Posts Tagged ‘erect’

The Fickle Phallus

June 10, 2017

Andrew Siegel MD  6/10/17

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The penis is a fickle and temperamental friend who can be volatile, unpredictable and even hot-headed at times.  He has many states of existence, ranging from as shrunken and soft as a marshmallow to a “proud soldier”– rock-hard with exquisite posture. Between deflated and inflated, there are an infinite number of intermediate states, dependent on the dynamic balance between the closing and opening mechanisms of the blood flow to the penile erectile chambers.  It is important to understand that the same physiology applies to female genitals and clitoral function. 

The Autonomic Nervous System: The Network Ultimately Responsible for this

The autonomic nervous system controls “unconscious” body functions, including heart rate, breathing, digestion and contributes in a large way to regulate sexual function.

Heart rate and contraction are dynamic, changing moment-to-moment, even beat-to-beat, since they are “governed” by two competing halves of the autonomic nervous system.  The two systems—sympathetic and parasympathetic—are in a constant tug-of-war based upon external stimuli and one’s interpretation of them.

The sympathetic nerves respond to threats, fears and anxieties —an agitated state of mind and blood vessel tone—with the classic flight-or-fight response, which accelerates heart rate, heart contractility, respiratory rate, blood pressure and constricts arteries throughout the body.  The sympathetic system boots up when one is presented with a sudden anxiety-provoking event, such as being in a near-miss car accident.

On the other hand, the other half of the autonomic nervous system is the parasympathetic nervous system—the calmer and more relaxed state of mind and blood vessel tone—which slows down heart rate and respiratory rate, reduces heart contractility and lowers blood pressure by dilating arteries. The parasympathetic system is the system that predominates when we are not in situations that provoke fear and anxiety, governing many day-to-day bodily functions.


Above image from Wikipedia, in public domain


Erectile function is complex and based upon many factors, both physical and psychological, but the ultimate determinant is chemistry that drives penile blood flow or lack thereof.  The state of the penis (flaccid vs. rigid vs. any intermediate state) at any given moment is based upon the balance between sympathetic (contractile) and parasympathetic (relaxant) factors. As the cardio-vascular system function is predicated upon the predominance of sympathetic versus parasympathetic stimulation, so the function of the peno-vascular system is predicated upon the predominance of sympathetic versus parasympathetic function. After all, the penis can be considered to be an extension of the vascular system that can be referred to as the “dangling aorta.”

Penile erection occurs with activation of parasympathetic (nitric oxide-cyclic guanosine phosphate pathway) nerves, which foster the relaxation of the penile arterial smooth muscle and the smooth muscle of the erectile tissue and inhibition of contractile mechanisms, all of which cause blood to rush into and inflate the penile erectile chambers.

Alternatively, penile flaccidity occurs with activation of sympathetic (norepinephrine pathway) nerves, which foster the contraction of the penile arterial smooth muscle and the smooth muscle of the erectile tissue and inhibition of relaxing mechanisms, all of which causes blood to exit and deflate the penile erectile chambers.

Sympathetic nervous system activity causing increased smooth muscle tone in erectile tissue is likely involved in the occurrence of psychological as well as in cardiovascular erectile dysfunction.

The bottom line is that the state of penile inflation at any given moment is highly influenced by the balance between sympathetic and parasympathetic function. High sympathetic activity causes a shriveled and decompressed penis, while high parasympathetic activity an erect and rigid penis. This is the very reason why one needs to have a relaxed temperament in order to perform sexually and also explains why anxiety can doom erectile function. A perfectly healthy 21-year-old with absolutely normal “plumbing” can be doomed to sexual failure if performance anxiety creates such a high sympathetic tone state. Similarly, a 50-year-old man who uses Viagra to increase penile blood flow and help obtain a rigid erection can have the beneficial effect of the medicine neutralized by a highly anxious state of mind.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health


You Can’t Think It Up, But You Can Think It Down

November 21, 2015

Andrew Siegel MD   11/21/15


(Above fortune from Chinese fortune cookie relevant to this discussion.)

Q: What is the most powerful sex organ?

