My Penis Stuff

As the channel for semen and urine, the penis serves two important functions in men. But a disease described as early as the mid-18th century by a French physician, Francois Gigot de la Peyronie, which causes hardened patches on the penile shaft, can severely impact a man’s sexual performance. If you have pain and penile curvature characteristic of Peyronie’s disease, the following information should help you understand your condition.

What happens under normal conditions?

The penis is a cylindrical organ consisting of three chambers: paired corpora cavernosa (Two cylinder-shaped bodies that lie side by side in the penis and that, when filled with blood, enlarge to cause the penis to swell and become erect.) that are surrounded by a protective tunica albuginea (The hard covering that covers the testicle.); a dense, elastic membrane or sheath (A tubular covering that protects some body parts.) under the skin; and the corpus spongiosum (A column of erectile tissue in the center of the penis and surrounding the urethra. When filled with blood it enlarges and causes the penis to swell and become erect.), a singular channel, located centrally beneath and surrounded by a thinner connective tissue sheath. It contains the urethra, the narrow tube that carries urine and semen out of the body.

These three chambers are made up of highly specialized, sponge-like erectile tissue filled with thousands of venous cavities, spaces that remain relatively empty of blood when the penis is soft. But during erection, blood fills the cavities, causing the corpora cavernosa to balloon and push against the tunica albuginea. While the penis hardens and stretches, the skin remains loose and elastic to accommodate the changes.

What is Peyronie’s disease?

Peyronie’s disease (also known as fibrous cavernositis) is an acquired inflammatory (Characterized or caused by swelling, redness, heat and/or pain produced in an area of the body as a result of irritation, injury or infection.) condition of the penis.  It is the formation of a plaque or hardened scar tissue beneath the skin of the penis. This scarring is non-cancerous, but often leads to painful erection and curvature of the erect penis (a “crooked penis”).

What are the symptoms of Peyronie’s disease?

This scarring, or plaque, typically develops on the upper side of the penis (dorsum). It reduces the elasticity of the tunica albuginea (The hard covering that covers the testicle.) in that area and, as a result, causes the penis to bend upward during an erection. Although Peyronie’s plaque is most commonly located on the top of the penis, it may occur on the underside or on the lateral side of the penis, causing a downward or lateral bend.  Some patients may even develop a plaque that goes all the way around the penis, causing a “waisting” or “bottleneck” deformity of the penile shaft. The majority of patients complain of generalized shrinkage or shortening of their penis.

Painful erections and difficulty with intercourse usually lead men with Peyronie’s disease to seek medical help. Since there is great variability in this condition, sufferers may complain of any combination of symptoms: Penile curvature, obvious penile plaques, painful erection and diminished ability to achieve an erection.

Any of those physical deformities make Peyronie’s disease a quality-of-life issue. Not surprising, it is linked to erectile dysfunction in 20 to 40 percent of sufferers. While studies have shown that 77 percent of men demonstrate significant psychological effects, the numbers, medical researchers believe, are under reported. Instead, many men affected with this truly devastating condition suffer in silence.

How frequently does Peyronie’s disease occur?

Peyronie’s disease affects a reported one to 3.7 percent  (about one to four in 100) of males between ages 40 and 70, even though severe cases have been reported in younger men. Medical researchers believe the actual prevalence may be higher due to patient embarrassment and limited reporting by physicians. Since the introduction of sildenafil citrate, an oral therapy for impotence, doctors have reported increased incidence of Peyronie’s cases. With more men being treated successfully for erectile dysfunction in the future, an increasing number of cases presenting to urologists are anticipated.

What causes Peyronie’s disease?

Ever since Francois Gigot de la Peyronie, personal physician to King Louis XV, first reported penile curvature in 1743, scientists have been mystified by the causes of this well-recognized disorder. Yet medical researchers have speculated on a variety of factors that might be at work.

