ED means no erections from masturbation. According to the American Urological Association, erectile dysfunction (ED) is “the inability to achieve or maintain an erection sufficient for satisfactory sexual performance.” Huh? That’s absurdly vague. If you define “an erection” as what you see in porn, and “satisfactory sexual performance” as porn sex—instant, hard-as-rock erections that last forever with climaxes always on cue—then just about every guy has ED. What is it, really? For practical purposes, ED means that a man who’s sober (no alcohol or other erection-impairing drugs) cannot raise an erection during extended masturbation.

ED is not inevitable. According to landmark studies by University of Chicago researchers, among men aged 50 to 64, about one-third suffer ED. From age 65 to 85, the figure is approximately 44 percent. While ED is quite common in older men, more than half never develop it.

Most older men suffer not ED but erection dissatisfaction. Starting around age 50 (often earlier for smokers and/or diabetics), erections change, in some men gradually, in others more quickly. Men lose the ability to raise erections solely from sexual fantasies. Direct fondling becomes necessary. When erections appear, they rise more slowly and do not become as firm as they were during men’s thirties and forties. And minor distractions—an ambulance siren on the street—may cause wilting. These changes alarm many men, who jump to the conclusion that they must have ED. If you can still raise erection during masturbation, you don’t. You have erection dissatisfaction.

Post-50 erection changes are normal and inevitable. But some lifestyle factors can postpone or even temporarily reverse them: falling madly in love, getting in shape (see below), and making love earlier in the day when you have more energy.

Unfortunately, other factors exacerbate erection dissatisfaction: anxiety, alcohol, many other drugs, relationship problems, and making love when fatigued, i.e., late at night after a long day and a big dinner with wine.

Anxiety is particularly pernicious. It triggers the fight-or-flight reflex that sends blood away from the central body, including the penis, and out to the limbs for self-defense or escape. Less blood in the central body means less blood available for erection. Erection dissatisfaction is upsetting, but try to accept it. It’s normal. And if you become anxious, erections become less likely.

Good ways to minimize anxiety: a hot shower before sex, and during lovemaking, deep meditative breathing, a slow pace, and lots of sensual touch all over.

Erection dissatisfaction can actually enhance lovemaking. The dark cloud of erection changes has a silver lining. Young couples often have problems because young men become aroused faster than young women. Young men are often all finished before young women have even become aroused. Post-50 erection changes slow men’s arousal so their erotic pace more closely matches women’s. A slower pace allows plenty time for kissing, cuddling, and whole-body massage, all essential to most women’s enjoyment of sex. Seen in this light, for many older couples, erection dissatisfaction can be a gift.

Healthy lifestyle minimizes risk of ED. Erection depends on blood flow through the penis. Anything that impairs it increases ED risk: smoking, diabetes, high cholesterol, high blood pressure, heart disease, being overweight, little regular exercise, more than two alcoholic drinks a day, and fewer than five daily servings of fruits and vegetables. Avoiding these risk factors does not prevent post-50 erection changes, but it preserves erection function and helps prevent ED.

The drugs are worth trying, but don’t expect miracles. Everyone has heard of Viagra, but Cialis is actually more popular because it’s effective longer—24 to 36 hours instead of three to five. Erection drugs improve erections in around two-thirds of men. They don’t work for about one-third. They do not produce porn-star erections. Over time, many men need larger doses. But as dosage increases, side effects become more likely, notably, headache and nasal congestion. Finally, the drugs have no effect on arousal, so men may raise erections but do not feel particularly interested in sex. Many men feel disappointed with the drugs. Fewer than half refill their prescriptions.

If you’re no longer having intercourse, you don’t need erections. Most men assume that erections are necessary for sex. No. Couples can have great sex without them. Intercourse becomes problematic for older couples. Men have erection issues and post-menopausal women develop vaginal dryness and atrophy that can make intercourse uncomfortable (or worse) even with lubricants. Many older couples jettison intercourse in favor of mutual massage, oral sex, and sex toys—and still enjoy hot sex.

Men can have orgasms without erections. That’s right, you don’t need an erection to have an orgasm. In an erotic context filled with kissing, cuddling, fondling, massage, oral, and sex toys, a man with a semi-erect or even flaccid penis can enjoy orgasms as intense as any he ever experienced during intercourse.

