Posts Tagged ‘erectile dysfunction’

Game Plan for Men’s Healthy Sexual Functioning

September 30, 2017

Andrew Siegel MD 9/30/17


Thank you, Pixabay, for image above.

Functioning well in the bedroom–like health in general–should never be taken for granted. During early adulthood it rarely, if ever, crosses our minds that at sometime in the future many body functions decline, including sexual function.  However, the truth of the matter is that paralleling general health and fitness, maintaining our sexual health and fitness takes some effort to avoid the almost inevitable deterioration in function.  Today’s entry reviews a “game plan” for maintaining healthy sexual functioning into our golden years.

  • Know the Fundamentals

For better or worse, penile erections are not on the basis of a bone in the penis, as they are in many mammals.  Erections occur when pressurized blood inflates the erectile chambers of the penis. The erect penis has blood pressure in excess of 200 mm (extreme hypertension), giving rise to bone-like rigidity and hence the slang term, boner.

The penis is a marvel of hydraulic engineering, uniquely capable of increasing its blood flow 50 times over baseline within nanoseconds of sexual stimulation, transforming its shape and size. This is accomplished by smooth muscle relaxation within the penile arteries and within the sinuses of the erectile chambers.

Once blood inflates the erectile chambers, closure of penile veins and contractions of the pelvic floor muscles effectively trap the pressurized blood in the penis and maintain the penile hypertension necessary for a sustained erection.

  • Know the Stats

The Massachusetts Male Aging Study showed that after age 40 there is a decline in all aspects of sexuality.  Erectile dysfunction (ED) is present in about 40% of men by age 40 with an increase in prevalence of about 10% for each decade thereafter. Although there are many causes of ED, the common denominator is insufficient blood flow to fill the erectile chambers of the penis, or alternatively, sufficient inflow but poor venous trapping, both often caused by a decline in smooth muscle relaxation with aging.

  • Know the Score

Performance ability with every physical activity declines as we get older and this explains why most professional athletes are in their twenties or thirties. Although everything eventually goes to ground, hopefully it will happen slowly. Young men can achieve a rock-hard erection simply by seeing an attractive woman or thinking a vague sexual thought. As we get older, it is not uncommon for erotic thoughts or sights to no longer be enough to provoke an erection, with the need for direct touch. Some of the common male sexual changes that occur with aging are: diminished sex drive; decreased rigidity and durability of erections; decrease in volume, force, and arc of ejaculation; decreased orgasm intensity; and an increased recovery time before being able to get a second erection.  

  • Know the Opponents: Gluttony and Sloth

A healthy weight and healthy eating habits, exercise, adequate quality and quantity of sleep, tobacco avoidance, use of alcohol in moderation, stress avoidance, and a balanced lifestyle will optimize sexual potential.  Abide by the golden rule of the penis: “Treat your penis nicely and it will be nice to you in return; treat your penis poorly and it will rebel.

  • Fuel for Performance

A healthy diet will reduce the risk of sexual dysfunction. Eat a variety of wholesome natural foods including fresh vegetables and fruit, plenty of fiber, lean protein sources, legumes and healthy fats including nuts, avocados and olive oil. Avoid eating processed foods and minimize sugar, refined carbohydrates and highly saturated animal fats.

  • Stay in Peak Form

Try to achieve “fighting weight” to maximize your performance in the sexual arena.

  • Train for Performance

Exercising—including cardio, core, and strength training—is vital for health in general and sexual health in particular. When it comes to sexual health, it is vital to focus on the all-important pelvic floor muscles (PFM). PFMT (pelvic floor muscle training) will help optimize erectile function and prevent/treat ED.

To understand why PFMT can help your performance in the bedroom, it is necessary to have some understanding of what the PFM do. When you have an erection, the bulbocavernosus muscle and ischiocavernosus muscles engage. Contractions of these muscles not only help prevent the exit of blood from the penis, enhancing rigidity, but also increase blood flow to the penis—with each contraction of these muscles, a surge of blood flows into the penis. Additionally, they act as powerful struts to support the roots of the penis (like the roots of a tree), the foundational support that, when robust, will allow a more “skyward” angling erection (like the trunk of a tree).  The bulbocavernosus muscle also is the “motor” of ejaculation, contracting rhythmically at the time of sexual climax and forcing semen out of the urethra.

Increasing the strength, tone and condition of these muscles through PFMT will allow them to function in an enhanced manner—namely more powerful contractions with more penile rigidity and stamina as well as improved ejaculatory issues, including premature ejaculation.

  • Talk to your Coach

Visit the PelvicRx website where you can purchase a male pelvic floor training DVD and have a private chat session with a pelvic floor trainer.

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 dire need of bridging.

Author of:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

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

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Co-creator of the male pelvic floor training DVD: PelvicRx





Practical Approach To Erectile Dysfunction

September 16, 2017

Andrew Siegel MD  9/16/17

shutterstock_side view manjpeg

ED is a highly prevalent condition and a common reason for a urology consultation.  A pragmatic approach to its diagnosis and treatment–the topic of today’s entry–has always worked well for my patients.  A practical approach starts with simple and sensible measures, and only in the event that these are not successful, proceeding with more complex and involved strategies, dividing management options into four tiers of complexity. 

 Principles to managing male sexual issues are the following:

  • If it ‘ain’t broke,’ don’t fix it: “First do no harm.”
  • Educate to enable informed decisions: “The best prescription is knowledge.”
  • Try simple, conservative options before complex and aggressive ones: “Simple is good.”
  • Healthy lifestyle is vital: “Genes load the gun, but lifestyle pulls the trigger.”

Questions that need to be asked in order to evaluate ED include the following:

AS and DM

  • How long has your problem been present?
  • Was the onset sudden or gradual?
  • How is your sexual desire?
  • How is your erection quality on a scale of 0-5 (0 = flaccid; 5 = rigid)?
  • Can you achieve an erection capable of penetration?
  • Is your problem obtaining an erection, maintaining an erection, or both?
  • Is your problem situational? Consistent? Variable?
  • Are nocturnal, early morning and spontaneous erections present?
  • Do you have a bend or deformity to the erect penis?
  • How confident are you about your ability to complete the sexual act?
  • Are there ejaculation issues (rapid, delayed, painful, inability)?
  • Do you have symptoms of low testosterone?
  • What treatments have been tried?

Of equal relevance are medical, nutritional, exercise and surgical history, medications, and use of tobacco, alcohol and recreational drugs.  A tailored physical includes blood pressure, pulses and an exam of the penis, testes and prostate.  Basic lab tests including urinalysis, serum glucose, HbA1c, lipid profile and testosterone.

Information derived from the evaluation as described above will provide a working diagnosis and the ability to formulate a treatment approach.  Although a nuanced and individualized approach is always best, four lines of treatment for ED are defined—from simple to complex—in a similar way that four lines of treatment can be considered for arthritis.  For arthritis of the knee, for example, first-line therapy is weight loss to lessen the mechanical stress on the joint, in conjunction with physical therapy and muscle strengthening exercises. Second-line therapy is anti-inflammatory and other oral medications that can help alleviate the pain and inflammation. Third-line therapy is injections of steroids and other formulations.  Fourth-line therapy is surgery.