A: If you think it is the erect and throbbing penis, you are incorrect. The BRAIN is the bossman and the most influential force driving sexuality. The penis is a mere buck private soldier that responds and bends to the will of the five-star general and commander-in-chief of sexuality, the central nervous system.

Despite the authority and assertive presence of the brain, it is only under rare circumstances that it is capable of willing the limp penis to become erect. Some form of touch or erotic stimulation is most often necessary to get the erection process going, with the exception of nighttime-related erections associated with a phase of sleep known as REM (Rapid Eye Movement).

If the central nervous system cannot will the limp penis to become erect, it certainly can will the erect penis to become limp or will the limp penis to remain limp. This is the case with performance anxiety, a classic instance of the powerful mind-body connection. In this circumstance, stress or anxiety causes the output of high levels of adrenaline, which functions to constrict penile blood flow and erectile smooth muscle relaxation, resulting in a limp penis.

The central nervous system is the commander-in-chief of sexuality, but it demands working the way it likes to work, i.e., naturally, unhindered and unburdened by cognitive thought. Conscious and willful thought clearly can interfere with the smooth function of the central nervous system. When conscious thought enters the picture, the ability to perform many complex movements goes south. Much the same as a golf swing or any action like using a fork to feed yourself or walking down a flight of stairs, when it comes to sexuality, the brain works best when it is working subconsciously. Overthinking is the enemy of any complex motor activity. With all of these examples, one needs to be in the moment and engaged in the activity without conscious thought, in order to enable a smooth execution.

The moment one starts overthinking, the complex motion is virtually destined to be flawed. The golf swing is a classic example, with a poor shot almost guaranteed if one has too many swing thoughts that confound execution and performance. For the non-golfers, try walking down a flght of stairs at a good clip, stating to yourself in your inner voice each step in the process and you will likely trip up. When you are in a sexual situation, if you focus on thinking about your sexual function or lack thereof or reliving a previous problem, then your performance will most often be doomed to failure.


(Thank you, Pixabay for image above)

Too much thought is capable of empowering self-fulfilling prophecies and bringing them to fruition. If one has had erection issues and in a passionate moment starts thinking, assessing, evaluating and analyzing, he is almost certain to be incapable of obtaining or maintaining an erection. Likewise, if one suffers with premature ejaculation and his thought pattern becomes obsessively focused on this possibility instead of being in the moment and enjoying the situation, he is almost certain to ejaculate way sooner than desired. The same is true with the rarer but equally disturbing problem of delayed ejaculation. Focusing on trying to make oneself ejaculate will most often bring on the inability to ejaculate.

Masters and Johnson coined the term spectatoring, an intense self-focus during sexual interactions as opposed to immersing oneself in the sensory aspects of the sexual experience. Essentially, spectatoring is observing and monitoring yourself having sex as if you were a third party, often accompanied by an anxious internal, self-conscious dialogue with concerns about some aspect of your sexual performance. It is being a spectator instead of the player and it will DESTROY your game.

The solution to spectatoring is to “be present” and “in the moment,” totally immersing yourself in the experience without observation or conscious internal thoughts. When you lose yourself in the sensations and do not allow thoughts to interfere with the process, you maximize your chances for an optimal performance. When distracting thoughts uncontrollably float into the present like dark clouds in the sky, take a deep breath, exhale slowly and allow the thoughts to pass and return to a state of being present.

Bottom Line: Overthinking is the enemy of complex actions, including erections and ejaculation. Allow the central nervous system to do what it does so well– subconsciously– without trying to help things along with deliberate thought.  Let instinct prevail over conscious thought–you cannot make it happen, you have to let it happen. There is an  time and place for conscious thought, but it is not in the heat of the moment in the bedroom.  Be present without thought of the past or future. 

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: or Amazon.

