Treatment methods will depend on the underlying cause of the problem, meaning the chosen method will differ from case to case. There is no clearer demonstration of this than psychological erectile dysfunction. On average, men with erectile dysfunction do not have lower testosterone levels in their blood, but administration of androgen to men with this problem can increase their sex drive and their erection capacity. More rarely, low testosterone can be caused by the pituitary (a small gland at the base of the brain) not secreting sufficient hormones to stimulate the testes to produce testosterone. Implants allows a couple to be spontaneously intimate. Causes of performance anxiety Performance anxiety is typically caused by negative thoughts about one’s ability to perform well during sexual activity. These can include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Psychological impotence is where erection or penetration fails due to thoughts or feelings; this is somewhat less frequent, on the order of about 10% of cases.
Prolonged erections (>1 hour) can be reversed by a second injection (antidote) in the office. Tools, one patient, with early and predominant right anterior temporal involvement, was easily aroused by slight stimuli, such as touching her palms . Explained; the more anxious a man gets about being able to perform, the less able they are to do so, and the more anxious they get, and so on, causing a spiral of deterioration. Armed with new structure and strategies, you can reach a point where you can deal with your issues without a therapist. Implant surgeries usually result in decreased penis size which may dissuade some men from undergoing surgery. Aside from being referred by your GP, there are a number of places that provide therapy.
16 Patient education should be aimed at increasing exercise, losing weight to achieve a body mass index (BMI) less than 30 kg per m2, and stopping smoking.
The simplest kind of implant is made from two easy-to-bend rods that are most often made of silicone. However, sexual activity is also likely to be beneficial for your cardiovascular health. But one of the less talked about albeit common symptoms of depression is erectile dysfunction. You should also tell your doctor about any over-the-counter medicines or complementary remedies you may be taking. What you may not know is that psychological factors are a major contributing factor for many cases of ED. Porn-induced erectile dysfunction is a concept which was first identified by the Kinsey Institute in 2020, soon after internet-based pornography became a worldwide phenomenon. The controllable risk factors for arteriosclerosis--being overweight, lack of exercise, high cholesterol, high blood pressure, and cigarette smoking--can cause erectile failure often before progressing to affect the heart. Now, doctors know that many cases of impotence have a physical cause, which usually can be treated.
Viagra acts by slowing the breakdown of cyclic GMP (cGMP), and the resultant increase in cGMP dilates the penile arteries and leads to an erection. In a meta-analysis of over 700 men, Gupta and colleagues (2020) assessed the effects of lifestyle modification on the severity of erectile problems. Cognitive behavioral therapy (CBT) is a common and highly effective treatment for psychological issues in general, but also for ED. Men who are taking medications that contain nitrates, such as nitroglycerin, should NOT use these medications. Sources, but do younger men with ED tend to have arterial inflow problems and endothelial dysfunction? PDE-5 inhibitors can cause some side effects, including: ED may be a short-term or long-term problem for you. Some of the most common symptoms of depression include the following: Erectile disorder (ED) is defined in the DSM-5 as the recurrent inability to achieve an erection, the inability to maintain an adequate erection, and/or a noticeable decrease in erectile rigidity during partnered sexual activity.
Most cases of ED have a physical cause, such as heart disease, diabetes, and obesity. By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. An occasional difficulty may be considered normal, however, frequent episodes or prolonged problems lasting more than a couple of weeks may require further evaluation by a physician. Erectile dysfunction, also known as impotence, is the inability of a man to achieve or maintain an erection sufficient for sexual intercourse. Viagra (sildenafil) and other drugs used to treat ED inhibit PDE Type 5. The pituitary is also sometimes affected by small benign (non-cancerous) tumours that secrete prolactin, another hormone that can cause impotence.
Inability to delay ejaculation on all or nearly all vaginal penetrations; and, negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.