If the initial evaluation indicates a high likelihood that the ED is largely psychological/emotional in origin, referral to a qualified psychologist/counselor is often in order.  If the lab evaluation is indicative of low testosterone, additional hormone blood tests to determine the precise cause of the low testosterone are done prior to consideration for treatment aimed at getting the testosterone in normal range.  If the lab evaluation demonstrates unrecognized or poorly controlled diabetes or a risky lipid and cholesterol profile, appropriate medical referral is important.

Practical treatment of ED

elephant penis
 Credit for photo above goes to one of my patients; note the 7 prodigious appendages!

First-line: Lifestyle makeover

 A healthy lifestyle can “reverse” ED naturally, as opposed to “managing” it. ED can be considered a “chronic disease,” and as such, changes in diet and lifestyle can reverse it, prevent its progression and even prevent its onset.

My initial approach is to think “big picture” (and not just one particular aspect of the body working poorly).  Since sexual functioning is based upon many body components working harmoniously (central and peripheral nerve system, hormone system, blood vessel system, smooth and skeletal muscles), the first-line approach is to do what nurtures every cell, tissue and organ in the body. This translates to getting down to “fighting” weight, adopting a heart-healthy and penis-healthy diet (whole foods, nutrient-dense, calorie-light, avoiding processed and refined junk foods), exercising moderately, losing the tobacco habit, consuming alcohol in moderation, managing stress (yoga, meditation, massage, hot baths, whatever it takes, etc.), and getting adequate quantity and quality of sleep. Aside from general exercises (cardio, core, strength and flexibility training), specific pelvic floor muscle exercises (“man-Kegels”) are beneficial to improve the strength, power and endurance of the penile “rigidity” muscles.

If a healthy lifestyle can be adopted, sexual function will often improve dramatically, in parallel to overall health improvements. Many medications have side effects that negatively impact sexual function. A bonus of improved lifestyle is potentially allowing lower dosages or elimination of medications (blood pressure, cholesterol, diabetic meds, etc.), which can further improve sexual function.

“The food you eat is so profoundly instrumental to your health that breakfast, lunch and dinner are in fact exercises in medical decision making.”  Thomas Campbell MD


healthy meal

Above: A nice, healthy meal consisting of salmon, salad, veggies and quinoa


fat belly

Above: Not the kind of belly you want–visceral obesity is a virtual guarantee of pre-diabetes–if not diabetes–and greatly increases one’s risk of cardiovascular disease, including ED

Bottom line: Drop pounds, eat better, move more, stress less, sleep soundly = love better!

Second-line: ED pills and mechanical devices

In my opinion, the oral ED medications should be reserved for when lifestyle optimization fails to improve the sexual issues. This may be at odds with other physicians who find it convenient to simply prescribe meds, and with patients who want the quick and easy fix.  However, as good as Viagra, Levitra, Cialis and Stendra may be, they are expensive, have side effects, are not effective for every patient and cannot be used in everyone, as there are medical situations and medications that you might be on that preclude their use. In the second-line category, I also include the mechanical, non-pharmacological, non-surgical devices, including the Viberect and the vacuum suction devices.

Viagra (Sildenefil). Available in three doses—25, 50, and 100 mg—it is taken on demand and once swallowed, it will increase penile blood flow and produce an erection in most men within 30-60 minutes if they are sexually stimulated, and will remain active for up to 8 hours.

 Levitra (Vardenefil). Similar to Viagra, it is available in 5, 10, and 20 mg doses. Its effectiveness and side effect profile is similar to Viagra.

Cialis (Tadalafil).  Available in 2.5, 5 mg, 10mg, and 20 mg doses, its effectiveness and side effect profile is similar to Viagra. Its duration of action is approximately 36 hours, which has earned it the nickname of “the weekender.” Daily lower doses of Cialis are also FDA-approved for the management of urinary symptoms due to benign prostate enlargement.

Stendra (Avanafil). Similar to Viagra, it is available in 50, 100 and 200 mg doses. Its advantage is rapid onset.

Vacuum suction device                                                                                                                          This is a mechanical means of producing an erection in which the penis is placed within a plastic cylinder connected to a manual or battery-powered vacuum. The negative pressure engorges the penis with blood and a constriction band is temporarily placed around the base of the penis to maintain the erection.

Viberect device                                                                                                                               Initially employed as a means of triggering ejaculation in men with spinal cord injuries using vibrational energy, it has achieved wider use in provoking erections in men with ED. The device has dual arms that are placed in direct contact with the penile shaft. The vibratory stimulation will cause an erection and ultimately induce ejaculation.

Third-line: Vasodilating (increase blood flow) urethral suppositories and penile injections

These drugs are not pills, but other formulations (suppositories and injections) that increase penile blood flow and induce an erection.

M.U.S.E. (Medical urethral system for erection).  This is a vasodilator pellet—available in 125, 250, 500, and 1000 microgram dosages—that is placed into the urinary channel after urinating.  Absorption occurs through the urethra into the adjacent erectile chambers, inducing increased penile blood flow and potentially an erection.

Caverject and Edex (Prostaglandin E1) are vasodilators that when injected directly into the erectile chambers result in increased blood flow and erectile rigidity. After one is taught the technique of self-injection, the medication can be used on demand, resulting in rigid and durable erections.  A combination of medications can be used for optimal results– this combination is known as Trimix and consists of Papaverine, Phentolamine, and Alprostadil.

Fourth-line: Penile implants

There are two types of these devices that are surgically implanted into the erectile chambers under anesthesia, most often on an outpatient basis. Penile implants are totally internal, with no visible external parts, and aim to provide sufficient penile rigidity to permit vaginal penetration.

The semi-rigid device is a simple one-piece flexible unit consisting of paired rods that are implanted into the erectile chambers. The penis with implanted flexible rods is bent up for sexual intercourse and bent down for concealment. The inflatable device is a three-piece unit that is capable of inflation and deflation. Inflatable inner tubes are implanted within the erectile chambers, a fluid reservoir is implanted behind the pubic bone and a control pump in the scrotum, adjacent to the testes. When the patient desires an erection, he pumps the control pump several times, which transfers fluid from the reservoir to the inflatable inner tubes, creating a hydraulic erection which can be used for as long as desired. When the sexual act is completed, he deflates the mechanism via the control pump, transferring fluid back to the reservoir.

Penile implants can be a life changer for a man who cannot achieve a sustainable erection. They provide the necessary penile rigidity to have intercourse whenever and for however long that is desirable.


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.

Men’s Health: Holistic Urology Approach

August 19, 2017

Andrew Siegel MD   8/19/17


Thank you, Pixabay, for image above

Men Don’t Ask For Directions, Etc…

With respect to their health, women are usually adept at preventive care and commonly see an internist or gynecologist regularly.  On the other hand, men—who could certainly take a lesson from the fairer sex—are generally not good at seeing doctors for routine checkups. Not only has our culture indoctrinated in men the philosophy of “playing through pain,” but also the lack of necessity of seeking medical care when not having a specific problem or pain (and even when men do develop dangerous health warning signs, many choose to ignore them.). Consequently, many men have missed out on some vital opportunities: To be screened for risks that can lead to future medical issues; be diagnosed with problems that cause no symptoms (such as high blood pressure, glaucoma and prostate cancer); and counseled regarding means of modifying risk factors and optimizing health.