Penile Erection Geometry

June 7, 2014




(Illustration credited to Dr. Henry Gray, Gray’s Anatomy of the Human Body, 20th edition, original publication 1918, public domain)

Blog # 156

A flaccid penis is soft like a marshmallow and dangles limply from its attachment to the pubic bone. With stimulation, the penis fills, firms, and increases in length and girth, as tumescence turns to rigidity. Not only does the penis undergo a metamorphosis into a rigid erection, but it also starts angling up towards the heavens—majestically pointing towards the sky, a marvel of human hydraulic engineering in defiance of the laws of gravity. At its extreme, the erect penis can touch the abdominal wall. A young man’s erection can easily support the weight of a towel.

Who Knew? Birthday and New Year’s Eve party blowouts—those party toys that when blown unfurl and extend outwards—are a useful means of thinking about erections. In the flaccid state, the erectile cylinders are very similar to the party blowout when it is not being blown into; in the erect state, the erectile cylinders are comparable to the party blowout when it is being blown into.  In the flaccid state, there is an acute bend at the junction of the external and internal penis. With a rigid erection, this acute angle is lost and the external penis develops an obtuse angle relative to the internal penis.

Analogous to penile size, there is a great amount of variability in the angle of the erect penis relative to the body (the pubo-penile angle). Like belly buttons that can be “outies” or “innies,” erections can be “uppies” or “outies,” depending on a number of factors. “Flagpoles” can be vertical, horizontal, or any angle in between.

Who Knew? In summer camp there was always that smart aleck camper who cited a complex equation of the physics of erection intensity, involving the “angle of the dangle,” “the heat of the meat,” “the direction of the erection,” “the dimension of the extension,” “the torque of the pork,” etc. Who knew that there was actually validity to some of these factors in determining the angle of erection!

The pubo-penile angle is determined by the following factors: the tension in the suspensory ligaments of the penis; the attachments of the penis to the pelvic bones; the size of the penis; the extent of the erection; and the tone and strength of the ischiocavernosus (IC) and bulbocavernosus (BC) muscles.

The suspensory ligaments support and maintain the erect penis in an upright position, essentially anchoring the base of the penis to the pubic bone. The tighter the ligaments are, the greater the potential upward angulation of the erect penis.

Who Knew? In an effort to increase penile length, some surgeons perform a procedure in which the suspensory ligaments of the penis are cut. What this actually does is to expose some of the internal penis, allowing more of the penis to hang outside the body. The price one pays for this sleight of hand is that one’s erection will no longer point majestically to the heavens. Essentially, one gains a bit of flaccid length and loses angle—robbing your Peter to pay Paul, literally!

As the suspensory ligaments provide support and anchorage of the external penis from above, so the attachments of the erectile cylinders to the pelvic bones provide support and anchorage of the internal penis from below. Every individual has different anatomy, and the variations in pelvic anatomy and support can engender variations in erectile angulation. In general, the more firm and secure the attachments are from below, the greater the potential foundation of support and the greater the potential upward angulation of the erect penis.

Who Knew? The internal, concealed penis that is attached to the pelvic bones can be thought of as the roots of a tree. Similarly, the external penis can be considered in terms of the trunk of a tree. Without a solid root system—the foundation—no tree can assume a tall and erect stature. But with a solid foundation, the penis, like the tree, has the support to point high to the heavens.

Penile size is generally inversely proportional to the potential for upward angulation. Largely due to the force of gravity, there is a tendency for less upward angulation with longer and heavier penises.

Conceptually easy to understand, if flaccid is considered a 0% erection and full rigidity is 100%, the greater the magnitude and extent of the erection, the greater the upward angulation.

There are two particularly important pelvic floor muscles called the bulbocavernosus (BC) and ischiocavernosus (IC) muscles. These muscles are crucial to male sexual function. There are a total of 3 erectile cylinders that form the bulk of the tissue of the penis. The solitary erectile cylinder known as the “corpus spongiosum” (“spongy body”) runs from the perineum (the area between the scrotum and anus)” through the length of the penis to the “glans,” the head of the penis. Its innermost, protuberant portion is known as the “bulb.” The corpus spongiosum contains the urethra (urinary channel) and during sexual stimulation, the corpus spongiosum and the glans become swollen and plump. The BC is the muscle that covers the penile “bulb.” The “corpora cavernosa” (“cave-like bodies”) are the paired erectile cylinders are responsible for rigid erections. The IC refers to the muscle that covers the inner, deep aspects of the corpora cavernosa.

