Friday, November 24, 2017
Authors Posts by Dr. Andrew Siegel

Dr. Andrew Siegel

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Dr. Andrew Siegel is a board certified, practicing physician and surgeon at Hackensack University Medical Center, New Jersey. He is an Assistant Professor of Urology at the University of Medicine of New Jersey and has been featured in Gold Journal of Urology, Journal of Urology, Urologic Clinics of North America, Postgraduate Medicine, Neuro-Urology and Urodynamics, International Urogynecology Journal, Radiotherapy and Oncology, and the Journal of Brachytherapy International. He is a Certified Diplomate of the American Board of Urology, is a member of the Alpha Omega Alpha Honor Medical Society, and is also a Diplomat of the American Board of Urology and the National Board of Medical Examiners. Siegel was named 2013 Castle Connolly Top Doctor, and he is the author of "Male Pelvic Fitness: Optimizing Sexual and Urinary Health."

The Ins & Outs Of Female Anatomy

Some people remain clueless about female genital anatomy and for good reason, as they’ve likely had no formal instruction on the topic. Education often involves knowledge imparted from friends and schoolmates and perhaps a talk from a parent on the “birds and the bees,” generally less than adequate means. “Sex Ed” classes in junior high school (a.k.a. middle school) were cursory and insufficient. Your dad’s Playboy, your mom’s Cosmo and other magazines may have provided some insight, but were certainly not the gospel. Pornography offers a totally skewed perspective. As a consequence, most people have been educated through practical experience with their own vagina or with those of sexual partners. Although there is no substitute for “hands on” experience, a bit of vaginal academics is certainly a good addition to practical experience.

For many men—and women for that matter—the vagina is a dark and mysterious place, a “black hole” of human anatomy, hidden in the deep recesses of the body. This landscape is complex terrain and unfortunately does not come with a topographical map explaining its intricate subterranean geography.

The following are quotes about the vagina from Tom Hickman’s book: “God’s Doodle: The Life and Times of the Penis”:

“A place of procreative darkness, a sinister place from which blood periodically seeped as if from a wound.”

“Even when made safe, men feared the vagina, already attributed mysterious sexual power – did it not conjure up a man’s organ, absorb it, milk it, spit it out limp?”

The objective of this blog is to explore and demystify the vagina to help you comprehend and navigate its complexities. Knowledge is power and whether female or male, a greater understanding and appreciation of the anatomy, function and nuances of this curious and special female body part will most certainly prove useful.

Female Genital Anatomy 101

The hidden female nether parts and their inner workings are a mystery zone to a surprising number of women. Many falsely believe that the “pee hole” and the “vagina hole” are one and the same…not surprising given that lady parts are much more unexposed, subtle and complex than the more obviously exposed man parts. However, what lies between the thighs is more complicated and intricate than one might think…. three openings, two sets of lips, swellings, glands, erectile tissue, muscles and more.

Let’s first set the record straight on the difference between the vagina and vulva, geography that is often confused. When referring to external visible “girly” anatomy, most people incorrectly speak of the “vagina”—this is actually the “vulva,” divided in half by a midline slit known in medical jargon as the pudendal cleft or cleft of Venus or in slang terms, “camel toe.” The “vagina,” on the other hand, is the internal, flexible, cylindrical, muscular passageway that extends from vulva to cervix (neck of the uterus). The vaginal opening on the vulva is known in medical terms as the vaginal introitus. Further down south is the landscape between the vulva and the anus known in medical jargon as the perineum or in slang terms, “taint.”

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(Anatomy of the vulva by OpenStax College – Anatomy & Physiology, Connexions Web site., Jun 19, 2013., CC BY 3.0, no changes made to original)

Bottom Line: The vulva is external, the vagina internal. Good to remember.

Fact: The word “vulva” derives from the Latin “cunnus” (hence the derivation of the slang C-word. The word “vagina” derives from the Latin word for “sheath,” a cover for the blade of a knife or sword, an apt term.