Many Men Don’t Have A Doc

Urologists evaluate and treat a large roster of male patients, a surprising number of whom have not sought healthcare elsewhere and do not have a primary physician. Urological visits offer an opportunity to not only focus on the specific urological complaint that drives the visit (usually urinary or sexual problems), but also to take a more encompassing holistic health approach, emphasizing modifications in diet, physical activity, and other lifestyle factors that can prevent many untoward consequences and maximize health. By getting men engaged in the healthcare system on a timely basis, they can be helped to minimize those risk factors that typically cause the illnesses that afflict men as they age.

Identifying and modifying risk factors can mitigate, if not prevent, a number of common maladies.  Modifiable risk factors for the primary killer of men—cardiovascular disease—include poor diet, obesity, physical inactivity, excessive alcohol, tobacco consumption, stress, high blood pressure, high blood glucose and diabetes, high cholesterol, obstructive sleep apnea, low testosterone and depression. The bottom line is that every patient contact provides an opportunity for so much more than merely treating the sexual or urinary complaint that brought the patient into the office. Furthermore, many systemic disease processes—including diabetes, obstructive sleep apnea, cardiovascular diseases, etc.—have urological manifestations and symptoms that can be identified by the urologist who in turn can make a referral to the appropriate health care provider.

Erections are an Indicator of Health

Many men may not cherish seeing doctors on a routine basis, but a tipping point occurs when it comes to their penises not functioning!  Erectile dysfunction (ED) is a common reason for men to “bite the bullet” and call their friendly urologist for a consultation. The holistic approach by the consultant urologist is to not only manage the ED, but to diagnose the underlying risk factors that can be a sign of broader health issues than simply poor quality erections. Importantly, ED can be a warning sign of an underlying medical problem, since the quality of erections serves as a barometer of cardiovascular health.

    “A man with ED and no known cardiovascular disease                                                                      is a cardiac patient until proven otherwise.”

Graham Jackson, M.D., cardiologist from the U.K.

Since the penile arteries are small in diameter and the coronary (heart) arteries larger, it stands to reason that if vascular disease—generally a systemic process that is diffuse and not localized—is affecting the tiny penile arteries, it may affect the larger coronary arteries as well, if not now, then at some time in the future. In other words, the fatty deposits that compromise blood flow to the smaller vessels of the penis may also do so to the larger vessels of the heart and thus ED may be considered a “stress test.” In fact, the presence of ED is as much of a predictor of cardiovascular disease as is a strong family history of cardiac problems, tobacco smoking, or elevated cholesterol.

Dr. Jackson cleverly expanded the initials ED to mean: Endothelial dysfunction (endothelial cells line the insides of arteries); early detection (of heart disease); and early death (if missed). For this reason, men with ED should undergo a medical evaluation seeking arterial disease elsewhere in the body (heart, brain, aorta, and peripheral blood vessels).

Urologists have a broad network of colleagues (including internists, cardiologists, pulmonologists, gastroenterologists, medical oncologists, radiologists, radiation oncologists, general surgeons, etc.) that can be collaborated with and to whom patients can be referred to if and when their expertise is needed.

Urine is Golden

Of all the bodily secretions that humans produce, urine uniquely provides one of the best “tells” regarding health.  A simple and inexpensive urinary dipstick can diagnose diabetes, kidney disease, urinary tract infection, the presence of blood and hydration status, in a matter of moments.

What a dipstick can reveal:

specific gravity… hydration status

pH…acidity of urine

leukocytes…urinary infection

blood…many urological disorders including kidney and bladder cancer

nitrite…urinary infection

bilirubin…a yellow pigment found in bile, a substance made by the liver; its presence may be indicative of jaundice

protein…kidney disease


Case report of a recent patient

54-year-old male with six-month history of frequent daytime urination as well as awakening 3-4 times during sleep hours to urinate. Additionally, he has difficulty maintaining erections and premature ejaculation. Physical examination of the abdomen, genitalia and prostate was unremarkable. Urinalysis showed large glucose. Lab studies showed glucose 204 (normally < 100); HbA1c 10.6% (normally < 5.6); testosterone 202 (normally > 300) and PSA 4.2 (elevated for his age). 

He was referred to an internist for management of diabetes that manifested with urinary frequency, elevated urine and blood glucose and elevated HbA1c (a measure of blood glucose levels over the past 6 weeks).  With appropriate management of the diabetes, the urinary frequency resolved. Because of the PSA elevation he is scheduled for an MRI of the prostate, and because of the low testosterone, he is undergoing additional endocrine testing to see if the problem is testicular or pituitary in origin and certainly will be a candidate for medical therapy if improved lifestyle measures fail to sufficiently elevate the testosterone.

Bottom Line: Preventive and proactive care—as many pursue regularly for their prized automobiles (e.g., lubrication and oil changes, replacing worn belts before they snap while on the road, etc.)—provides numerous advantages.  The same strategy should be applied to the human machine!  Since contact with a urologist may be a man’s only connection with the healthcare system, a vital opportunity exists for the urologist to offer holistic care in addition to specialty genital and urinary care.  The goal is to empower men by getting them invested in their own health in order to minimize disease risk and optimize vitality. 

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 


Penile Shockwaves To Improve Erections

June 24, 2017

Andrew Siegel MD   6/24/17

Storz image DUOLITH_SD1_ultra_URO_003Thank you Storz Medical and Robert Remington ( for above image of a shock wave unit used for the treatment of erectile dysfunction; note treatment of both the external (left side of image) and internal aspects of the penis (right side of image)

Shockwaves are acoustic vibrations that carry energy, e.g. the sound waves generated by clapping your hands. Compression and expansion of a medium creates a mechanical force that can be put to practical use. Since the 1980s, urologists have used focused shockwave therapy to pulverize kidney stones, revolutionizing their treatment.  A much tamer form of shockwaves–low energy shockwave therapy–is a new treatment for erectile dysfunction.  When applied to the penis, shock wave therapy causes cellular micro-trauma and mechanical stress, stimulating the growth of new blood vessels and nerve fibers that ultimately improves penile blood flow and erectile function. The long and the short of it is that the physical energy from shockwaves can be tapped into to cause a benefit that can prove advantageous in the bedroom.  

Shockwave therapy–which triggers renewed circulation and induces structural changes that can regenerate and remodel damaged tissues–been used for many medical purposes:

  • chronic wounds
  • neuropathy
  • cardiac disease
  • plantar fasciitis
  • tennis elbow

Shockwave Treatment for Erectile Dysfunction

Erection quality is all about pressurized blood filling and remaining in the erectile chambers of the penis. Although erectile dysfunction (E.D.) typically has many underlying causes, some of the key reasons are aging and lifestyle-related changes in penile arterial blood flow as well as alterations in the integrity of penile erectile tissue. Most treatments for E.D. to date—pills, urethral suppositories, injection therapy, and prosthetic implants—do not treat the underlying cause of the problem nor modify the natural history of the disease.   Penile shockwave therapy can be considered “revolutionary,” since it is a disease-modification paradigm, ultimately changing the health of the erectile tissues and improving penile blood flow .

Penile shocks stimulate penile circulation via growth of new blood vessels, growth of new nerve fibers (neural regeneration), stem cell activation and cellular proliferation, and protein synthesis. On a molecular level, the cell membrane, mitochondria and endoplasmic reticulum respond the most profoundly to shockwaves.  As the cells are mechanically stressed, multiple adaptive pathways triggered, inducing structural changes that are capable of regenerating  and remodeling penile tissue.