Most experts believe that acute or short-term cases of Peyronie’s disease are likely the consequence of a minor penile trauma, sometimes caused by sports injuries, but more often by vigorous sexual activity (e.g., the penis accidentally being jammed into a mattress). In injuring the tunica albuginea, that trauma triggers a cascade of inflammatory and cellular events resulting in the abnormal fibrosis (excess fibrous tissue), plaque and calcifications characteristic of this disease.

Such trauma, however, may not account for those Peyronie’s cases that begin slowly and become so severe that they require surgery. Researchers believe genetics or relationship with other connective tissue disorders may play a role. Studies already suggest that if you have a relative with Peyronie’s disease you have a greater risk of developing it yourself.

How is Peyronie’s disease diagnosed?

A physical examination is sufficient to diagnose curvature of the penis. The hard plaques can be felt with or without erection. It may be necessary to use injectable medications to induce an erection for proper evaluation of the penile curvature. The patient may also provide pictures of the erect penis for evaluation by the physician. Ultrasound of the penis may demonstrate the lesions in the penis but is not always necessary.

How is Peyronie’s disease treated?

Because Peyronie’s disease is a wound-healing disorder, changes are constantly occurring in the early stages. In fact, this disease can be classified into two stages: 1) an acute inflammatory phase persisting for six to 18 months during which men experience pain, slight penile curvature and nodule formations and 2) a chronic phase during which men develop a stable plaque, significant penile curvature and erectile dysfunction.

Occasionally the condition regresses spontaneously with symptoms resolving themselves. In fact, some studies show that approximately 13 percent of patients have complete resolution of their plaques within a year. There is no change in 40 percent of cases, with progression or worsening of symptoms in 40 to 45 percent. For these reasons, most physicians recommend a non-surgical approach for the first 12 months.

Conservative approaches:  Instead of requiring invasive diagnostic procedures or treatments, men who experience only small plaques, minimal penile curvature and no pain or sexual limitations, need only be reassured that the condition will not lead to malignancy or another chronic disease. Pharmaceutical agents have shown promise for early-stage disease but there are drawbacks. Because of a lack of controlled studies, scientists have yet to establish their true effectiveness. For instance:

• Oral vitamin E: It remains a popular treatment for early-stage disease because of its mild side effects and low cost. While uncontrolled studies as far back as 1948 demonstrated decreases in penile curvature and plaque size, investigation continues concerning its effectiveness.
• Potassium aminobenzoate: Recent controlled studies have shown that this B-complex substance popular in Central Europe yields some benefits. But it is somewhat expensive, requiring 24 pills each day for three to six months. It is also often associated with gastrointestinal issues, making compliance low.
• Tamoxifen: This non-steroidal, antiestrogen medication has been used in the treatment of desmoid tumors, a condition with properties similar to Peyronie’s disease. Researchers claim that inflammation and the production of scar tissue are inhibited. But early-stage disease studies in England have found only marginal improvement with tamoxifen. Like other research in this area, however, these studies include few patients, and no controls, objective improvement measures or long-term follow up.
• Colchicine: Another anti-inflammatory agent that decreases collagen development, colchicine has been shown to be slightly beneficial in a few small, uncontrolled studies. Unfortunately, up to 50 percent of patients develop gastrointestinal upset and must discontinue the drug early in treatment.

Injections:  Injecting a drug directly into the penile plaque is an attractive alternative to oral medications, which do not specifically target the lesion, or invasive surgical procedures, which carry the inherent risks of general anesthesia, bleeding and infection. Intralesional injection therapies introduce drugs directly into the plaque with a small needle after appropriate anesthesia. Because they offer a minimally invasive approach, these options are popular among men with either early phase disease or who are reluctant to have surgery. Yet their effectiveness is also under investigation. For instance:

•  Verapamil: Early uncontrolled studies demonstrated that this substance interferes with calcium, a factor shown by in vitro cattle connective tissue cell studies to support collagen transport. As such, intralesional verapamil reduced penile pain and curvature while improving sexual function. Other studies have concluded that it is a reasonable treatment in men with non-calcified plaques and penile angles of less than 30 degrees.
• Interferon: The use of these naturally-occurring antiviral, antiproliferative and anti-tumorigenic glycoproteins to treat Peyronie’s disease was born out of experiments demonstrating the antifibrotic effect on skin cells of two different disorders — keloids, overgrowth of collagenous scar tissue and scleroderma, a rare autoimmune disease affecting the body’s connective tissue. In addition to inhibiting proliferation of fibroblast cells, interferons, such as alpha-2b, also stimulate collagenase, which breaks down collagen and scar tissue. Several uncontrolled studies have demonstrated intralesional interferon’s effectiveness in reducing penile pain, curvature and plaque size while improving some sexual function. A current multi-institutional, placebo-controlled trial will hopefully answer many of the questions about intralesional therapy in the near future.

Other investigative therapies:  The medical literature is replete with reports on less invasive methods for treating Peyronie’s disease. But the effectiveness of treatments such as high-intensity focused ultrasound and radiation therapy, topical verapamil and iontophoresis, introducing soluble salt ions into the tissue via electric current, must still be investigated before these alternative therapies are considered clinically useful. Likewise, controlled studies using larger patient groups with longer follow ups are necessary to prove that the same high-energy shock waves used to break up kidney stones will have positive effects on Peyronie’s disease.

Surgery:  Surgery is reserved for men with severe disabling penile deformities that prevent satisfactory sexual intercourse. But, in most cases, it is not recommended for the first six to 12 months, until the plaque has stabilized. Since a spin-off of this disease is an abnormal blood supply to the penis, a vascular evaluation using vasoactive agents (drugs that cause erections by opening the vessels) is done prior to any surgery. A penile ultrasound if performed can also illustrate the anatomy of the deformity. The images allow the urologist to determine which patients are most likely to benefit from reconstructive procedures versus a penile prosthesis. The three surgical approaches include:

• Nesbit procedure: First described to correct congenital penile curvature by cutting a portion of tissue from the tunica albuginea and shortening the unaffected side of the penis, this procedure is used by many surgeons today for Peyronie’s disease. Variations on the approach include the plication technique, where sutured tucks are placed into the side of maximum curvature to shorten and straighten the penis and the corporoplasty technique, where a longitudinal or lengthwise incision is closed transversely to correct the curvature. Nesbit and its variations are simple to perform and involve limited risk. They are most beneficial in men with ample penile length and lesser degrees of curvatures. But they are not recommended in individuals with short penises or severe curvatures as this procedure is recognized to shorten the penis somewhat.
• Grafting procedures: defect with a When plaques are large and curvatures severe, the surgeon may choose to incise or cut out the hardened area and replace the tunicagraft material of some type. While the choice of materials depends on the doctor’s experience, preferences and what is available, some are more attractive than others. For instance:
  • Autograft tissue grafts: Taken from the patient’s body during surgery and thus less likely to cause an immunologic reaction, these materials usually require a second incision. They are also known to undergo postoperative contracture or tightening and scarring.
  • Synthetic inert substances: Materials such as Dacron^® mesh or GORE-TEX^® can cause significant fibrosis, a spreading of connective tissue cells. Occasionally palpated or felt by the patient, these grafts may cause more scarring.
  • Allografts or xenografts: Harvested human or animal tissues are the focus of most grafting material today These substances are uniformly strong, easy to work with and readily available because they are “off-the-shelf” in the operating room, so to speak. They act as scaffolds for the tunica albuginea tissue to grow over as the graft is naturally dissolved by the patient’s body.

• Penile prostheses: A penile prosthesis may be the only good option for Peyronie’s disease patients with significant erectile dysfunction and insufficient blood vessels verified by ultrasound. In most cases, implanting such a device alone will straighten the penis, correcting its rigidity. But when that does not work, the surgeon may manually “model” the organ, bending it against the plaque to break the deformity, or the surgeon may need to remove the plaque over the prosthesis and apply a graft to completely straighten the penis.