Bulbocavernosus and ischiocavernosus muscle strength can factor strongly into erectile angulation. A voluntary contraction of the BC and IC muscles will cause the erect penis to deflect in an upwards direction. As the BC and IC muscles are flexed, one can easily observe movement of the external penis towards the heavens as the increased blood filling of the erectile cylinders nudges the external penis up. The better the tone and conditioning the BC and IC muscles, the greater the potential upward angulation of the erect penis.

We must accept what nature has given us regarding our suspensory ligaments, our attachments of the penis to the pelvic bones, and the size of our penises. However, the factors that we can modify are the extent of our erections and the strength of our IC and BC muscles. So if we want to maximize our pubo-penile angle, PFM exercises become of paramount importance

An erection needs to be hard enough to penetrate, but flexible enough to be able to negotiate the various “acrobatic” requirements of different sexual positions. So, although an erection that points to the heavens is a wonderful phenomenon, one that is so angled to the extent that it is inflexible will not help one’s performance in the bedroom.

Who Knew? The vagina is shaped like a banana, with its innermost and deepest part angling downwards toward the sacral bones. In order to accommodate female anatomy and position, a penis needs to be both rigid and flexible at the same time—“flexible rigidity,” to use an oxymoronic phrase. If one has a highly angled, inflexible erection, sexual positions such as the reverse cowgirl or woman on top leaning backwards can be painful and can potentially inflict damage to the penis, as well as prove uncomfortable for the woman.


Andrew Siegel, MD


The aforementioned is largely excerpted from my new book: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook) and coming soon in paperback.


A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:


Penis Size: Does It Matter?

May 17, 2014

Blog #154

As I was walking through the gateway on my way to board an airplane, I saw a poster advertisement stating the following: Size should never outrank service, referring to the smaller size regional jets that now offer first-class, wi-fi and more. I recently saw another poster ad for the same airline stating: How fast the flight goes isn’t always up to pilot. I find these double entendres quite amusing and entertaining.

With all biological parameters, there is a bell curve with a wide range of variance, with most clustered in the middle and outliers at either end. Penis size is no exception, with some of us phallically endowed, some phallically challenged, but most of us somewhere towards the center. In a study of 3500 penises published by Alfred Kinsey, the average flaccid length was 8.8 centimeters (3.5 inches). The average erect length ranged between 12.9 -15 centimeters (5-6 inches). The average circumference of the erect penis was 12.3 centimeters (4.75 inches).

As a urologist who examines many patients a day, I can attest to the fact that penises come in all shapes and sizes and that there is no clear cut correlation between ethnicity and penis size. Flaccid length does not necessarily predict erect length and can vary depending upon emotional state and ambient temperature. There are showers and there are growers. Showers have a large flaccid length without significant expansion upon achieving an erection, as opposed to growers who have a relatively compact flaccid penis that expands significantly with erection.

Some women prefer men who are formidably hung, just like some men prefer women with large breasts. Whereas men with tiny penises may be less capable of sexually pleasing a woman, men who have huge penises can end up intimidating women and provoking pain and discomfort, particularly if cervical contact occurs. The long and the short of it are summarized in the adage, “It’s not the size of the ship, but the motion of the ocean.

Who Knew? “Genital Genetics.” As with so many physical traits, penis size is largely determined by genetic and hereditary factors. Blame it on your father (or mother). In actuality, it is the roll of the genetic dice and how the inherited blueprint that determines physical traits interacts with the local hormonal environment.

Who Knew? Hung like a horse—forget about it! The blue whale has the mightiest genitals of any animal in the animal kingdom: penis length is 8-10 feet; penis girth is 12-14 inches; ejaculate volume is 4-5 gallons; and testicles are 100-150 pounds. Hung like a whale!

Who Knew? On the subject of penis size, one of my favorite things to do when driving on the highway and seeing some idiot in a Lamborghini driving hazardously from lane to lane at about 95 miles an hour is not to flash him my middle finger, but to show him my hand with my thumb and index finger separated about 1 inch apart to indicate to him what I think is the likely size of his penis.