In research carried out by Dr. Tom Lue, shockwave therapy was used to treat diabetic rats that had the arteries and nerves responsible for erections surgically tied off. Cellular activation, regeneration of erectile tissue (smooth muscle and endothelial cells), and improved penile blood flow and erectile function was clearly demonstrated.

The pilot human study on penile shockwaves for E.D. was performed in 2010 by Yoram Vardi. 20 patients were treated twice weekly for three weeks, with application of shockwaves to five separate sites on the penis.  This study showed a meaningful increase in erectile rigidity and durability of erections using the International Index of Erectile Function (IIEF) as a metric with improved overall satisfaction and ability to penetrate. An additional study showed positive short-term effects in men who previously had responded well to oral erectile dysfunction medications.  To date, clinical trials have shown both subjective improvement in erectile dysfunction as well as objective increased penile blood flow and erectile rigidity.  In a large randomly controlled trial with over 600 subjects, the average improvement in IIEF was a significant 6.4.

Treatment variables include the shockwave energy, number of shocks delivered, the sites treated and duration of the treatment. For E.D., low energy shockwaves that are less focused than those used for kidney stone fragmentation are used.  Too little energy has proven ineffective, while too much energy can actually kill cells, resulting in scarring and erectile dysfunction.  There seems to be a “sweet spot” in terms of the energy level that will optimize erectile function that is generally about 2-10% of the power of shockwave therapy for kidney stones.  A recent study used ten once-weekly treatment sessions.  During each session, 600 shocks were applied to the erectile chambers of both the internal and external penis with a total of 6000 shocks applied over the course of the 10-week period.  The procedure was found to be well tolerated aside from a slight pricking or vibrating sensation that is perceived during the delivery of the shockwaves.

Bottom Line: Low energy penile shockwave therapy is an exciting new treatment option for men with E.D.  Safe and well tolerated, it works by causing mechanical stress and trauma to erectile tissues, stimulating the growth of new blood vessels and nerve fibers and potentially enabling penile tissue to regain the ability for spontaneous erection.  It uniquely modifies the disease, unlike most traditional E.D. treatments that function as “Band-Aids.”  Further clinical investigation is necessary to determine optimal treatment protocols.  It is highly likely that in the near future, low energy penile shockwave therapy will be approved by the FDA for the treatment of E.D.

For more information on Sonicwave technology from STORZ see FullMast website.

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

Co-creator of the PelvicRx male pelvic floor exercise program:

Putting Some “Lead” In Your Pencil: A Fix For The “Innie” Penis

April 29, 2017

Andrew Siegel MD   4/28/2017

pencil pixbay

Thank you, Pixabay, for image above

As Multi-Functional as a Swiss Army Knife

The penis is an extraordinary organ with urinary, sexual and reproductive functions. The possession of a penis endows man with the ability to stand to urinate and direct his urinary stream, a distinct advantage over the clumsy apparatus of the fairer sex that generates a spraying, poor-directed stream that demands sitting down on a toilet seat. The advantage of being able to stand to urinate (and keep one’s body appropriately distanced from the horrors of many public toilets) is priceless. Although man does not often have to employ this, the capability (when necessary) of urinating outside is another benefit of our design.  Many find the outdoor voiding experience pleasing, observing the pleasant sounds and visuals of a forceful stream striking our target (often a tree) with finesse, creating rivulets and cascades to show for our efforts.

Getting beyond the urinary, the most dramatic penis magic is its ability to change its form in a matter of seconds, morphing into an erect “proud soldier” and enabling the wherewithal for vaginal penetration and with sufficient stimulation, for ejaculation.  All that fun, but really serving the purpose of the passage of genetic material and ultimately the perpetuation of our species…reproductive wizardry!

The water tap that could turn into a pillar of fire.”

Eric Gill

tap pixabay

pixabay pillar

Thank you, Pixabay, for images above


The Sometimes Cruel Process of Aging Does Not Spare the Penis

 “Getting older is an honor and a privilege, but getting old is a burden.”

Beverly Radow (my aunt, who will turn 90-years-old this year)

Long after our reproductive years are over and fatherhood is no longer a consideration, most men still wish to be able to achieve a decent-enough erection to have sexual intercourse.  As well, we still desire to be able to urinate standing upright with laser-like urinary stream precision.

However, the ravages of time (and poor lifestyle habits) can wreak havoc on penile anatomy and function.  Many middle-aged men typically gain a few pounds a year, ultimately developing a bit of a pubic fat pad–the male equivalent of the female mons pubis– and before you know it the penis appears shorter and becomes an “innie” as opposed to an “outie.”  In actuality, penile length is usually more-or-less preserved, with the penis merely hiding behind the fat pad, the “turtle effect.” Lose the fat and presto…the penis reappears. This is why having a plus-sized figure is not a good thing when it comes to size matters.

Useful Factoid: The Angry Inch…It is estimated that there is a one-inch loss in apparent penile length with every 35 lbs. of weight gain.

One of the problems with a shorter and more internal penis is that the forceful and precise urinary stream of yesteryear gives way to a spraying and dribbling-quality stream that can drip down one’s legs, spray over the floor and onto one’s feet (and even at times towards or on the gentleman next to you at the urinal!).

Almost Useless Factoid: Water Sports…Turkey vultures pee on themselves to deal with the heat of the summer on their dark feathers, since they lack sweat glands.  By excreting on their legs, the birds use urine evaporation to cool themselves down in the process of “urohidrosis.”  Unless you are a turkey vulture, peeing on yourself or others is rather undesirable!

The solution to having a recessed penis that is often hidden from sight and has lost its aiming capabilities is to sit on the toilet bowl to urinate, joining the leagues of our female companions who are “stream-challenged” because of their anatomy.

With aging (and poor lifestyle habits) also comes declining sexual function and activity as rigid erections going by the wayside.  However, like any other body part, the penis needs to be used on a regular basis—the way nature intended—in order to maintain its health. In the absence of regular sexual activity, disuse atrophy (wasting away with a decline in anatomy and function) of the penile erectile tissues can occur, resulting in a de-conditioned and smaller penis that does not function like it used to.

Factoid: Disuse Atrophy…If one goes too long without an erection, collagen, smooth muscle, elastin and other erectile tissues may become compromised, resulting in a loss of penile length and girth and limiting one’s ability to achieve an erection.  Conversely, sexual intercourse on a regular basis protects against ED issues and the risk of ED is inversely related to the frequency of intercourse.

The point I am trying to hammer home is that aging, weight gain and poor lifestyle habits often render men with penises that are:

  1. Shrunken and recessed
  2. Unreliable in terms of ability to pee straight, requiring sitting down on the toilet bowl like women
  3. Unreliable with respect to sexual function

Factoid: Point 1 + Point 2 + Point 3 = EMASCULATION (depriving man of his male role and identity)

What To Do?

The first step is to keep one’s body (and penis) as healthy as possible via intelligent lifestyle choices. These include the following: smart eating habits; maintaining a healthy weight; engaging in exercise (including pelvic floor muscle training); obtaining adequate sleep; consuming alcohol in moderation; avoiding tobacco; and stress reduction. The use of ED medications on a low-dose, daily basis can sometimes help all 3 issues.