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Above image (public domain) entitled “Vagina Collage”…note that it should be entitled  “Vulva Collage”

Many Functions Of The Vagina

The vagina is an amazingly versatile and multifunctional organ that is truly a “cave of wonders.” Beyond being a sexual organ, it is an inflow pathway and receptacle for semen, an exit pathway for menstrual blood, and a birth canal. It is not simply a passive channel, but an active and dynamic, highly responsive passageway that has the capacity for voluntary muscular contraction.

Anatomy Of The Vagina

The average depth of the vagina (without sexual stimulation) is 3-4 inches or so, but with sexual stimulation and arousal, the vagina is capable of considerable expansion and distension to a much greater potential. The elasticity of the vagina is truly impressive (perhaps the most elastic and stretchable organ in the body), with the ability to stretch to accommodate a full-term infant and then return to a relatively normal caliber. The width of the vagina varies throughout its length, narrowest at the vaginal opening and increasing in diameter throughout its depth. It is typically about 1 inch in diameter at the external opening.

Joke from Maxim.com:

  1. Just how deep is the average vagina?
  2. Deep enough for a man to lose his house, his car, his dog and half of all his savings and assets…

All vaginas are unique with a great variety in shape, size and even color, similar to variations in penile anatomy. The vagina is a banana-shaped structure and when a woman lies down on her back, the more external part of the vagina (closest to the vaginal opening) is straight, and the inner, deeper part angles/curves downwards towards the sacral bones (the lower part of the vertebral column that forms the back bony part of the pelvis). This vaginal “axis” often changes with aging and childbirth.

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Banana representing vaginal axis, with inner portion curved towards sacrum and outer portion straight (Thank you Pixabay for image)

Fact: Although the vagina recovers remarkably well after childbirth, anatomy does generally change to some extent. Pelvic examination is usually easily able to distinguish between women who have and have not had children vaginally. Of note, elective C-section (no labor) preserves vaginal anatomy. Women who have an enlarged vaginal outlet due to childbirth may have difficulty in satisfactorily “accommodating” the penis, resulting in the vagina merely “surrounding” the penis rather than firmly “squeezing” it, with the end result being diminished sensation for both partners.

The vagina has pleats and corrugations called rugae that maximize the elasticity and stretchiness of the vagina. They are accordion-like ruffles and ridges that supply texture, which increase friction for the penis during sexual intercourse. In a young woman they are prominent, but with aging they tend to disappear.

Fact: Vaginal rugae are like tread on a tire…in young women they appear like deep grooves on a new snow tire, whereas in older women they appear like thinning tire tread, completely bald at their most extreme…aging can be cruel.

The vaginal wall has an inner lining of “skin” known as epithelium, which is surrounded by connective tissues and a muscular coat. The vaginal muscle is comprised of an inner layer that is circular in orientation and an outer layer that is oriented longitudinally. Contraction of the inner muscle tightens the vagina. Contraction of the outer muscle shortens and widens the vagina. The vagina is secured within a “bed” of powerful pelvic floor muscles.

To better understand vaginal anatomy, it is useful to divide it arbitrarily into thirds: outer, inner and middle. The outer and inner thirds are where “all the action is,” the outer third being the hub of sexuality, the inner third the hub of reproduction and the middle third essentially a connection between the inner and outer thirds.

Outer third: The outer third of the vagina is rich in nerve fibers and is the most sensitive part of the vagina. The “orgasmic platform” is the Masters and Johnson term for the anatomical “base” that responds to sexual arousal and stimulation with pelvic blood congestion. It consists of the outer third of the vagina and the engorged inner lips.

Middle third: The middle third is a conduit connecting the outer and inner thirds.

Inner third: The cervix (opening to the uterus) sits in the inner third of the vagina. Its presence within the deep vagina defines the deepest recesses of the vagina, which are referred to as the fornices (singular fornix), derived from the Latin word for “arches.” The largest fornix is the one behind the cervix (posterior fornix) with the two smaller fornices above and to the sides of the cervix (anterior and lateral fornices).

Question: What do you think is the origin of the word “fornicate”?