What can be expected after treatment for Peyronie’s disease?

Routinely, a light pressure dressing is applied for 24 to 48 hours after the surgery to prevent any accumulation of blood. The Foley catheter is removed after the patient recovers from anesthesia and most patients are discharged later the same day or the following morning. During the healing process, medications to counteract erections are usually prescribed. The patient is also asked to take antibiotics for seven to 10 days postoperatively to ward off infection, and analgesics for any discomfort. If patients have no penile pain or other complications, they can resume sexual intercourse in six to eight weeks.

Frequently asked questions:

What happens to the cells following penile trauma?

In theory, following any penile trauma, there is a release of growth factors and cytokines or daughter cells that activate fibroblasts, cells that produce connective tissue. They, in turn, cause abnormal collagen deposition or scarring, which damages the internal elastic framework of the penis. Similar wound-healing disorders are commonly seen in the practice of dermatology, with conditions such as keloids and hypertrophic scarring, both involving tissue overgrowth in wound healing.

Are Peyronie’s disease sufferers prone to other related conditions?

About 30 percent of Peyronie’s disease sufferers also develop other systemic fibrosis in other connective tissue in the body. Common sites are the hands and feet. In Dupuytren’s contracture, scarring or thickening of the fibrosis tissue in the palm leads progressively to a permanent bending of the pinkie and ring fingers into the hand. While the fibrosis occurring in both diseases is similar, it is not clear yet what causes either plaque type or why men with Peyronie’s disease are more likely to develop Dupuytren’s contracture.

Will Peyronie’s disease evolve into cancer?

No. There are no documented cases of progression of Peyronie’s disease to malignancy. However, if your doctor observes other findings that are not typical with this disease—such as external bleeding, obstructed urination, prolonged severe penile pain—he or she may elect to perform a biopsy on the tissue for pathological examination.

What should men remember about Peyronie’s disease?

Peyronie’s disease is a well-recognized but poorly understood urological condition. Interventions need to be individualized to each patient, based on the timing and severity of the disease. The objective of any treatment should be on reducing pain, normalizing penile anatomy so that intercourse is comfortable and restoring erectile function in patients who suffer erectile dysfunction. Although surgical correction is ultimately successful in the majority of cases, the early acute phase of this disease is customarily treated by either oral and/or intralesional approaches. As medical researchers continue to develop basic and clinical research for a better understanding of this disease, more therapies and targets for intervention will become available.

Sex therapy may be helpful for some men who have erection problems (erectile dysfunction). Sex therapy does not involve having sex with or in front of the sex therapist. It is also not long-term or open-ended therapy. It usually involves working with a therapist who recommends gradual steps to change sexual behavior.

Sex therapy helps you understand and accept that emotions (such as anxiety or sadness) can easily become associated with physical factors or reactions. It is based on the following premises:

• Both partners share responsibility for helping solve the problem, even if it is due to physical causes.
• You and your partner receive information and education about sexual techniques.
• It is necessary to change any negative attitudes toward sex.
• It is necessary to open up lines of communication between you and your partner.

Sex therapy may involve:

• Talking about the multiple causes of sexual problems and how emotions can play a role in physical causes.
• Using a variety of psychological tests.
• Talking about the natural changes in sexual function that occur with aging.
• Offering specific suggestions for enhancing sexual enjoyment (such as altering foreplay, using lubricants, getting enough rest, eliminating distractions).

For many men, psychological issues play a role in erection problems (erectile dysfunction). Careful attention to these issues and attempts to relieve sexual anxieties should be a part of therapy for all men with these problems.

The type of therapy and how long it lasts depends on what type of problem (depression, anxiety disorder, or another mental disorder) you have.

Group or individual therapy may be indicated. Involving your partner in counseling is often helpful.