In the event that the aforementioned means fail to correct the problem, a virtually sure-fire way of rectifying all three issues is by a simple surgical procedure.  Malleable penile implants (penile rods) are surgically placed into each erectile chamber of the penis (the two inner tubes of the penis that under normal circumstances fill with blood to create an erection). The implants act as skeletal framework for the penis (“bones” of the penis). Two USA companies, Coloplast and AMS (American Medical Systems) manufacture the rods that are in current use. They are very similar with subtle differences.

464x261_GenesisColoplast Genesis implant

AMS Spectra

American Medical Systems Spectra implant

The implant procedure of these two stiff-but-flexible rods into the erectile chambers of the penis is performed by a urologist on an outpatient basis.  Like shoes, the penile rods come in a variety of lengths and widths and fundamental to the success of the procedure is to properly measuring the dimensions of the erectile chambers in order to obtain an ideal fit. The small incision needed to implant the rods is closed with sutures that dissolve on their own. Healing typically takes about 6 weeks, after which sexual relations can be initiated.

An erection suitable for penetration and sexual intercourse is available 24-7-365, simply by bending the penis up. The penis is angled down for concealment purposes. It is flexible enough to be comfortably flexed up or down, while rigid enough for intercourse, the best of all worlds.


Penile rods in action, bent down for concealment and up for urination and sex

Bottom Line:  It is not uncommon for aging, weight gain and unhealthy lifestyle factors to conspire to compromise penile anatomy and function with respect to apparent penile size, urinary stream precision and erectile rigidity.  This leaves one emasculated with a penis that is often concealed, shortened and habitually limp, impeding the ability to have sexual intercourse, as well as a spraying quality urinary stream necessitating sitting to urinate.  If lifestyle improvement measures do not correct the situation, literally and figuratively “putting some lead in your pencil” using a simple malleable penile implant can “kill three birds with one stone.” (I could not resist the very mixed metaphor.)  Confidence can be restored with the conversion of the “innie” penis to an “outie,” the ability to resume sexual intercourse and the reestablishment of a directed, non-spraying stream to permit standing to urinate.

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

The Penis Pump (Vacuum Erection Device): What You Need To Know

April 8, 2017

Andrew Siegel MD  4/8/17

The vacuum erection device (VED) is an effective means of inducing a penile erection suitable for sexual intercourse–even in difficult to treat men who have diabetes, spinal cord injury, or after radical prostatectomy for prostate cancer.  The device is also useful in the post-operative period following radical prostatectomy to maintain penile length and girth. It has some utility in Peyronie’s disease patients in order to improve curvature, pain and maintain penile dimensions. It can be used prior to penile prosthesis surgery in order to enhance penile length and facilitate the placement of the largest possible implant.  


Image Above: Vacuum Erection Device (obtainable via–use promo code UROLOGY 10 for 10% discount and free shipping)


Tissue expansion is local tissue enlargement in response to a force that can be internal or external.  Internal tissue expansion occurs naturally with pregnancy, weight gain and the presence of slow growing tumors. Plastic surgeons commonly tap into this principle by using implantable tissue expanders prior to breast reconstructive surgery.

The VED uses the principle of external tissue expansion by using negative pressures applied to the penis to stretch the smooth muscle and sinuses of the penile erectile chambers. The resultant influx of blood increases tissue oxygenation, activates tissue nutrient factors, mobilizes stem cells, helps prevent tissue scarring and cellular death and, importantly, induces an erection.

There are many commercially available VEDs on the market, which share in common a cylinder chamber with one end closed off, a vacuum pump and a constriction ring.  The penis is inserted into the cylinder chamber and an erection is induced by virtue of a vacuum that creates negative pressures and literally sucks blood into the erectile chambers of the penis. To maintain the erection after the vacuum is released, a constriction ring is applied to the base of the penis.  The end result is a rigid penis capable of penetrative intercourse.

Interesting factoid: Similarly designed vacuum suction devices are available for purposes of nipple and clitoral stimulation.

Brief History of VED

In 1874, an American physician named  John King came up with the concept of using a glass exhauster to induce a penile erection. The problem with the device was the loss of the erection as soon as the penis was withdrawn from the exhauster. In 1917 Otto Lederer introduced the first vacuum suction device.  After many years of quiescence, the VED was popularized by Geddins Osbon and named “the Erecaid device.” Currently, the VED is a popular mechanical means of inducing an erection that does not utilize medications or surgery.

Nuts and Bolts of VED Use

The VED is prepared by placing a constriction ring over the open end of the cylinder. A water-soluble lubricant is applied to the base of the penis to achieve a tight seal when the penis is placed into the cylinder.  Either a manual or automatic pump is used to generate negative pressures within the cylinder, which pulls blood into the penis, causing fullness and ultimately rigidity. Once full rigidity is achieved, the constriction ring is pushed off the cylinder onto the base of the penis. Importantly, the ring should never be left on for more than 30 minutes to minimize the likelihood of problems. After the sexual act is completed, the constriction ring must be removed.

Interesting Factoid: The VED can be used alone or in combination with other forms of treatment for ED, including pills (Viagra, Levitra and Cialis), penile injection therapy and penile prostheses.

Pluses and Minuses of the VED

A distinct advantage of the VED is that it is a simple mechanical treatment that does not require drugs or surgery.  Disadvantages are the need for preparation time, which impairs spontaneity.  Another disadvantage is the necessity for wearing the constriction device, which can be uncomfortable and can cause “hinging” at the site of application of the constriction ring resulting in a floppy penis (because of lack of rigidity of the deep roots of the penis) as well as impairing ejaculation. Other potential issues are temporary discomfort or pain, coolness, numbness, altered sensation, engorgement of the penile head, and black and blue areas.

VED After Radical Prostatectomy

Erectile function can be adversely affected by radical prostatectomy with recovery taking months to years. The VED can be used to enhance the speed and extent of sexual recovery after surgery, minimize the decrease in penile length and girth that can occur, and enable achievement of a rigid erection suitable for sexual intercourse.  Clinical studies have clearly demonstrated that VED use after prostatectomy helps maintain existing penile length and prevents loss of length.

Bottom Line:  The VED is one of the oldest treatments for ED that remains in contemporary use.  It works by creating negative pressures that cause an influx of blood into the penile erectile chambers resulting in penile expansion and erection.  Although effective even in difficult to treat populations, the attrition rate is high, perhaps because of the cumbersome nature of the device and the preparation regimen and time involved. However, the VED is an important part of the “erection recovery program” (penile rehabilitation) after prostatectomy, second only to oral ED pills in use for this purpose. It is particularly vital in the preservation and restoration of penile anatomy and size.  It also is useful in ED related to other radical pelvic surgical procedures including colectomy for colon cancer. It remains a viable alternative in men not interested or responsive to ED pills or penile injections and those not interested in surgery.

There are many different VED systems on the market. The Urology Health Store ( has a nice selection of VEDs (use promo code UROLOGY 10 for 10% discount and free shipping).

** The Urology Health Store  is offering live video VED instructional classes via Skype, Go-To-Meeting or FaceTime.  These classes are available by appointment from 1PM-3PM, U.S. Eastern Time, Monday-Friday.  Call 301-378-8433 for appointment.  No purchase is necessary to take the class.