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Image above:  Uterus, Cervix and Inner Third Vagina from Dr. Johannes Sobotta – Sobotta’s Atlas and Text-book of Human Anatomy 1906, note the vaginal rugae and the relationship of the cervix with the inner vagina

Fact: In the man-on top sexual intercourse position, the penis reaches the anterior fornix, while in the rear-entry position it reaches the posterior fornix.

The Pelvic Floor Muscles And The Vagina

The pelvic floor muscles play a pivotal role with respect to vaginal and sexual function, their contractions facilitating and enhancing sexual response. They contribute to arousal, sensation during intercourse and the ability to clench the vagina and firmly “grip” the penis. The strength and durability of their contractions are directly related to orgasmic potential since the pelvic muscles are the “motor” that drives sexual climax and can be thought of as the powerhouse of the vagina. During orgasm, the pelvic floor muscles “shudder.”

There is great variety in the bulk, strength, power and voluntary control of the pelvic floor muscles that support the vagina. Some women are capable of powerfully “snapping” their vaginas, whereas others cannot generate even a weak flicker.

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Image above: Female pelvic floor muscles, illustration by Ashley Halsey from The Kegel Fix

Fact: “Pompoir” is a sexual technique in which a woman contracts her pelvic floor and vaginal muscles rhythmically to stimulate the penis without the need for pelvic motion or thrusting. Women who diligently practice Kegel exercises can develop powerful pelvic floor muscles and become particularly adept at this technique resulting in extreme vaginal “dexterity” and the ability to refine pulling, pushing, locking, gripping, pulsing, squeezing and twisting motions, which can provide enough stimulation to bring a male to climax. 

Fact: “Penis Captivus” is a rare condition in which a male’s erect penis becomes stuck within a female’s vagina. It is thought to be on the basis of intense contractions of the pelvic floor muscles, causing the vaginal walls to clamp down and entrap the penis. It usually is a brief event and after female orgasm and/or male ejaculation, withdrawal becomes possible. However, it sometimes requires medical attention with a couple showing up in the emergency room tightly connected, like Siamese twins. Not a good call to 911!

Sexual Function And The Vagina

Under normal circumstances, the vagina is not “primed” for sex and is little more prepared for intercourse than is a flaccid penis. The un-stimulated vagina is essentially a closed “potential space” in which the vaginal roof and floor are in contact. With sexual stimulation, the vagina expands with lengthening and widening of its inner two-thirds and flattening of the rugae. The cervix and uterus pull up and back. Pelvic blood flow increases and the vaginal walls undergo a “sweating-like” reaction as a result of pelvic blood congestion, creating a slippery and glistening film. Most of the lubrication is based upon seepage from this increased blood flow, but some comes from Bartholin’s and Skene’s glands. Bartholin’s glands are paired, pea-size glands that drain just below and to each side of the vagina. During sexual arousal they secrete small drops of fluid, resulting in moistening of the opening of the vagina. Skene’s glands are paired glands that drain just above and to each side of the urethral opening. They are the female equivalent of the male prostate gland and secrete fluid with arousal.

With sexual excitement and stimulation, in addition to vaginal lubrication from increased pelvic blood flow, there is congestion and engorgement of the vulva, vagina and clitoris.

Fact: The profound vaginal changes that occur during sexual arousal and stimulation are entirely analogous to the changes that occur during male arousal: expansion of penis length and girth, retraction of the testicles towards the groin, and the release of pre-ejaculate fluid.

With increasing stimulation and arousal, physical tension within the genitals gradually builds and once sufficient intensity and duration of sexual stimulation surpass a threshold, involuntary rhythmic muscular contractions occur of the vagina, uterus, anus and pelvic floor muscles, followed by the release of accumulated erotic tension (a.k.a. orgasm) and a euphoric state. Thereafter, the genital engorgement and congestion subside, muscle relaxation occurs and a peaceful state of physical and emotional bliss and afterglow become apparent.

Fact: Anatomy can affect potential for experiencing sexual climax.

Sexual intercourse results in indirect clitoral stimulation. The clitoral shaft moves rhythmically with penile thrusting by virtue of penile traction on the inner lips, which join together to form the hood of the clitoris. However, if the vaginal opening is too wide to permit the penis to put enough traction on the inner lips, there will be limited clitoral stimulation and less satisfaction in the bedroom. Furthermore, studies have suggested that a larger clitoris that is closer to the vaginal opening is more likely to be stimulated during penetrative sexual intercourse.