Psychological treatment is most likely to be helpful for men who:

• Have an erect penis when they wake up in the morning.
• Can get a firm erection when masturbating.
• Have gone through a stressful major life event, such as divorce, separation, death of a loved one, change in job, or moving.
• Grew up in an environment where sex and sexuality were considered negative, wrong, or “bad,” or who were sexually or physically abused as a child.
• Lost their mother or father during early childhood.
• Have a history of serious relationship problems.
• Have a history of anxiety disorders or physical problems that have a psychological component (such as irritable bowel syndrome, migraines, asthma, or nervous bladder).

Treatment Overview

A vacuum device, which is sometimes used to treat erection problems (erectile dysfunction), is a tube made of plastic that fits around the penis. You coat the base of the penis with lubricant and insert it into the tube. Air is pumped out of the tube, which creates a vacuum. The vacuum helps blood flow into the penis, producing an erectionlike state in about 5 minutes. A constrictive band is placed around the base of the penis to maintain the erection, and the tube is removed.

See an illustration of a vacuum device below

The constrictive band may be left in place for up to 30 minutes. If you want the erection to last longer, you may remove the band for a few minutes and then repeat the process.

Vacuum devices block ejaculation. You still have an orgasm but do not ejaculate (release semen).

Some men say the erection is “wobbly” or has a “hingelike” feeling, since the tissues beneath the ring on the base of the penis don’t get hard. A small number of men consider this a major problem, and it may make penetration difficult.

A prescription is not needed to buy these devices. They are reusable and should be cleaned after each use.

What To Expect After Treatment

The device usually produces an erection, which goes away when the constrictive band is removed.

Why It Is Done

Most men who have erection problems from physical causes can use vacuum devices. Men who have erection problems because of psychological causes may also use these devices.

These devices can be used by men who take medications to prevent blood clots (anticoagulants, such as warfarin [Coumadin]).

How Well It Works

Studies indicate that more than 90% of men using these devices are able to get an erection that is satisfactory for sexual intercourse. 

Most men and their partners are satisfied with the device and the quality of the erections. Studies have reported satisfaction rates ranging from 70% to 94%. However, some studies report that only 26% to 30% of men are satisfied with the erections they receive from a vacuum device. 

Most men who stop using the vacuum device do so for a variety of reasons, including inconvenience and interruption of foreplay (the man has to take a brief “time-out” to use the device to get an erection). Your satisfaction with the device may be better if you meet with a representative of the manufacturer who can show you how to use the device correctly. Your doctor can arrange a meeting.

Regular use may improve success and satisfaction. Most men who use the device successfully for 3 months continue to use it. With regular use, the time it takes to get an erection decreases.

Men who have erection problems from psychological factors may regain the ability to have unaided erections after using the device for a time.

The cause of the erection problem (blood vessel, nerve, or psychological) does not appear to affect the results. The device also may produce erections in men who have had a failed penile implant.

Risks

The risk of side effects is low and they are usually minor. Possible problems may include:

• Bruising.
• Pain or discomfort.
• Numbness or loss of sensitivity. This occurs occasionally in about half of men but is a major problem for only a few men.
• A sensation that the penis is cold.
• Pinching scrotal tissue in the device.

No significant side effects or complications have been reported.

What To Think About

Be sure to discuss using a vacuum device with your partner. It is important that both of you have realistic expectations of what the device can do. The vacuum device gives you an erection that may be suitable for sexual intercourse but is not the same as a normal erection.

A trial period at home is helpful. The device can be difficult to learn to use, and about four tries are needed to learn to use it successfully.

Some men find the band around the base of the penis distracting or irritating during sex. Also, the band may prevent ejaculation.

Penile implants to treat erection problems (erectile dysfunction) replace the spongy tissue (corpora cavernosum) inside the penis that fills with blood during an erection with rigid, semirigid, or inflatable cylinders. The implants come in a variety of diameters and lengths.