Excellent resource: External Mechanical Devices and Vascular Surgery for Erectile Dysfunction.  L Trost, R Munarriz, R Wang, A Morey and L Levine: J Sex Med 2016; 13:1579-1617

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

Male Sexual Enhancement Supplements: Don’t Waste Your Money

January 28, 2017

Andrew Siegel MD  1/28/17

During my urology clinic hours at least one patient a day–if not more–shows me a recently purchased bottle of herbal supplements slated as beneficial for “sexual health.”  The composition of these products often includes one or more of the following: arginine, ginko biloba, horny goat weed, maca, yohimbine, etc. After I have had a chance to look at the product and its ingredients the following question is typically posed: “Any good, doc?”  I often reply with: “Don’t waste your money, you’re getting stiffed.”  (Pun intended.)


Image above from Wikipedia Commons, public domain


The male herbal enhancement business is billion dollar in scale, one that preys upon the desperation of men willing do anything to improve/enhance the dimensions of their penis and sexual function. Unfortunately, many men believe erroneously that supplements are natural and innocuous solutions to an array of sexual issues. The truth of the matter is that most sexual enhancement products are ineffective and make false claims. Of those that do have some beneficial effects, many contain small amounts of the chemicals used in legitimate ED medications without that being indicated on the label. The problem is that the quantity of added Viagra, Cialis, etc., is unknown and the origin a mystery, often counterfeit and/or produced in unregistered and unregulated labs. An additional problem is that the presence of these legitimate medicines in the herbal product makes the supplement dangerous to a segment of the population in which their usage is contraindicated.

Because these products are “supplements,” they are not under the domain of the FDA and therefore not subject to the regulation and scrutiny normally directed towards FDA approved pharmaceutical products. Furthermore, when a problem surfaces with one of these herbal products, the FDA will do no more than issue consumer alerts and request a voluntary recall.

Bottom Line: When it comes to male sexual enhancement supplements, save your resources, which would be much better spent elsewhere. Now that there is a generic 20 mg formulation of Viagra available (Sildenafil), you can get “stiff” without being “stiffed.” See your urologist for an ED consultation instead of heading to the Internet or convenience store to hunt for ineffective herbal products that are often tainted and contaminated.

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

Testosterone Update 2017: Untangling The Web

January 21, 2017

Andrew Siegel, MD   1/21/17

Testosterone deficiency (TD) is a not uncommon male medical condition marked by characteristic symptoms and physical findings in the face of low levels or low activity of testosterone (T). TD is most often seen in men above the age of 50 years and is a frequent reason for why men make appointments with urologists.


What are the 3 best predictors of TD?

1. Decreased sex drive

2. Erectile dysfunction (ED)

3. Decreased frequency of morning erections

T is a hormone that is essential to male vitality. TD can affect the function of many different organ systems and negatively impact one’s quality of life. Its signs and symptoms can vary greatly. Since T regulates the male sexual response—including desire, arousal, erections, ejaculation and orgasm—sexual dysfunction is a common component of TD and is often the presenting symptom. Low T can give rise to diminished libido, altered penile rigidity, decreased morning and nocturnal erections, decreased ejaculate volume and has been associated with delayed ejaculation. Other common symptoms are decreased energy and vigor, fatigue, muscle weakness, increased body fat, depression and impaired concentration and cognitive ability. Common signs are weight gain, visceral obesity (increased waist circumference), decreased muscle mass and bone density, decreased body and pubic hair, gynecomastia (male breast development) and anemia.

TD is often seen in men with chronic diseases including obesity, diabetes, metabolic syndrome, osteoporosis, HIV infection, opioid drug abuse, and chronic steroid usage.

Why does TD occur?

TD can result from a problem with the ability of the testes to produce T, or alternatively, because of an issue with the hypothalamus or pituitary gland in which there is inadequate production of the hormones that trigger testes production of T. At times there is adequate T, but impairment of T action because of inability of T to bind to the appropriate receptors. Additionally, increased levels of sex hormone binding globulin (SHBG), a molecule that binds T, can result in decreased levels of “available” T despite normal T levels.

Not an Exact Science

It is important to note that not everybody who has a low T level will have characteristic signs and symptoms and also that it is possible to have signs and symptoms of TD with a normal T level.

 Checking for TD should be done under the circumstance of a male complaining of any of the aforementioned symptoms and signs. Shortcomings of measuring T levels are results that can vary from laboratory to laboratory, a lack of a consistent and clinically relevant reference range for T, the variability of T levels depending on time of day that levels are drawn (values are highest in the early morning) and the fact that it is the free T and not the total T (TT) that is “available” to most tissues. T circulates in the blood mainly bound to proteins (SHBG and albumin). It is free T and albumin-bound T that are tissue “available” and active.

If TT and/or free T are low, the levels of the pituitary hormones luteinizing hormone (LH) and prolactin (P) levels should be obtained to distinguish between a pituitary versus a testes issue. Symptomatic men with a TT < 350 are candidates for treatment. A 3-6 month trial of treatment may also be considered in men with symptoms and signs, but without definitive TD on lab testing since there is no absolute T level that will reliably distinguish who will or will not respond to treatment.

T and Prostate Cancer

Although testosterone deprivation has proven effective in treating advanced prostate cancer, there is no evidence to support that treatment of TD with T will increase the risk of prostate cancer. Studies indicate that if T < 250, increasing levels of T will stimulate prostate growth, but once T > 250, a saturation point (threshold) is reached with further increases in T causing little or no additional prostate growth.

T and Cardiac Disease

 A broad review of many articles fails to support the view that T use is associated with cardiovascular risks. In fact, the weight of evidence suggests that treating TD offers cardiovascular benefits.

T and Fertility

T causes impaired sperm production as T is a natural contraception and T replacement should not be used in men desiring to initiate a pregnancy.

TD Treatment

There are numerous different means of T treatment. T pills are not a satisfactory option since testosterone is inactivated in its pass through the liver. There is a buccal formulation that is placed and absorbed between the gum and cheek. There are numerous skin formulations including patches and gels. These skin formulations are commonly used, but are expensive, carry the risk of transference to children, spouses, and pets, and can cause skin irritation. They have the advantage of flexible dosing, easy administration, and immediate decrease in T levels after stopping treatment. Long-acting T pellets can be implanted in the fatty tissue of the buttocks, generally effective for 3 to 4 months or so. The insurance hoops that are required to get this formulation approved and covered have proven to be a major challenge. T injections are also commonly used, typically using a slowly absorbed “depot” injection that, depending on the dosage, can last 1-3 weeks. There is also a very long-acting formulation that, like the T pellets, requires a very taxing process to gain insurance approval.

As an alternative to T replacement, clomiphene citrate is a selective estrogen receptor modulator that when taken on a daily basis will increase both testosterone levels and sperm count by stimulating natural testes production. Human chorionic gonadotropin (hCG) can be used as well. Advantages are that they stimulate natural testosterone production and do not impair sperm count.

Adverse Effects of T Treatment

Careful monitoring is imperative for anybody on T treatment. T levels must be checked in order to assure levels in the proper range. Prostate exams and PSA levels are used to monitor the prostate gland and a periodic blood count is performed to ensure that one’s red blood cell count does not becoming too elevated, which can incur the risk of developing blood clots.