At the time of sexual climax, some women are capable of “ejaculating” fluid. The nature of this fluid has been controversial, thought by some to be hyper-lubrication and others to be Bartholin’s and/or Skene’s gland secretions. There are certain women who “ejaculate” very large volumes of fluid at climax and studies have shown this to be urine released because of an involuntary bladder contraction that can accompany orgasm.

Fact: “Persistent genital arousal disorder” is a rare sexual problem characterized by unwanted, unremitting and intrusive arousal, genital engorgement and multiple orgasms without sexual interest or stimulation. It causes great distress to those suffering with it and there are no known effective treatments. It typically does not resolve after orgasm.

The G-Spot—named after German gynecologist Ernst Grafenberg—was first described in 1950 and was believed to be an erogenous zone located on the upper wall of the vagina, anatomically situated between the vagina and the urethra (urinary channel). Stimulation of this spot was thought to promote arousal and vaginal orgasm.

Fact: There is little scientific support for the existence of the G-spot as a discrete anatomical entity; however, many women feel that they possess an area on the roof of the vagina that is a particularly sensitive pleasure zone. Although its existence remains controversial, the G-spot is certainly a powerful social phenomenon.

Regular sexual activity is vital for maintaining the ability to have ongoing satisfactory sexual intercourse with the vagina staying fit and healthy if one remains sexually active, as nature intended. Vaginal penetration increases pelvic and vaginal blood flow, optimizing lubrication and elasticity, while orgasms tone and strengthen the pelvic floor muscles that support vaginal function“Disuse atrophy” is a condition when the vagina adapts to not being used, with thinning and fragility of the vaginal walls and weakness of the pelvic floor muscles. Use it or lose it!

Getting In Touch With Your Inner Penis

When I use the term “inner penis,” I am not referring in a new age, meditative way to the unexpressed, indiscernible, and unacknowledged spiritual-mental-emotional drive underpinning male sexuality (although that is a good topic for another day).  I am referring to the physical, not metaphysical, literal inner part of the penis.  Did you know that one half of the penis is actually internal while the other half is external?

Why does man have an inner penis at all? It seems to be such a waste of human flesh.  In reality it is very clever engineering—man has an inner penis for the same reason a house has a foundation and a tree has roots. Without solid foundational support, there would not be the infrastructure to enable to a rigid erection, angling proudly up towards the heavens. If the purpose of the penis was only to conduct urine and there was no need for rigidity, there would be no need for such support.  However, in order to defy gravity and stand tall and proud at appropriate times, the penis must have strong roots.  If a house had a weak foundation, it could easily blow down in a storm and if a tree has a poor root system, a gust of wind could level it, and so robust penile foundational support is a necessity for supporting a rigid erection and allowing it to survive in the “stormy turbulence” it may encounter with sexual activity.

Let’s briefly study the anatomy of the penis: The pendulous penis (hanging like a pendulum) is the external and visible portion of the penis. The penile shaft extends from the base of the penis (where the penis attaches to the body in the pubic region) to the glans (the head of the penis, derived from the Latin word for acorn). The infrapubic penis (“below” the pubic bone) is the inner, hidden, deeper aspect ofthe penis that extends down the pubic bones on each side. The crura (derived from the Latine word for legs) are the deep penile roots, which are secured to the bones and provide the internal support necessary for an erection.

The bulk of the tissue of the penile shaft is composed of three erection chambers that contain spongy, vascular erectile tissue: the paired corpora cavernosa (cave-like bodies) and the single corpus spongiosum  (spongy body). Although they are individual cylinders, the corpora cavernosa are interconnected and communicate.  The corpora cavernosa run parallel down the shaft of the pendulous penis, and diverge at the level of the inner component of the penis, forming the crura that are anchored to the pelvic bones.  The urethra (channel that conducts urine and semen) is enveloped by the corpus spongiosum, which begins in the perineum (area between the scrotum and anus), where it expands to form the bulb and extends to and forms the glans penis. It lies in the groove between the corpora cavernosa.