Results have been mixed and are not at all guaranteed, although progress is more likely to be achieved if both partners approach sessions with an open-mind and willingness to share. In some cases, treatment can involve inserting prostaglandin pellets into the urethra, injecting smooth muscle relaxants and vasodilators into the penis, a penile implant, a penis pump, or vascular reconstructive surgery. The following table contains a list of specific medicines that may cause or contribute to erectile dysfunction. Although it’s not always comfortable to discuss the topic of ED with a healthcare provider, most likely, your doctor has several patients with similar problems and has had many discussions about sexual health with them—after all, sex is an integral part of life. Article information, adherence to recommendations and improvement over time in men with erectile dysfunction. Performance anxiety is inherent in most cases of ED. Sex education involves therapist guidance on the different aspects of sexual intercourse, and interpersonal therapy focuses on the relationship problems that may be driving psychogenic erectile dysfunction. If you're concerned about erectile dysfunction, talk to your doctor — even if you're embarrassed.
All of these medications work by increasing blood flow to the penis, causing an erection. The same problem in the brain may cause a stroke, but in the penis, it causes erection problems. Anxiety, whether about something specifically sexual or part of a wider anxiety syndrome, is never helpful to good sexual function. Erectile dysfunction (ED), also known as impotence, is a type of sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual activity.
Psychological factors are responsible for about 10%-20% of all cases of erectile dysfunction, or ED. Sexual stimulation is required for sildenafil citrate to have the best efficacy. The good news is treatment of the problem is available and typically successful. Many men do not seek treatment due to feelings of embarrassment.
However, the true number may be even higher than 20%.
Saline is infused under pressure into the corpus cavernosum with a butterfly needle, and the flow rate needed to maintain an erection indicates the degree of venous leakage. Nevertheless, the key to recovering from ED is to recognize the early warning signs and symptoms and promptly get help. A s exological bodyworker will teach you breathing techniques and focus on sensation. In the past, erectile dysfunction was commonly believed to be caused by psychological problems. About menshealthquestions (mq), glina S, Sharlip ID, Hellstrom WJ. Illicit drug use. Many of these can achieve results faster,with fewer side effects and a quicker recovery. Many men feel their ability to have and keep an erection should stay the same throughout their lives – but this is far from reality. Common causes include:
Managing other health conditions and making the necessary lifestyle changes are important to help overcome erectile dysfunction. These medications are also known to react with nitrate-containing drugs used to treat heart disease, so it is important to discuss possible interactions with the doctor in cases where PDE-5 inhibitors may be taken in combination with other medications, especially heart medications. How do doctors decide which treatment to try? If you’re looking for a non-medial solution to your ED, you might want to consider engaging a sex coach, sexological bodyworker or even a sex surrogate. Many people with low self-esteem get so caught up in their own perception of themselves, that they begin to project it onto others. Sometimes, therapy sessions are "as simple as helping couples understand what happens in typical couples’ sex lives. "
Alprostadil (Caverject) is a viable second-line therapeutic option for the treatment of ED. Post stroke: addressing thinking and memory problems, bruising bending:. Patients who are interested should discuss the risks and benefits (informed consent) of each, as well as costs before starting any clinical trials. This, in turn, can cause performance anxiety and psychological ED.
Inability To Get An Erection
This is a form of therapy in which both you and your partner see a therapist together. When you’re stressed and focusing on other issues apart from sex, you might find that you don’t want to have sex as often and there might be a drop in your ability to perform when you do try. In general, exercise, particularly of the aerobic type, is effective for preventing ED during midlife. Common adverse effects of intracavernosal alprostadil include penile pain, edema and hematoma, palpable nodules or plaques, and priapism. Like ICI therapy, IU Alprostadil should be tested in the office, before home usage.
One way to know if you are dealing with medical or psychological ED is to pay attention to the signs of erectile dysfunction. Some couples consider seeking treatment for ED together, while other men prefer to seek treatment without their partner's knowledge. Alcoholism, endocrine disease, and neurological disorders are typical physical causes. These include drugs for high blood pressure, depression, heart disease and prostate cancer. Millions of men have benefited from three drugs that treat ED. What is the Surgery Like? What is the link between performance anxiety and ED? Psychological impotence is a real thing, and it is much more common than you might think.
The medicine may also be known by other trade names. How do couples cope with ED? A range of other treatments exists for cases of impotence that arise from purely physiological causes. 11 Clues to the diagnosis of ED are listed in Table 5. A physical cause can be identified in about 80% of cases. In a study of case records for 64 men with erectile dysfunction or premature ejaculation, there was a significant link between ED and anxiety disorders or depression. For 2025, the prevalence of ED is predicted to be approximately 322 million worldwide. In the same study, a number of psychosocial factors, such as anxiety, negative emotions, and dysfunctional beliefs, were commonly cited reasons for discontinuation.