Rigid and semirigid implants are always firm. The semirigid models can be bent into different positions (outward to have sex; back toward the body to conceal under clothing).

The cylinders in an inflatable implant are hollow. You get an erection by pumping them full of saltwater, or saline, stored in a reservoir in your lower abdomen. A release valve on the pump drains the saline out of the cylinders and back into the reservoir.

See an illustration of a penile implant below

Surgery will be done using regional or general anesthesia. The implants are inserted through an incision made in the penis, lower abdomen, or scrotum. A thin, flexible tube is inserted briefly up the urethra and into the bladder to drain urine.

A three-chamber implant (with a cylinder in the penis, a reservoir in the abdomen, and valve in the scrotum) is usually more reliable than a two-chamber implant (with a reservoir and valve in the scrotum). Inserting the three-chamber implant is a slightly more complicated surgery.

What To Expect After Surgery

Generally, you stay 1 or 2 days in the hospital. You will take antibiotics for up to 2 weeks after surgery to prevent infection.

The urinary catheter is used for about 1 day after surgery.

Do not wear tight underwear or clothing until the surgical incision has healed. Men with inflatable implants may need to avoid tight clothing for 6 weeks to avoid pushing the saline reservoir out of position.

You can generally return to strenuous physical activity and sex after about a month. Inflatable implants usually are not inflated for a month.

Why It Is Done

Penile implants are an option when other, less invasive treatments for erection problems have not been successful and further treatment is desired.

Implants may be the treatment of choice for young and middle-aged men with erection problems from physical causes. Penile implants may be appropriate treatment for men with erection problems caused by:

• Diabetes.
• Pelvic surgery.
• Blood vessel disease.
• Injury to the pelvis, genitals, or spinal cord.
• Peyronie’s disease, curvature of the penis caused by scar tissue.

Because implants permanently change the tissue in the penis, they are not used for men whose erection problems are psychological.

How Well It Works

The satisfaction rate for most men is high for both noninflatable and inflatable implants. ¹ An erection with a properly working implant may seem more natural than one from other, nonsurgical methods, such as a vacuum device. The head (glans) of the penis is not made fully rigid by the devices. Semirigid implants do not increase the size of the penis or produce the fullness of a natural erection.

Implants do not interfere with ejaculation, though ejaculation and orgasm are not ensured. Implants neither increase nor decrease sexual desire.

Noninflatable implants and inflatable devices can last indefinitely.

Risks

The site of the implant may become infected. The risk of infection is higher in men with diabetes, spinal cord injuries, or urinary tract infections. If the infection is severe, the implant must be removed.

Pain may occasionally require removal of the implant.

The most common cause of failure is leakage from the cylinders. Other, less common complications include the following:

• Tissue near the implant (erosion) may be injured.
• The implant may break through the skin.
• The implant may break.
• The implant may be positioned incorrectly.
• The implant may be defective and not work.

What To Think About

When considering surgery for erection problems, it is important to include your partner in your decision.

It is important that you have realistic expectations about the type of erections you can have with an implant. The use of penile implants is declining as men consider the risks of surgery—including infections—and as other options become available, such as vacuum pumps, injections, and medications.

No problems have been reported from the shedding of silicone particles from the implants.

Semirigid implants are the least expensive option. This surgery is usually covered by insurance policies and by Medicare.

Surgery to repair blood vessels may be done for some men who have erection problems (erectile dysfunction).

Venous ligation

In an erection, blood fills chambers in the penis, causing it to expand and become rigid. The veins that would normally drain blood from the penis are constricted, trapping the blood inside and maintaining the erection. Some men are unable to sustain an erection because the blood drains out too quickly through the veins. If this occurs, the veins that drain the penis may be tied off. This surgery is called venous ligation.

The surgery generally works only when the veins that are not working can be identified. However, the results of tests used to assess blood vessel problems are difficult to interpret, and it is difficult to know which men will benefit from this surgery. Success of this surgery depends on the severity of the problem and the experience of the surgeon.