If you imagine your body to represent the penis, your legs are your crura, your torso is the external penis, and your head is the glans. In order for your torso and head to stand tall and erect, you need your legs planted firmly; otherwise, your torso would crumble to the ground.

Important and intimately connected allies of your inner penis are the pelvic floor muscles, which work with the erection chambers of the penis. The two important pelvic floor muscles involved with sexual function are the bulbocavernosus (BC) and ischiocavernosus (IC) muscles. The BC surrounds the inner, deeper portion of the urethra and covers and compresses the bulb of the penis. It is really a compressor muscle, so I call it the urethral compressor. In its relaxed state, it acts as an internal strut that helps anchor the deepest, internal aspect of the penis. When the muscle is contracted actively after urination, it compresses the urethra to expel the last few drops of urine that remain in the deep urethra. During sex, it helps support the tumescent (swollen) corpus spongiosum and glans. At the time of climax, this muscle is responsible for the expulsion of semen by virtue of its strong rhythmic contractions, allowing ejaculation to occur and contributing to orgasm. The classic 1909 textbook Gray’s Anatomy aptly labeled the BC muscle as “ejaculator urine.”

The paired IC muscles cover and compress each corpus cavernosum of the penis.  They, too, are compressor muscles, so I call them the corporal compressors. In their relaxed state, they act as internal struts that help anchor the deepest aspect of the corpora—the crura—to the perineum.  The IC muscles stabilize the erect penis and compress the corpora, decreasing the return of blood to help maintain penile rigidity and sky-high blood pressures in the penis. At the time of climax, they contract rhythmically and are responsible for maximal erectile rigidity at the time of ejaculation.

Erection Rigidity: A Perfect Storm

Sex length

 

Note: Although this is written primarily for men, it is equally relevant to females. Since the penis and clitoris are homologous organs, whenever you see the word “penis” you can substitute the word “clitoris.” In terms of solutions, only simple and natural ones will be mentioned. A discussion of oral medications, urethral suppositories, injections and penile implants will be a topic for another time.

The penis is one of the most “magical” of organs—uniquely capable of transforming its size, shape, and constitution in a matter of nanoseconds. The remarkable upsurge is possible because blood inflow is maximized while outflow is minimized, resulting in penile blood pressures that far exceed arterial blood pressure.

Rigid erections can only occur when there is a “perfect storm” of three events:

Event #1 (Pre-penile): Arterial blood flow to the pelvis needs to increase substantially.

Event #2 (Penile): Smooth muscle within the arteries and the spongy sinuses of the erectile chambers of the penis must relax to allow engorgement with blood.

Event #3 (Post-penile): The pelvic floor muscles must engage and compress the deep roots of the penis to morph the swollen penis into a rigid one. The blood pressure in the penis resulting from the inflow of blood alone, in the absence of the contribution from the pelvic floor muscles, will not exceed systolic blood pressure, so the pelvic floor muscles play a vital role with respect to both rigidity and durability of erections.

When erections go south, it comes down to failure in one or more of the three events, which can be pre-penile, penile, or post-penile.

Pre-penile ED

The problem lies within the arterial blood supply to the pelvis, which is not capable of delivering enough blood flow to fill the penis. Typically, the pelvic arteries are clogged with fatty plaque (atherosclerosis), which is often due to an unhealthy lifestyle: poor diet, physical inactivity, being overweight and use of tobacco. Diabetes is a very common cause of impaired blood flow (although it also adversely affects the nerve supply). Insufficient blood flow may also occur because of the blood pressure lowering effect of blood pressure medications. Psychological issues such as performance anxiety cause constriction of the inflow to the penis by virtue of the adrenaline released as a result of anxiety, adrenaline being a potent constrictor of blood flow.

Solution to Pre-penile ED

Lifestyle “angioplasty”—meaning getting down to “fighting” weight, adopting a heart-healthy (and penis-healthy diet), exercising regularly, drinking alcohol moderately, avoiding tobacco, minimizing stress, getting enough sleep, etc.—all common sense measures to improve all aspects of health in general and blood vessel health in particular.

