Dr. Susie Gronski
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The Skinny About Hard-Ons 🍆

Photo by  Annie Spratt  on  Unsplash

Ah, the penis. Despite what you think you know, many guys don’t actually have the full lowdown on how this body part operates.

But if you’re interested in achieving an erection - and I think you are! - it’s important to understand how it requires a team approach between your mind, nervous system and blood flow.[1]

The most important organ involved for arousal and erection is the one that sits between your ears. Your brain! The brain releases chemicals that signal all systems go.

Dopamine and oxytocin are brain chemicals that ignite the nerves going to the penis to release a molecule called nitric oxide (NO). Nitric oxide relaxes the arteries in your penis to allow blood flow to enter. And voilà! You got yourself a boner.

Sounds simple, right? I wish it were that simple.

Anywhere on the path from the brain, spinal cord or nerves to the penis, you can put a damper on the fun ‘down there.’ And all it takes is one time when things don’t work well to build worry in your mind about the next time, and the next, and the next.

Your penis doesn't know the difference between a bear chasing you or a “what if it happens next time?” worry. Both situations use the same physiological process to disrupt arousal, erections, and fun: igniting the sympathetic nervous system AKA the fight-or-flight reaction.

Chemicals such as norepinephrine and adrenaline can pour cold water on any party in your pants. These chemicals reduce the effects of nitric oxide to shunt blood away from your penis to greater areas of need like your heart, big muscle groups, and brain. You might not be running away from a bear, but daily chronic stressors can have a similar impact, especially if you're worried or anxious about what's going on down under, such as if you’re experiencing  pelvic pain.

Just because you couldn't 'lift off' one time doesn't mean you’re going to have a heart attack or not be able to perform the next time. Performance anxiety is normal and there's a lot to be said about the context of any given situation that you're in. Your reaction and outlook on what's happening will change the outcome.

Arousal and aging

Aging is another hard reality we all face (sorry, fellas). As you age, your body changes and so do your erections. It’s been estimated that when a man reaches 40 years old, the chance of experiencing erectile issues is 40% and continues to increase in 10% increments per decade thereafter.[2]

Natural physiological processes take place that change the elasticity, tone, and composition of the smooth muscle lining your arteries. Smooth muscle contraction and relaxation is not under your voluntary control, but is impacted by your health and lifestyle.

Oxidation, a process of cellular death, occurs in all of us no matter what age we are. The molecules that induce oxidation are called ‘free radicals,’ and these break down smooth muscle and increase the collagen ratio. In other words, blood vessels that were once stretchy are now having a hard time expanding and accommodating for blood flow, making ‘lift-off’ a bit challenging.

The good news is that your body has a natural defense mechanisms called ‘antioxidants.’ NO is one of those potent molecules released by the smooth muscle of your arteries that aids artery relaxation to increase blood flow to your penis and the rest of your body.² [3] ⁴ ⁵

But we can’t go around blaming age and anxiety for stealing your thunder down under. Other potential issues contribute to erectile dysfunction (ED) too: cardiovascular disease, smoking, uncontrolled blood sugar, diet, environmental toxins, alcohol, drugs, lack of sleep, sedentary lifestyle, pelvic trauma. It’s the accumulation of these factors over your lifetime that can lead to erectile issues later down the road. 

How about hormones?

And let’s not forget about the influence of the hormone system on your erections. Testosterone and other male hormones influence cognitive function, mood, and sexual and musculoskeletal health.

It’s common for testosterone levels to decrease with age. Typically, they plateau at around 30 years old and vary per individual. Testosterone levels may decrease 1 to 2% per year from your baseline.[4]

But how low is too low?

There’s actually no ‘normal’ value better than your own baseline for comparing testosterone levels. Most lab tests use wide reference ranges, including for age, which means they are not individually specific. Plus, all labs represent a snapshot in time as biological processes change and can be altered in any given moment, so it’s wise to repeat testing a few times or more to have a more reliable measure.³ 

For most clinicians, as a general rule of thumb, less than 200 ng/dl with accompanying signs or symptoms can be indicative of too low testosterone.³

Sometimes your number can look normal on blood tests, but testosterone may still not be working properly in your body, which would necessitate more investigation. Your levels might not compare to the reference range, but that’s okay as long as you’re feeling great and your love muscle is functioning strong.

Testosterone levels shouldn’t be taken at face value or used on their own. Instead, consider them in conjunction with your reported symptoms.