Elderly men are especially sensitive to the effects of these medical treatments, which may increase their chance of having side effects. The good news is that many healthcare providers and urologists are equipped to discuss and treat ED. The car accident shocked him enough psychologically that it impacted his sexual functioning. In older men, ED usually has a physical cause, such as a drug side effect, disease or injury. Guilt and shame are feelings that are commonly linked to mental health issues such as depression. Prostate cancer, hypogonadism, ED, and premature ejaculation show significant correlations with physical and mental health in men and in particular with quality of life, metabolic syndrome, cardiovascular diseases, and depressive symptoms . There is no point in worrying and not doing anything about it. 0branched chain amino acids (special reference to leucine). ED is also more likely to occur in people who smoke, are overweight and/or are not active enough.
Read More About Erectile Dysfunction
An efficient medication for assisting erectile function is thought to be alprostadil, a man-made version of prostaglandin E1, a substance naturally made in the body to help produce erections. These cause your muscles to tense and your heart to beat rapidly. If you work with male patients, especially older ones, you might find some of them dealing with erectile dysfunction (ED). The ‘senate focus’ exercise is particularly popular, where both partners agree to abstain from sex for a few weeks but increase non-sexual bodily contact and understanding. Almost any disease or condition can affect erectile function by altering the nervous, vascular, or hormonal systems. Occasional failure to achieve an erection is a common phenomenon and does not constitute a medical problem. A commonly prescribed topical medication for ED is Vitaros©, a prescription medicine in the form of a cream, containing the active ingredient alprostadil. This type of counselling is a deeper-dive, relationship ‘talk therapy’ looking at the emotional, psychological, and sexual issues which may be influencing your ED.
The amount of each drug used can be changed based on the severity of your ED, by an experienced health professional. The risk of developing erectile dysfunction increases as you get older. You may find that you can only get an erection when you’re watching porn. In fact, one study showed that men who use these medications recreationally, when they’re not really needed, were more likely to develop psychological impotence! Impotence can be caused by spinal cord injury; injury to your sex organs; or a pelvic fracture, which can cause damage to the nerves of the penis, or damage the blood vessels, resulting in reduced blood flow to the penis.
A couple could also experience relationship difficulties that then lead directly to sexual difficulties, and so the man experiences erectile dysfunction. If you have any conditions that have changed the structure of the penis or the surrounding area, this can cause ED. Many partners of people with ED feel that it is a reflection on them, but this is rarely the case. Let’s assume that you have never been diagnosed with a medical condition that is physically linked to erectile dysfunction, such as type 2 diabetes, obesity or heart disease. Levitra can be taken, with or without an empty stomach, 30 to 60 minutes prior to sex. Don’t wait to talk to your doctor about what you’re experiencing. Detumescence (i. )
Signs of Erectile Dysfunction
Like we mentioned earlier, stress hormones are released to the blood stream when we’re stressed. To restore access and understand how to better interact with our site to avoid this in the future, please have your system administrator contact [email protected] Get help, what is Porn Induced ED? Ellis, treatment of erectile dysfunction in men with depressive symptoms:. Are there any home remedies or natural products that can be used to prevent or treat erectile dysfunction? However, GPs are trained to deal with ED and in the end it’s usually not as embarrassing as was feared. Using the drug this way means you don't have to give yourself a shot, unfortunately it may not work as well as ICI.
It’s possible that a man’s ED may have both biological and psychological causes. For example, research found that 70% of men treated with Guided Imagery and sexual re-education succeeded in overcoming their mental impotence and were able to get erection whenever they wanted to. Below, we look at the psychological causes of ED, and assess the usefulness of the different types of therapy for ED available. Though childhood trauma is a completely valid reason for developing ED, we’re going to focus on the psychological issues that develop later in life. Urology care foundation, this is consistent with other studies in which an increased risk of ED was only associated with a higher amount of alcohol intake in terms of grams of alcohol (<20 g per day as reference, OR=0. Erectile dysfunction (updated May 2020). In the absence of physical health problems, we must delve a little deeper to determine the underlying cause of erectile dysfunction. In atherosclerosis, the arteries are clogged and narrowed, resulting in reduced blood flow.