Penile ED

The problem lies within the penis itself. Because of poorly functioning smooth muscle within the arteries and sinuses of the erectile chambers, the penis cannot properly swell with blood. This smooth muscle cannot relax enough to allow blood flow to inflate the penis and pinch off the venous drainage. This failure of relaxation of the smooth muscle in the penile arteries and spongy sinuses parallels the failure of relaxation of smooth muscle in our arteries that causes high blood pressure (a.k.a. “essential” hypertension). Loss of this smooth muscle and scarring can happen with aging, following prostate cancer surgery, from Peyronie’s disease (abnormal scar tissue within the penis) or because of disuse atrophy (loss of penis form and function because of lack of use as it was intended to be used).

Solution to Penile ED

Age-related malfunctioning smooth muscle and scarring is a difficult issue to manage. However, lifestyle measures can be helpful as well as adopting a “use it or lose it” attitude towards erectile function—exercising the penis via regular sexual activity will actually help its continued functioning and health of the smooth muscle of the penile arteries and sinuses.

Post-Penile ED

The problem is weakened pelvic floor muscles. These feeble muscles are incapable of compressing the roots of the penis sufficiently to increase the blood pressure in the penis to the levels needed for rock-hard rigidity.

Solution to Post-Penile ED

Pelvic floor muscle training to improve the strength, tone and endurance of the pelvic floor muscles will optimize erectile rigidity and durability.

Penis Hydraulics – What You Don’t Know About Your Erection

Couple

Humans are hardwired for two basic functions: survival and reproduction. Nature’s forces have made the reproductive process a pleasurable one, and by so doing have ensured the greatest likelihood of reproduction being successful. What a clever bait and switch scheme! In the seeming pursuit of a feel-good activity—determined by this evolutionary sleight of hand—we have been hoodwinked into reproducing!

The goal of reproduction is fusion of DNA from two individuals to perpetuate the species. The penis functions as a “pistol” to penetrate the female’s reproductive tract and inject DNA. A flaccid penis is unable to complete this task.

Many mammals—including the gorilla and chimpanzee—have a bone in the penis (the baculum), which functions to keep the penis hard enough for vaginal penetration and injection of the DNA. (There is also a bone in the clitoris called the os clitoridis.) However, the human penis is boneless (as is the human clitoris). While we can debate whether or not this is a good thing, it certainly helps to keep the penis concealed!

Creating a “Bone” Where One Doesn’t Exist

How did nature overcome this challenging design problem: creating bone-like rigidity in a boneless organ?

The answer is hydraulics—using blood as a hydraulic mechanism—not the typical use of blood, which is for the transportation of oxygen, carbon dioxide, hormones, nutrients, and waste products to and from our organs. This use of blood as a hydraulic mechanism for erections—both penile erections in men and clitoral erections in women—is nothing short of brilliant…our bodies having evolved to use blood the way a tire uses air, to inflate deflated organs to allow them to function!

An example of an animal that uses hydraulics is the jumping spider, which uses blood forced into the legs to straighten them out to facilitate powerful jumps, avoiding the need for muscular legs that are bulky and clearly not spider-like.

Erection hydraulics requires a special means of regulating flow. To do so, the inflow needs to turn on like a gushing faucet and the outflow needs to shut off like a plugged drain in a sink. This is not the usual state of affairs for blood flow to an organ, which typically requires a relatively small amount of inflow to meet basic metabolic needs and an equal amount of outflow, creating a dynamic state of equilibrium. An erection demands that the arteries of the penis function as high-pressure faucets (inflow increasing many times over baseline) and the penile veins to close off completely.

So how has our body evolved this capacity?

The penis is a marvel of design and engineering, capable of increasing its blood flow by a factor of 40-50 times over baseline! This surge happens within seconds and is accomplished by relaxation of the smooth muscle within the arteries supplying the erection chambers and within the sinuses of the erectile chambers. This is not the case of non-genital organs, in which blood flow can be increased upon demand (for example, to our muscles when exercising), but not anywhere to this extent.

