Dear Dr. Eva,

Guys sometimes wake up with an erection. We call this a piss hard-on because it goes down after pissing. Is there a difference between this and an erection caused by sexual arousal?

Thank you.


Dear Mike,

There is no physical difference. Men have erections as part of the normal sleep cycle. These erections are not necessarily associated with sexual dreams. Because of these normal sleep erections, men often wake up with erections whether they need to urinate or not. Erections go down with urination because it is near-impossible to urinate when the penis is fully erect. Men can sometimes urinate with a partial erection but in that situation they often need to use a lot of pressure to get the urine out. So people think it is the urine or urge to urinate that causes an erection, but it really isn’t.

Dear Dr. Eva,

I recently turned 50. My erections aren’t as hard as they used to be (still hard enough to have sex) and I notice that the fluid that comes out is more clear, when it used to be more white.

Is there something wrong with me?


Dear Worried,

There may not be anything wrong with you. These changes can be a normal part of getting older. As men age, the firmness of their erections decreases. This is a progressive change, gradually increasing with age – not something that happens suddenly when you turn 50.

There is also a decrease in sperm production with aging. Sperm is what gives ejaculate (“cum”) a white color. The clear part of ejaculate is fluid made in the prostate gland. As sperm production decreases, there is less white material in the ejaculate.

These changes are worth a discussion with your health care professional, because there are also many medical problems that can cause softer erections. These problems include:

• Circulation problems: decreased blood flow to the penis, caused by cholesterol blocking the arteries.

• Smoking: smoking tobacco causes narrowing of the arteries in all parts of the body, including the penis. Decreased circulation lasts for 90 minutes after each cigarette smoked!

• Damage to nerves: the nerves to the penis have to be healthy for erections to occur. These nerves are damaged by diabetes and by chronic viral illnesses such as HIV and hepatitis C.

• Alcohol use, which affects both libido (sex drive) and nerve function.

• Drug use, especially methamphetamines, but also cocaine and opioids such as heroin, Oxycontin, and Percocet.

• Many prescription medications, especially two categories of blood pressure medications: beta blockers and thiazide diuretics.

• Emotional problems, including anxiety, depression, and stress.

• Not getting enough sleep.

• Performance anxiety: if a man is worried that he will not have a firm erection, that worry can become a self-fulfilling prophecy, leading to more problems with erections, leading to more worry, in a vicious cycle

• Low testosterone: low testosterone affects sexual drive or interest more than it directly affects erections, but the lowered interest translates to less sexual stimulation, which causes decreased erections.

Dear Dr. Eva,

I have (always) had a ring of little bumps around the base of the head of my penis, like a tiny ruffle. My previous partner thought it was cute and accepted it as part of me. My new partner thinks I have warts and is insisting we use condoms. What do you think?


Dear Decorated,

Please see the photo. Is this what your penis looks like? If so, you are the proud possessor of pearly penile papules. (See, even the name is cute!) This is a normal variation in the shape of the glans (head of the penis). It is not a form of warts. However, there are so many good reasons to use condoms that I suggest you go ahead and use them, even after you explain to your partner that PPP’s are not warts. Good reasons to use condoms: HIV, syphilis, herpes, warts, Chlamydia, gonorrhea, and more! t

Eva Hersh, MD, is a family physician and fellow of the American Academy of Family Physicians.

Doctors call them Pearly Penile Papules.You might call them nature’s own French ticklers. Either way, they’re a natural variant

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