Taking testosterone may help maintain an erection. The choice may depend on: Some medicines can contribute to impotence, as can some types of surgery and radiotherapy treatments. Everyone experiences stress at some point in their life. Corporate information, hyperglycemia was confirmed if the glucose level exceeded 250 mg/dL in heparinized tail vein blood (measured by a glucometer) 2 weeks after treatment with STZ. ED treatment involves tackling the cause of the problem, whether this is physical, psychological or a mixture of both.
How do couples cope with ED?
There are several determinants that contribute to erectile dysfunction. In fact, statistics show that up to 20% of ED cases are psychological in nature. Keep in mind that the only two ingredients necessary for an erection are to be aroused and to be relaxed. The inability to achieve an adequate erection can cause psychologic troubles, which then make it even more difficult to achieve an erection the next time. It is important to realize, however, that discussing your problem with your partner is an important part of the healing process. Physical causes of ED include aging, high blood pressure, conditions which affect the blood vessels and/or nerves associated with the penis, and nerve damage to the area which occurs due to injuries, or certain surgeries such as prostate surgery. Many ED patients feel like they’re “less of a man” because they can’t perform sexually the way they used to. If the inability to get or maintain an erection happens to you once or twice, you may not need to see a doctor.
In most cases, the side effects are linked to PDE5 inhibitor effects on other tissues in the body, meaning they are working to increase blood flow to your penis and at the same time impacting other vascular tissues in your body. These tests may require blood and urine samples. You’re also more likely to have morning erections, and be able to have an erection when you masturbate, than men whose impotence has a physical cause. However, the combination of lifestyle modifications and PDE-5 inhibitors may more effectively improve erectile function than either method alone. Medication for erectile dysfunction is a route many men with decreased blood flow take. Download or request our booklet ‘Sex and the heart’ and/or our factsheet ‘Explaining sexual problems to your GP’. By age 40, the condition becomes more frequent as men age. Non nerve-sparing prostatectomies and unsuccessful nerve-sparing prostatectomies damage the two bundles of nerves associated with producing erections.
- Any leftover cream can be rubbed in around the tip.
- A man who has been sexually abused in the past may need to work through feelings of fear, humiliation, or guilt before he can have satisfactory erection.
- Advanced procedures involve the insertion of an inflatable rod.
- Let’s explore the most common underlying causes.
- This is usually caused by stress, tiredness, anxiety or drinking too much alcohol, and it's nothing to worry about.
- Finding a treatment approach that can cure erectile dysfunction usually depends on identifying its root cause.
What is the Surgery Like?
This is because on a neurochemical level the brain can become “trained” to expect and need pornography for sexual arousal to occur. Working through these problems with your partner can help ease your symptoms of ED. Erection can be induced by injecting 10-20 µg of prostaglandin E1, with evaluations of the arterial flow every five minutes for 25-30 min (see image). Impotence may be a manifestation of a poor relationship, or a problematic time in a relationship.
What Causes Male Pattern Baldness?
In fact, a man with heart problems should not use these drugs. Testosterone replacement therapy is available as a cream or gel, topical solution, skin patch, injectable form and pellet form placed under the skin. Only take one tablet within a 24-hour period. What are your options if your inability to have or maintain an erection is due to a psychological problem? Professional sex therapists, while they identify two distinct dysfunctions as forms of impotence, prefer not to use the term impotence per se. PDE-5 inhibitors are not recommended for people who have already been affected by NAION, or who have a family history of retinal degenerative disorders. One of the difficult things to realize is that self pleasure is much easier to accomplish than sex with a living being as relational sex tends to be more complicated due to the many feelings experienced, the interactions that are occurring and the expectations that are directly or indirectly brought forward. Hormonal problems — Abnormal levels of certain hormones can interfere with erections and sex drive.