Now for a little deviation off course for some interesting trivia:

  1. The spongy sinus tissue in the erectile chambers is virtually identical to the spongy sinus tissue in our facial sinuses. (My pathologist friend claims that he can’t tell the difference under a microscope.)
  2. When this spongy tissue in the penis or clitoris becomes congested with blood, an erection occurs; when it happens in ours facial sinuses it is known as sinus congestion or a stuffed nose.
  3. The spongy tissue in the erectile chambers is surrounded by connective tissue known as the tunica albuginea, the second toughest connective tissue in our bodies, the toughest being the dura mater that surrounds our brains and spinal cords.
  4. A side effect of the ED meds like Viagra is nasal congestion…now you understand why.
  5. Prolonged erections (priapism) are often treated with the same medications used to treat a stuffed nose, e.g., phenylephrine.
The Important Role of the Pelvic Muscles

So, under the right circumstances the penis becomes swollen (tumescent) with blood. How has our body evolved the capacity to trap the blood so it does not return to the circulation? How does the penis go from swollen to rock-hard rigid?

First, as the sinuses within the erectile chambers fill with blood, they pinch off the veins, which traps blood in the penis. Second, nature—in its typical brilliant way—has designed a means of increasing the blood pressure in the erectile chambers to sky-high levels by means of a “muscular tourniquet” that not only chokes off the exit of blood, but with each squeeze causes a surge of blood with increased filling of the erectile chambers, the end result being bone-like rigidity.

What are the names of these specialized muscles and what muscle group are they part of?

These are the ischiocavernosus and bulbocavernosus muscles (man’s best friends) that are part of the group of muscles known as the pelvic floor muscles, which form the floor of the important group of muscles known as the “core” muscles. When a man has a rigid erection and he voluntarily contracts these muscles, the erection will lift up and point majestically towards the heavens, thank you pelvic floor muscles. It is no wonder that in the classic Gray’s Anatomy textbook in 1909 referred to the ischiocavernosus muscle as the “erector penis muscle!”

What To Expect Of Your Erections As You Age

Men's Sexual Health

It is shocking how ill prepared we are for aging. Nobody informs us of exactly what to expect with the process, so we just sit back and observe the changes as they unfold, dealing with them as best we can. Although educational books are available on many topics regarding other expected experiences, such as “What To Expect When You’re Expecting,” I have yet to see “The Manual of Man,” explaining the changes we might expect to experience as time goes on. Some day I wish to author a book like that, but for the time being I will blog about what to anticipate with male sexual function as time relentlessly marches on.

“But the wheel of time turns, inexorably. True rigidity becomes a distant memory; the refractory period of sexual indifference after climax increases; the days of coming are going. Sexually speaking, men drop out by the wayside. By 65, half of all men are, to use a sporting metaphor, out of the game; as are virtually all ten years later, without resort to chemical kick-starting.”

Tom Hickman

God’s Doodle: The Life and Times of the Penis

Aging can be unkind, and Father Time does not spare your sexual function. Although erectile dysfunction (ED) is not inevitable, with each passing decade, there is an increasing likelihood. Present in some form in 40% of men by age 40 years, for each decade thereafter an additional 10% join the ED club. All aspects of sexuality decline, although libido (sexual interest and drive) suffers the least depreciation, leading to a swarm of men with eager “big heads” and apathetic “little heads,” a most frustrating combination indeed.

With aging often comes less sexual activity, and with less sexual activity often comes disuse atrophy, in which the penis actually becomes smaller. Additionally, with aging there is often weight gain, and with weight gain comes a generous fat distribution in the pubic area, which will make the penis appear shorter. With aging also comes scrotal laxity and testicles that hang down loosely, like the pendulous breasts of an older woman. Many of my older patients relate that when they sit on the toilet, their scrotum touches the toilet water. So, the penis shrinks and the testicles hang low like those of an old hound dog…Time and gravity can be cruel conspirators!