The drugs work best in combination with sex therapy. Several studies have shown this. There’s more to satisfying sex than an erection. Relationship issues are crucial, especially if sex has been a sore point or if the couple hasn’t had much for a while. To find a sex therapist near you, visit the American Association of Sex Educators, Counselors, and Therapists, the Society for Sex Therapy and Research, or the American Board of Sexology.

Erection changes can mark the end of sex or a new erotic beginning.  When erection dissatisfaction develops, some men decide that’s it, sex is over. Others accommodate and continue to enjoy lovemaking as long as they live. The choice is yours.

As recently as 2007, Viagra controlled 62 percent of the U.S. erection-medication market, while Cialis ran a distant second at 26 and Levitra  was just a blip on the radar at 12 percent. Since then, it’s not exactly clear what’s been happening to sales of erection medications. The companies that manufacture the drugs make contradictory claims. However, one thing seems certain. Cialis is gaining on Viagra, especially outside the U.S. Eli Lilly, maker of Cialis, says its drug is number one worldwide, though Pfizer, maker of Viagra, disputes this. Viagra is still the top-seller in the U.S., but its market share is slipping.

The reason is that Cialis has a longer duration of action. Take one pill, and a man gains erection assistance for 72 hours. Viagra and Levitra last for about four hours, though recent studies suggest some benefit for up to about 10 hours. But even granting Viagra extended benefit, Cialis still works much longer. In Europe, it’s marketed as “the weekend pill.” One dose and a man gets an erection boost for three days.

In eight published studies, researchers have asked couples to try both Viagra and Cialis. Participants used each drug for two to six months. By the end of all eight trials, the couples preferred Cialis, typically by ratios of more than two-to-one. The main reason: It offers greater freedom from sexual time pressure.

Chemically, the three erection medications are quite similar, with similar side effects. But individual men react differently to them. If you’d like to use one, it’s best to try all three to see which provides the greatest benefit with the fewest side effects.

These drugs work in about 70 percent of older men, but they don’t help about 30 percent, so don’t be surprised if you notice little or no benefit.

However, even when they work, erection drugs do not produce the rock-hard erection men recall from their youth or see in pornography. Porn actors are overwhelmingly young men at the stage of life when erections are most firm (not to mention that porn actors pop erection drugs like candy). After around 45, erections become less firm and firmness continues to subside with advancing age. A man in his fifties who takes an erection  drug may have a firmer erection than he would without the medication. But chances are it won’t be as firm as the erections he recalls from his twenties.

In addition, erection medications are not aphrodisiacs. They do not boost libido. The just increase blood flow into the penis. In young men, erection and arousal are typically synonymous. But as men age, erection and arousal become uncoupled, and older men find it increasingly difficult to become aroused. The drugs don’t help with arousal.

For most, but not all men, erection drugs are safe. The most frequent side effects include: headache (16 percent of users), flushing (like menopausal hot flashes, 10 percent), upset stomach (7 percent), nasal congestion (4 percent), and rarely, visual disturbances, mostly in men with severe diabetes or chronic eye conditions such as macular degeneration.

But, some men should absolutely never use erection drugs, those taking nitrate medication for heart disease, notably nitroglycerine for angina, or the party drug, amyl nitrate (“poppers”). The combination of Viagra and nitrate drugs can cause a precipitous drop in blood pressure—and possibly death. Before this problem was identified, the combination of Viagra and nitrate medication killed more than 500 men. If you take any nitrate drug, don’t use Viagra, Levitra, or Cialis.

In this article:

• But First, Do You Really Want Erections?
• How to Consult a Doctor
• The Ladder Of Treatment
• Sex Toys Might Help
• Everything You Need To Know About Viagra, Cialis, and Levitra
• Other Treatments
• “Viagra-vation”

• How erection drugs work.
• 5 Advantages of erection medications.
• 5 Disadvantages.
• Duration of the drugs’ effects differ.
• Don’t buy erection drugs over the Internet.
• The yohimbine controversy.
• There’s much more to great sex than an erection.
  

Shortly after Viagra was approved, pundits predicted sales of $4.5 billion a year. Today, combined sales of the three major drugs (Viagra, Levitra, and Cialis) total only about $2 billion. That’s a lot of money, but older men did not flock to the drugs in anywhere near the numbers the experts anticipated. Fewer than half of men who get a prescription refill it. And only about 10 percent of men over 50, the age group the drugs were intended for, have even tried them.

In this article:

• 7 reasons men don’t men refill prescriptions.
• Why so few older men have tried erection drugs.
• The irony of erection medications.