Give your partner the opportunity to ask questions to help them understand – you may even be able to give them some tips on how to help you when you are experiencing difficulties. In rare cases, the drug Cialis® can cause or increase back pain or aching muscles in the back. This was not directly related to anything except his own level of vulnerability of being human. Vitaros will usually take effect in 5-30 minutes after application. These can be wide-ranging, and not even apparent to some until problems have arisen during intercourse. This form of therapy can be great at building a more communicative, honest relationship, as well as helping to reduce sexual anxiety. For instance, performance anxiety relating to ED may cause a person to ejaculate prematurely and, likewise, worries related to the possibility of ejaculating prematurely may bring on ED.
Penile biothesiometry This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis. It privileges the idea that thoughts, feelings, and physical sensations are all interlinked. Contrary to what so many of us believe, this is what the latest research is saying:
Intraurethral (IU) Therapy
The article urges all men who have symptoms of ED to take a proactive approach to healthcare and get screened for CAD and related conditions. The strategies for managing negative thought cycles are extremely practical and can affect real change in terms of breaking down overwhelming feelings of failure, hopelessness, depression and anxiety. While it’s no surprise that erectile dysfunction can cause low self-esteem, did you know that the opposite is also true? Various risk factors can contribute to erectile dysfunction, including: Excessive alcohol use. Injury to the penis, spinal cord, prostate, bladder, and pelvis, can lead to erectile dysfunction by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.
Mildly decreased levels of testosterone are often not due to specific testicular or pituitary problems, but rather stress or depression. Impotence can also be caused by a blood clot that prevents enough blood from flowing into the penis to cause an erection. All three of these involve specific bodily systems including the hormones, muscles, blood vessels, nervous system, and emotions. The main causes of ED include:
A natural supplement that may help to widen the blood vessels in the penis, but Ginkgo. If stress, anxiety or depression are causing erectile dysfunction, counseling may be an effective treatment. When this happens, doctors will usually try to identify and treat the root cause of ED first, with the assumption that PE may get better as a result. Psychology may also play a role in the development of erectile dysfunction. Archives, acupuncture, identified as insertion of needles into acupoints at the skin and underlying tissues, is an important therapeutic method of TCM to treat various diseases. 36 When comparing psychosocial interventions versus alprostadil injections and vacuum pump devices, no differences in effectiveness were found.
This usually interferes with sexual activity.
Acquired premature ejaculation. If you are taking medication that can cause erectile dysfunction, there may be an alternative. Treatment strategies in ed and novel perspectives, there is no need for the prescription. Why do people have sex therapy?
Some of the most common causes of this type of ED include the following: When veins that drain blood from the penile cavernous bodies fail to sufficiently close during erection, this ‘leak’ will inhibit pressure buildup needed for a sufficient erection. Erectile dysfunction (ED) is the most common sexual problem in men. Other people also read: However sex therapy is not widely available on the NHS, you can look for qualified registered therapists on the College of Sexual and Relationship Therapists (COSRT) or the Institute of Psychosexual Medicine. However, if one is noticing that erection is not lasting, even though an occurrence of orgasm occurs, there is likely some medical or biological impact going on.
Are erectile dysfunction and premature ejaculation (PE) related? Download PDF Email the Guide Send to yourself or a loved one. Married men are less likely to report erectile problems compared to never married or divorced men (Laumann et al. )
PDE-5 inhibitors are the most commonly prescribed medication for treating erectile dysfunction.
What is Erectile Dysfunction (ED)?
It can take the form of about 20 one-hour sessions. It is possible for the pain – which usually affects the perineum and pelvis – to occur either occasionally, at regular intervals or every time the affected person engages in sexual intercourse. ED is not the same as premature ejaculation. The potential clue that psychosocial factors may be a cause is that a man is able to achieve normal erections and orgasm through masturbation or sex with a partner other than the “index case” partner with whom he has erectile dysfunction (e. )You will gain a realistic expectation of what your body is capable of and learn to maximize your erotic potential. Clitoral stimulation is more important than penetration when it comes to satisfying sex.
Testosterone is a hormone that affects your sex drive. 0branched chain amino acids (special reference to leucine), chen J, Wollman Y, Chernichovsky T, et al. Psychogenic erectile dysfunction on the other hand, is described by one study as that largely caused by psychological or interpersonal determinants. A specialized mechanical pump is used to cause an erection by placing it over the penis and sucking air out of the pump, drawing blood into the penis. A very smart man, psychologist, and mentor of mine.
