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Urology/Erection difficulty when standing up


QUESTION: Dear Dr.Leslie,

I know this problem has come up before, and have seen some of your careful, considered responses to this and other related issues. But I feel like there are still few clues to go on, and that the relatively few (though not insignificant number of) people suffering from this problem would love a doctor to give a better idea of what the cause may be.

As for my particular case, for as long as I can remember after finishing puberty (I remember this problem not existing as I was going through puberty itself), I almost never naturally get an erection while standing up (there are a very few sparse occasions where a half-erection appears for a few seconds). Equally when I am sitting or lying down and get an erection, then stand up the erection will disappear within seconds.

I'd say my erections while sitting and lying (especially when lying) are usually good and strong. There have been periods when I've been under stress in life, am tired, or feel some performance anxiety, where an erection seems difficult to get or I would lose an erection after a time and feel stressed and unable to continue, but in general in times of good mood I feel everything works fairly well.

In these times of good mood, there have been occasions when I've been consistently erect for anything from 10 minutes to an hour with little to no physical stimulation, but when I go to stand up the erection disappears quickly.

I have seen it said that it is most probably a psychological issue. In most respects this seems unlikely to me as it is not as if I worry about standing up or experience any anxiety. It is just a simple movement, and no change in mood, but the result is still the loss of the erection. The only way I could see it being a psychological issue is if it is really deep-rooted in the subconscious, or somehow programmed as a stimulus-response process.

Admittedly with concentrated sexual thoughts and continual manual stimulation, when on good form, I can masturbate to ejaculation when standing up, and can sometimes engage in standing sex (her on the table) with continued thrusting, but I would say it is not a relaxing 100% pleasurable experience due to the erections tendency to disappear on momentary cessation of thrusting.

As far as I'm aware I have night time erections, though mostly they don't stick around for long on waking (again I think it depends on mood at the time). When they do stick around, when getting out of bed to go to bathroom, the erection will almost immediately be lost.

I went to an NHS hospital appointment (after waiting months on the waiting list) in the UK. I was given an assistant specialist to talk the issue over with. He told me that 1 in 4 men experience this problem due to blood being diverted away from the penis to the legs. At the time I thought it very strange as in all my research I had never stumbled upon this reason and certainly not in such a large subset of the population. But he said it with such conviction that I accepted it and felt somewhat happy that the problem was "normal". He gave me a prescription for cialis and he said it should help the situation somewhat, and agreed with a suggestion I gave of taking l-arginine supplements. Later I felt a bit disappointed and cheated, as what he said about the 1 in 4 thing seems very inaccurate.

After using cialis I noticed that on standing the erection would retract slower, but still retract. Manual stimulation while standing became much easier, and I didn't feel the need to bombard myself with manic sexual thoughts in order to keep the erection alive. Equally I find that cialis allows me, when lying and sitting, to maintain erections even in those times when my mood is low or I'm very tired, which can in fact put me in a good mood and relieve tiredness. It also gives me the feeling of stronger erections in general.

Well I guess what I want to know is what really is the most likely reason for this issue? Is this information available in the medical journals etc? It certainly doesn't seem to be available online in any definite measure. And I think it is even less likely to be available on another trip to the doctor's/hospital, as they just want to give you viagra/cialis and get you out of there. Also as it is not a frequently occurring problem most doctor's would tend to pass it off. Of course there are certain tests that can be done if one pushes hard enough. I wonder which tests are really likely to show up anything of note?

I've previously had blood pressure and testosterone checked before and they came back normal. Also have had a few diabetes tests, one very recently, and it came back normal. I'm fit and healthy, go to the gym about 3 times a week, do plenty of walking and some running, though don't overdo it. I'm 26 years old. I'm  183cm in height, and around 65kg in weight. I'd say I'm fairly thin though BMI is normal. My legs are a little skinny but not stand out noticeably so. They sometimes feel quite tired, but I can run fast and push a lot of weight on them. I've been trying to build more muscle and strength in my legs as I thought this may help. Though I wonder if I'm giving my body more leg muscle that it needs to supply, and this will be taking more blood away from the groin, therefore bringing a more negative result?

I should also mention I took accutane as a teenager. I saw a few other people mention this in terms of erection difficulty, including one or two who mentioned losing erections on standing up. Though I'm not particularly positing it as a cause.

Thank you for your help Dr.Leslie, hope you can shed some light on this problem. I know a lot of people would be glad to read a somewhat more definite consideration of the problem, rather than finding no leads on their journey through their search engine.

ANSWER: Charlie:

The advice you got from the PA was correct.  The thinking is that when you stand, the muscles in the lower back and buttocks need extra blood to hold you erect.  There isn't always enough blood for both so in borderline cases there can be a loss of erection.  The condition is called pelvic steal syndrome and it is in the medical journals.

---------- FOLLOW-UP ----------

QUESTION: Thank you for the response Dr.Leslie. I was under the impression that pelvic steal syndrome would result in a loss of erection when thrusting in the missionary position. I don't have such a problem. Does this imply that that the blood is being "stolen" to a lesser extent, or that there are different arteries at work as compared with those with the thrusting in missionary problem?

The main thing I would like to know is what you would recommend to lessen the effects of such an issue. Would you recommend weight training for the lower back and buttocks to build muscle in these areas? Or will more muscle steal more blood away?...Would increased running have any effect?...Would improving posture be effective?...Also how about kegels?...Any other advice?

Thank you again.


Your guess is as good as mine.  Loss of erection with thrusting can also be a sign of pelvic steal but you can have one without the other.  We can try something like viagra but there is no specific treatment for the erection issue.  There is no evidence that increased running or other exercise will help or work and neither will better posture or kegels.


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Stephen W. Leslie, MD


Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.


Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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