It is important to understand that external T will suppress whatever natural T is being made by the testes, since the body recognizes the T and the testes loses its stimulation to produce both T and sperm. Long term T use can cause atrophy (shrinkage) of the testes.

Ongoing Treatment

Those patients who are experiencing benefits of T treatment can have periodic “holidays” of discontinuation to reassess the continued need for the treatment.

Excellent resource: Diagnosis And Treatment Of Testosterone Deficiency: Recommendations From The Fourth International Consultation For Sexual Medicine, Journal of Sexual Medicine 2016; 13:1787 – 1804

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

Erection “Destiny”

December 24, 2016

Andrew Siegel MD  12/24/2016

Uninformed, uneducated and unprepared for the aging process, one has little choice but to passively observe and accept the gradual changes that unfold over time.  The purpose of this entry is to inform, educate and prepare you for the expectations of sexual function as you age.  Sadly, it is often not a pretty picture as aging can be unkind and Father Time does not spare sexual function.

Although erectile dysfunction (ED) is not inevitable, with each passing decade, more and more men join the ED club. All aspects of sexuality decline, although sexual interest suffers the least depreciation, leading to a swarm of men who are eager, but unable–a most frustrating combination. With aging there is typically less sexual activity, and with less sexual activity “disuse atrophy” in which the de-conditioned penis becomes smaller in stature and, in a vicious cycle, even less functional. The senior years also bear witness to the testicles dangling loosely like pendulous breasts of elderly women. Time and gravity are cruel conspirators.

shutterstock_side view manjpeg

A Few Definitions

Erection: The rigid state of the penis under circumstances of sexual stimulation.

Destiny: What the future has in store for you.

Erection Destiny: What the future has in store for your erection capabilities.

What Might Be In Store In The Future

The general trends that follow are structured by decade. Individuals may vary significantly from others in their age group, as “chronological” age is not the ultimate factor and may be trumped by “functional” age.  This guide was crafted after many years spent in the urology trenches, working the front line with thousands of patient interactions.

Age 18-30: Your sexual appetite is prodigious and sex often occupies the front burners of your mind. It requires very little stimulation to achieve an erection—even the wind blowing the right way might be enough to stimulate a rigid, gravity-defying erection, pointing proudly at the heavens. The sight of an attractive woman, the scent of her perfume, merely the thought of her can fully arouse you. You get erections even when you don’t want them…if there was only a way to bank these for later in life! You wake up in the middle of the night sporting a rigid erection. When you climax, the orgasm is intense, forceful and powerful. When you arise from sleep, it is not just you that has arisen, but also your penis.

It doesn’t get better than this…you are an invincible king… a professional athlete at the peak of his career! All right, maybe not invincible…you do have an Achilles heel—you may sometimes ejaculate prematurely because you are so hyper-excitable and at times in a new sexual situation you have performance anxiety, a mechanical failure brought on by your all-powerful mind dooming the capabilities of your exceptional plumbing.

Age 30-40: Changes occur ever so slowly, perhaps so gradually that they are barely noticeable. Your sex drive remains vigorous, but not as obsessive and all consuming as it once was. You can still get quality erections, but they may not occur as spontaneously, as frequently and with such little provocation as they did previously. You may require some touch to develop full rigidity. You still wake up in the middle of the night with an erection and experience “morning wood.” Ejaculations and orgasms are hardy, but you may notice some subtle differences, with your “rifle” being a little less powerful and of smaller caliber. The time it takes to achieve another erection after ejaculating increases. You are that athlete in the twilight of his career, seasoned and experienced, with the premature ejaculation of yonder years occurring much less frequently.

Age 40-50: After age 40, changes become more obvious. You are still interested in sex, but not nearly with the passion you had two decades earlier. You can usually get a pretty good-quality erection, but it now often requires touch and the rock-star rigidity of years gone by gives way to a firm penis, still suitable for penetration. The gravity-defying erections don’t have quite the upward angle they used to. At times you may lose the erection before the sexual act is completed. You notice that orgasms have lost some of their kick and ejaculation has become feebler than previously. Getting a second erection after climax is not only more difficult, but also may be something that you no longer have much interest in. All in all though, you still have some game left.

Age 50-60: Sex is still important to you and your desire is still there, but is typically diminished. Your erection can still be respectable and functional, but is not the majestic sight that it once was, and touch is often necessary for full arousal. Nighttime and morning erections become few and far between. The frequency of intercourse declines while the frequency of prematurely losing the erection before the sexual act is complete increases. A dribbling-quality ejaculation occurs with diminished volume and force, begging the question of why you are “drying up.” Orgasms are less intense and at times it feels like nothing much happened—more “firecracker” than “fireworks.” Getting a second erection is difficult, and you may find much more delight in sleeping rather than pursuing a sexual encore. Sex is no longer a sport, but a recreational activity…sometimes just reserved for the weekends.

Age 60-70: “Sexagenarian” is a misleading word…more apt a term for the 18-30 year-old group, because your sex life doesn’t compare to theirs—they are the athletes and you the spectators. Your testosterone level has plummeted over the decades, probably accounting for your diminished desire. Erections are still obtainable with some coaxing, but they are not five star erections, more like three stars, suitable for penetration, but not the rigid flagpole of yonder years. They are less reliable, and at times your penis suffers with “attention deficit disorder,” unable to focus and losing its mojo prematurely, unable to complete the task at hand. Spontaneous erections, nighttime, and early morning erections become rare occurrences. Climax is not so climactic and explosive ejaculations are a matter of history. At times, you think you climaxed, but are unsure because the sensation was un-sensational. Ejaculation is down to a mere dribble. Seconds?…no thank you…that is reserved for helpings on the dinner table! Sex is no longer a recreational activity, but an occasional amusement.

Age 70-80: When asked about his sexual function, my 70-something-year-old patient replied: “Retired…and I’m really upset that I’m not even upset.”

You may still have some lingering sexual desire left in you, but it’s a far cry from the fire in your groin that you had when you were young. With physical coaxing and coercion, your penis can at times be prodded to rise to the occasion, like a cobra responding to the beck and call of the flute of the snake charmer. The quality of erections has noticeably dropped, with penile fullness without the rigidity that used to make penetration such a breeze. At times, the best that you can do is to obtain a partial erection that cannot penetrate, despite pushing, shoving and manipulating. Spontaneous erections have gone the way of the 8-track player. Thank goodness for discovering that even a limp penis can be stimulated to climax, so it is still possible for you to experience sexual intimacy, although the cli-“max” is more like a cli-“min.”

Age 80-90: You are now a full-fledged member of a group that has an ever-increasing constituency—the ED club. Although you as an octogenarian may still be able to have sex, most of your brethren cannot; however, they remain appreciative that at least they still have their penises to use as spigots, allowing them to stand to urinate, a distinct competitive advantage over the womenfolk. Compounding the problem is that your spouse is no longer a spring chicken and because she has likely been post-menopausal for many years, she has a significantly reduced sex drive and vaginal dryness, making sex downright difficult, if not impossible. If you are able to have sex on your birthday and anniversary, you are doing much better than most. To quote one of my octogenarian patients in reference to his penis: “It’s like walking around with a dead fish.”