Who Knew? “Men are from Mars, Women from Venus.” Leonardo Da Vinci had an interesting take on perspectives: “Woman’s desire is the opposite of that of man. She wishes the size of the man’s member to be as large as possible, while the man desires the opposite for the woman’s genital parts.”

Who Knew? There are a bunch of “amenities” that accompany the aging process, one of which is “presbyopia” or farsightedness, which demands reading glasses. They are a real nuisance, never around when you need them and always getting lost. But one thing I have observed is that if you forget to take them off when you get up to relieve your full bladder, when you glance down, you see a rather large “member,” thanks to the magic of magnification. I am currently wearing 1.5 power; perhaps it’s time for 2.0!

Who Knew? There is no correlation between penis size and shoe size, hand size or nose size.

Who Knew? “Where’s Woody?” Three of the most common words I hear in my urology practice are the following: “Doc, I’m shrinking.”

Who Knew? Part of the problem is the pervasive pornography industry, where many male stars are endowed like the centaur, the mythological creature with the head and torso of man and the lower body of a horse. This has given the average guy a bit of an inferiority complex.

Many men complain of “shrinkage,” which is a very real phenomenon on the basis of blood flow. The typical circumstances evoking this are exposure to cold weather or cold water, the state of being nervous, and athletic pursuits. The mechanism in all cases involves blood circulation. Cold exposure causes vasoconstriction (narrowing of arterial flow) to the body’s periphery to help maintain core temperature. This is the very reason one places ice on an injury as the vasoconstriction will reduce swelling and inflammation.

It stands to reason that exposure to heat will cause vasodilation (expansion of arterial flow) and this is the very reason that some penile tumescence (state of fullness without rigidity) can occur in a warm shower. Nervous states or anxiety cause the release of the stress hormone adrenaline, which functions as a vasoconstrictor, resulting in a flaccid penis. Participation in vigorous athletic activity “steals” blood flow to the organs that need the oxygen and nutrients the most, namely the muscles, at the expense of organs like the penis.

Who Knew? Do you remember the Seinfeld episode in which Jerry’s girlfriend Rachel sees George naked after George steps out of a swimming pool?

 Rachel: “Oh my God, I’m really sorry.”

George: “I was in the pool; I was in the pool.”

George to Jerry: “Well I just got back from swimming in the pool and the water was cold.”

Jerry: “Oh, you mean shrinkage.”

George: “Yes, significant shrinkage.”

As mentioned, truly not a day goes by in my practice when I fail to hear the following complaint from a patient: “Doc, my penis is shrinking.” The truth of the matter is that the penis can shrink from a variety of circumstances, but most of the time it is a mere illusion—a sleight of penis, if you will. Weight gain and obesity will cause a generous pubic fat pad, the male equivalent of the female mons pubis, which will make the penis appear shorter. However, penile length is usually intact, with the penis merely hiding behind the fat pad, what I call the “turtle effect.” Lose the fat and presto…the penis reappears. Having a plus-sized figure is just not a good thing when it comes to man-o-metrics.

Who Knew? “Fatal Retraction.” It is estimated that for every 35 lbs. of weight gain, there will be a one-inch loss in apparent penile length.

Who Knew? “Penile Dysmorphic Disorder,” very much paralleling “Body Dysmorphic Disorder,” is a condition in which one’s image of their penis is at odds with reality. Typically, one envisions himself as small when in fact he is quite within the normal range and an obsessive focus on this issue creates a great deal of psychological stress.

Who Knew? “Koro” (“head of the turtle” in Malay) is a cultural form of psychological panic that occurs predominantly in East Asian men. Those who suffer from this delusional disorder are terrified that their genitals will retract into their bodies and take extreme measures to prevent this from occurring.