So, what can you expect of your sexual function as you age? I have broken this down by decade with the understanding that these are general trends and that you as an individual may well vary quite a bit from others in your age group, depending upon your genetics, lifestyle, luck and other factors. There are 30- year old men who have sexual issues and 80-year old men who are veritable “studs,” so age per se is not the ultimate factor.

You may wonder about the means by which I was able to craft this guide. I was able to do so through more than 25 years spent deep in the urology trenches, working the front line with thousands of patient interactions. My patients have been among my most important teachers and have given me a wealth of information that is not to be found in medical textbooks or journals, nor taught in medical school or during urology residency. Furthermore, I am a 50-something year-old man, keenly observant of the subtle changes that I have personally witnessed, but must report that I am still holding my own!

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 just be enough to stimulate a rigid, gravity-defying erection, pointing proudly at the heavens. The sight of an attractive woman, the smell of her perfume, merely the thought of her can arouse you fully. 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 and you are capable of ejaculating an impressive volume of semen forcefully with an arc-like trajectory, a virtual comet shooting across the horizon. When you arise in the morning from sleep, it is not just you that has arisen, but also your penis that has become erect in reflex response to your full bladder, which can make emptying your bladder quite the challenge, with the penis pointing up when you want to direct its aim down towards the toilet bowl.

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 sometimes in a new sexual situation you have performance anxiety, a mechanical failure brought on by the formidable mind-body correction, your all-powerful mind dooming the capabilities of your perfectly normal genital plumbing.

Age 30-40

Things start to change ever so slowly, perhaps even so gradually that you barely even notice them. Your sex drive remains vigorous, but it is not quite as obsessive and all consuming as it once was. You can still get quality erections, but they may not occur as spontaneously, as frequently, or with such little provocation as they did in the past. You may require some touch stimulation 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, and the premature ejaculation of yonder years is much less frequent an occurrence.

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 tactile stimulation and the rock-star rigidity of years gone by gives way to a nicely firm penis, still suitable for penetration. The gravity-defying erections don’t have quite the 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 a bit feebler than previous. Getting a second erection after climax is not only difficult, but also may be something that you no longer have any interest in pursuing. 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 to behold that it once was, and touch is 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. Your orgasms are definitely different with less intensity of your climax, and at times, it feels like nothing much happened—more “firecracker” than “fireworks.” Ejaculation has become noticeably different—the volume of semen is diminished and you question why you are “drying up.” At ejaculation, the semen seems to dribble with less force and trajectory; your “high-caliber rifle” is now a “blunt-nosed handgun.” Getting a second erection after climax is difficult, and you have much more interest in going to sleep 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 bit of a misleading word…this is 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 and coercion, but they are not five star erections, more like three stars, suitable for penetration, but not the 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, well, not so climactic and explosive ejaculations are a matter of history. At times, you think you climaxed, but are unsure because the sensation was so un-sensational. Ejaculation may consist of a few drops of semen dribbling out of the end of the penis. Your “rifle” has now become a child’s plastic “water pistol.” Seconds?…thank you no …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 remaining sexual desire left in you, but it’s a far cry from the fire in your groin you had when you were a younger man. With physical coaxing, 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 your erections has noticeably dropped, with penile fullness without that rigidity that used to make penetration such a breeze. At times, the best that you can do is to obtain a partially inflated erection that cannot penetrate, despite pushing, shoving and manipulating every which way. Spontaneous erections have gone the way of the 8-track player. Thank goodness for your discovery that even a limp penis can be stimulated to orgasm, so it is still possible for you to experience sexual intimacy and climax, although the cli-“max” is more like a cli-“min.” That child’s “water pistol”…it’s barely got any water left in the chamber.

Age 80-90

You are now a 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. (But even this plus is often compromised by the aging prostate gland, wrapped around the urinary channel like a boa constrictor, making urination a challenging chore.) Compounding the problem is that your spouse is no longer a spring chicken. Because she 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! Penis magic has gone the way of defeated phallus syndrome. So, when and if you get an erection, you never want to waste it!

Wishing you the best of health,

Andrew Siegel, M.D.

www.AndrewSiegelMD.com

Private Gym website for pelvic floor instructional DVD and resistance training equipment

www.PrivateGym.com