Penile revascularization

This surgery generally is done in younger men who have injuries that affect blood flow to the penis. During surgery, a portion of a blood vessel from elsewhere in the abdomen is used to bypass the damaged portion of artery that supplies blood to the penis.

In some cases you can treat occasional episodes of erection problems (erectile dysfunction) at home, without a health professional’s help. However, involve your partner in the process, and don’t be embarrassed about seeking professional help if erection problems are consistent and troublesome. You may be able to help yourself by:

• Changing lifestyle factors that may affect erections. These factors include alcohol, smoking, and using illegal drugs.
• Examining your relationships and life events.
• Talking with your partner.
• Trying sensual exercises with your partner.

Some men may try methods available in health food stores or through magazine advertisements. Most of these methods have never been medically proven to work, may be unsafe, and are often expensive. They are not recommended.

Sensual exercises may help with erection problems (erectile dysfunction). Doing these with your partner may help you relax and focus more on the pleasurable touching of lovemaking than on the erection itself. Focusing too much on having an erection may make it difficult to have one.

Sensual exercises may be most helpful if done in a soothing, relaxing, and playful atmosphere. Put on some pleasant music, turn off the phone, and concentrate on your partner.

• Nongenital pleasuring. Remove your clothes. Have your partner lie face down. Beginning at your partner’s neck, slowly caress and/or kiss from head to toe. Then, have your partner turn over. Repeat the caressing and kissing. Avoid touching the nipples or any part of the genitals. Concentrate on how good touching your partner feels. Then, trade places. Lie on your stomach while your partner caresses you. Do not have intercourse the first day. Enjoy holding, relaxing, and laughing.
• Genital pleasuring. After you and your partner are comfortable with nongenital pleasuring, include genital touching as part of the exercise. Again, do not have intercourse. If sexual tension from any erection that occurs is too much to stand, masturbate to relieve the tension.
• Nondemanding intercourse. When both partners are ready, continue a session of genital pleasuring by having intercourse. Do not force lovemaking too soon. Rather, fully enjoy the genital pleasure leading up to it.

Talking with your partner may help your erection problems (erectile dysfunction). Couples often assume that they each know what the other person likes when it comes to sex. Sometimes they are wrong.

• Don’t assume. Tell your partner what you do and don’t find pleasurable.
• Make time outside of the bedroom to talk about your sex life together. If you withdraw sexually because you are afraid of having erection problems, your partner may worry that you are no longer interested or that you are involved in another sexual relationship.
• In some cases, you may find that your partner is less concerned about intercourse and is more concerned and interested in foreplay and other forms of sexual satisfaction.
• Discuss the strong and weak points of the whole relationship, not just the sexual relationship. Identify positive areas, areas of conflict, and areas that need improvement. Come to agreement on how or if you will both make changes.
• If you have difficulty discussing sex with your partner, see a person who can help facilitate communication, such as a certified therapist.
• Read books with your partner on sexual health.

The following lifestyle changes may reduce the risk of erection problems (erectile dysfunction):

• Limit alcohol to fewer than 2 drinks per day, or eliminate alcohol if it seems to interfere with erections. Even small amounts of alcohol can result in erection problems.
• Stop smoking. Smoking interferes with the ability of the blood vessels in the penis to relax and allow blood to flow in, which can affect your ability to have an erection.
• Avoid the use of cocaine, heroin, and other illegal drugs.
• Check your medications. Many medications can cause erection problems. Ask your doctor or pharmacist whether the medications you are taking have any sexual side effects.
• Relax. Worrying about sexual performance may only worsen erection problems.
• Talk to your partner about your problems and concerns. Sexual intimacy is a form of communication. If you and your partner aren’t talking outside of the bedroom, it’s unlikely that you will have good sexual intimacy.
• Reduce stress. A heavy workload or stressful job can reduce your interest in and energy for sex. Regular exercise and other stress-relievers can help.