The erectile cylinders of the penis are essentially our “erector sets,” consisting of three inner tubes within the penis that are composed of vascular (consisting of blood vessels) smooth muscle and sinuses that fill with blood upon sexual stimulation. An erection is on the basis of blood expanding these cylinders to the point of penile rigidity. Like any other muscle, the muscle of the penis needs to be used on a regular basis, the way nature intended for it to be used. In the absence of regular sexual activity, disuse atrophy (wasting away with a decline in anatomy and function) of the penile smooth muscle can occur. In a vicious cycle, any loss of sexual function can lead to further progression of the problem. Poor genital blood flow produces a state of poor oxygen levels in the genital tissues, that, in turn, can induce scarring, which further compounds the sexual dysfunction.

Radical prostatectomy, the surgical removal of the entire prostate gland as a treatment for prostate cancer, can cause penile shortening by virtue of the removal of the prostate gland. The resultant gap in the urethra because of the removed prostate is repaired by sewing the bladder to the urethra with a consequent loss of urethral length. Penile shortening can be compounded by the disuse atrophy and scarring that can occur as a result of the erectile dysfunction associated with the surgical procedure, which sometimes can damage the nerves that are responsible for erections. Getting back in the saddle as soon as possible after surgery will help “rehabilitate” the penis by preventing disuse atrophy.

Peyronie’s Disease can cause penile shortening because of scarring of the erectile cylinders that prevents them from expanding properly.

Androgen deprivation therapy is a means of suppressing the male hormone testosterone, typically used as a form of treatment for prostate cancer. The resultant low testosterone level can result in penile atrophy and shrinkage.

Who Knew? Penile enlargement surgery, aka, “augmentation phalloplasty,” is highly risky, ineffective and not ready for prime time. Certain procedures are what I call “sleight of penis” procedures including cutting the suspensory ligaments, disconnecting and moving the attachment of the scrotum to the penile base, and liposuction of the pubic fat pad. These procedures unveil some of the “hidden” penis, but do nothing to enhance overall length. Other procedures attempt to “bulk” the penis by injections of fat, silicone and other tissue grafts. The untoward effects of enlargement surgery can include an unsightly, lumpy, discolored, painful and perhaps poorly functioning penis—certainly a far cry from a “proud soldier” and more like a “wounded warrior.” Realistically, in the quest for a larger member, the best we can hope for is to accept our genetic endowment, remain physically fit, and keep our pelvic floor muscles well conditioned.

Who Knew? The world’s first penis transplant was performed at Guangzhou General Hospital in China when microsurgery was used to transplant a donor penis to the recipient, whose organ was damaged beyond repair in an accident. Hmmm, now there is a concept for penile enlargement.

Andrew Siegel, MD

The aforementioned is largely excerpted from my new book: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; available in e-book (Kindle, iBooks, Nook) and coming soon in paperback.

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:



“Elective” Male Sexual Dysfunction: How We Are Eating Ourselves Limp

June 11, 2011

“It is like a firstborn son—you spend your life working
for him, sacrificing everything for him, and at the
moment of truth, he does just as he pleases.”

Gabriel Garcia Marquez, Love In The Time Of Cholera


Two weeks ago, my blog dealt with the relationship between overeating/obesity and urinary incontinence/pelvic organ prolapse in females. In fairness to the male gender, today’s essay will be how overeating/obesity affects our manhood and vitality. What we eat—or don’t eat—can directly affect our sex lives! While the achievement of good sexual function is predicated upon many factors, it must be recognized that the particular diet we choose plays a definite role in its attainment.