Most cases of erectile dysfunction are caused by physical factors. © Verywell, 2020. In this situation, testosterone replacement is rarely of any benefit. Today is the day to take the first step toward seeking help and finding the right treatment program. Treatment for young men affected by ED caused by psychological factors may involve taking medications such as PDE-5 inhibitors.
Sex with the Lights On – or Off?
In some cases, men who experience abuse or sexual trauma in childhood may develop erectile issues later in life. The nervous system responds to arousal by releasing chemicals, such as nitric oxide, into the penile blood to cause the blood vessels that carry blood to the penis to enlarge, increasing blood flow to the sponge-like cylinders, and forming an erection. This leads directly to interference with his subsequent performance. It could be not knowing what the other person wants because the lack of communication or conversation regarding sexual behavior. Men who have diabetes have a higher risk of developing impotence than other men.
Hello Everyone Get The Cure
This cycle can continue until you see your doctor to find a treatment. Depression and anxiety are more common in men with ED. There are risks to prosthetic surgery and patients are counselled before the procedure. If the problem persists, the guilt becomes more than just a side effect – it can contribute to the ongoing cycle of ED as well. This is called retrograde ejaculation. If you have had erectile issues in the past, those experiences will add to the weight of performance anxiety.
Similarly, in men with a history of arterial trauma, surgical intervention can restore erectile dysfunction. Therefore, if you’re experiencing erectile dysfunction with a partner, this is probably due to psychological factors. Article, therefore, it is obvious that ED is a common worrisome complication of diabetes which is under diagnosed. A man whose ED stems from psychological causes may find counseling or sex therapy helpful. These are the only oral agents approved in the U.
Read on to learn about the psychological causes of ED, and how they can be addressed. Still, it helps to ask your health care provider about side effects that could result from each option: Medical treatments: Smoking contributes to vascular disease (disease of the blood vessels), so it can contribute to erectile dysfunction by affecting blood flow to the penis. For most men, erectile problems are caused by an issue, not a medical issue. When should you seek help? The most common psychological causes for ED include the following: It works by widening the blood vessels and increasing the blood flow to the penis, causing an erection.
Today more than ever, science is telling us that the body and mind are closely connected. The possible causes of ED are numerous. Some natural remedies for ED include: At one time, these factors were thought to be the major cause of impotence. The effects of marijuana on your memory, how often should I use them? Sexual function is influenced by a person's overall wellbeing. Common characteristics of young men with erectile dysfunction include: This can lead to fear or low self-esteem.
Male Pelvic Floor Dysfunctions And Evidence-based Physical Therapy
Though it may not always be possible to prevent erectile dysfunction, certain steps can be taken to reduce the risk of the condition. Perelman suggested that one’s sexual tipping point is determined by a variety of multidimensional factors that fall into two general categories, physiological or organic issues and psychosocial, cultural, and behavioral issues. It is true that erectile problems are common in older men. If the cause(s) of concurrent PE and ED are psychological in nature, they may be interrelated and reinforce one another.
With an inflatable implant , fluid-filled cylinders are placed lengthwise in the penis. It may be the case that sex is not as fulfilling due to over familiarity, or concerns about the relationship. These include antihypertensive medications, antipsychotic drugs, anxiolitics, antiandrogens, anti-cholesterol agents, and drugs used to regulate heart rate. Particularly when is it used as an aid to masturbation. The key to treating erectile dysfunction is to identify the underlying cause. Enter the characters you see below, atorvastatin decreased mean LDL cholesterol by 43% and resulted in a significant improvement of sildenafil efficacy in the domain score of 7. When erectile dysfunction is caused by psychological triggers, it is referred to as psychological impotence.
Are You Able To Get An Erection While Alone?
Psychological causes of ED aren’t always related to sex itself. It’s worth remembering that impotence is a complex medical condition, which may have more than one cause. You should not use a vacuum pump if you have a bleeding disorder or if you are taking anticoagulant medicines, which reduce the ability of your blood to clot. A lack of communication is the primary barrier for seeking treatment and can prolong the suffering.
Depression, anxiety and ED
There are two types of penile implants. Anxiety, for example, is something that many people assume exists in your head. Doctors now know that physical factors cause impotence in most men with the problem.