All in all, don’t let getting older cramp your style, fellas. You can slow the impacts of aging with a good diet and ample sexercise. Oops! I mean exercise. Exercise reduces inflammation in the body and boosts NO so it’s good for your ticker and for your flicker.[5]

And let’s not forget to exercise your love maker. Although the penis itself is not a muscle, it’s surrounded by some small but mighty muscles that help keep blood flow in your penis during an erection, intensify your orgasms and ability to ejaculate. (Cue Dr. Susie’s physical therapy expertise.)

Stress management and healthy sexual relationships also help strengthen your erections.

A word about pornography

Since we’re on the topic of hard-ons, it’s worth discussing the impacts of pornography on erectile function. There’s a lot of controversy over pornography and my intention is to keep this discussion to biologically plausible explanations on erectile function. I’m not blaming porn as the cause of erectile issues, because as we already know, it’s a multifactorial issue. However, porn may be another piece of the puzzle that contributes to the overall picture.

Research shows that there’s an increasing number of younger men experiencing erectile dysfunction. So aging isn’t necessarily an excuse, guys. In 2002, rates of ED in men <40 years old was about 2%. Fast forward a decade, the rates jumped to 14-28%.[6] During the same time, the world wide web was taking off and porn exploded (no pun intended) as it gained popular accessibility. What was once only accessible in nudey magazines is now accessible for free in the palm of your hands, literally.

And the frequency and intensity of what you’re watching can influence your overall ability to get it up. How come?

Let’s dive deeper into the physiological mechanisms at play here.

Pornography has been shown to stimulate the reward centers of the brain. The stimulation releases dopamine, a feel-good neurotransmitter. The same thing happens when you have sex. Great, who doesn’t want to feel good, right?

But what happens if we stimulate too much of this response? Research suggests that physiological mechanisms and sexual conditioning change. In other words, with a repetitive stimulus like watching pornographic videos, your tolerance changes as your dopamine receptors become resistant. (The same reward centers of the brain are involved with addictive behaviour as well.)

Each hit of dopamine is temporary. You will typically require more and more of the stimulus (porn) to get the same ‘high’, until it becomes a self-reinforcing activity.

This can become a problem when virtual reality doesn’t match your bedroom reality. Men and women alike bring expectations and beliefs about what is ‘normal’ sexual behaviour. But there is no normal to compare to other than yourself. Much of what we’re comparing ourselves to is an unrealistic and even undesirable representation of sexuality, which creates tension, sexual discrepancies and a falling short in the bedroom. As mentioned before, psychological stressors impact your sexual performance. Talk about a ‘fatal retraction’... Gulp!

What’s the alternative? Relying on your mind’s own visual imagery and your own thoughts put you in charge of take-off. No screens necessary. Just the one in your head that you can take anywhere. Heck, just thinking about a good time can start a party in your pants. Yes!

If you’re wondering where all this leaves you, I’ve got you covered. Since erectile issues can stem from both physical and psychological origins, finding a healthcare professional to help you figure out the dominating factor(s) is key. Yes, Google MD can be helpful if you know how to weed out the bullsh*t. But even better to get the pros to help you out.

A little education goes a long way, even in the bedroom. So, if you’re struggling with erectile issues, know you’re not alone. There’s help out there. Let’s chat.


[1] Nguyen H., Gabrielson, A., Hellstrom, W. (2017). Erectile Dysfunction in Young Men - A Review of the Prevalence and Risk Factors. Sexual Medicine Reviews. 5, 508-520.

[2] Ferrini, M., Gonzalez-Cadavid, N., Rajfer, J. (2017). Aging related erectile dysfunction - potential mechanism to halt or delay its onset. Translational Andrology and Urology. 6(1), 20-27.

[3] Spitz, A. The Penis Book: A Doctor’s Complete Guide To The Penis- from size to function and everything in between. United States of America. Rodale.

[4] Corona, G., Isidori, A. M., Aversa, A., Burnett, A. L., &amp; Maggi, M. (2016).

Endocrinologic Control of Men’s Sexual Desire and Arousal/Erection. The Journal of

Sexual Medicine,13(3), 317-337. doi:10.1016/j.jsxm.2016.01.007

[5] Gerbild, H., Larsen, C., Graugaard, C., Josefsson, K. (2018). Physical Activity to Improve Erectile Function: A Systematic Review of Intervention Studies. Sexual Medicine.6; 75-89.

[6] Park, B., Wilson, G., Berger, J., Christman, M., Reina, B., Bishop, F., Klam, W., Doan, A. (2016). Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports. Behavioral Sciences.6, 17; doi:10.3390/bs6030017