extra years of healthy life).

Second, maximize the strength of your pelvic floor muscles throughout each day by doing the PFE's while standing, sitting, walking and lying down.

If you practice them while doing other activities they will take no more time from your day and no one will know you are doing them.

For example, do them while standing shaving in the morning, while standing or sitting in front of your computer screen or in your car at a stop light, while doing your daily exercise, and while lying on your back in bed or when exercising at the gym.

It is particularly important when walking, as a study showed walking was associated with decreased pelvic floor strength (Sousa LE, 2018). That is ly because the natural tendency is to relax those muscles when walking. 

Third, be sure to also read our book called “Survival of the Firmest”, available at Amazon/kindle or itunes or for download below. You will find more information there and on some topics not covered here.

Even for the same material it may be explained in a different way that you may find easier to understand and it describes 10 steps toward better erections.

Above all, carefully read chapter 8, which may save you half of your net worth, heartbreak for many loved ones and friends, and numerous complications in your life.

“Survival Of The Firmest” $9.99

Stress and erectile performance

Stress is certainly a factor. All men have come to realize that stress is a non-starter for developing an adequate erection. Stress activates nerves that constrict blood flow, the exact opposite of what is required for distention of the penis with blood.

The role of stress is too complex a topic to cover here. It may require simply taking on fewer tasks, or it may require visiting a psychologist for therapy. Yoga, meditation, and other forms of relaxation therapy may be helpful.

If stress is a factor, you will want to maximize all of the factors we outine in this website and in our book.

How about my partner?

It is very ly if you do all of the things recommended here and in our book, your erections, sexual enjoyment and desire will markedly improve. Studies have shown that improved erectile function results in marked increases in female sexual function and satisfaction.

(Cayan, 2004)) It may be difficult for any man to know how good he is at this, but one thing you will both know for sure is when he is better! And you will be less ly to develop erectile dysfunction and vascular diseases as you get older.

 Now that’s a no-brainer.

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