Sexuality is a very important part of our human existence, both for purposes of procreation as well as pleasure. Healthy sexual function involves a satisfactory libido, the ability to obtain and maintain a rigid erection, and the ability to ejaculate and experience a climax. Although not a necessity for a healthy life, the loss or diminution of sexual function can result in loss of self-esteem, embarrassment, a sense of isolation and frustration, and even depression. Therefore, for many of us, it is vital that we maintain our sexual health.
On a functional level, sexuality is a very complex event dependent upon a number of systems, including the endocrine system (which produces sex hormones); the central and peripheral nervous systems (which provide nerve control); and the vascular system (which conducts blood flow). A healthy sexual response is, at its physical essence, largely about adequate blood flow to the genital and pelvic area. Increased blood flow to the genitals from sexual stimulation is responsible for the penis going from a flaccid to an erect state. Blood flow to the penis is analogous to air pressure in a tire: if there is not enough air, thereby causing the tire to be improperly inflated, the tire works less optimally and may even suffer a flat!
The penis is a rather amazing, multifunctional organ that has a role as a urinary organ allowing directed urination that permits men to stand to urinate, and a sexual and reproductive organ that when erect, allows the rigid penis the ability to penetrate the vagina and function as a conduit for release of semen into the vagina. No other organ in the body demonstrates such a great versatility in terms of the physical changes between its “inactive” versus “active” states! The penis has an abundant supply of vascular smooth muscle, and like every other muscle in the body, “use it or lose it” is relevant when it comes to the sexual domain. Disuse atrophy can occur if the penis is not used the way it was designed to be, and this often results in patients complaining of penile shrinkage.
Erectile dysfunction is a common problem, occurring in millions of American men. About one-third of the male population over age 60 is unable to achieve an erection suitable for intercourse. However, erectile dysfunction is NOT an inevitable consequence of the aging process as there are many elderly men who have intact sexual function.
Diminished blood flow occurs most commonly on the basis of an accumulation of fatty plaque deposits within the walls of blood vessels. As we age, physiological and lifestyle factors combine to increase this plaque build-up, causing a significant narrowing of many of the body’s blood vessels. The resultant decrease in blood flow to our organs negatively affects the functioning of all of our systems, since every cell in our body is dependent upon the vascular system for delivery of vital oxygen and nutrients and removal of metabolic waste products. Pelvic atherosclerosis, the accumulation of fatty deposits within the walls of the arteries that bring blood to the penis, will compromise blood flow to the genitals and incite sexual dysfunction.
The presence of erectile dysfunction can be considered the equivalent of a genital stress test and may be indicative of a cardiovascular problem that warrants an evaluation for arterial disease elsewhere in the body (heart, brain, aorta, peripheral blood vessels). In other words, the quality of erections can serve as a barometer of cardiovascular health and those who can get hard attacks are unlikely to get heart attacks. The presence of sexual dysfunction is as much of a predictor of cardiovascular disease as is a strong family history of cardiac disease, tobacco smoking, or elevated cholesterol. The British cardiologist Graham Jackson has expanded the initials E.D. (Erectile Dysfunction) to mean Endothelial Dysfunction (endothelial cells being the type of cells that line the insides of arteries), Early Detection (of cardiovascular disease), and Early Death (if missed). The bottom line is that heart healthy is sexual healthy.

Many adults in the USA are beset with Civilization Syndrome, a cluster of health issues that have arisen as a direct result of our poor dietary choices and sedentary lifestyle. Civilization Syndrome can lead to obesity, high blood pressure, elevated cholesterol, and can result in such health problems as diabetes, heart attack, stroke, cancer, and premature death. The diabetic situation in our nation—often referred to as “diabesity” has become outrageous and it probably comes as no surprise that diabetes is one of the leading causes of sexual dysfunction in the United States.
Obesity (external fat) is associated with internal obesity and fatty matter clogging up the arteries of the body including the pudendal artery, which supplies blood to the penis. Additionally, obesity can have a negative effect on our sex hormone balance (the balance of testosterone and estrogens), further contributing to sexual dysfunction. The fatty tissue present in our obese abdomens contains abundant amounts of the enzyme aromatase—functioning to convert testosterone to estrogen—literally emasculating us! High blood pressure will cause the heart to have to work harder to get the blood flowing through the increased resistance of the arteries. Blood pressure lowering medications will treat this, but as a result of the decreased pressure, there will be less blood flow through the pudendal arteries. Thus blood pressure medications, although very helpful to prevent the negative affects of hypertension—heart attacks, strokes, etc.—will contribute to sexual dysfunction. High cholesterol will cause fatty plaque buildup in our arteries, compromising blood flow and contributing to sexual dysfunction. Tobacco constricts blood vessels and impairs blood flow through our arteries. Smoking is really not very sexy at all! Stress causes a surge of adrenaline release from the adrenal glands. The effect of adrenaline is to constrict blood vessels and decrease sexual function. Hence, the physiologic explanation for the common occurrence of performance anxiety. Interestingly, men with priapism (a prolonged and painful erection) are often treated with penile injections of an adrenaline-like chemical to bring down the erection.
Obesity is stealing away one of our most precious resources—the ability to obtain and maintain good quality erections. Remember the days when you could achieve a rock-hard erection—majestically pointing towards the sky—simply by seeing an attractive woman or thinking some vague sexual thought? Chances were that you were young, active, and perhaps had an abdomen that somewhat resembled a six-pack. The loss in function is often so gradual and insidious that it barely gets noticed. Maybe it takes a great deal of physical stimulation to achieve an erection barely firm enough to be able to penetrate. Maybe penetration is more of a “shove” than a ready, noble, and natural access. Maybe you need “daddy’s little helper”—a little blue pill (Viagra), or yellow pill (Cialis), or orange pill (Levitra), to get the blood flowing.