Age 90-100: To quote the comedian George Burns: “Sex at age 90 is like trying to shoot pool with a rope.” You are grateful to be alive and in the grand scheme of things, sex is low on the list of priorities. You can live vicariously through pleasant memories of your days of glory that are lodged deep in the recesses of your mind, as long as your memory holds out. When and if you do get an erection, you never want to waste it!

Sometimes A Cigar Is More Than A Cigar

Although changes in sexual function are virtually inevitable with the aging process, a decline is sexual function can also be a “canary in the trousers”—an indicator that a underlying medical problem exists that is of greater significance than the ED. In other words, erection quality can serve as a barometer of cardiovascular health– rigid and durable erections a gauge of good cardiovascular health and ED often a clue of poor cardiovascular health. Since the blood flow to the small penile arteries (diameter 1-2 millimeters) is often compromised in ED, the larger coronary arteries (4 millimeters) may be affected as well—if not now, then at some point in the not-to-distant future. For this reason, men with ED should have a medical evaluation seeking arterial disease elsewhere in the body.

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 & Urinary Health

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

The Little Muscles That Could: The Mysterious Muscles You Should Be Exercising

November 5, 2016

Andrew Siegel MD 11/5/2016

This entry was a feature article in the Fall 2016 edition of BC The Magazine: Health, Beauty & Fitness.

(A new blog is posted weekly. To receive the blogs via email go to the following link and click on “email subscription”:


Image above: female pelvic floor muscles, illustration by Ashley Halsey from The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health


Image above: male pelvic floor muscles, illustration by Christine Vecchione from Male Pelvic Fitness: Optimizing Sexual and Urinary Health

There are over 600 muscles in the human body and they all are there for good reasons. However, some are more critical to health and survival than others. In the class rank it is a no-brainer that the heart muscle is valedictorian, followed by the diaphragm. What may surprise you is that the pelvic floor muscles (a.k.a. Kegel muscles) rank in the top ten of the hierarchy.

The pelvic floor muscles are a muscular hammock that make up the floor of the “core” muscles. They are located in the nether regions and form the bottom of the pelvis. They are among the most versatile muscles in the body, equally essential in both women and men for the support of the pelvic organs, bladder and bowel control and sexual function. Because they are out of sight they are frequently out of mind and often not considered when it comes to exercise and fitness. However, without functional pelvic muscles, our pelvic organs would dangle and we would be diapered and asexual.

Our bodies are comprised of a variety of muscle types: There are the glamour, for show, mirror-appeal, overt, seen and be witnessed muscles that offer no secrets—“what you see is what you get”—the biceps, triceps, pectorals, latissimus, quadriceps, etc. Then there are muscles including the pelvic floor muscles that are shrouded in secrecy, hidden from view, concealed and covert, unseen and behind the scenes, unrecognized and misunderstood, favoring function over form, “go” rather than “show.” Most of us can probably point out our “bi’s” (biceps), “tri’s” (triceps), “quads” (quadriceps), “pecs” (pectorals), etc., but who really knows where their “pelvs” (pelvic floor muscles) are located? For that matter, who even knows what they are and how they contribute to pelvic health?

Strong puritanical cultural roots influence our thoughts and feelings about our nether regions. Consequently, this “saddle” region of our bodies (the part in contact with a bicycle seat)—often fails to attain the respect and attention that other zones of our bodies command. Cloaking increases mystique, and so it is for these pelvic muscles, not only obscured by clothing, but also residing in that most curious of regions–an area concealed from view even when we are unclothed. Furthermore, the mystique is contributed to by the mysterious powers of the pelvic floor muscles, which straddle the gamut of being critical for what may be considered the most pleasurable and refined of human pursuits—sex—but equally integral to what may be considered the basest of human activities—bowel and bladder function.

The deep pelvic floor muscles span from the pubic bone in front to the tailbone in the back, and from pelvic sidewall to pelvic sidewall, between the “sit” bones. The superficial pelvic floor muscles are situated under the surface of the external genitals and anus. The pelvic floor muscles are stabilizers and compressors rather than movers (joint movement and locomotion), the more typical role that skeletal muscles such as these play. Stabilizers support the pelvic organs, keeping them in proper position. Compressors act as sphincters—enveloping the urinary, gynecological and intestinal tracts, opening and closing to provide valve-like control. The superficial pelvic floor muscles act to compress the deep roots of the genitals, trapping blood within these structures and preparing the male and female sexual organs for sexual intercourse; additionally, they contract rhythmically at the time of sexual climax. Although the pelvic floor muscles are not muscles of glamour, they are certainly muscles of “amour”!

Pelvic floor muscle “dysfunction” is a common condition referring to when the pelvic floor muscles are not functioning properly. It affects both women and men and can seriously impact the quality of one’s life. The condition can range from “low tone” to “high tone.” Low tone occurs when the pelvic muscles lack in strength and endurance and is often associated with stress urinary incontinence (urinary leakage with coughing, sneezing, laughing, exercising and other physical activities); pelvic organ prolapse (when one or more of the female pelvic organs falls into the space of the vagina and at times outside the vagina); and altered sexual function, e.g., erectile dysfunction or vaginal looseness.  High tone occurs when the pelvic floor muscles are over-tensioned and unable to relax, giving rise to a pain syndrome known as pelvic floor tension myalgia.

A first-line means of dealing with pelvic floor dysfunction is getting these muscles in tip-top shape. Tapping into and harnessing their energy can help optimize pelvic, sexual and urinary health in both genders. Like other skeletal muscles, the pelvic muscles are capable of making adaptive changes when targeted exercise is applied to them. Pelvic floor training involves gaining facility with both the contracting and the relaxing phases of pelvic muscle function. Their structure and function can be enhanced, resulting in broader, thicker and firmer muscles and the ability to generate a powerful contraction at will—necessary for pelvic wellbeing.

Pelvic floor muscle training can be effective in stabilizing, improving and even preventing issues with pelvic support, sexual function, and urinary and bowel control. Pursuing pelvic floor muscle training before pregnancy will make carrying the pregnancy easier and will facilitate labor and delivery; it will also allow for the effortless resumption of the exercises in the post-partum period in order to re-tone the vagina, as the exercises were learned under ideal circumstances, prior to childbirth. Similarly, engaging in pelvic training before prostate cancer surgery will facilitate the resumption of urinary control and sexual function after surgery. Based upon solid exercise science, pelvic floor muscle training can help maintain pelvic integrity and optimal function well into old age.

Bottom Line: Although concealed from view, the pelvic floor muscles are extremely important muscles that deserve serious respect. These muscles are responsible for powerful and vital functions that can be significantly improved/enhanced when intensified by training. It is never too late to begin pelvic floor muscle training exercises—so start now to optimize your pelvic, sexual, urinary, and bowel health.

Wishing you the best of health,

2014-04-23 20:16:29

Andrew Siegel MD practices in Maywood, NJ. He is dual board-certified in urology and female pelvic medicine/reconstructive surgery and is Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and attending urologist at Hackensack University Medical Center. He is a Castle Connolly Top Doctor New York Metro area and Top Doctor New Jersey. He is the author ofTHE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health ( and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health ( He is co-creator of PelvicRx, an interactive, FDA-registered pelvic floor muscle-training program that empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance, this program helps improve sexual function and urinary function. In the works is the female PelvicRx pelvic floor muscle training for women. Visit: to obtain PelvicRx. Use promo code “UROLOGY10” at checkout for 10% discount.