Sexual function in men is a combination of motivation or sex drive/desire and mechanics i.e., the equipment working properly. These two functions are by no means separate and distinct. An erection begins with sensory and mental stimulation. Impulses from the brain and local nerves cause the release of nitric oxide that cause the muscles of the penis to relax allowing blood to flow into the spongy tissue of the penis making it hard. Man's ability to have an erection is a recurring miracle of hydraulic engineering.

Possible solutions:

Risking over simplification we will endeavor to keep it to a two-step problem and three-step solution.

Problem 1:

No desire/no sex drive. Cause – lack of nerve stimulation in the brain: Think of it as priming the pump - the body has to want to do it. The want/sex drive/desire is controlled by testosterone stimulating nerves in the brain.

Solution 1:

Replacing testosterone to healthy levels should take care of sex drive and often also takes care of issues of sexual mechanics or function by causing the body to produce the all important nitric oxide.

Problem 2:

Desire is there but mechanics/function is not where it should be. If desire is there but the mechanics are still not what they should be, you need to look to something that will increase the flow of blood in the penis.

Solution 2a:

That substance is nitric oxide. Nitric oxide is produced in several areas of the body. A key area of production is the walls of the arteries. Arteriosclerosis (build up of plaque in the arteries) inhibits the production of nitric oxide and also contributes to blocking the flow of blood particularly to the There are several alternatives available to counter this and we would suggest you take it in stages. There are non-prescriptive products that contain things like L-Arginine, gingko biloba, etc. that work nicely as an assist to mechanics by increasing levels of nitric oxide and blood flow. There are many of these products on the market and we have looked long and hard to find one with a good formula and a manufacturer. We like a product called Male Performance Plus. This product also contains yohimbine to aid in nerve stimulation but in such quantity that it should not be a risk to increased heart rate.

Solution 2:

If the problem still persists, the next step is to use something like prescription Viagra for men, which adds significant amounts of nitric oxide to the blood. We have found the above process for dealing with sexual function in men takes care of 90% of the problems. We would also advise approaching the problem in the above sequence. An anecdote makes the point: We had a call recently from a gentleman who was 47-years-old and had been put on Viagra by his doctor to deal with some sexual performance concerns. He called us stating that he had a good erection but no desire to use it.

We recommend that our clients take care of the hormone issues first by getting testosterone replaced to a healthy level and proceed from there as necessary. As frequently is the case, when we raised the above gentleman's testosterone he found he did not need the Viagra.

More technical information for those who are interested

Research indicates that as many as 3 percent of men at age 40 may be impotent. This is a terrible figure and it does not get any better as men get older. By age seventy, over 40 percent of men are impotent. Why is this? To understand one possible cause, we need to look at the mechanism of erection.

Dr Eugene Shipman in his book the "Testosterone Syndrome" describes this in great detail. To sum up what he says: two muscles extend forward from the bones on which we sit, to support and anchor the base of the penis. The fibers of one of these muscles, called the ischio cavernosa, surround the main chambers of the penis, the corporae cavernosae, at their base, and are mainly responsible for allowing arterial dilation and promoting venous constriction during an erection so that blood cannot escape. There is in fact up to eight times more blood in an erect penis than a flaccid one. Another muscle of the penis is called the bulbo cavernosa; it causes the expansion in the chamber at the head of the penis. It also allows a man to "twitch" his penis upwards, and is responsible for the force of ejaculation and the pleasurable sensations that go with it. All of the muscles - and even the nerve fibers - in the genital region have many more testosterone receptors than those in other parts of the body. This is no coincidence.

As Shippen emphasizes, it is testosterone that maintains the conditioning of the vital muscles of the genital region. Without hormonal input, the muscles gradually wither and sustained fullness of erection becomes impossible. Even more catastrophically, a decrease in the tension of the ischio cavernosa prevents blood from being maintained in the chambers of the penis, with results as "deflating to the ego as a flat tire in the Indianapolis 500".

The fact that testosterone is responsible for much of the functioning of a man's sexual organs has been demonstrated by studies in rats. When male rats are castrated, the muscle fibers in the genital muscles degenerate rapidly: even the nerve-endings cease to transmit messages effectively. The rat, perhaps not surprisingly, begins to lose interest in sex as well as his capacity to produce an erection. Needless to say, when testosterone is administered, the rats regenerate both muscles and nerves and their sexual function is brought back almost one hundred percent. It seems that although mankind may differ from rats in many ways in this respect of our physiology we have much in common.

Shippen takes the view that hormonal solutions to erectile dysfunction will work in a majority of cases, although he does admit that not every man gets erectile function back after hormone administration. He points out that many things can damage the circulatory system of the penis: drinking, smoking, fatty deposits in the arteries, and the actions of certain drugs can all destroy the capacity of the penile vascular system to function correctly. Indeed, one of the tests of correct functioning is a blood pressure test. If the pressure in the man's penis is not the same as in his arm, it implies there has been some permanent degeneration of the vascular system in the penis that bodes ill for his ability to be restored to sexual function. And Shippen also points out that estrogen, or more correctly estradiol, can be as much of an enemy on the testosterone receptors of the genital region as it is elsewhere on a man's body. He also emphasizes that restoration of sexual function may take a while as the muscles and nerves regenerate to a fully effective state. Indeed, he says that it may take as long as a year, but he maintains that the majority of his patients are restored to sexual function.

Shippen makes other important points to support his case. For example, the overall importance of adequate testosterone levels in the sexually active man is illustrated by the subtlety of its effects, which extend to the biochemical: testosterone in the penis seems to stimulate the production of nitric oxide gas. Nitric oxide is a neurotransmitter that stimulates nerves and stimulates open blood vessels to create erections and hence full sexual function.