If this is the case, it is probable that you are carrying extra pounds, have a soft belly, and are not physically active. When you’re soft in the middle, you will probably be soft down below. A flaccid penis is entirely consistent with a flaccid body and a hard penis is congruous with a hard body. Perhaps when you are standing naked in the shower and you gaze down towards your feet, all you see is the protuberant roundness of your large midriff, obscuring the glorious sight of your manhood. Perhaps you’re wondering where your penis is hiding. In most cases, the abundant pubic fat pad that occurs coincident with weight gain obscures the penis, what I like to refer to as the “turtle effect.” If your pubic fat pad makes your penis difficult to find, your man-boobs are competitive with your wife’s breasts, and your libido and erections are just not performing up to par, it may be just time to rethink your lifestyle habits!
So, where does this leave us? It leaves us with what should by now be obvious: a healthy lifestyle is of paramount importance towards the endpoint of achieving an optimal quality and quantity of life. Intelligent lifestyle choices, including proper eating habits, maintaining a healthy weight, engaging in exercise, adequate sleep, alcohol in moderation, avoiding tobacco and stress reduction are the initial approach to treating many of the diseases caused by poor health decisions. Sexual dysfunction is in the category of a medical problem that is brought on by unwise lifestyle choices. It should come as no surprise that the initial approach to managing it is to improve lifestyle choices. By simply improving one’s daily habits, Civilization Syndrome can be ameliorated or even prevented, and the various medical problems that often follow, including sexual dysfunction, can be mitigated.
In terms of maintaining good cardiovascular health—and thus healthy sexual function—eating properly is incredibly important, obviously in conjunction with other smart lifestyle choices. Maintaining a healthy weight and fueling up with wholesome and natural foods will help prevent the build-up of harmful plaque deposits within blood vessels that can lead to compromised blood flow to the penis as well as every other organ. Poor dietary choices with a meal plan replete with calorie-laden, nutritionally-empty selections (e.g., fast food or processed or refined anything), puts one on the fast tract to clogged arteries that can make your sexual function as small as your belly is big!
If you want a “sexier” lifestyle, first start with a “sexier” style of eating that will help you feel better, look better and optimize your sexual, emotional and psychological well-being. Smart nutritional choices are a key component of sexual fitness. Exercise is a fundamentally important component of maintaining good sexual health and partners well with healthy eating. At times, even with the achievement of a very healthy lifestyle, erectile dysfunction can still persist. Under these circumstances, there are numerous excellent treatment modalities available, and the reader is referred to the following links below for more information.



I have done a number of educational videos on the subject of erectile dysfunction. These are intended for mature adults only as they contain language and images of a graphic and sexual nature and viewer discretion is advised.

Introduction to erectile dysfunction:


Penis size:

Causes of erectile dysfunction:

Treatment part 1:

Treatment part 2:

This is just a taste of what you will find in Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food. The website for the book is: It provides information on the book, a trailer, excerpts, ordering instructions, as well as links to a wealth of excellent resources on healthy living. It is also available on Amazon Kindle.

Andrew L. Siegel, M.D.